CARE HOMES FOR OLDER PEOPLE
The Limes 41/45 Church Street Bridgwater Somerset TA6 5AT Lead Inspector
Jane Poole Announced Inspection 15th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Limes DS0000015987.V256147.R01.S.doc Version 5.0 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 Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service The Limes Address 41/45 Church Street Bridgwater Somerset TA6 5AT 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) 01278 422535 MR BRIAN THOMAS MRS ANGELA MARGARET BREWER Care Home 28 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (23) of places The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Registered for 23 persons in category OP and 5 persons in category DE(E) An additional bathroom equipped with assisted bathing facilities will be installed within 10 months from Date of Registration The large pond in the rear garden is protected in a manner which prevent accidents to vulnerable service users, within 8 weeks of Date of Registration 2nd June 2005 Date of last inspection Brief Description of the Service: The Limes is located in a quiet but central part of Bridgwater. It is currently registered with the Commission for Social Care Inspection to provide personal care to up to 28 people over the age of 65, this includes 5 people who have a dementia. Service user accommodation is arranged on 4 floors, with lift access to all floors. All communal areas are on the lower floors. The registered provider is Mr Brian Thomas and the registered manager is Mrs Angela Brewer. The home is well maintained and furnished in comfortable domestic style. There are twenty four single bedrooms and two double rooms. Twenty-three of the bedrooms have en suite facilities. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out over a 6.5 hour period. During this time the inspector was able to meet with service users, talk with staff, observe care practices and view the environment. All records requested were made available. The manager and home owners were available throughout the day. 5 comment cards from healthcare professionals were received prior to the inspection and some comments have been included in this report. On the day of the inspection there were 27 people living at the home. What the service does well: What has improved since the last inspection?
At the last inspection an immediate requirement was issued in respect of care plans. An additional visit was made on the 13th June 2005 to follow this up. Care plans seen at this inspection were all up to date and showed evidence that they are up dated as needs and wishes change and reviewed on a monthly
The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 6 basis. All accidents in the home are now recorded and daily records appear more thorough. This is a definite improvement from the last inspection. The home continues to refurbish, since June the first floor lounge and hallway has been decorated to provide a light airy atmosphere. Some bedrooms have also been re-carpeted and some have been decorated. This is an ongoing process. Two additional staff have completed the NVQ 2 and 3 staff are planning to enrol to undertake the NVQ 3. What they could do better: 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 Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 7 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 Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. The manager sees and assesses all prospective service users before offering a place at The Limes. Staff require additional training in order to fully meet the needs of the service users. EVIDENCE: The home has a statement of purpose and service user guide that continue to reflect the scope of the service offered. The service user guide is not routinely given out to service users but is available in the entrance hall and individual copies are given out on request. The home also has a brochure, which gives very basic details about the home. All prospective service users are seen and assessed by the manager prior to a placement being agreed. The inspector saw copies of these assessments, and more comprehensive assessments completed by professionals outside the home, in individuals files. When a new person moves to the home a summary of the assessment is made available to all staff.
The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 9 All prospective service users and their representatives are given the opportunity to visit The Limes prior to making a decision to make it their home. The home’s terms and conditions do not state that the home offers a trial period. The inspector was given copies of the home’s terms and conditions that are given out to all service users. These documents need to be up dated to reflect the current registration body and to give up to date information about the complaints procedure. The home is registered to provide care for up to 28 people over the age of 65, 5 of who may have a dementia. Some of the staff spoken to on the day of the inspection had not received training in the care of people who have a dementia and appeared unclear about best practice in this area. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Care plans have improved since the last inspection but need to be further developed. The manager regularly audits medication records and addresses any issues of poor practice. EVIDENCE: The inspector viewed 3 care plans in detail and briefly viewed a further 2. All care plans are extremely personal to the individual and give good detail in respect of the service users wishes and preferred routines. Since the last inspection there has been an improvement in the reviewing and up dating of these plans, with all changes in circumstance or need being recorded and dated. The care plans now need to be further developed to ensure that they give clear instructions for staff to follow. For example; for some service users who became agitated or anxious at times there were no guidelines as to how this need would be met by staff. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 11 Risk assessments were in place for some service users. These were basic in nature and did not cover many areas of risk or give detailed information about how risks could be minimised whilst enabling independence and choice. All service users are registered with local GPs and other healthcare professionals appropriate to their individual needs. The home is currently exploring ways to improve the dental and chiropody service for service users. All medical appointments are recorded in personal files and service users spoken to stated that staff assist them to attend appointments outside the home. The home has policies and procedures in respect of caring for some one who is dying. At the last inspection some staff stated that they felt that they would benefit from further training in this area and this has been arranged for the end of this month. The home uses a monitored dosage system for medication. Staff spoken to stated that they had received training in respect of medication and felt confident with this role. There is appropriate storage in the home for medication including storage for controlled drugs and medication that requires refrigeration. The inspector viewed Medication Administration Records and found them to be well maintained. The quantities of controlled drugs correlated with the records held. The inspector saw evidence that the manager regularly audits the MAR charts and addresses any errors found. All personal care is assisted with, in the privacy of bathrooms and en suites. Two of the bedrooms at the home are shared and screening is provided. Staff observed were seen to address service users in a friendly manner. People who are physically mobile and able to make independent choices are able to spend time in communal areas or in the privacy of their rooms. The inspector shared their concerns with the manager that many service users are unable to express their views on where they spend their day and do not appear to be given opportunities to spend time in private or other communal settings. 5 healthcare professionals completed comment cards prior to the inspection one person answered NO to the question “Are you always able to see service users in private?” The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. There is a range of activities available at the home, however there is little information about the interests of service users, particularly people who are no longer about to express their views. The food in the home is of a good quality and was complimented by many service users. EVIDENCE: Care plans give details of the times people like to get up and go to bed. Staff spoken to stated that the routines in the home are flexible in line with these expressed wishes. There are three lounge areas in the home two on the ground floor and one on the lower ground floor. The lounge on the lower floor is occupied by people who require a high level of staff supervision. Many of these people have a dementia. Due to the layout of the building there is little room for service users to safely wander around this area and the inspector noted that people who got up to move around were assisted back into the room and not afforded freedom of movement around the home. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 13 The home has many activities, some organised by the home’s care staff and others by a dedicated activity worker. Records are maintained of activities undertaken these include music and singing, films, ball games, knitting, quizzes and trips out to the local town and cafes. Some staff have had training in reminiscence therapy and the home regularly hires prompt boxes. At the time of the inspection the home had hired a box about special occasions and had a large display about weddings in one of the lounges. Care plans contain a section entitled activities. These sections gave little information about people’s past or present interests or lifestyles. Two care plans seen by the inspector stated “Not capable of taking part in activities.” The inspector viewed some personal rooms and noted that these had been personalised to reflect their individual tastes and wishes. Service users have their own bank accounts and are assisted with personal finance by family and friends where appropriate. The home holds small amounts of personal monies for some service users and records are kept of these. These records were not viewed at this inspection. Some service users are able to access the local community without staff assistance and others go out with staff. People are able to choose what they have to eat at each meal and those who expressed an opinion stated that the food was very good. The main meal of the day was seen by the inspector, it was eaten in a relaxed unhurried manner and appeared to be enjoyed by all. Throughout the inspection the inspector noted that the many of the staff did not appear to offer choices and opportunities for social stimulation to people who have a dementia. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. The home takes reasonable steps to minimise the risk of abuse to service users. EVIDENCE: The home has policies and procedures in respect of making a complaint and whistle blowing. At the time of the inspection the policy in respect of recognising and reporting abuse was not available. The complaints procedure is available in the service user guide. Staff spoken to were aware of issues of abuse and some people stated that they had covered the subject in their National Vocational Training. Staff were aware of the ability to take serious concerns outside the home. All staff undergo a Criminal Records Bureau check when they commence work at the home. Service users asked, stated that if they were unhappy with any aspect of their care then they would be comfortable to approach a member of staff. The manager gave evidence that any concern expressed was taken seriously and appropriate action taken. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 25 & 26. There is an ongoing programme of upgrading and refurbishment in the home. The layout of the home is not suitable for people who like to wander. EVIDENCE: The Limes is located in a central residential area of Bridgwater, within walking distance of the town centre. It is a large older style building with service user accommodation set over 4 floors. To the rear of the property is a large pleasant garden with seating for service users. Keypads have been fitted to external doors which are linked to the fire alarm system and automatically release in the event of a fire. Communal areas are located on the ground and lower ground floor. There are three lounges and two dining rooms. One lounge on the ground floor has been redecorated since the last inspection. This room is furnished in domestic style
The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 16 and provides a comfortable environment for service users. The other sitting room on the ground floor is used mainly for activities. As previously stated the lounge on the lower ground floor is used mainly by people who require a high level of staff support. At the time of this inspection this lounge appeared very cramped and unwelcoming. There was no space in the lounge for staff or visitors to sit comfortably to interact with service users. The only natural light is from a patio door and the room can only be ventilated by opening the door. The home is looking into ways that the room can be more appropriately ventilated. There is little space on the lower ground floor for people to wander and because of the layout of the home it would be difficult for people using this room to find their way back to their own room if they wished to be alone. There are 26 bedrooms, 24 singles and 2 doubles. 23 of the bedrooms have en suite facilities. There are communal bath/shower rooms on the ground floor, lower ground floor and second floor. All bedrooms seen by the inspector were comfortably furnished and had been personalised to reflect the individual tastes of service users. There was a malodour present in one bedroom and this was discussed at the time of the inspection. The laundry facilities are located on the lower ground floor. The floor and walls in this area are in a poor state of repair and pose a risk to infection control. The main areas of the home appeared clean and fresh on the day of the inspection. All areas are centrally heated and were warm. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30. Staff morale at the home is very low at the present time affecting people’s motivation and enthusiasm for the job. EVIDENCE: The manager ensures that there are sufficient staff on duty throughout the day to meet the needs of service users. There are 4 care staff on duty each morning until 2pm, between 2 and 5pm this falls to 2 staff and then raises to 3 carers in the evening. At night there are two waking night staff. The manager’s hours and all domestic hours are in addition to this. Staff spoken to felt that there were sufficient staff. 5 health care professionals completed comment cards prior to the inspection all answered NO to the question “Is there always a senior member of staff to confer with?” The home employs 18 care staff who work full and part time. 8 members of the team have an NVQ at level 2 or above. All staff have received manual handling training since the last inspection The inspector was able to speak in private with the majority of staff on duty. All complained of the morale in the home being low at the present time. Staff observed did not display the motivation and enthusiasm that they have at past inspections. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 18 The home is registered to provide care to older people including up to 5 people who have a dementia. Some staff spoken with had received training in this area and some had not. All staff felt that they would benefit from up to date dementia care training. No new staff have been appointed since the last inspection therefore recruitment files were not viewed on this occasion. All service users who expressed an opinion were very complimentary about the staff and stated that they were always kind and patient. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 The manager of the home has a wealth of experience of caring for older people. Appropriate steps have been taken to ensure the health and safety of service users. EVIDENCE: The registered manager of the home is Angela Brewer. She has worked at the home for over 17 years and has been the manager for almost 5 years. She is currently undertaking the Registered Managers Award (NVQ Level 4) The manager is able to demonstrate a good knowledge of staff and service users and liaises with other relevant professionals. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 20 The manager does not act as an appointee or power of attorney for any service user at the home. The home does hold small amounts of personal allowance for some service users. This is securely stored. There are regular staff meetings in the home where information is shared. Staff and service users stated that the manager is very open and approachable. Quality assurance questionnaires were sent out in May of this year. The inspector viewed some of the completed questionnaires and noted that they were positive about the standard of care and facilities within the home. Reasonable steps have been taken to ensure the health and safety of service users. A fire detection system is fitted throughout the home. The fire log shows that this is regularly tested by outside contractors and in house. All staff received fire safety training in June of this year. Equipment in the home is regularly serviced and documentation was seen in respect of this. Electrical portable appliances were tested in June 05. There up to date safety certificates in respect of the gas and electrical installation. Appropriate insurance is in place. The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 X 3 2 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? 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 2 Standard OP4 OP4OP30 Regulation 12 (1) 18 (1) Timescale for action The Manager must not admit any 22/11/05 new service users who require care due to a dementia. The manager must ensure that 31/12/05 all staff have ongoing training in the care of people with a dementia to ensure that the home is able to fully meet the needs of service users. The manager must ensure that 31/12/05 care plans give clear guidelines to enable staff to meet the individual needs of service users. The manager must ensure that 30/11/05 all service users have opportunities to choose where they spend their time. Service users must always be able to see personal and professional visitors in private. The manager must ensure that 31/12/05 the physical layout of the home is suitable to meet the needs of service users before agreeing a placement The floor and walls in the 28/02/05 laundry areas must be impermeable and easily cleanable.
DS0000015987.V256147.R01.S.doc Version 5.0 Page 23 Requirement 3 OP7 15 (1) 4 OP10 12 (4)[a] 5 OP19 23 (2) [a] 6 OP26 13 (3) The Limes 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 OP2 OP12 Good Practice Recommendations The terms and conditions should be updated to ensure that they give correct details of the registration body and complaints procedure. The manager should ensure that care plans contain information in respect of service users interests and hobbies. Activities should be tailored to individual needs and abilities. The bedroom carpet discussed at the inspection should be replaced. The manager should ensure that senior staff on duty make themselves known to visiting professionals. 3 4 OP23 OP27 The Limes DS0000015987.V256147.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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