Random inspection report
Care homes for older people
Name: Address: The Old Rectory Nursing Home 45 Old Tiverton Road Exeter Devon EX4 6NG two star good service 21/04/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Teresa Anderson Date: 2 6 0 3 2 0 1 0 Information about the care home
Name of care home: Address: The Old Rectory Nursing Home 45 Old Tiverton Road Exeter Devon EX4 6NG 01392431839 01392436216 enquiries@southernhealthcare.co.uk www.southernhealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Southern Healthcare (Wessex) Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 47 Number of places (if applicable): Under 65 Over 65 47 old age, not falling within any other category Conditions of registration: 0 The maximum number of service users who can be accommodated is 47 The registered person may provide the following category of service: Care home with nursing - code N to service users of either gender whose primary care needs on admission to the home are within the following category:- Old Age, not falling within any other category (code OP) Date of last inspection Brief description of the care home The Old Rectory Nursing Home is registered to provide care for up to 47 people over retirement age with general nursing needs. It is owned by Southern Healthcare (Wessex) Limited.
Care Homes for Older People Page 2 of 13 2 1 0 4 2 0 0 9 Brief description of the care home The home is on the eastern side of the city of Exeter, in a residential area approximately one mile from the centre. The former Rectory - which dates back to 1875 - has been converted and extended for its present use but retains some original features. A health centre, Anglican church, pub and local shops are relatively close, with a bus stop opposite the home. Accommodation is on three floors, with two shaft lifts and a platform lift providing level access within the home. There are two conservatory areas overlooking well-tended gardens to the rear, which include a pond and enclosed courtyard garden. There is a car parking area at the front of the home, with time-limited roadside parking available in the area. Mature trees screen the front of the building from the road below. Up to date information about fees are available direct from the home. Fees do not include the cost of items such as hairdressing, private chiropody, aromatherapy, newspapers and toiletries (which are charged at cost price). Care Homes for Older People Page 3 of 13 What we found:
We carried out this unannounced random inspection in response to concerns raised with the Commission and with the Safeguarding Team. The last time we visited the service was in April 2009 when it was rated as a 2 * good service. The Commission first received concerns which we asked the owner to investigate. These related to call bells not being answered in a timely way, some residents not having their personal care needs met sufficiently well, issues with staff relations and care records not being up to date. The owner investigated these concerns. He did not find evidence to show the concerns were upheld. He did however report that care records were not up to standard and that work was ongoing to address this. He also said that he would continue to monitor the quality of care provided. The Commission was subsequently informed that a safeguarding alert had been received by Devon County Council Safeguarding Team, relating to one person living at the home. This person has mental health needs as well as physical nursing needs. A strategy meeting was called. As a result of that meeting, and as part of the agreed safeguarding strategy, the Commission agreed to carry out a random inspection. The focus of this inspection was to look at the quality of care and safety of people with mental health needs. We do this by looking at the care and safety of a small sample of people, using a case tracking method. This means we look care records relating to the assessment of needs and how these needs are to be met. We speak with staff, carers and nurses, to determine their understanding of peoples care needs and the care to be delivered. We speak with people who receive care to gain their views about the care they receive and we observe care being given. This helps us to understand the whole experience of care and to make judgments based on that experience. Two inspectors, Teresa Anderson and Jo Walsh, visited the home for one day from 10.00am until 5.30pm. We case tracked two people as described above. We also spoke with some people living here who we had not case tracked and with the manager, the owner and the Director of Nursing. At the time of this inspection there were 42 people living at the home. There were 2 Registered Nurses on duty, together with 9 carers and ancillary staff. In addition, the companies Director of Nursing was at the home. We found in the care records that we looked at, that peoples broad needs are identified during the pre admission assessment. For example people are described as having cognitive failure, being at risk of malnutrition and/or being at risk of developing pressure sores. However, we found in records that these broad needs are not broken down into specific or individual needs and do not always form the basis for a plan of care that staff can work to. Care plans that we looked at contained a lot of documents. Some of the information in these documents is duplicated, and some provide contradictory information. However,
Care Homes for Older People Page 4 of 13 there are few written instructions about how care needs are to be met. For example one person with cognitive problems cannot feed themselves or express their hunger. Since admission 5 months ago, the care plan has recorded that this person is at risk of malnutrition and of developing pressure sores. The care plan does not contain a plan as to how these risks are to be managed. We asked staff about this persons diet. They told us that they have breakfast, lunch and tea. The last meal, tea, is served at about 5.30pm. We asked if this person gets anything else to eat before they go to bed. Staff told us that this is the last meal this person has before their breakfast the next day. This person does not eat or drink anything between approximately 5.30pm and 8.00am This person is very thin, has lost weight and has had two pressure sores since their admission to the home. The care plan in different places, told us that this person should have a normal diet, a soft diet and a liquidised diet. The information that the home obtained from the health and social care assessment team stated this person needed a soft diet. Staff told us this person should have a pureed or liquidised diet because they are at risk of choking when swallowing due to having had strokes. We asked if this person had been assessed by a Speech and Language Therapist as is good practice. Staff told us this had not happened. We observed this person being supported to eat at lunch time. They were fed a diet which was not pureed. In addition they were being fed in a way that is contrary to good practice when feeding someone who is at risk of choking. This included the use of a dessert spoon which was loaded with food, and the person being given more food whilst they still had food in their mouth. During this observation, we noticed that another person was coughing when they drank. Staff did not respond to this. We asked a member of nursing staff about this person and they told us that the coughing and choking had been noted and that the GP had been informed in January. We asked what had happened since then, and staff did not know. They confirmed that, at times this person sometimes coughs and possibly chokes when eating and/or drinking. Staff also told us that another person living here has recently had a stroke and that this person is showing signs that they might be at risk of choking. Staff told us that a referral to the Speech and Language Therapist had not been made for this person. We looked at records relating to one persons dietary intake. We saw that they usually eat a good breakfast, but that they then tend to refuse lunch and then have tea. We asked staff if they had noticed this. Staff told us they had. As we could not find a written plan as to how the low dietary intake was being managed we asked a nurse how they were managing this. We were told that this person refuses to eat. We asked if smaller, different foods were offered as we could not find a record of this, only a record relating to breakfast, lunch and tea. We were told this person is offered a biscuit or chocolate, but that this is not recorded. This means that staff cannot accurately assess how satisfactory this persons dietary intake is. Staff also told us that this persons relatives visit daily. However, records did not contain information taken from these visitors as to what this persons favourite foods are, what their previous eating pattern had been or what might tempt them to eat.
Care Homes for Older People Page 5 of 13 In records relating to one person we case tracked we found a care plan which states that the person is at risk of developing pressure sores. The care plan instructs staff to care for this person on a pressure relieving mattress and this is happening. According to the owner of the home, this person was admitted from hospital with pressure sores and these have since healed. We noted in the care plan that this person has experienced bruising and skin tears. Records kept do not record that an investigation has taken place as to how these injuries occurred. Staff told us that these injuries are caused by the bed rail on this persons bed. However, the bed rail remains in place and action has not been taken to address this and to prevent these injuries occurring. We asked if other people living here had tissue damage. We were told that approximately seven people have or have recently had tissue damage. In addition to this, we were told that approximately three people had received traumatic injuries possibly caused by bed rails. We noticed in one care plan that a relative of one person had been asked to complete the risk assessment as to whether a bed rail should be used, and in another that the instructions for staff on what type of bed rail equipment to use were contradictory and confusing. We looked in care plans to see how the care of people with mental health needs are met. We found that care plans state that the person has a cognitive failure but that there is no recorded plan of care as to how each persons abilities will be maintained or how their disabilities will be managed. We would expect that where someone is described as having cognitive failure, that the effects of this would be recorded. For example, one person living here has had a tendency to enter other peoples private rooms because of their mental health needs. However, this was not identified as part of the assessment process, or since admission. A strategy for preventing and managing this was not put in place by the home and therefore this person continued to put themselves and others at risk until a visiting professional noted the risk and asked the home to take some action. We looked in care plans for evidence that care plans and care delivery is being reviewed so that staff can determine the effectiveness of the care provided. We found that staff are signing to say they have reviewed plans but we could not find evidence of what information had been used in these reviews or to make care decisions. For example, one review stated that dietary supplements in the form of prescribed high calorie drinks had been stopped because this person is eating well and does not like these drinks. However, daily records inform us that this person sometimes eats well and sometimes does not. Staff told us that this person likes banana and vanilla supplements and also likes ice cream and yogurts. However, these extra portions are not offered as supplements to meals, which would help to increase this persons calorie intake. This type of intervention would be appropriate for a person who is of a very low weight and who was admitted with pressure sores, and who due to their fraility, remains at risk of further skin damage. We spoke with one person who was able to give us their opinion about care and attention received in the home. They told us that the call bells were out of action, and that staff
Care Homes for Older People Page 6 of 13 were checking on people every hour. We asked what would happen if they wanted help in between the hourly checks and were told they would have to call out or wait. This person said that it could feel like a very long time before they were attended to. During our visit to the home we heard people calling out trying to get attention. We were also told about other concerns which made this person think that there is a lack of attention. They told us they had bought these concerns to the attention of the management but did not feel they were listened to and that they continued to need to point things out for improvements to be made. The Director of Nursing had told us that some call bells were not working. During routine maintenance it had been noted that 20 were not reliable. These were taken away to be fixed but were not replaced. Before the inspection we checked our records relating to this home. We found that we had not received any notifications of incidents or deaths. When we asked if there had been events about which we should be notified, we found that the home has had events which should have been reported to us and which have not. This means the Commission are unaware of events in the home and therefore could not take appropriate action if needed. We gave feedback to the management team and owner at the end of the inspection. We asked them to make referrals to the Speech and Language Therapist regarding three people, to ensure that records show what people are having to drink and to ensure that working call bells are in place. We have since heard from the service that the call bells are now working and that these referrals have been made. We have passed the above information to the Safeguarding Team under our Sharing Information procedures. We have done this to help ensure that actions are taken to ensure that all people living here are safe. What the care home does well: What they could do better:
We found the following shortfalls to the quality of care and safety of people living here. Care plans do not always provide enough detail about what peoples needs are and how these should be addressed and met. They are not reviewed meaningfully, and do not account for how some care decisions are made.
Care Homes for Older People Page 7 of 13 Some peoples care needs are not being sufficiently well met. In particular in relation to preventing the development of pressure sores; ensuring that all appropriate actions are taken to prevent people from losing weight and/or becoming malnourished; ensuring that all actions are taken to address peoples swallowing needs and to ensure that actions are taken to prevent those at risk from choking; and addressing and meeting peoples mental health needs. This means that people cannot be assured that they will receive safe and appropriate care. Risks to peoples health and safety are not always being sufficiently well addressed or managed. This includes meeting general health and welfare needs, and the use of equipment which is causing injury to people and the lack of investigation and action when someone receives an unexplained traumatic injury. This means that people cannot be assured of their safety in this home. The service is not keeping the Commission informed or up to date of incidents, accidents, deaths and changes in the home, through the notification system. This means that people cannot be assured that action will be taken by the Commission where appropriate. People living here cannot be assured that they will have all the equipment needed, in working order, to meet their needs. This includes having working call bells so that they can easily request help at the time that they need it. Staff are not always putting into practice the training they have received and knowledge they have in relation to supporting people who have swallowing problems to eat safely. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 8 of 13 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements
These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 7 15 The work started to improve care planning and reviews should continue. This will help to ensure that people get the care they need and that reviews of the care delivered are based on feedback from those delivering the care. This Will help to ensure that reviews are based on factual information and that changes to care are made accordingly. 31/07/2009 2 8 12 Measures must be taken to ensure that where risks are identified that appropriate actions are always taken to minimise or manage these risks. In particular this relates to people who are identified as being at risk of developing pressure sores. This will help to ensure that people do not develop pressures sores and they are helped to remain healthy. 31/07/2009 Care Homes for Older People Page 9 of 13 Requirements and recommendations from this inspection:
Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.
No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action 1 7 15 Each person living here must 28/05/2010 have a plan of care which details their care needs and gives instructions to staff on how these needs are to be met. Care plans must be reviewed at least monthly, and when needed. Reviews must account for how care decisions have been made and evidence the information used in the review and in making the decision about care. People can be assured that their health and welfare needs will be planned and delivered and that decisions made can be accounted for. 2 8 13 People must be able to 28/05/2010 receive advice and other services from appropriate health care professionals. This would include, but is not exclusive to, a Community Psychiatric Nurse, Dietician and Speech and Language
Page 10 of 13 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action Therapist. People can be reassured that they will remain healthy for as long as possible and will have their health and welfare needs met through the most appropriate professionals. 3 8 13 Unnecessary risks to the 28/05/2010 health or safety of service users must be identified and so far as possible eliminated. People can be reassured that, as far as possible, they will be kept safe. 4 8 12 People must have their 28/05/2010 health and welfare promoted. This includes, but is not exclusive to, taking action to prevent pressure sores, prevent choking, prevent weight loss and malnutrition, and taking action to address peoples mental health needs. This would further include recording how healthcare decisions made on behalf of people who lack capacity are made. People can be reassured that they will remain healthy for as long as possible, and that healthcare decisions are being made in their best interests. 5 22 23 Equipment provided at the care home must be maintained in good working order. This includes, but is 28/05/2010 Care Homes for Older People Page 11 of 13 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.
No. Standard Regulation Requirement Timescale for action not exclusive to, call bells. People can be reassured that they will have the equipment they need to meet their needs. 6 38 37 All deaths, outbreaks of 28/05/2010 infectious diseases, serious injury or any event which adversely affects the well being or safety of any person living here must be notified to the Commission. This must be carried out for all future notifications and retrospectively from the start of 2010. People can be reassured that the Commission will take appropriate action when needed. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.
No Refer to Standard Good Practice Recommendations 1 27 People should be cared for by staff who have received appropriate training and are sufficiently skilled in supporting people who have swallowing difficulties to eat and drink safely. Care Homes for Older People Page 12 of 13 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 13 of 13 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
