CARE HOMES FOR OLDER PEOPLE
The Laurels Nursing Home South Road Timsbury Nr Bath Bath & N E Somerset BA2 0ER Lead Inspector
Kathy Marshalsea Key Unannounced Inspection 10:00 5 , 8 & 10th January 2007
th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Laurels Nursing Home DS0000049317.V315714.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 Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Laurels Nursing Home Address South Road Timsbury Nr Bath Bath & N E Somerset BA2 0ER 01761 470631 01761 471351 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) European Care (SW) Ltd To be registered: Lesley Weir Care Home with nursing 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (4) of places The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. 5. 6. May accommodate 36 persons aged 50 years and over requiring Nursing Care. May accommodate up to 4 persons aged 18-64 years with Physical Disabilities. Staffing Notice dated 22/08/2001 applies. Manager must be a RN on parts 1 or 12 of the NMC register. May continue to accommodate named persons who require dementia care. Any further admissions of service users with a definitive diagnosis of Dementia or Alzheimer’s disease is prohibited until an application to change the category of registration to DE(E) has been approved by the CSCI. Date of last inspection JULY & AUG 2006 Brief Description of the Service: The Laurels is a care home operated by European Care, a limited company that operates numerous other care homes registered with the Commission for Social Care Inspection. The company has one other registered care home within Bath and North East Somerset. The home was first registered under The 1984 Registered Homes Act. European Care purchased and took over as the registered providers in May 2003. The Laurels is registered to accommodate up to 36 older people who require nursing care. Additional conditions of registration enable the home to offer accommodation to four younger adults with a physical disability. The home is an older detached property which has been considerably extended and adapted. It is situated in the village of Timsbury, which is approximately 9 miles from the city of Bath. Accommodation is offered on two floors and there is a passenger lift between floors. There are a total of twenty-eight single bedrooms and five shared rooms. Only one of the single bedrooms offers en-suite facilities. There is extensive parking available to the side of the property. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the home’s second key inspection and conducted over three days. Information was taken from the home’s records; time was spent talking with residents, some visiting relatives, some staff and the Manager. Unfortunately only one of the survey forms sent to the home to be completed (by relatives and health care professionals) was returned. This was the first inspection for the new manager. She started at the home in August 2006 and has not yet completed the fitness process with CSCI. This is purely due to the fact that we are unable to process this until her CRB Disclosure application has been processed by the Criminal Records Bureau. There were some immediate concerns during the inspection about some Health & Safety issues that are detailed in the Section “What they could do better”. The manager and programme manager were told about these concerns. Immediate requirement notices were served to the Manager at the inspection with timescales for these deficits to be worked upon. A separate meeting with the Manger and Programme manager was held to allow a full and constructive feedback of the inspection findings. This was followed by a meeting with the representatives from European Care as well as those from Bath & North East Somerset Social Services and Bath & North East Somerset PCT. This is to ensure that they are kept up to date with the home’s status and whether any progress made previously had been sustained. Some areas needed to be significantly improved to achieve the National Minimum Standards for Older people. What the service does well:
One resident told the inspector that they found the night staff very good and that they kept on checking that they were comfortable. One care plan was written in the first person and gave good details of how the staff needed to support the person. It was written in plain English and was jargon free, which should enable the staff to be able to deliver effective and personal care. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 6 There are referrals made to the GP for some heath care problems. The communication book kept shows the GP’s response to those problems. This should enable the staff to keep themselves up to date with issues and treatments ordered. One senior care assistant is to be commended for the way they gave instructions to service users before they tried to deliver care and for their knowledge of the service users. This promotes the concept of person-centred care. An entertainer comes to the home regularly to play music. Service users spoken with appreciate this particularly as there is not an activities organiser at the moment. The Manager had dealt with an allegation of abuse promptly and involving the relevant agencies. This should reassure the agencies that the manager will respond appropriately to any further allegations. What has improved since the last inspection?
The manager conducted a bed audit and requested new beds plus pressure relieving systems and high bed rails, delivery pending. This will improve the safety of the residents and promote safer manual handling for the staff. Monthly in-house training sessions have commenced, as the home no longer uses the training provider mentioned in the last report. The Manager leads these sessions and so is able to concentrate on subjects she feels are a problem. This should help to tackle the ongoing resistance to providing best practice in care delivery. Some Health & Safety issues have been addressed such as portable appliance testing and a Fire risk assessment of the building. This should promote a safer home for staff and residents. There has been a sustained improvement in the recording of fluids taken by the residents who are at risk from dehydration. This still needs frequent reminders from the manager but charts checked had been completed regularly. The cleaners have started their Level 2 NVQ. This should assist them to understand the importance of their role in infection control within the home. A monthly award is given for a member of staff who has shown outstanding effort. This should encourage the staff’s morale. There is a Photo board in the lobby of staff for visitors to establish who’s who.
The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 7 The storage of food in the fridge was being carried out correctly. Recruitment records showed a robust process for the trained staff who have joined the staff since this manager has been in post. The trained staff spoke well of the manager and appreciated their clear sense of direction and firmness when dealing with poor practice. Fire safety records have generally improved so that it is possible to determine if the tests are up to date and if staff have attended a recent drill. The Manager has responded promptly to the Immediate Requirement notices and begun to take actions to remedy the deficits. What they could do better:
Immediate requirement notices were served for the following: Ensure that any risks to residents after an accident are minimised by reviewing the incident and any possible risk. Three residents were found to have had accidents without any review of that incident and if an additional risk was present. This has been a requirement at other inspections and so will be referred to the Commission for Social Care’s Inspection’s legal department for possible enforcement. Risk assessments should be completed for those residents who are in divan beds with bed rails, as the beds are not designed to have bed rails fitted, and can leave a gap, posing a risk of a resident falling between them and the bed. This had happened for one resident and some staff were using pillows to plug the gap. This then poses a risk from suffocation so should not be used. This was communicated to the manager who then took steps to stop using the pillows. Ways of reducing any identified risk must be considered and communicated to all staff to ensure the safety of all residents. Ensure those residents who are at risk nutritionally have the actions set out in the company’s own nutritional assessment tool for those residents (who have a low Body Mass Index). These include being weighed regularly, being referred to the dietician by the GP, providing an enriched diet. Actions to reduce the risk of weight loss and malnutrition need to be taken individually. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 8 Other areas where requirements have been made are: The company doing better monitoring of the quality of care being delivered and taking actions to ensure consistent and sustained improvement. They should be checking that areas of grave concern in 2005 are carefully monitored so that residents well being and safety is not compromised. Actions needed from the Regulation 26 visits must be followed through. This will ensure that the manager is properly supported by the company to enable her to fulfil her responsibilities. The inspector was concerned at three very hot radiators in the dining room and corridor. The Programme Manager organised for the maintenance department to deal with those by making covers. As a quick response the inspector asked for the tables in the dining room to be moved away from the very hot radiators. By the third day of the inspection the radiator in the corridor had been covered. This should have happened after the last inspection in June 2006 and had been repeated on the Regulation 26 visit report conducted in August 2006. Some other heath & safety issues that were noted during the inspection were that an oxygen cylinder was not being stored according to BOC advice and to promote the safety of the staff. The company needs to provide a recognised induction programme and record that process. This is to ensure that staff are aware of the home’s policies and procedures and have a knowledge base for safe care delivery. This is to ensure that staff are aware of the home’s policies and procedures and have a knowledge base for safe care delivery. Clinical competency should also be assessed as part of this process for qualified nurses. It is important for the trained staff to have a satisfactory clinical competence so that they can prescribe the care safely, monitor that and lead the shifts competently. Staff were being regularly supervised but the suitability of the supervisor had not been assessed. Some disciplinary issues discussed were not recorded in the supervision notes nor had the new trained staff had an initial session as part of their induction. The company also needs to ensure that the values of respect and dignity of residents are promoted by all staff by staff not reprimanding residents. The inspector overheard two examples of this during the inspection. The emphasis of the concept of providing 24-hour care is also an area that the manager is working towards with the night staff. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 9 The care plans need to be holistic and reflect the ongoing changes to each resident. The ones read during the inspection do not give a sound basis for care to be delivered as they do to reflect the changes noted in other documentation such as the daily notes. There was some evidence of the relatives being consulted about the care plan review but no evidence of the involvement of the residents themselves. Staff spoken with about the response to a possible abuse situation could not give an account of the actions they would take in line with the home’s policy or the local authority’s policy. At the last inspection this had been an issue and the recommendation was for them to produce a local policy and increase the staff’s awareness. Staff need to be confident about this area and the training they have had so far has not equipped them with this knowledge. The home has failed to meet the target of getting 50 of care staff through their Level 2 NVQ qualification in care by 2005. Several had been enrolled onto a course at the last inspection but had not started it. It was unclear why that was. Doing this qualification should increase staff’s awareness of the needs of older people so that they can meet those needs. The communication needs of one resident have not been met. Alternative methods of ways of this resident being able to express themselves has not been explored and has led to some difficult situations for them and the staff. This need should be properly assessed and referred for specialist advice. The complaints procedure still needs to be made accessible for service users who cannot read the copy available in the home. The staff have not had sufficient or effective training in the care of those service users who suffer from Dementia. This is necessary in order for them to give care according to best practice and for there to be a consistent ad person centred approach. 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 Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are not consistently completed so that some needs may not be met. Specialist care is not being delivered for those residents who suffer from Dementia. One resident does not have a communication system in place to help staff understand their needs. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 12 EVIDENCE: 3. Two pre-admission assessments were checked for compliance with this standard. One contained comprehensive information and included the resident’s remaining abilities. It also included risks to the resident. The other was incomplete, undated and unsigned. This was also the case for the residents who were later case tracked (when looking particularly at nutritional needs). Two identified and significant problems for one resident in 2005 had not been mentioned at all in their care plan. Contracts were present in the files for both persons mentioned above from BANES Social Services and European Care. The contracts were not looked at in detail. 4. The home does have a significant number of residents who have a form of Dementia. The home is not registered to care for Dementia sufferers and should not admit people who already have that diagnosis. This was agreed at one of the multi-disciplinary meetings held; the manager stated that she was unaware of this, as she had recently admitted a resident with a diagnosis of Alzheimer’s disease. In order to meet the needs of these residents, staff should have the skills and ability to care for this condition and understand how it will affect the resident. Training records showed that staff have not had recent training in this subject, which will be a requirement. One resident has communication problems that are not associated with mental health. Despite them being at the home for over a year no efforts have been made to offer alternative communication systems. Efforts should be made to refer this resident for an assessment so that every option could be explored. This is particularly important to reduce the frustration and associated problems that causes. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 13 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): 7,8,10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Care plans do not set out all of the health, personal and social care needs that should provide the basis of care to be delivered. There is not consistent consultation and the reviews are not done using all the information needed. Some health care needs are met. Staff spoken to, including the cook, were not giving individuals the attention needed to meet their nutritional needs. There was no review of any risk posed for residents following a fall/accident so that residents cannot be assured that all risk to them are being reduced... Equipment needed to reduce the risk of residents developing pressure sores is in place. Some instructions to reduce the risk of pressure sores were not being followed. Some residents’ dignity was being compromised by them being reprimanded by staff.
The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 14 EVIDENCE: 7. Initially six care plans were checked through the case tracking process. Two were for new residents. Two who had been at the home for some time and two who had suffered an accident recently. One new care plan was written in the first person and gave the detail of actions needed to meet the identified needs. Some entries (such as “ I need to stand every two hours”) were not being put into practice by the staff. Risks that had been identified in the pre-admission assessment had been explored in the care plan. There were also risk assessments for those risks. Care staff are not involved in the reviewing of the care plans and risk assessments. They do daily writing about the care they have delivered that shift which is kept in a separate file to the care plans. Discussion took place with the Manager about the benefits of including care staff in the drawing up and reviewing of the care plans. The two plans for residents who had been at the home for some time contained no entries for social care needs and had not been reviewed with the relatives since January 2006. There were also no end of life plans despite these residents becoming increasingly frail (some files did contain end of life plans). A care plan for a resident who had an fall in November 2006 had no mention of this in the care plan for safety or the risk assessments for the use of bed rails. Some staff spoken with about this incident were not aware of this fall and the associated risks. (An additional risk had occurred by staff filling the gap between the bed and the bed rails with pillows posing a risk of suffocation). The other plan for a resident who had three incidents recorded in the accident book since November 2006 did not have these incidents mentioned in the care plan or risk assessments. Another plan did not contain two significant health issues which were assessed before admission. Overall the care plans are not meeting the standard required to set out the health, personal and social care needs of the residents. 8. Observation, reading of documents and discussion with staff demonstrated that some health care needs are assessed and responded to. Communication books are kept for doctor’s visits and the trained nurses, which show that changes are detailed, and the doctors respond to that change.
The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 15 The manager had dealt with concerns she had about the inadequate completion of fluid charts and had talked to the staff during a group supervision. She then monitored the fluid charts until she was satisfied with them. Staff spoken with during the inspection were aware of the importance of completing these. She had already noticed that there was a risk to many residents from the divan beds and therefore poorly fitted bed rails. She had requested 20 hospital type beds from Head Office who had approved the staged replacement of the inappropriate beds. Due to the inspector’s concerns the Programme Manager for the home chased this order during this inspection and was able to speed the delivery of 10 beds. This will help reduce the problem but the risk for the remaining divan beds remains. The care plans in some instances did not mention the health care issues discovered by reading various records such as daily statements and communication books. The trained nurse’s daily records for each resident has been removed from each individual file and placed altogether in one file. This may be quicker for the staff but would not prompt them to refer to the care plan. Wound care records were examined. These records showed that wound dressings were checked regularly. However, there was only one recording of the size of wounds, and there were changes of dressing used without any rationale for that happening in documentation such as GP visits. On the third day of the inspection two inspectors concentrated on tracking the care of four residents who had been losing weight. It had been recognised in their nutritional assessments that there was a risk but there was not a consistent response to this risk as directed in the actions to be taken on the form, e.g. give an enriched diet, refer to GP/dietician, give fortisips, record weekly weight and record the food intake. Staff spoken to including the cook were not giving individuals the attention needed to meet their nutritional needs. The care staff do not inform the cook if a resident has not eaten well, and so the cook does not then ensure that this is compensated for. She had been asked by the manager to add full cream to mash potato and puddings if milky such as rice pudding. This is adding extra calories for all the residents but not providing an enriched diet for those at risk. The cook stated that they have ordered a food locker so that the meals will be served directly from that in the dining room. There were food charts being completed but a poor intake does not seem to lead to any other actions. An immediate requirement notice was served to ensure that residents who have been losing weight receive the attention necessary.
The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 16 Pressure relieving equipment and lifting equipment is present in the home. The manager had done an audit of lifting equipment and ordered more lifting belts to ensure that staff have easy access to them. 10. Two incidents of staff reprimanding residents were heard by the lead inspector. One incident was by an agency nurse who was challenged by the inspector and the manager informed. She resolved to inform the agency and not to use that person again. The other incident was at lunchtime and a permanent member of staff spoke to a resident in an infantile way. This was passed to the Manager for her action. Some staff did not talk to the residents while carrying out care tasks such as placing feet onto footplates and moving residents in wheelchairs. A senior carer who was on duty for all 3 days of the inspection is to be commended to the way she spoke with the residents and gave them directions before delivering any care. This person also took the time to soak a resident’s hand, which had been noticed as being dirty by them on 2 separate occasions. Their knowledge of the residents they were caring for was extensive and would be a very useful aid to the trained staff writing the care plans and reviewing them. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents do not benefit from having an activities co-ordinator so that regular planned events take place. Individuals who choose to stay in their room are at risk from being socially isolated. Mealtimes had to be revised so that all those residents who needed assistance could receive this in a timely way. EVIDENCE: 12. Since the last inspection the Activities co-ordinator resigned. A new appointment has been made subject to satisfactory employment checks. The staff stated that they try to provide some social activities in the afternoons and an entertainer has been coming to the home regularly. This standard will be assessed again at the next inspection. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 18 Two residents told inspectors that they did not like coming into the lounge as they felt there was no one they could talk to due to the condition of the other residents. 15. The lunchtime meal was observed on the first day of the inspection. This meal was very protracted and meant that not all residents could be assisted as they needed to be. Some residents struggled to eat and meals were getting cold as staff tried to be in two places at once. It was agreed with the manger that this was completely unsatisfactory. After this feedback a two sitting meal was tried and worked much better. This was observed on the second day of the inspection and was quicker and promoted the residents dignity. After the lunchtime meal was changed to two sittings staff reported that for three days after they had been able to meet the needs of the residents in a timely way. Residents spoken with commented positively about the meals. Regulation 26 reports show that there have been ongoing problems with the cleanliness of the kitchen. The inspector checked this. Cleaning schedules show that a daily, weekly and monthly list is completed. Most areas looked reasonably clean and tidy. There were some opened packets of food substances in the storeroom, which should be placed in airtight containers. Actions needed to be taken following an Environmental Health inspection in November 2006 had been actioned except that there was concern expressed at the inadequate size of the fridge. There are 2 chest freezers in the storeroom. Staff in the kitchen agreed that the fridge is inadequate for the size of the home. Food in the fridge was covered and dated appropriately. Fridge and freezer temperatures were being recorded regularly. The dishwasher was broken and waiting for a replacement part. The cook spoke about the change of menus and that they needed to be changed so that they suited the residents rather than using another home’s menu. The cook said she was hoping to be able to have time to do them with the Manager soon. It may be helpful for her to attend training courses in the particular needs of the elderly client group. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 19 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Complaints have been dealt with according to the home’s policy. The policy is not accessible for many of the residents. Some staff are not aware of how to react to a possible abuse situation in accordance with the BANES policy. The Manager has responded appropriately to an allegation of abuse. EVIDENCE: 16. The complaints log had 2 complaints. Both from relatives, one was regarding various issues being addressed by the manager. The other cannot be discussed in the report due to confidentiality. However, the Manager had completed a timely investigation of this issue and was able to respond to the complainant with an explanation. The complaints procedure is displayed in the home but is geared towards visitors and relatives. It is not accessible for many of the residents and this deficit needs to be addressed. Those who are visually impaired should be provided in a form suitable for that person. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 20 18. The home is still using the generic company abuse policy which needs to be updated. The previously held BANES policy could not be found. Trained staff spoken with were very hesitant with their response to questions about how they would deal with an incident of abuse on their shift. It was of concern that they were not aware of the involvement of Social Services and what the term POVA meant. The manager stated that there had been training in abuse in August 2006 by the previously used training provider but this had concentrated on signs of abuse and had not included the actions to be taken. It will be a requirement that staff attend the BANES course so that staff are confident about the topic and what happens when suspicions are raised. The home should obtain their policy and ensure that this is used alongside the organisation’s policy. The Manager has dealt with an allegation of abuse made by a resident about an agency nurse. This was reported appropriately and speedily so that the residents were protected from abuse. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is (excellent, good, adequate or poor). This judgement has been made using available evidence including a visit to this service. Not assessed. EVIDENCE: These standards were not assessed though some environmental issues were addressed during the course of the inspection. These are detailed in the body of the report. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 22 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): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are sufficient to meet the needs of the residents but is dependent on the quality of the staff on duty. Residents are not supported by sufficient staff who have their NVQ training. Recruitment records of those staff recently recruited were satisfactory. Staff need to be given training soon in the care of Dementia sufferers, response to an abuse situation and be kept updated in mandatory topics such as Food Hygiene. EVIDENCE: 27. The staffing levels are 2 trained nurses in the mornings with 6 care assistants. This reduces in the afternoons to one trained nurse and 5 c/a’s. Rotas confirmed the numbers and that agency staff are booked when there is a deficit. Staff spoken with stated that they felt that it was sometimes the case that they could not always deliver care in a timely way but this was not due to numbers of staff but how some staff worked. This was passed on to the Manager.
The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 23 There were only 31 residents in the home during the inspection. One new resident told the inspector that they were able to tell staff when they wanted to go to bed and get up. They also said that the time taken to answer the call bell was variable but never unreasonably long. A comment card received after the inspection took place stated that it takes a long time for the buzzers to be answered. It was noticed during the inspection that the buzzers take quite some time to answer. Consideration could be given to staff going to answer the call bells as a matter of priority to ascertain what is wanted and if it is routine and they were busy with another resident for them to inform the resident and come back to them as soon as possible. During the three days of the inspection it was noted that most residents had been attended to by 11am. The two trained nurses on duty assist the care staff after they have completed their drug administration rounds. 28. The home only has 2 members of care staff who have a qualification in NVQ for care. It is recommended that 50 of staff should have had their NVQ by 2005. At previous inspections staff have spoken of their desire to achieve this certificate. It was also seen as a desire in the supervision records of some care staff. Domestic staff are completing their Level 2 NVQ in cleaning. 29. Recruitment records were checked for 3 trained nurses employed locally. Appropriate references were taken and confirmation of their fitness to practice as a nurse with the NMC. Satisfactory criminal records bureau checks were obtained before employment was commenced. The recruitment of care assistants has been more problematic. There are 3 full time posts vacant. The organisation is purchasing property locally for staff to rent to try and ease this recruitment problem. If unsuccessful locally the organisation will recruit abroad. Vacant hours are taken up by some staff doing overtime and the use of agency staff. 30. The organisation no longer uses the training provider Hygea. To compensate for this the manager has organised monthly in-house sessions. So far these have been about eye care and catheter care. One on communication and teamwork is planned. Trained staff were leading these sessions but the Manager has taken this role back. The manager stated that she did not have access to an induction programme so staff are not receiving a programme which follows the Skills for Care guidelines. The inspector requested that in the interim they use the programme used by their sister home. This was requested. A file was later found with some induction information including a clinical assessment for the trained nurses. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 24 The training matrix seen showed some gaps for the mandatory training, it is unclear how up to date this matrix is and what gaps there are. Some staff spoken with had been unable to go to some sessions provided due to the staffing situation. The manager will need to update this matrix and send it to the lead inspector. Despite previous training some staff still insist on using poor techniques for delivering care. This includes working in a task orientated way so that choices are not offered to residents and 24-hour care is not recognised. The manager stated that this is being addressed through the trained staff working alongside care staff for part of their shifts and through discussions with them. The trained staff spoken with had been surprised at observing this poor practice and were confident that as a team they could change this over time. Any staff who persist in behaving in this way should be dealt with through the disciplinary route. Supervision records read did not reveal any examples of this being done and one member of staff had their probation period extended without any supervision sessions. It is appropriate to conduct supervision sessions for any concerns about conduct and provide structured actions for improvement. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 25 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The Manager has the knowledge of the client group she is caring for and promotes good practice; however, she needs additional management support from the company to fulfil her role. The service is not informed by the views of the service users so that it can be run in their best interests. Staff receive regular supervision but the supervisors have not been trained in this area. Some disciplinary issues had not been explored in the supervision notes. Some areas of Health & safety were of concern and subject to immediate requirement notices.
The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 26 EVIDENCE: 31. The acting Manager Lesley Weir has been in her post since 28th August 2006. Due to new protocols for the registering of managers with CSCI her application cannot be submitted until a completed CRB Disclosure process has occurred. This process should have started on or soon after starting this post but was not started until October 2006. The Disclosure is still undergoing processing by the Criminal Records Bureau. Mrs Weir has managed nursing homes for the elderly before and has the experience to meet the home’s aims and objectives. She is supported by a new Regional Manager, now called a Programme Manager, who started in post at about the same time. This person visits the home fortnightly and completes Regulation 26 reports monthly. These reports need to be sent to CSCI so that the home can be monitored in between inspections. 32. Staff were asked about how they found the leadership of Mrs Weir. Most of the responses were positive and the trained staff in particular welcomed the fact that she was firm. They felt that this enabled them to reinforce good practice. They feel able to make suggestions and that they will be listened to and that their ideas count. Care staff had a mixed reaction but those who commented positively thought that some aspects of the home had improved. When pressed they were unsure exactly what had improved apart from their being an allocation system so that staff are accountable. There has only been one residents/relatives meeting since Mrs Weir has been the Manager. She said that this had not been a very positive experience so had not had one since. No relatives were at the meeting. There has also not been a relatives meeting as one was to be held after residents meetings so that that information could be passed on. Mrs Weir stated that she sees a lot of relatives during the week so hopes they will see her if they have any concerns. There have been staff meetings including one for the domestic and kitchen staff. Minutes were seen for all these meetings. There are plans to hold trained staff meetings in the future. One survey form received from a relative stated that they did not feel that they were kept informed of important matters affecting their relative, nor consulted about their care. Nor were there sufficient staff on duty and that they were not satisfied with the overall care provided. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 27 They also commented that it takes a long time for the buzzers to be answered, and that it would be nice to be offered a cup of tea when they visit. Another relative contacted the CSCI with some concerns which were looked at during the inspection, these included the rotas not reflecting how many staff are actually on duty, the fact that the evening meal is provided by staff with poor skills and that the quality of the food has deteriorated. The relative also did not feel confident that the Manager would deal with these concerns. The inspector has found the Manager very responsive to any issues of concern raised and she has endeavoured to take actions to deal with any issues raised with her. The Manager has also been pro-active at informing the inspector about situations arising within the home which has been very useful and led to a confidence in the Manager’s capabilities. 38. It was of concern that no steps had been taken to reduce any risk to the residents from scalding from excessively hot radiators. It had been agreed at the inspection of June 2006 that the home needed to cover all radiators and could do so by covering the high risk ones assessed by the home first in a staged programme. This had not happened. Three radiators on the ground floor were so hot that the inspector could not keep her hand on them. Two were in the dining room and had residents sitting very close to them. The manager was asked to reduce the risk immediately by moving the tables and chairs away from the radiators. This was done. The other hot radiator was in the corridor leading towards the lounge. This was covered by the third day of the inspection. The maintenance logs showed that regular testing is completed for areas such as hot water and bed rails. There have been some urgent Health & Safety issues, which were mentioned in other areas of this report. The Manager stated that she had given information to the maintenance person about bed rails and how to check that they are fitted correctly. The Fire log records showed that the regular testing of equipment was mostly up to date. Drills had been held regularly and the alarms had been triggered during the inspection. The alarm test due the week before the inspection had not been done due to the sickness of the maintenance person. This deficit was passed onto the supervisor who stated that he would do the test the following day and make sure the tests were kept up to date. An oxygen cylinder was found by an inspector in a resident’s room. There was no sign on the door indicating that it was in there, nor was there a trolley for it to be safely held. The mask and tubing were trailing on the floor. The manager was asked to deal with this. The cylinder was removed and taken to the medical room. It was agreed that a trolley needed to be purchased and that if oxygen is in bedrooms then signs must be used. The inspector was concerned about the close proximity of the medical room to the kitchen and asked the Manager to complete a risk assessment.
The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 X X X X X X X X STAFFING Standard No Score 27 3 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 X X 2 X 2 The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 13(4)(c) Requirement Complete risk assessments for the use of bed rails on divan beds. Immediate Requirement 2 OP8 12(1)(a) 13(1)(b) Ensure that those residents identified as losing weight have the appropriate intervention. Immediate Requirement 3 OP8 13(4)(c) Ensure that all accidents/falls/incidents are recorded in the residents’ notes and for the care plan and relevant assessments to be reviewed for any additional risk. Immediate Requirement THIS IS A REPEATED REQUIREMENT FROM THE LAST INSPECTION 4 OP38 13(4)(a), 13(4)(c) Risk assess the radiators and if necessary take action to reduce the risk of scalding.
DS0000049317.V315714.R01.S.doc Timescale for action 17/01/07 11/01/07 10/01/07 31/01/07 The Laurels Nursing Home Version 5.2 Page 30 5 OP7 15(1) Ensure care plans include any medical history recorded in the pre-admission assessment and reflect social interests, hobbies, religious and cultural needs. Ensure care plans are reviewed in consultation with residents or their representatives. Ensure staff receive induction training meeting the National Training Organisation targets and record such training. Ensure pre-admission assessments are fully completed and include any risks to that person. 28/02/07 6 OP7 15(2) 31/03/07 7 OP30 18(1)(c) (i) 17(2) 14(1) 30/01/07 8 OP3 30/01/07 9 10 OP10 OP30 12(4) 18(1)(a), 18(1)(c) (i) Ensure residents are treated with 10/01/07 respect and dignity at all times. Ensure staff have training appropriate to the work they are to perform, this must include Dementia. Send a copy of the plan as to how this is to be achieved to CSCI no later than 20/02/07 30/04/07 11 OP18 18(1)(a) & (1)(c)(i) Ensure the manager and other senior staff attend the BANES training in the prevention of abuse. Ensure Regulation 26 reports are sent to the Commission. Ensure the complaints procedure is made accessible for those residents who have impairment. The registered person must not admit any person who has a diagnosis of dementia.
DS0000049317.V315714.R01.S.doc 30/03/07 13 14 OP33 OP16 26(5)(a) 22(6) 31/01/07 30/04/07 15 OP4 10(1) 11/01/07 The Laurels Nursing Home Version 5.2 Page 31 16 OP8 12(1) Ensure all options are explored 30/03/07 for communication systems to be offered to the service user identified in the report. Ensure fire safety tests are carried out as prescribed in the Fire Log. Ensure oxygen cylinders are stored safely and the appropriate warning signs used from 31/01/07 Complete risk assessments for their storage. 28/02/07 30/04/07 11/01/07 17 OP38 23(4) 18 OP38 13(4) 19 OP33 24 The registered provider must ensure that the home is run in the best interests of the service users by conducting quality assurance monitoring, making sure that requirements made at inspections are met, and that Regulation 26 reports reflect the state of the service and any progression with requirements made. 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 2 Refer to Standard OP28 OP33 Good Practice Recommendations A minimum of 50 of care staff should achieve their Level 2 NVQ in care. Residents should be consulted about the running of the home so that it is run in their best interests. The Laurels Nursing Home DS0000049317.V315714.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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