Inspection on 11/02/08 for The Warwickshire

This inspection was carried out on 11th February 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Warwickshire 11/08/08

The Warwickshire 14/08/06

The Warwickshire 01/03/06

The Warwickshire 24/05/05

The Warwickshire 25/02/05

The Warwickshire 30/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Warwickshire Main Street Thurlaston Rugby Warwickshire CV23 9JS Lead Inspector Yvette Delaney Unannounced Inspection 11th February 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Warwickshire DS0000004326.V358608.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 Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Warwickshire Address Main Street Thurlaston Rugby Warwickshire CV23 9JS 01788 522405 01788 817260 WARKS97@aol.com 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) Mr R A Perry Mrs Perry Mrs Jeanette Margaret Corby Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 2006 Brief Description of the Service: The Warwickshire Nursing & Residential Home is set in the small village of Thurlaston, near Rugby. The nearest amenities and shops are in the near by village of Dunchurch. The home can be reached via public transport although this is not very regular. The nearest bus stop is approximately ½ mile away, on the main Dunchurch road. The Warwickshire was originally a 19th century manor house, which has been converted and extended to make a large care home. It is set in its own extensive grounds, which are laid to lawn, meadow and flowerbeds. The home provides accommodation, with nursing and personal care to frail elderly persons and palliative care to up to 46 elderly persons over 60 years. The bedroom accommodation is in either single or shared rooms. Several of the rooms are suites that are large enough to accommodate couples and many have ensuite facilities. Range of fees: £456 - £650 per week. Additional charges are made for hairdressing, private chiropody and other sundries such as newspapers and toiletries. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is poor and therefore the home has a no star rating. This means that the overall outcomes for residents in this home are poor based on the information gained during the inspection process. This was the first Key unannounced inspection of this year, which examines all essential aspects of operating a care home. This type of inspection seeks to establish evidence showing continued safety and positive outcomes for residents. The unannounced inspection took place over two days and lasted a total of fifteen hours. A second visit took place because of concerns received about practises in the home. One of the concerns was a formal complaint about the care received by a resident. The manger of the home has been asked to investigate this complaint. Since the last Key inspection carried out in August 2006, two random inspections were undertaken in March 2007 and January 2008 by the pharmacist inspector. The visit in March identified that medicine management in the home was poor and a number of requirements were made. At the follow up, visit in January medicine management had improved to a safe level. The manager had installed good systems to ensure that the residents’ needs are met. This key inspection visit showed that improvements are needed in a number of key areas. The manager and staff need to address requirements and consider the recommendations made at inspections. This will show that progress is being made to meet the Care Home Regulations and National Minimum Standards of practice. Before the inspection the manager of the home had been asked to complete an Annual Quality Assurance Assessment (AQAA) detailing information about the services provided, care and management of the home. The returned document offered very little information on developments made in the home. Following the return of the AQAA, a number of questionnaires were sent out to a randomly selected number of residents and their families to ask their views on the service. Questionnaires were also sent to staff working in the home. Twenty surveys were sent to residents thirteen of these were returned (65 ). Twenty questionnaires were sent to family members, nine were returned (45 ). Ten questionnaires were issued to staff working in the home eight The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 6 were returned (80 ). These provided various responses some of which has been included in this report. Four people who were staying at home were ‘case tracked’. This involves establishing an individuals experience of living in the home, meeting or observing them, discussing their care with staff and relatives (where possible), looking at their care files and focusing on the outcomes for the resident. Tracking peoples care helps us to understand the day-to-day life of people who use the service. Other records examined during this inspection and used to inform this report includes staff training records, the Service User Guide, staff duty rotas, health and safety records and complaint records. A tour of the home was undertaken to view the layout, rooms accessible to residents and the décor An ‘expert by experience’ accompanied the inspector on part of this visit. This is someone who has experience of care services themselves, due to having a member of their family in a care home. This person is actively involved with ‘Help the Aged’ and sits on a relative’s forum for an elderly person’s care home. The expert by experience takes the opportunity on the inspection visit to talk to residents, visiting families and staff. Findings in this report are also based on the persons’ observation of the interaction between people who live in the home and staff. Their findings are also included in this report and used as evidence when deciding on the quality of service provided at the home. What the service does well: Comments received from residents and relatives on what they felt that the home does well include: • • • • • • • • “The standard of meals is very good and has recently improved.” “Cleaning is regular and efficient.” “Staff (All grades) are very kind, helpful and pleasant towards relatives.” “Well staff.” “Very inviting to visitors and friendly.” “They treat… (Resident) as an individual.” “Providing sensitive and helpful support at the end of my father-in-laws life.” “We as a family, feel that … (Resident) is cared for so well that she has forgotten how poorly she is.” Pre-admission Assessments completed by the home manager provides sufficient information to support staff in completing appropriate and meaningful care plans. Meals served by the home, including soft diets are well presented and appetising. This encourages residents to eat a nutritious diet, which will help to promote their wellbeing. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Comments received from residents and relatives on what the home could improve on include: • • • • “Please listen carefully to requests from families.” “My… (Resident) cannot write to me or phone due to impaired hearing. An email to say emails or letters have been received would be appreciated.” “More care staff would be welcome.” “Keep relatives better informed of the problems that arise.” Other areas discussed in this report, which identifies where the home could do better include: Care plans must be sufficiently detailed and updated to reflect the current care needs of residents admitted to the home. This will ensure that people who live in the home receive appropriate care. Care plans must provide nurse and care staff with information on the action to be taken by them to meet the care needs of people living in the home. This will ensure that people receive person centered care. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 8 Nursing staff must ensure that a thorough assessment is carried out on a resident following an accident and a prompt decision made as to whether medical aid is needed. This will ensure that people living in the home receive appropriate and timely first aid and/or medical treatment, which will prevent deterioration in their health and wellbeing. The manager must monitor all care practises, procedures and responses to accidents or incidents in the home to ensure that staff are making safe and appropriate decisions at all times when attending to residents following a fall or other incident affecting their health and wellbeing. This will ensure that people living in the home are protected and safeguarded from harm home. Working and easily accessible bath and shower facilities must be available to meet the needs of people living in the home. This will ensure that residents have their personal hygiene needs met in a way that promotes their comfort, care and dignity. The Commission must be notified of all accidents, incidents or events, which affect the well being of the residents accommodated in the home. This will assist in ensuring that appropriate actions are taken to safeguard vulnerable people living in the home. A suitable lock must be fitted on the sluice door where chemicals and cleaning products are stored and the door kept locked to minimise the risk of harm to people who use the home. The registered manager must ensure that all opened food stored in the fridge is suitably covered, labelled and dated. 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 Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 9 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 Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. People who are considering moving into the home do not have up to date written information available to fully support them in making a decision about the home. People have their care needs assessed before moving into the home so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide are available in residents’ bedrooms. Information in the Statement of Purpose had not been reviewed as requested in the last Key inspection carried out in August 2006. These documents allow people to make an informed decision about whether they move into the home. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 11 During his conversation with a relative, the expert by experience was told that the Home had provided them with good written information when a choice had to be made about whether to move into the home. The relative said: “The transition from sheltered housing to the Home was very smooth”. The relative also confirmed that they had read the booklet (Statement of Purpose/Service User Guide) behind the bedroom door. The case files of two people recently admitted to the home plus two others identified for case tracking were examined to assess the pre-admission process. The pre-admission information for these residents was examined. Assessments provided details of their health and personal care needs, which include information on mobility, history of falls and health history, communication and wellbeing. The availability of this information helps to ensure that the specific care needs of each person can be identified and used to help complete a plan of care. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 12 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 and 10 Quality in this outcome area is poor. Care plans do not consistently identify the individual care needs of residents, which puts them at risk of not receiving appropriate care. People living in the home are treated respectfully. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We examined the care files for two residents admitted to the home since the last inspection and two further residents requiring varied levels of care. The care plans were not well ordered. The manager is making an effort to improve the care planning system throughout the home but there is still a lot of work needed. Care plans examined did not show that they had been written based on peoples assessed needs. There was not sufficient information to give staff clear direction about what they need to do to meet the individual needs of The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 13 these residents. The care plans being implemented are generic; this means that the same plans are used for all residents. When this type of plan is used, they should contain any additional information based on an individual assessment of each resident. Care plans are not person centred to show information about the personal preferences of individual people living in the home. This information would help residents to have some control over their day-to-day lives and involve them in developing their plan of care. Care files did not show that residents or relatives had been involved in planning their care. Examples of the contents of care plans were: • Some care plans refer to the residents as ‘patients’. A care plan headed ‘CONTINENCE’ (female) states; “ensure patient has mobility aids and any assistance required”. What assistance and the link between continence and mobility so that staff had clear instructions on the action needed to be taken by them was not discussed. • A care plan relating to ‘MAINTAINING SAFETY’ states: “Transfer and assist resident to move with correct manual handling techniques”. The care plan for this resident was written on the 18/12/07 and reviewed on 8/02/08 but did not identify what manual handling techniques should be used for the resident. • A further care plan on ‘COMMUNICATION’ states: “Needs to be able to communicate. Unable to do so due to… Please specify. However, no reason is given as to why the resident cannot communicate and what support the resident would need to help them to communicate. Residents, relatives and staff raised concerns about people not being able to have a bath or shower. Information in care plans said that a resident should be offered a bath once weekly, information in a complaint said that the resident had not received a bath or shower since moving into the home: “… (Resident) has not had a bath or shower since… (Resident) has lived at the home for 2 years… there does not seem to be a shower that … (Resident) can access.” A further resident said: “I have had only about four baths in a year and would like to have them more often as I am used to having one a day”. Daily statements written by nursing staff are not always written in a logical way. The time of the entry is not always recorded. Nursing staff should be The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 14 particularly aware of this, as this is a requirement under their professional code of conduct. The expert by experience learned from the residents that most have access to the Home’s GP; one resident has requested to transfer from their own GP to the Home’s GP. Residents said that the Dentist visits as needed. One resident has requested to see the Dentist and is awaiting her appointment. A Chiropodist and Optician also visit the home. Risk assessments had been completed, those examined include identifying the risk of falls, potential risk of poor nutrition, pressure area risk assessment and the resident’s ability to transfer from one place to another safely, for example bed to chair. A further care plan examined contained appropriate information related to the care of a resident with a pressure sore. The care file had evidence that an assessment had been completed as a result; of this the care plan and evaluation documentation detailed the area, type and size of the pressure sore. The dressings to be used to treat the pressure sore were also clearly documented for nursing staff. A written entry in one of the care plans did cause concern. A care plan read detailed the management of a resident following a fall. The information available evidenced poor management and initial treatment of the resident. The entry had been made on 22/11/07 at 21.50 pm and states that a carer called a nurse because a resident was on the floor. The information available indicates that the resident had twisted their knee. The nurse states that she rushed to assess the situation and writes: “I asked another carer… (Carer) and… (Carer) to put (Resident) back to bed. She was screaming in agony and the knee started to swell. We made her comfortable and gave her analgesics for pain and she settled.” A further entry not timed but indicated as written nocte (at night) states: “Settled and slept. Not unduly complaining. Knees measured 10 pm 16 inches. Repeated am, remains 16 inches but swollen”. Another written entry following on from this one but not written in the same handwriting states: “? GP review”. A further written entry dated 23/11/07 again not timed states: “… (Resident) was given personal care and assisted to the lounge where …(Resident) sat with …(Resident) leg elevated and had lunch. SB (Seen by) The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 15 Dr.… (Name of Doctor) who ordered an X-ray. X-ray confirmed X-ray below pin from fracture to right hip. For transfer to hospital… for orthopaedic assessment….” The above written statement does not make it clear whether the X-ray showed any injury to the resident. The resident then appears to have spent four days in hospital. The next written report is not made until the 27November 2007 again not timed but indicates that it was written in the night (Nocte). There are no written details to suggest that the person had returned to the home from hospital. No entries were written for the period absent from the home. A discussion was held with the manager about this incident, as it clearly had not been managed appropriately causing increased stress and pain for the resident. The discussion was to determine why the resident was moved and why medical aid was not called immediately even though staff state that the knee was twisted and the person screamed with pain when moved. The manager was unable to give an appropriate explanation of the incident and an investigation had not been carried out. On the days of the inspection, people living in the home were treated with respect and their dignity maintained. This was seen when staff attended to resident’s personal care needs, or helped them to the toilet this was done discreetly and behind closed doors. During observation of working practises, it was evident that staff were caring and attentive towards residents. Residents looked well groomed and dressed appropriate for the time of day and the day’s weather condition. To support the resident’s with their appearance the hairdresser visits every Monday and most residents use the service. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. Social, and recreational activities are limited and therefore do not meet the needs or expectations of residents. Open visiting arrangements encourage regular contact with relatives and friends. Mealtimes are a social occasion and residents benefit from a varied tasty and nutritious choice of food. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observations made by the expert by experience shows that some interaction was observed between staff and residents. He commented that there was no evidence of room-bound residents being visited by carers during a walk around in the afternoon. There was an ‘Activities Board’ but this showed no evidence of any activities taking place on the day of the Inspection. In conversation with residents, the Expert by Experience gained the following information from residents: “We played Dominoes last week but would like to do more”. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 17 “It (activities) is a bit hit and miss”. “Activities do take place but I choose not to take part”. The Home has a car but this only accessible by residents who are fully mobile. One resident said “I would like the opportunity to go out more often in the mini-bus”. The manager said that the mini bus owned by the home is not intended for residents’ use due to insurance conserns. Birthdays are treated specially and residents are given a cake. An open visiting policy is practised. This helps to support residents to maintain links with their families and friends. Relatives and friends were seen to visit during the day of inspection. People visiting were willing to speak to the inspector and the expert by experience accompanying the inspector on this visit. The expert by experience said that conversations with families confirmed that relatives are aware they are able to visit at any reasonable time. There were no menus available, the cook staff and residents said that they order lunch on the previous day. The expert by experience and inspector had lunch with the residents in the main dining room with the residents. The expert by experience spoke to the residents about their lunch and provided his views on the lunch he received saying: “I experienced the lunch (3 courses) and after being served the wrong meal, found it tasty, wholesome and served hot. I also observed the serving and help given to residents in both the dining room and lounge, where some residents choose to eat. The residents, I was sharing a table with, seemed to enjoy the meal and said: “the food was good”. “There is a good cook here”. “Things (meals) are better”. Room-bound residents were given their meals after the residents in the lounge areas and dining rooms were served. Time was taken by staff to support residents when eating. One care staff was in the kitchen calling out the meals to the cook. The meal was then prepared and given to care staff as they queued outside the kitchen door, indicating that they had finished feeding a resident and was ready for another resident’s meal. This system could be good practise for many reasons some of these being; staff should have the opportunity to spend time with residents and would be aware of what and how much residents had eaten. However, concerns were expressed as the process was chaotic and six residents had not received their lunch by 2.30pm. Soft food meals were taken to six or seven residents in their bedrooms and these were observed to be mashed together”. Presentation of a soft meal in this way does not help residents to identify what they are eating and maintain The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 18 an appetite, which would encourage them to eat and enjoy the meal if the meal. On the second day of the inspection the expert by experience again observed activities in and around the dining, lounge area and the serving of meals to residents in their bedrooms. The following observations were made: There was two kitchen staff on duty at 8.00am. The kitchen staff rota showed three members on duty in the kitchen; the cook had an appointment and came on duty late morning. The two staff started preparing the hot elements of the breakfasts. The assistant cook was preparing food, keeping it warm, and the kitchen assistant was laying up trays and generally keeping the kitchen clean and tidy as necessary. The cooked breakfast consisted of a fried egg, bacon, sausage and fried bread. Hot food did not leave the kitchen until it was due to be served or delivered to a room. The two kitchen staff seemed to cope and worked well together. Residents were being prepared for breakfast from 8am, and as they were ready, those eating in the dining room, were being assembled from 8.15am. The dining room was staffed by two carers, one serving breakfasts from the kitchen and a table in the dining room and then moving residents to the lounge, while the other was delivering breakfasts to room bound residents when carers notified the kitchen (by phone) the resident was ready. On occasions, no carer was available in the dining room to serve or help those needing it. Residents continued to be brought to the dining room well beyond 9.20am by other care staff. Breakfast continued until 10.15 and residents were served their choice of breakfast as they arrived. Serving breakfast over this period of time allowed residents to eat without being rushed. In all about ten residents passed through the dining room. On the second day of the inspection, the expert by experience again observed a soft food breakfast being taken and fed to a room bound resident by the carer covering the dining room. The presentation of the meal had improved from those seen on the first day of the inspection. The carer fed the resident with care and engaged with them by having a conversation and providing encouragement. The cook returned at about 10.15am and was interviewed. The cook was very accommodating towards residents’ requests and has tailored the menus to suit most choices. The cook told the expert by experience that she would order anything the residents requested (even caviar!). The lunch meal preparation was started at 10.30am and the cook reported that all residents would be served between 12.30 and 1.15pm. A resident spoken with commented: “In general the food is good”. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 19 “The catering manager is very good but I am concerned that she may be moving on which leads to concerns for the future”. One resident previously spoken to on the first day of the inspection made the following comments to the expert by experience, which indicates some improvement in the home. “Things seem to be better since your last visit”. “The kitchen staff are very obliging. They get in anything I ask for example J2O drinks and particular types of fish”. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 20 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. People living in the home can be confident that their concerns will be listened to and acted upon. Inappropriate actions by staff in response to accidents in the home put residents at risk of abuse through neglect. This practise does not ensure that people living in the home are protected from harm at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in the reception area of the home. Copies are also available in the Service User Guide. Two residents spoken with are aware of the complaints procedure, as are their relatives. Comments made include: The policy and procedure detailing the action to be taken by staff to ensure the protection of vulnerable adults were examined. The information guides staff on the procedures to follow if they saw or suspected evidence of abuse. We received one complaint and the manager has been asked to formally investigate the issues raised using the home’s complaint procedures. The issues raised relate to the level of care a resident has received while living in the home. The home has received both verbal and written complaints and The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 21 records seen evidence that they have been suitably investigated and resolved with the complainant. Concerns received by the home relate to: • • • • • • Failure of the home to tell the family that their relative had a fall. Resident unhappy about the length of time it took maintenance to repair the television. The state of a resident’s room. A resident wearing another resident’s clothes. Family member found medication in relatives draw showing that they had not been taking their medication. The general appearance of a resident. The manager said that this complaint had previously been investigated by the social care team. Staff were able to confirm that they had attended training related to the protection of vulnerable adults. Two members of staff were able to explain the action they would take if they saw abuse. Both answered appropriately. Training records examined indicates that protection of vulnerable adults training had been received by staff in 2007. There have been no incidents referred to the adult protection team for further investigation. The expert by experience reported that he had not seen any evidence of abuse, verbal or otherwise on the day of inspection. Care and consideration by members of staff towards residents was evident at during the inspection. Examples of this was seen when care staff were handling or feeding residents. Comments made to the expert by experience by one resident does cause some concern as they link to other observations made during the inspection and information received about Warwickshire Care Home. The interview with the resident resulted in the following comments: “On occasions, I am ignored when I request to be taken to the toilet”. “During breaks all staff seem to be absent with no cover being provided”. The expert by experience noted while carrying out one interview, in the afternoon that an alarm bell rang for three minutes before someone answered. Although this may not look like a significant amount of time, this could be important to someone who needs the toilet or has fallen. The concerns discussed under the ‘Health and Personal Care’ section of this report about the care of a resident following a fall was not handled appropriately. The management of this situation caused increased stress and pain for the resident and put the person at further risk of harm. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 Quality in this outcome area is adequate. The environment is varied throughout the home in relation to safety, comfort and hygiene, which might reduce the experience of quality of life for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Warwickshire is an old building with two wings spreading out in two directions from a central point, which accommodates the common areas, bedrooms, lounges, kitchen and the administration area. The inspector and expert by experience toured the home with the care home manager. The tour provided the expert by experience and the inspector with the opportunity to view the home, as it was our first visit to the home. A number of the views expressed below are as seen through the eyes of the expert by experience the The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 23 outcomes were observed by the manager for the home and us. We noted the following: The general condition and décor of the Warwickshire was okay but there are signs of wear and tear to walls and carpets. There was evidence of odours in one part of the east wing of the home. Cleaning seems to take place twice a day and cleaners were seen cleaning the home on both days of the inspection. On the second day of the inspection, cleaning of the common areas (lounges) was taking place from 8am. The furniture in the common areas was functional and appropriate and some recently introduced easily moveable chairs were available for residents use. The main lounge was fitted out with a large television at one end and a music system with a radio. A smaller lounge situated next to the lounge also had a television in it. On the second day of inspection, three residents were sitting in this area watching the television. All the residents looked comfortable and were sitting in comfortable chairs. Bedrooms, of various size and shape, are arranged on two floors with a small lift and three staircases serving the access between the floors. Some bedrooms have bathrooms attached while others have bathrooms and toilets positioned conveniently around the corridors; these have special equipment in them so that people with all levels of mobility can use them. All the bathrooms are dated. One shower room on the ground floor of the home provided level access, which make it easier for residents to use. This shower room was not easily accessible to residents on the first floor and would be difficult for anyone to use due to boxes being stored in the room on the floor. A shared bedroom had a connecting bathroom; this was locked, as it was not used. The bathroom was unsuitable because it was positioned down 3 steep steps with a sloping ceiling. The manager said that the taps in bathrooms and shower facilities were regularly flushed. Bedrooms are personalised and residents are able to bring in their own possessions and items of furniture if they wish. Bedrooms visited were clean and tidy and furniture provided by the home was reasonable. One shared bedroom had a loose floorboard under the worn carpet. There were no lockable drawers in the bedrooms visited. Comments received from residents about their bedrooms were positive. One person said: “I have a nice room which I am able to make my own”. Some bedroom doors were observed propped open on both visits. On the second day of the inspection a programme for installing ‘Dorguards’ on residents bedroom doors had been started. Installation of ‘Dorguards’ would allow the doors to close if the fire alarm was activated. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 24 There is a well equipped kitchen and on the day of the inspection “organised chaos” seemed to be apparent. The surfaces were clean and tidy. The cook was too busy to be spoken to although she seemed to be in control. On inspection of the fridge and freezer in the cold store, some items (iced buns and fishcakes) were uncovered and undated and some current buns were out of date. Not every item was date labelled. It is important to securely cover and identify food stored in the fridge with the date when it was opened or prepared. This will let staff know whether it is safe to use the food product and so prevent the risk of contamination and possible infection. This issue is an outstanding on highlighted at previous inspections. The south-facing sun lounge seemed hot on a winter’s day and concern was expressed as to how comfortable this room would be in the summertime. The only comment from staff was to say that the doors could be opened. Leaving residents to sit in a hot room could affect their wellbeing and may lead to dehydration if sufficient drinks are not given. The laundry process was demonstrated by a member of staff and seemed reasonable. All clothing is marked and resident’s clothes are kept in baskets. There is a lost property area. There is limited storage in the home and wheelchairs were observed to be stored in three inappropriate places these were in an alcove off the lounge, an upstairs bathroom and in the hairdressers’ salon. A programme to show the maintenance work carried out in the home was not available. This made it difficult to know what work had been carried out and when. There were other others areas related to maintenance and safety in the home that could not be confirmed due to records not being organised and available in one place. These include electrical testing and chlorination of water. Details of these are included under the section headed Management and Administration of this report. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. The allocation of staff on duty does not allow for ongoing observation of residents during peak times of activity. This could expose to residents to the risk of harm. The majority of staff are qualified and have attended Mandatory and other training related to the needs of people in their care. This will ensure that competent staff care for people living in the home. Staff recruitment procedures are not robust and consistent to ensure residents are protected from the risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has sufficient staff to provide a good level of care to people living in the home. Three nurses and nine care staff on an early shift, two nurses and five care staff on a late shift and one nurse and three carers on night duty. Duty rotas for a four week period show that this level of staffing has been constantly maintained. Additional staffing in the home include the services of three domestic staff and three kitchen staff during the day with one kitchen assistant covering the evening and is responsible for preparing residents suppers. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 26 The expert by experience noted that there was only one male care assistant evident on the day of the inspection. Staff did not feel that this has adverse effects on providing residents care as male residents had not expressed any concerns about having their care needs met by a female carer. The attitude of staff towards residents seemed good. Some residents were seen to be having difficulty understanding staff from the continent of Europe. This could be distressing and frustrating for elderly residents who already have trouble in hearing and may as a result not have their care needs fully met. Despite staffing levels being good, there seemed to be a shortage of staff present to move and feed residents at breakfast time and on occasion as discussed previously the lounge where residents were having breakfast was left unattended. This was also the case at lunchtime on the first day of inspection when six residents who were cared in bed were still waiting for their lunch at 2.30pm Staff working in the home were observed to be caring and supportive to residents and positive comments are made about staff these include: “Staff go out of their way to ensure that… (Resident) needs are met and …is cared for appropriately.” “I have never had any reason to believe that the staff are not suitably qualified.” “The staff at the Warwickshire are very friendly and attentive.” Training records were available for examination. These showed that staff had completed a series of training in 2007. Training attended includes moving and handling, fire awareness and food hygiene. A care staff spoken with confirmed that they had received this training. National Vocational Qualification (NVQ) in care. There are 18 care staff employed in the home 11 have completed NVQ Level 2 or above (61 ). Information included in the induction process shows that it is linked to the common induction standards developed by the Skills for Care Council. Topics covered in the induction programme were the principles of care, values, organisation, policies, support with personal care and maintaining safety at work. On the second day of inspection, the majority of staff files were examined. The files were found to be disorganised and in poor order. A review of the files showed that two references were not always available or were difficult to find. Evidence that the protection of vulnerable adults (PoVA) register and Criminal Records Bureau (CRB) checks for all staff employed in the home had been The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 27 completed before full employment in the home were not evident. There was also evidence that the adverse outcome of a CRB result had not been followed through as part of the recruitment process. A risk assessment had not been completed inform the decision to appoint and identify what monitoring if any was needed. Appropriate staff files were not available for a new member of staff employed in the home and a voluntary member of staff. Both these members of staff were under the age of eighteen. The manager confirmed that these staff are not involved in giving personal care to residents living in the home. An immediate requirement was issued requesting a timescale for when all staff files would be checked for completeness. A further requirement was made for the home to confirm that complete information is available for all new staff and volunteers in the home. Two staff files for nursing staff did not contain up to date evidence of a recent Personal Identification Number (PIN). Evidence of a current PIN confirms that a nurse is registered with their regulatory body, the Nurses and Midwifery Council (NMC) and therefore is legally able to practice and use the title of ‘Nurse’. A nurse is now required to register with the NMC every year. The administrator obtained confirmation of up to date registration and confirmation of the PIN for both nurses before completion of the inspection. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. Shortfalls in the monitoring of services provided and health and safety management does not promote residents’ safety and wellbeing. Residents’ benefit from having their needs met by staff who are supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for a number of years and is a qualified nurse. She is experienced in the care of the elderly. Concerns have been raised with this home, as although some requirements had been addressed from previous inspections a number remain outstanding. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 29 Concerns received and information provided by some staff identified that there remains issues within the staff groups. There was also evidence that these may not at all times be appropriately handled and resolved by the manager. Concerns were raised by some members of staff and relatives on the way the home is run and about the care given by some staff. There were some positive comments given related to the management of the home. “There is a good manager here”. “I enjoy coming to work and feel valued as part of the team.” The manager said that an open door policy is operated at the home. Residents, relatives and staff are encouraged to voice concerns at any time. The manager has started to put in place systems to monitor the quality of the service provided by the home. The views and opinions of residents and relatives have been sought through questionnaires. The outcome of two surveys one for relatives and one for residents carried out in March 2007 were seen and read. The information received had been analysed and this was read. However, information was not available to show how the outcome of the surveys had been used to make changes for the benefit of residents. The expert by experience spoke to the manager about the benefits of a ‘Relatives Forum’. The forum would provide input from or on behalf of residents to feedback joint concerns (or positive comments) to the management. The manager said that she had tried to set up resident/relatives meetings with little response. There was evidence that staff meetings are held, one was being held on the day of inspection and staff spoken with confirmed that that they met regularly with the manager. Minutes of one of the meetings were seen and read. Items on the agenda include staff allocation, mobile phones and daily room checks. The minutes did not demonstrate that two-way discussions with staff had taken place on the issues included in the agenda. Systems for the safe keeping of monies to safeguard residents’ financial interests are good. Advocacy services are used for a number of residents where requested or where it is thought to be of benefit to residents. Records seen are appropriate and receipts and written records of transactions are kept. Two people audit records. This practise will support the safe keeping of resident’s monies. Record keeping generally within the home as identified at the last inspection is poor. Care plans detailing the care needs of residents and action to be taken by staff to meet these needs are not clearly and individually written. Staff records are disorganised. Records evidencing maintenance and servicing work carried out in the home are not easily accessible and are inconsistently The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 30 maintained. Records examined for checking the safety of electrical equipment used in the home showed that they were last tested in October 2003. Water temperatures in resident areas were last examined in January 2008. Chlorination of water had last taken place on 28-30th September 2004. This was discussed with the manager who agreed to find out how often it advised to have chlorination procedures carried out in the home. Safe practices were not observed at all times in the home. These practises were noted mainly during the tour of the home and are health and safety issues. Some of, which were evidenced at the last inspection and still need to be addressed, these include: • • Food stored in the fridge must be labelled and dated. The sluice door was again unlocked at this inspection visit. Chemicals were not being stored in this room at the time of inspection. However chemicals would be used in the room when disposing of waste products or cleaning soiled equipment. Although chemicals were not stored in this room at this time keeping the door locked will help to ensure that people living in the home are safe. These were all discussed with the manager at the inspection. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 2 2 3 3 3 2 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 1 The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement All people using the service must have an up to date, detailed care plan, which provides details of residents individual care needs. This will ensure that they receive person centred support that meets their needs. Care plans must provide staff with information on how to meet the care needs of people living in the home. This will ensure that people receive person centered care. Nursing staff must ensure that a thorough assessment is carried out on a resident following an accident and a prompt decision made as to whether medical aid is needed. This will ensure that people living in the home receive appropriate and timely first aid and/or medical treatment, which will prevent deterioration in their health and wellbeing. Timescale for action 30/06/08 2 OP7 15 30/06/08 3 OP8 13 30/06/08 The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 33 4 OP9 13(2) All nursing staff must refer to the 30/06/08 Medicines Administration Record (MAR) chart before the administration of medicines and directly sign following the transaction or record the reasons for non-administration. The MAR chart must accurately reflect what has been administered within the home. Not assessed at this inspection, previous timescales 30/09/06 and 09/01/08. The practice of administering one 30/06/08 service user’s medication to another must cease. This is because all medication remains the property of the service user they are prescribed to. In addition, audits cannot take place to demonstrate they have been administered as prescribed. Not assessed at this inspection, previous timescale 09/02/08. All care practises, procedures 30/06/08 and responses to accidents or incidents in the home must be monitored to ensure that staff are making safe and appropriate decisions at all times when attending to residents following a fall or other incident affecting their health and wellbeing. This will ensure that people living in the home are protected and safeguarded from harm home. Working and easily accessible 30/06/08 bath and shower facilities must be available to meet the needs of people living in the home. This will ensure that residents will have their personal hygiene needs met in a way that promotes their comfort, care and dignity. DS0000004326.V358608.R01.S.doc Version 5.2 Page 34 5 OP9 13(2) 6 OP18 13 7 OP21 OP22 23 The Warwickshire 8 OP29 19 Sch.2 Sufficient information must be 30/06/08 secured to determine the fitness of potential employees before they start working at the care home. To include: • Two written references, including where applicable, a reference relating to the person’s last period of employment, which involved work with vulnerable adults. • A full employment history, together with a satisfactory written explanation of any gaps in employment. • The outcome of a Criminal Record Bureau (CRB) disclosure and checks against the Protection of Vulnerable Adults register (PoVA). • A risk assessment following the adverse outcome of a CRB disclosure and records maintained relating to decision as to whether an offer of employment will be made. Details of any additional conditions of employment must be recorded. This will ensure that the home’s staff recruitment practices safeguard people living in the home. Records required by Regulation must be readily available in the home, maintained in a format that makes them easily accessible and are up to date to contain current and accurate information. These must include: • Care plan documentation, • Staff files • Servicing of equipment used in the home • And records demonstrating DS0000004326.V358608.R01.S.doc 9 OP37 17, Sch. 1, 2&3 30/06/08 The Warwickshire Version 5.2 Page 35 maintenance and ongoing refurbishment of the home This will ensure that the best interests of people living in the home are maintained within a safe environment. 10 OP38 13, 23 The sluice door must be kept locked to minimise the risk of harm to residents in the home. The registered manager must ensure that all opened food stored in the fridge is suitably covered, labelled and dated. This requirement is outstanding from 30/09/06. 12 OP38 13, 18 The standards of health and safety management within the home must be reviewed. This should include: • • Testing the safety of all electrical appliances used in the home. Gaining information and advice from the local Environmental Health Department about the frequency of chlorination of water in the home to prevent the risk of Legionella contamination. 30/06/08 28/02/08 11 OP38 13 10/03/08 This will ensure that people who use the services have their health safety and welfare protected. The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 36 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be updated and available in alternative formats. This will ensure prospective residents have all necessary current information to enable them to make an informed decision about using the home. Written entries in resident’s care files should be dated, timed and signed with the signature of the person writing the entry. This will ensure that a legible and effective audit trial is available to track the care given to people living in the home. Daily reports written by nursing and care staff should provide a true and detailed statement of a residents day, health, wellbeing and any incident or accident which affects the residents wellbeing. Residents should be offered a bath or shower to meet their personal care needs. This will ensure that residents have a choice and have their hygiene needs met. Residents should be consulted about a programme of activities that takes into account individual and group needs. Records of social and therapeutic activities should include the residents’ views on the activity and whether they enjoyed this or were satisfied with the outcome. This will ensure mental and physical stimulation, which meets their individual needs. Evidence should be available to show how residents are supported to exercise choice in their day-to-day life. This will support residents to maintain their independence. The home should consider if forming a relatives/residents forum would be in the best interests of people living in the home. The forum would provide feedback on positive comments or concerns to the management team. The support needed by residents at mealtimes should be assessed and the outcome used to ensure sufficient numbers of staff are available to meet the needs of residents at peak times of activity. This will ensure people receive their meals in a timely manner. DS0000004326.V358608.R01.S.doc Version 5.2 Page 37 2 OP7 3 OP7 4 5 OP8 OP12 6 7 OP14 OP14 8 OP15 The Warwickshire 9 OP19 10 OP27 11 OP27 12 OP31 13 OP33 14 OP33 15 16 OP38 OP38 A programme detailing plans for carrying out ongoing maintenance in the home should be devised. This will ensure that residents are living in a homely, attractive and well-maintained home environment. Staffing levels should be reviewed to ensure that sufficient numbers are on duty at all times. Attention should be given to peak times of activity in the home, which includes mealtimes and any interaction with residents that requires two members of staff such as using appropriate and safe moving and handling techniques. This will ensure that residents care needs can be met safely at all times. Consideration should be given to language or communication skills of potential staff that may be employed in the home, which could cause interaction problems between staff and residents living in the home. The Registered Manager must ensure that practises and procedures carried out in the home are monitored. This will promote and support the health, safety and wellbeing of residents living in the home. The responsible individual needs to consider how they intend to monitor the quality of service provided by the home. This will ensure that they are able to make an informed opinion of, and monitor the standard of care provided to residents. An action plan should be produced from the outcome of any survey results produced in the home. The results of service user surveys should be shared with people who use the service. This will support improving the service delivered to people using the home. Advice should be sought from the local fire service about the most suitable areas in the home for the safe storage of wheelchairs. Doors in the home should not be propped open. The fitting of ‘Dorguards’ to resident bedroom doors should be fitted based on advice received from the local fire service to determine whether they are suitable to be used in the event of a fire The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Warwickshire DS0000004326.V358608.R01.S.doc Version 5.2 Page 39 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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