Inspection on 01/12/08 for The Laurels

This inspection was carried out on 1st December 2008.

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 Laurels 31/07/09

The Laurels 27/12/07

The Laurels 15/11/06

The Laurels 06/02/06

The Laurels 16/08/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE The Laurels West Carr Road Attleborough Norfolk NR17 1AA Lead Inspector Mrs Judith Last Unannounced Inspection 1st December 2008 09:10 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 Laurels DS0000064440.V373357.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 Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Laurels Address West Carr Road Attleborough Norfolk NR17 1AA 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) 01953 455427 Gooderham@btconnect.com Goodwood Care Homes Ltd Mr Ian Richard Gooderham Mrs Lois Fagg Care Home 39 Category(ies) of Dementia - over 65 years of age (39), Old age, registration, with number not falling within any other category (39), of places Physical disability (39) The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No further Service Users falling outside the category of DE(E) to be admitted to the home. 27th December 2007 Date of last inspection Brief Description of the Service: The Laurels is a single storey building that is registered as a residential home. The registration has changed to include residents with dementia. The registration for older persons without dementia or for adults over 50 with physical disability is only for those residents who are already in the home. The long-term plan is that only service users suffering from dementia will be accommodated and so the home cannot now admit people who are not older people who also have dementia. The home provides thirty-three single bedrooms and three shared rooms. None of the rooms has en-suite facilities and there are four bathrooms, one shower and eleven toilets available to service users. The shared rooms are only used to provide care to residents that chose to share together. The home does not provide nursing care but health care is by access to community resources. A chiropodist and dentist visit the home as required and a hairdresser visits weekly, for which additional charges may be made. Weekly charges are from £404 plus a £35 third party top up. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. People at this home are having an Adequate (One star) service at the moment. Before we visited the home, we reviewed all the information we had available, including the information the manager was asked to send us, as well as written comments we had received. We also took into account information we had available about concerns and complaints, the nature of these and how they had been managed. During our visit, we used two main methods of gathering information. One of these is called case tracking. This is used to see what records say about people’s needs and then to find out from observation and discussion with people and staff, how well these are being met. Because people with dementia are not always able to tell us about their experiences, we also used a formal way of observing people to find about their lives in the home. We call this a “short observational framework for inspections” (SOFI). This involved an inspector spending two hours observing five people and recording their experiences at regular intervals. This included looking at their state of wellbeing, how they interacted with staff, other people present in the home, and the environment around them. This inspection was carried out by two of the Commission’s inspectors – Mrs Judith Last and Mrs Susan Golphin. We both spent a total of around 9 and a half hours in the home. What the service does well: Staff work hard to try and provide opportunities for people to join in activities. They also try to offer choices to people on a daily basis, for example about their food and about their clothing. They also support people to maintain their personal hygiene and appearance, so enhancing self-esteem. Staff are aware of the importance of protecting people’s privacy when they are helping them with personal care tasks. Relatives feel that staff work hard in what are often difficult circumstances. The staff team told us that they felt they worked well under pressure. The environment is generally well maintained and there is considerable investment in this. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Support plans are not kept up to date and reviewed with people or their representatives. This includes updates about mobility, nutrition and emotional welfare. This means that staff cannot be clear from the documentation, exactly what they need to do to support people effectively. The home supports people who have dementia. However, there are no proper assessments carried out in accordance with the Mental Capacity Act, to support where decisions have been taken on behalf of people and to show that these decisions are only made in their best interests. We had particular concerns about this in relation to refusal of medication and guidance that this could be administered covertly (i.e. without the person’s knowledge or permission). Medication is not well managed. Records are not always clear about what has been given and how much. They also show it is sometimes unavailable when it is needed so people do not have access to the treatment they need to keep them well at all times. We also had concerns that people are given medicines to help control agitation when it is not always clear that it is justified. We have some concerns about staff supervision and training, particularly in relation to moving and handling, and also about occasions where numbers of The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 7 staff on duty may not be sufficient to effectively support people who are highly dependent. 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 Laurels DS0000064440.V373357.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 Laurels DS0000064440.V373357.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): 3 and 6 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 who are moving to the home would have their needs assessed. EVIDENCE: The manager is clear about the importance of gathering information about people’s needs before they come to the home. There are basic assessments on people’s files. The manager also wants to further develop systems for gathering information about people’s past lives and backgrounds. This would help improve the way that staff are able to support people who are confused. No one is admitted solely for rehabilitation, so key standard 6 is not applicable. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 10 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. Support plans do not always show how people’s physical and emotional health care needs are to be properly met. Staff are aware of the importance of protecting people’s privacy but sometimes when they are busy, overlook how they may better promote people’s dignity. Medication is poorly managed and monitored. EVIDENCE: We looked at the support plans for most of the people we observed and some additional ones making a total of 6. We also looked at the daily notes for an additional for an additional five people where there were issues arising about medication. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 11 The manager says in information that she sent to us, that the home does well in that they “identify achievable goals to support residents with specific issues”. We could not see evidence of clear goals for care being clearly specified and set down, with the actions and support required of staff to help the person achieve them. The manager also referred to care being “person centred” but this did not show up in support plans or individual goals. Information in support plans is not always clear and consistent and so does not set out clearly for staff how they are to meet people’s needs and promote their safety. For example, one person’s support plan shows mobility has improved and in November 2008 a record shows that the person has been able to “safely walk by herself for over a month”. This is inconsistent with the identification of “high risk” on the assessment chart which says the person is “unable to weight bear, requires full assistance and stand aid”. The assessment has not been reviewed and updated although it is clear that staff have been working in a way that has developed and increased the person’s confidence and mobility. Records for one person for this year show that in February they had lost a stone since the previous check and another 8 lbs by April. There were continued losses in June and August but there was no update to the support plan. There was no proper assessment of this and no indication that the advice of a dietician has been sought to help minimise the risk of poor nutrition. Support plans do not set out how people’s emotional and psychological health needs are to be met. For example, one person’s care notes show that the community psychiatric nurse felt the person was depressed and “needed time each day to talk one to one and feel valued”. The record then goes on to say, “Family informed”. It does not set out how staff are to help meet the person’s needs but indicates this has been left to the person’s family. There has been some improvement in the assessment of risk from pressure sores and people’s susceptibility to these. These reflect what staff are to monitor and where pressure-relieving equipment is to be used. Records also show that staff are aware of when someone may be becoming unwell and need to see their doctor or the district nurse. Support plans do not provide evidence of the involvement of service users or their representatives. One relative felt that they were not always kept informed about the care of the person they visited and although they were kept informed about hospital admissions they were not always informed of accidents that happened and “we are only aware when we visit and bruises are seen on arms etc”. None of the care records we saw contained proper Mental Capacity Act assessments in relation to specific decisions –such as a person’s refusal of The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 12 medication. The person’s notes record that they have been refusing medication making them susceptible to aggression and minor injuries. Records say, “discussed with GP. Liquid meds to be prescribed where possible, crush tablets if applicable when non-compliant. Covert medication when needed.” There was no evidence of a proper process according with the law, for assessing the person’s capacity to make this decision and in ensuring the any decision to administer medicines covertly was in the person’s best interests. Staff say that they have training in the administration of medication and do not administer it until they have had training. We identified a number of occasions when people had been without the medication they needed to help promote their health, reduce agitation or control pain. We also saw that some signatures were omitted from the administration record, so it was not possible to determine whether medicines had been given as prescribed, refused or withheld for some reason. The audit checks in place have failed to identify these problems promptly. Where medication is prescribed for use in variable amounts (e.g. one or two tablets), records do not consistently show how much has been given. Some people have medication prescribed to help control agitation. Records of administration for three people showed that these medicines were being given at regular times every day. The daily records did not show that the decision to do this was justified. For example, we found that notes made about the afternoon and evening shift for one person showed they were “very settled”. Despite this, the medication had been given at 10pm. We identified a number of examples involving different people where such medication had been given and where daily records do not show there were signs of agitation or distress for which the medicines had been prescribed. The manager has said at a strategy meeting convened for the protection of vulnerable adults that she has spoken to staff about not needing to administer such medication all the time, but does not appear to be monitoring the decisions made by staff in respect of this. There is no written guidance for each person indicating exactly when the administration of such medicines should be considered, and for example, guidance about the minimum interval between doses. There is no guidance about a process of recording why it was needed. We found medicines such as eye drops on the trolleys, which are supposed to be discarded four weeks after opening. We saw one of these was prescribed for regular administration and supplied on 23rd August according to the pharmacy label. These drops should therefore have all been used up if administered as prescribed and as signed on the chart - or disposed of by the time we visited. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 13 There was one box of medication on a trolley that was unnamed and was dated 2004. There was a room number written on the outside. Staff and the manager say that no one is prescribed this medicine now. They did not know when it had last been used. Individual care records are held securely in the treatment room to protect confidentiality. One staff member we spoke to was able to give an example of how people’s confidentiality was protected. Both staff members interviewed also referred to privacy and dignity when describing how people were supported with their personal care. During our visit we saw staff (including domestic staff) knocking on room doors before entering, showing respect for people’s privacy. However, a number of people who were in bed when we arrived had their room doors open. The manager says this is so staff can check on them easily to make sure they are all right. This has an effect on privacy and dignity. During the dedicated two hour observation we did, we saw one staff member engaging in conversation with a visitor but over the head of a service user who was seated between them. Additionally we observed that two staff were talking to each other while one of them helped a person to their seat. The staff member helping was not looking at the person or engaging positively with them. Likewise one person who was wandering in and out of the room was taken to a seat by staff without any engagement in conversation. The room the activity took place in was very crowded and congested. This meant that people were not able to have a choice of where they sat and one person was positioned where they could not see. They asked a number of times to be moved but were ignored by staff until they explained that it was because they were not able to see what was going on. The manager complimented one person on their hair but then went away without waiting for a response or engaging the person further. These examples reflect potential compromise to dignity and respect. However, our formal observation showed other interactions with staff that did help to promote respect and dignity. For example one person was disorientated and staff reassured them with an explanation of where they were and who they were sitting with. The staff member made eye contact and made sure that they were at the same level as the person while they were talking to them and offering reassurance. The Laurels DS0000064440.V373357.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have opportunities to engage in meaningful activity and their families are welcomed when they visit. EVIDENCE: The activities happening in the home are posted on a noticeboard by the front hall. It is unlikely that most people would see this, but staff did explain what was happening on the day we visited. We saw that people were encouraged to join the activities. During our formal observation a total of 25 separate “timeframes” were recorded. These show that people’s “state of being” or mood was positive on almost three quarters of the time frames observed. There were no negative states. Most of the time people were positively engaged or responding to what was happening around them. Our observation showed that people enjoyed listening to the music performance more than joining with the karaoke session. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 15 A reminiscence session took place while we were visiting. During our formal observation we saw that some people found this difficult to participate in because of the arrangement of the room and where the person leading the session had chosen to sit. This meant that some people had to lean forward in their chairs in order to see and hear, while others lost interest in the activity. Two of the three people living at the home who wrote to us say that there are “always” activities they can join in. The home employs someone specifically to help with this so that people get opportunities to join in activities. However, during the afternoon we saw that there were three people sitting in a lounge with no staff presence to encourage conversation or engage them in activity. All of the people were asleep. During our visit, relatives came to the home. People were assisted to their rooms if they wished to see people in private. There are also three lounge areas that can be used if preferred. Two relatives who wrote say that they are always made welcome. One comments that although the staff are always busy “they are happy to stop and talk with me when I visit”. Because the home is moving over entirely to dementia care, many people are not able to manage their own finances. Some relatives act with power of attorney to assist with this. However, we could not see evidence that, where decision making in any particular area was becoming difficult, a proper process as set out under the Mental Capacity Act was followed to show that the service only made decisions in accordance with guidance and the code of practice. (See comments about medication.) We saw that people were given opportunities to choose their drinks and biscuits and consulted about the lunchtime menu. Staff were also able tell us how they would present choices – for example by offering different items of clothing when they were supporting people with their personal care. People who needed assistance during mealtimes were given this, and we saw staff sitting with them to help them eat. However, we also saw that staff do not always sit with people when they are assisting them to drink between mealtimes. This could have been because the room the activity took place in and where mid morning drinks were served was very crowded. There are no nutritional screening tools in place to help identify where people might be at risk from poor nutrition – as is common with people who have dementia. Where there are concerns identified, support plans do not follow this up with clear guidance about how staff are to tackle this and make sure someone has adequate nutrition to maintain weight and health so far as possible. We have commented on this in the health care section. People are encouraged to choose what they would like although they may forget between making the choice and being served the food. We heard one The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 16 staff member taking great care to explain what the main dish was and to describe it because the person did not understand what was on offer. Menus show a range of different foods on offer. However, these do not always present real choices. For example, one day showed a choice of cheese and onion roly-poly and sausage roly-poly. This did not provide for a choice if someone does not like the pastry. Similarly another day provided for choice between beef stew and beef curry which does not provide a choice if someone does not like beef. The manager says that menus will be reviewed and she agreed that photos might be helpful in reminding people what was on offer. For this reason we have not made any recommendations. The Laurels DS0000064440.V373357.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): 16 and 18 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. Most people living at the home would need support of their representatives or of staff to make a complaint and relatives are not always aware of how they might do this. Because of our concerns about regular use of medication to control behaviour and apparent lack of justification for this, we could not conclude people were wholly protected from abuse. EVIDENCE: There is guidance for people about how to make a complaint. In practice, many of the people living at the home would need the support of other representatives in order to raise concerns. One relative’s survey sent to us says that the person does raise issues with them, like not having enough to eat but then says that they are not to say anything to the manager. This indicates people may not be confident that their concerns would be addressed constructively and that there is an open approach to responding to them. Two of the relatives who wrote to us say that they do not know how to complain. We know that some concerns have been raised directly with us and that the home has participated in meetings that are led by social services, to ensure that people are properly protected in the home. These have shown that The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 18 matters were not referred to the adult protection team as they should have been and the owner of the home is aware of this. We have been told that discussions have taken place to make sure that staff, particularly senior staff are aware of their responsibilities to raise issues of concern about people’s welfare or safety and to do this promptly. We spoke with the manager and owner about the routine administration of medicines that are prescribed for occasional use when people may have periods of agitation. Records show that these are administered routinely but do not show that the decision to give them is justified because levels of agitation warrant it. The manager agreed that this could be seen as “chemical restraint”. The Laurels DS0000064440.V373357.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 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 home that is well maintained and subject to continued improvement. EVIDENCE: Since our last visit there has been work to help make it easier for people to find their way around the home. There are signs for people to follow, as the layout can be complicated for visitors as well as people living there. The owner is aware of the need to try not to over do this and to strike a balance between helping people to orientate and keeping the Laurels homely. People are able to bring in some of their own belongings to help make their rooms more homely and comfortable. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 20 The owners have acted upon the requirements of the fire officer and have invested in fire doors for people’s rooms to upgrade the protection they would get should a fire break out. There are records to show that the fire alarm system is tested to make sure that it would work properly when it is needed. At the last inspection we noted the doors for toilets had been painted red to help distinguish them from doors to bedrooms. The manager says that an improvement in continence has resulted for some people, who are more easily able to find the toilet when they need it. This is good practice. During the morning’s activities, our observation showed that the squeaking of the door to the staff room disturbed some people and caused some agitation and distraction. Two relatives who wrote to us commented that parking was very limited and as they were elderly themselves they often found this difficult. This problem will get worse when the new unit is fully operational because there will be more staff and visitors to the home. One person also commented that it would be nice if visitors had somewhere to stand under cover while they were waiting for the door of the home to be opened. There is no porch for people to stand under if it is raining and while they are waiting for staff to be available to respond. Areas of the home that we saw were clean. The manager has told us that she planned to review cleaning rosters to make sure that standards are maintained. Three people living at the home were able to write to us and two say the home is always fresh and clean. One says it is usually. However, we did note an odour associated with continence difficulties when we entered the home. A relative has also commented to us in writing about this. The information the manager sent us before we went show that none of the staff has training in infection control. This is despite one person having MRSA infection the last time that this service was inspected. Staff did not raise any concerns with us about the adequacy of hot water supplies. We were able to see that maintenance of the system has taken place to make sure that supplies are properly balanced and that the engineer considered this had contributed to difficulties with some taps running too cold and others being too hot. We therefore consider that the requirement made at the last inspection has been addressed. The Laurels DS0000064440.V373357.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 and 29 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 is room for improving the effectiveness and competence of the staff team and the robustness of recruitment practices. EVIDENCE: When we arrived at the home we were informed that there were 6 staff on duty and 38 people in residence. We were also told that two of those people were attending to the administration of medication leaving four staff to attend to the personal care needs of the 38 people living in the home. We have had concerns raised with us in the past about staffing levels and that these were not adequate to meet the increasing dependency of people living in the home. One person wrote to us saying this about the home: “need more staff, staffing levels are not up to standard. We have to do domestic, like i.e. working in kitchens, laundry.” Staff on duty told us that having six staff on duty “makes a change”. They said that mostly there are 5 and sometimes staffing levels are down to four people on shift. We were also told that about 6 or 7 people require support from two staff in order to safely move and handle them. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 22 Staff told us that there had been problems but that they felt there was a good staff team that was now working more effectively with people living at the home. One person told us there is one weekend in the fixed duty roster which is covered by fewer staff than others but say that the team works well when it is under pressure. Relatives made positive comments to us about the staff are the home. These include remarks like the staff are “very caring”, “always most helpful and most efficient”, “they are most kind” and “considerate”. Information the manager sent us shows that staff have access to training for National Vocational Qualifications. She told us that most other training is delivered “in house” to reduce costs. Other professionals who visit the home have informed us that they have sometimes been involved in delivering training but that there are frequent interruptions that make both the teaching and learning processes difficult. The manager says she is a trainer for moving and handling. However, staff do not receive this training promptly when they start work at the home. We were concerned about this last time we inspected but the situation does not seem to have improved. For example, one person we spoke to has been in post since September without having had moving and handling training. During our formal observation we saw people being assisted in ways that were not wholly safe and use being made of wheelchairs without appropriate use of footrests, so placing people at risk of injury or discomfort. We know from a previous complaint that people were not always clear about the equipment that they needed to use for each individual and so were unclear about how to move and handle each person safely. Information provided by the manager and seen in staff files shows that there has been an improvement in the provision of training in food safety. Records for staff, including their training and recruitment, were not always well organised and so the evidence presented to us was not clearly accessible. References and Criminal Records Bureau checks are obtained for staff, and contribute to making sure that people living at the home are protected. However, recruitment does not always follow best practice. For example, we found that there were no recording notes of one person’s interview, the questions and responses. This means there are no proper records to underpin decisions about the suitability (or otherwise) of applicants. Likewise the manager could not show from her records that she had robustly questioned applicants to ensure she had fully tracked their employment histories and tried to establish that their personal skills and aptitudes made them suitable for the work. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 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. Management monitoring and systems have not been wholly robust enough to ensure that the home is always effectively run. EVIDENCE: The manager has appropriate experience and qualifications to run the home. The annual quality assurance assessment says under what is done well in management and administration, that there are audits of nursing, falls and medication done monthly. However, these audits and management monitoring systems did not identify for example that care plans were up to date and consistent in relation to mobility and risk of falls. Medication audits were The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 24 insufficiently robust or detailed or they would have promptly identified the issues that we raised in our inspection. There are systems for checking what people think about the quality of the service. However, the manager’s self assessment of the quality of the service that she sent to us, cites some evidence (for example in relation to improvements in care plan review processes) which was not available. The home is registered as run by a limited company. One of the owners maintains a very regular presence in the home and pays particular attention to the environment. However, none of these visits provides for a formal report and check on the quality of the service as well as the views of staff and residents. We checked records and balances of monies that were held for safekeeping on behalf of people living in the home, and to which staff have regular access. We were able to establish that transactions are recorded and eventually to establish that balances were accurate. However, some monies were held in unnamed envelopes in poor condition, and in one case receipts had been mixed up and put in the wrong envelope. This increases the potential for error. The manager has not kept records of specific events such as those she needs to tell us about, although this record is supposed to be kept in the home and to be checked on provider’s visits. Staff are not supervised as regularly as standards suggest is adequate, or to the agenda suggested. Neither of the two members of staff who wrote to us could confirm they met with the manager regularly to discuss their work. One person had no record of supervision since September and there was a lack of evidence of monitoring of performance and of review of performance during the induction/probation period. One person had supervision in February, April and then August and nothing since. This is despite the lack of supervision for staff having been discussed with the manager at our previous visits. Where staff performance has been an issue, records show comment and observation by the manager doing the supervision, but do not record any direct comments from the person being supervised. There is no clear record of how staff will be supported to improve their practice, what specific improvement is required and agreement about how it will be monitored and reviewed. Likewise, staff meeting minutes do not clearly identify how the manager will address problems and issues. The manager reports a decline in staff morale but we could not see from either supervision or staff meeting minutes, what efforts were being made to address this. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 25 We saw that people were not always moved and handled in a wholly safe manner. The manager says staff are expected to assist people to and from the hairdressing salon rather than the hairdresser doing so. However, our observation showed this did not happen and the manager was not aware of current practice. The hairdresser and another staff member were seen as assisting people by having a hand placed under their arm and being pulled up from their chair. One of the people concerned has records that show that they have been suffering from pains in their arms and so this practice may well have been uncomfortable as well as unsafe. People were transferred from wheelchairs to seats in a manner that was not wholly safe. A member of the district nursing team has commented at strategy meeting that she has seen moving and handling practices that are not wholly safe (including use of a shoulder lift) and that she had provided some training for staff. The owner has made arrangements for the thermostatic mixer valves supplying baths to be serviced regularly to make sure they are working properly. This is an improvement since our last visit. However, there is no routine day-to-day monitoring to check bath water temperatures and make sure that these are within safe and comfortable limits and to ensure there is no delay in identifying faults. The manager says that she has asked the owner for thermometers but these have not been forthcoming. We cannot conclude that the requirement made at our last inspection has been fully met. We were not able to conclude from the files we saw that there had been improvement in health and safety training. The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 26 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x x x x x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 2 1 x 2 The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 27 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 People’s care plans must be kept up to date. If they do not reflect people’s changing needs staff cannot be clear what support each person needs to meet their needs successfully. People or their representatives must be involved in reviewing and updating their care so that they are able to make decisions how they wish their needs to be met. People’s nutritional needs must be properly assessed and advice taken from other professionals where weight loss is of concern. If this does not happen then people are at risk of poor nutrition and associated health problems. Where someone may not be able to made individual and specific decisions about their care and treatment, a proper process for assessing mental capacity and ensuring each individual decision DS0000064440.V373357.R01.S.doc Timescale for action 31/03/09 2. OP7 15 31/03/09 3. OP8 13 31/03/09 4. OP7 12 28/02/09 The Laurels Version 5.2 Page 28 is made only in that person’s ‘best interests’ must be followed. This includes decisions about whether or not they wish to take their medicines. If this does not happen people are at risk of inappropriate treatment and withdrawal of their right to make decisions about their care. 5. OP9 13 Outstanding requirement Medication recording must be improved so there is a clear and auditable record of what medicines residents have received, administered and disposed of. This is so that errors can be more easily identified and put right, and to ensure that medication is not at risk of misuse or abuse. Timescale of 1st March 2008 has not been wholly met. 01/12/08 6. OP9 17 Where medication is prescribed 31/01/09 for use in variable amounts, the amount given must be recorded. This is so that people are not at risk of accidental under dosing or overdose. This is so statutory records are maintained. 7. OP9 13 Where medication is for use when needed to control agitation, the decision to offer it to people must be justified in supporting daily notes. If this does not happen people are at risk of abuse and of unwarranted restraint by use of medication. There must be proper guidance for staff about the administration of medicine that is to be given only when it is needed. This must set out the circumstances DS0000064440.V373357.R01.S.doc 31/01/09 8. OP9 13 31/01/09 The Laurels Version 5.2 Page 29 under which it may be given, the amounts, minimum interval between doses and how to show that the decision to administer it is justified. This is to ensure people receive the dose they may need, and to minimise the risk of overmedicating. 9. OP9 13 Medication that has a short shelf life must be dated on opening and disposed of promptly in accordance with instructions on packaging. If this does not happen people are at risk of the medicine not being effective or from it having been contaminated. Medication that is no longer in use or is not properly labelled must be disposed of properly and promptly. This is to minimise the risk of mistake or misuse. The registered persons must verify arrangements for the disposal of clinical waste are suitable. This is so the home complies with other applicable laws about waste and refuse disposal and does not place anyone else at risk. Staff must have training in the control and management of infection. This so staff have proper knowledge and skills about minimising the risk of any spread of infection within the home. Staffing levels, duty rosters and allocations must be reviewed. This is so they are always maintained at levels that are adequate for the safety, DS0000064440.V373357.R01.S.doc 31/01/09 10. OP9 13 31/01/09 11. OP26 16 28/02/09 12. OP26 13 31/03/09 13. OP27 18 28/02/09 The Laurels Version 5.2 Page 30 wellbeing and increasing dependency of people living in the home. 14. OP29 19 Recruitment practices must be revised to show how employment histories, experience and skills are assessed at interview. This is so there is evidence that people have been properly and fully assessed in relation to their suitability to work with vulnerable people. Staff must be trained promptly after appointment to move and handle people safely. This is so people are not at risk from inappropriate practices or improper use of equipment. The provider must arrange for monthly unannounced visits to report on the quality of the service. This is so the manager is given clear feedback, including the views of service users and staff, about the quality of the service and what needs to improve. This is so the provider is more fully aware of where the day-to-day delivery of the service is falling short of expectations. Outstanding requirement Staff must be given appropriate supervision, matching the minimum standards. This is so performance of staff is properly and clearly monitored and so that staff development and training is properly addressed. Most recent timescale of 01/03/08 has not been met. 31/03/09 15. OP30 13 31/03/09 16. OP33 26 28/02/09 17. OP36 18 01/12/08 The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 31 18. OP38 13 Outstanding requirement Water temperatures around the home must be monitored more regularly so that residents are not put at risk of scalding themselves. Timescale of 01/03/08 has not been met. 01/12/08 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 OP9 Good Practice Recommendations Service users photographs should be added to the medication administration record folders. This is to help minimise the risk of error and to provide an instant and easy reference and reminder for staff who are giving medicines. The routine practice of leaving bedroom doors open for people who are very frail and confined to bed, should be looked at to make sure people’s privacy and dignity is protected at all times. Arrangements for training should be reviewed so that staff are able to fully benefit from opportunities and develop and enhance their skills. 2. OP10 3. OP30 The Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Laurels DS0000064440.V373357.R01.S.doc Version 5.2 Page 33 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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