Inspection on 19/07/07 for Treetops

This inspection was carried out on 19th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Treetops 07/07/06

Treetops 14/12/05

Treetops 29/06/05

Treetops 01/02/05

Treetops 19/07/04

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Treetops St Clements Road Keynsham Bath & N E Somerset BS31 1AF Lead Inspector Kathy Marshalsea Unannounced Inspection 19th & 20th July 2007 09:30 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 DS0000020257.V339751.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. DS0000020257.V339751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Treetops Address St Clements Road Keynsham Bath & N E Somerset BS31 1AF 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) 0117 9869700 0117 9860063 treetops@shaw.co.uk Shaw healthcare Limited Mr Joe Caine-not yet registered Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (24), Mental Disorder, excluding learning disability or dementia - over 65 years of age (24) DS0000020257.V339751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of people who may be accommodated in the home at any one time shall not exceed 24. Manager must be a RN on parts 3 or 13 of the NMC register The home may accommodate people aged 55 years and over. Date of last inspection 7th July 2006 Brief Description of the Service: Treetops is registered as a Care Home for a maximum of 24 residents with dementia and or mental disorder requiring nursing care. The Home is situated in the grounds of Keynsham hospital, which easy access to local community facilities and is within easy access to Bristol and Bath. It can be accessed by car or by bus with a short walk. The Home is purpose built, providing a mix of single, double and en-suite rooms. Care is offered on the ground floor only, which is divided into 3 units. Each unit offers bedrooms, lounge-dining room and bathroom facilities. There is a communal common room and quiet room. There are also pleasant gardens to the rear and side of the property. All parts of the home are accessible to wheelchair users as well as the able-bodied. DS0000020257.V339751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced and conducted over two days. The manager was present for both days of the inspection. Before the inspection visits started survey forms were sent to the home for relatives and people who live in the home to complete. These were then sent to the Commission for Social Care Inspection. Information from these forms was used during the inspection visit. I spent time case tracking the records of four people who live in the home. I also met those four people and the staff who look after them. Various records related to those people were also checked. I spent time talking with staff particularly in relation to the management of care in the home. The inspection finished with a feedback session with the manager. What the service does well: This home provides support to those people who have a mental disorder or have a diagnosis of dementia. Some of these people can exhibit behaviour which may challenge the staff, which in some instances has meant that other services have not been able to meet their needs. The staff group met during the inspection visit accepted that any challenging behaviour was an expression of the persons condition. Incidents I witnessed were dealt with sensitively, patiently, and kindly by the staff. Staff spoken with showed a great understanding of each individual including their previous lifestyle, hobbies and interests. Medication systems were found to be in order, auditable and showed evidence of good practice. Sometimes medicines have to be given covertly and this had been done in consultation with the relevant parties. Risk management is taken seriously and the after care of accidents and incidents are reviewed and reassessed when necessary to reduce any risk as far as is possible. Complaints are taken seriously and actions taken to resolve matters to the complainants satisfaction. I saw several incidents where peoples privacy and dignity were upheld and that the staff treated them respectfully. Some positive comments in the survey forms included: The care home has a good staff to resident ratio. There is a programme of activities and there is a real sense of community. DS0000020257.V339751.R01.S.doc Version 5.2 Page 6 Providing entertainment for the residents, outings and trips, are available in the minibus. I am Centre newsletter from treetops management giving details of events, staff allocation, except sure on a regular basis. The staff are committed and caring, attitude towards relatives and residents. The staff seem to care for the residents and their well-being, there are activities which is a lot better than when my relative first came into the home”. I met a relative whod been visiting the home over two years. They said that they thought the home was excellent and that staff had a very good understanding of their relatives needs, and that they behaved very respectfully towards them. They also said that before coming to this home there were other homes that couldnt cope with their relative. What has improved since the last inspection? What they could do better: The care plans do not contain enough detail about all of each person’s needs to enable staff to give consistent care. This was particularly evident for mental health and psychological issues. Some of the strategies used by staff to reduce any chance of an episode of challenging behaviour had not been recorded in the care plan. Direct observation of peoples whereabouts and episodes of challenging behaviour could be used to greater effect. The detail given in the behavioural charts did not give sufficient information to enable anyone to analyse these incidents, and possibly prevent further incidents by recognising triggers for each person. The care plans showed little evidence of consultation either with the person themselves or their relative or representative. Relatives I spoke with were not aware of the contents of their relatives’ care plan. While it is recognised that there is an activities program, this is not tailored to individual needs. People need to be given the opportunity to engage in DS0000020257.V339751.R01.S.doc Version 5.2 Page 7 meaningful occupation, activity and receive social stimulation which fits with their previous lifestyle, interests and hobbies. In order for this to work properly all staff need to be engaged with this philosophy. For those residents unable to make a verbal choice of meals a visual choice ought to be offered. Staff must make sure that if someone does not eat their main meal that an alternative is offered. There needs to be communication with the cook and the care staff where there are concerns about someones diet. The manager needs to make sure that the staffs understanding of what constitutes abuse is clear. While staff spoken with were clear about the obvious forms of abuse, they were less clear about more subtle forms. On several occasions two staff members were seen talking in a patronising way to people living in the home and using terms of endearment. While this might be alright in some instances it is not always appropriate for everybody. The key workers need to make sure that they pay attention to detail regarding peoples possessions and their clothing. For example making sure clocks work and that clothing is in a state of good repair. There is a stable staff group at the home, many of whom have been working at the home for a number of years. Over the last couple of years in the absence of a permanent manager they had become a strong workforce. This has had both positive and negative affects. Staff need to be aware that sometimes changes are necessary to keep up-to-date with current standards, and improve the quality of life the people who live in the home. The management team also need to be aware of the impact that several changes of manager over a short period of time has had on the staff group. This makes the management of changes a more sensitive and difficult task. Negative comments on the survey forms included: The activity list used to be on the common room door it would be useful if it was automatically e-mailed to people who live along way as to give visitors/ phone calls something to relate to with the person theyre speaking to. The information kept on the units needs to be kept up-to-date. For example when staff leave. I send my relative things I do not get an acknowledgement which I have done in previous times. 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. DS0000020257.V339751.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000020257.V339751.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home are decided by a multi-agency team to make sure that the home can meet each person’s needs. The Statement of Purpose and Service User Guide are being updated. Staff need to be given training to make sure that the care is specialised and based on current good practice. EVIDENCE: The manager is in the process of updating the information in the Statement of Purpose and Service Use Guide. I asked that when he had done this he would send me these documents. DS0000020257.V339751.R01.S.doc Version 5.2 Page 10 Concerns have been raised at the last inspection about an inappropriate admission. The information gathered during this inspection visit was that there were no inappropriate admissions, and that staff could meet the needs of the people living in the home. I tracked the care of one person who had come into the home since the last inspection, by talking to staff about their care needs. They said that this person, after period of settling into their home, was able to find their way around the unit independently and that they were finding ways of reducing any risks to them. This home has contracted beds with the Primary care Trust and placements are co-ordinated by the Consultant Psychiatrists, and therefore the admission process is done slightly differently than most care homes. Admissions happen on a priority needs basis. When there is a vacancy one of the doctors liases with the Manager who will visit the person and complete an assessment of their needs. Many of the people living in the home have been in care homes where that placement has broken down. The home cares for people who suffer from dementia or a mental disorder, and in some instances these people will have behaviour that will challenge the staff. The staff I spoke with able to talk easily about peoples needs and obviously knew them very well. It was obvious from my observations of some staff that they accept peoples behaviour, and recognise that this behaviour is due to their condition. One care assistant in particular that I spoke with had the philosophy that I try to look after people in the way I would wish my relative to be looked after. However not all staff behaved in a way which showed that they were promoting a feeling of well-being in people. The manager said that he wishes to work towards a more a person centred approach, which means that staff need to ensure that they do not behave in a way which would produce a feeling of ill being in the people they are caring for. In order for all staff to understand the concept of what person centred care means, training needs to be given. If then does not change a staffs attitude to their work and this needs to be dealt with in a more direct manner. The manager has already recognised that there are some training needs for the staff and is arranging for staff to be trained in person centred care. DS0000020257.V339751.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans do not fully set out in detail actions staff need to take to meet all aspects of each persons health, personal and social care needs. People’s health care needs are fully met by either the staff or the primary health care team. Medication systems are well ordered and safe. Not all of the staff treat people with the respect they should. DS0000020257.V339751.R01.S.doc Version 5.2 Page 12 EVIDENCE: I looked at the care files for four people who are living in the home. The files contained a large volume of paper with various assessments some of which were out of date. There was some good information in the assessments I read, particularly in relation to peoples remaining abilities. Most of the plans were based upon peoples physical needs but were not person centred. This means that they did not express the wishes and preferences of each person. There had been an attempt by the activities organiser to include social interests in the plans I read. While this is a good thing some of the information in there was limited, and in one instance had some misleading information such as “this person likes to attend religious services because they attended a Catholic school”. The reviews did not express whether a person had enjoyed the particular activity or not. I talked to staff about the different ways they used to calm people down when they are agitated. The information that they gave me and in one instance which I saw used, were not recorded in the care plans. This could be because the registered nurses are not consulting with the care assistants about the techniques they use, or ask them their opinion about how the person is and if there have been any changes. One in particular was of poor quality and did not give adequate details for staff to follow in order to meet this persons needs. As this person had very limited communication skills it would be even more important to accurately record their care needs. This could lead to an inconsistency in how the staff deliver care which could be very confusing this person who has dementia. The plans were also very limited with details of peoples mental health problems or needs. As this would be the primary reason for them living at home they should be clearly recorded in their care plan. There were personal portraits of peoples previous background and lifestyle including where they came from, the sort of jobs that they did and their previous interests and family history. It was a shame that this information had not been used in the care plans. For those people who might sometimes behave aggressively a record was kept of the incident, what happened before the incident started, and then what happened afterwards (ABC charts). The information in here was not detailed enough to make any assessment of triggers for challenging behaviour. DS0000020257.V339751.R01.S.doc Version 5.2 Page 13 Charts were being kept for some peoples whereabouts. It was not completely clear why this was necessary. For one person these checks were being done every 15 minutes, the care plan said this was due to their possibly being aggressive towards other people living in the home. I spoke with one of the care assistants about this persons needs, they were fully aware of the signs of when this person was becoming agitated and said as soon as they see these signs they attempt to divert the person’s attention. I later saw this member of staff responding to the signs and then spending a considerable amount of time with this person trying to calm and reassure them. It may be more useful for staff to concentrate on completing the ABC charts and responding to the signs of possible aggressive behaviour rather than just recording where the person is every 15 minutes, unless there is a high risk of them falling. None of the plans seen showed evidence of consultation either with the person themselves or their relative or representative. Relatives I spoke with were not aware of the contents of the care plan to their relative. As mentioned previously there are various health care assessments done for each person. These included specific risk assessments such as manual handling and falls. There were also nutritional assessments, continence assessments and a specific risk assessment for the possibility of the development of pressure sores. As mentioned previously some of the information in these assessments need to be translated into actions for staff to take in the care plan. For example information from the continence assessment could be used for an individualised toileting program. Those people at risk from not eating sufficiently did not have a record kept of what the have eaten, and the cook was not being kept informed of those people at risk nutritionally. I looked at the record of accidents which also included some adverse incidents such as incidence of aggression and falls. These accidents are audited by the home manager. One person who had been newly admitted to the home had three falls in May 2007 which was recorded in the persons care plan and had been reviewed for its effectiveness. This is commended. I checked the medication systems with the deputy manager. The home uses a monitored dosage system from Boots the pharmacist. The medication systems were found to be orderly and auditable. Evidence of good practice included an example for a person who has diabetes; there was a detailed old care plan for signs of when their blood sugar might be too low or too high. This needs to be reviewed regularly to make sure that the instructions are up-to-date. DS0000020257.V339751.R01.S.doc Version 5.2 Page 14 There are records of present medication with indications for its use and possible side effects. The deputy manager said that when someone new comes to the home a GP visit is arranged shortly afterwards and the medication is reviewed. Where possible medications are reduced or stopped altogether. In two instances a decision had been made to conceal tablets in food so that vital medication was given. This had been done in consultation with peoples relatives and GP. This had that been done because it was in the best interests of those people to have the medication. Using guidelines from the Mental Capacity Act it is acceptable for this deception to take place for this particular decision. As it can be difficult for some people living in the home to indicate when theyre in pain, pain assessment charts are used. In accordance with a requirement from the last inspection visit medicines are now disposed of in the correct manner. I saw some staff on one unit preserving peoples dignity and treating them with respect. This was particularly so as one care assistant dealt with a particularly difficult situation as one person living in the home got extremely agitated. They were extremely patient, kind and sensitive to this persons needs. My observations during the course of the two days revealed that some staff did not seem to recognise that talking about a person to another member of staff in front of that person was not acceptable. I heard staff also talking about other peoples current condition in front of other people living in the home. This information was passed to the manager. DS0000020257.V339751.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The activities programme needs to be based upon individual needs, and staff to make sure they take the opportunities to engage people in meaningful occupation. There needs to be better communication between the cook and care staff about those people at risk from not eating their meals. People are not being offered visual choices if they are not able to express their choice any other way. EVIDENCE: At the moment the activities organiser is on sick leave. This has obviously left a gap in the activities program. On talking with staff it was apparent that they are trying to plug the gap, but due to time constraints are not always able to do this. DS0000020257.V339751.R01.S.doc Version 5.2 Page 16 There were positive comments on the survey forms returned about the activities, trips and outings arranged by the staff. It was evident during the inspection visits that spontaneous trips into the community take place. It is important that people with dementia are offered occupation that is meaningful to them. There was sufficient information in some of the assessments files I read about peoples previous lifestyle for this to be possible. The whole staff team need to be engaged in this process so the opportunities for occupation are taken at the time, rather than trying to wait for the activities organiser. It would also be important that the quality of the reporting about that activity and how the person responded to it was of good standard. There is some sensory equipment is in the main communal living room, it was unclear how often this is used. I observe the lunchtime meal on one unit. Staff said that people are offered a choice of two meals, and that they know the residents sufficiently well to make sure that they have a meal that they like. All of the people on this unit had a meal of shepherds pie with vegetables. This did look very appetising. One resident was assisted with their meal by a care assistant while the other attended to the needs of the other people. Three people did not eat their meal and sufficient attention was not given to them in regards to prompting them nor was an alternative meal offered to them. When questioned about this one staff member stated that some of the meals would be held back till later, and reheated. The Cook came in during this meal but did not did not ask any of the people eating the meal if they liked it. I later ate this meal myself and found it to be extremely salty; this could possibly have been why it wasnt eaten. One person actually said about the meal its not very good. On discussion with the staff it was not clear whether the kitchen are informed when people do not eat their meal, this may be of concern where someone is a little underweight and staff need to make sure that any nutritional and calorie intake is adequate. It was noted that there were no tablecloths, condiments, or ornaments to make the dining area more attractive. People were all asked which drink they would prefer and this was served up in plastic glasses. This was discussed with the manager due in the feedback session and he stated that tablecloths had been bought for each unit, but could no longer be found. DS0000020257.V339751.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and acted upon. Some staff do not understand the more subtle forms of abusive practice and are behaving in a way which detracts from peoples well-being. EVIDENCE: I looked at the complaints log and read about the complaints that had been received this year. There were five complaints recorded, two were from the same relative. One complaint had been about the quality of food which was dealt with by the previous manager. The second was regarding an item of clothing which had been spoilt by stains from food, this had been replaced. Another from a relative was regarding being notified of changes to her spouse’s condition. The two other complaints were regarding people not having a haircut and were both responded to. The manager intends to resume the “ Residents Forum” meetings so that relatives and people who live in the home can meet with the manager to discuss any issues that they have. DS0000020257.V339751.R01.S.doc Version 5.2 Page 18 For some people who have dementia it would be not possible for them to make a verbal complaint. If they also did not have a relative or anyone visiting them the staff need to be aware that it might be appropriate to involve an independent advocate. The staff I spoke with during the inspection were confident that they knew most residents well enough to pick up non-verbal signs of when they were unhappy with something. They would then take steps to find out what that was and resolve the issue. These indicators of people expressing their displeasure need to be clearly documented in the individual care plans. I spoke with staff about their understanding of abuse and how they would react if an allegation was made to them. One of the trained nurses was very clear about which authorities needed to be notified and that action should be taken to protect the people living in the home, but also anyone about whom the allegation was made. The organisation has a policy for the Protection of Vulnerable Adults. This gives clear definitions in indicators of abuse included a more subtle forms of abuse such as withholding and ignoring. The section about reporting procedures does not contain the contact name or telephone number of the local Social Services contact who would take the lead co-ordinating the investigation. This would be useful for staff. The organisation provides annual training for staff in abuse. During my observation of some staff it was evident that some of the more subtle forms of abuse such as ignoring still take place. Some staff were also observed talking about one person living in the home in front of other people, this is not acceptable. This was reported back to the manager. The manager and I discussed the implications of the Mental Capacity Act. He was aware of this new legislation and was keen for the staff to attend training which had been offered by the company. I gave him contact details to obtain booklets for all of the staff. We also discussed the need to record when they keep the cigarettes of people living in the home. DS0000020257.V339751.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Some refurbishments and redecoration would make the home more comfortable and homely. The key workers need to make sure that peoples possessions are well looked after. EVIDENCE: The home was purpose-built to care for elderly people and is divided into three individual units within the building. Each individual unit provides one double bedroom, single bedrooms and a communal lounge/dining area with conservatory and access to the secure garden. The units are centred on a communal reception area which has an open plan area and enclosed common room and quiet room. DS0000020257.V339751.R01.S.doc Version 5.2 Page 20 The home is all one level which ensures level access to all areas used by the people living in the home. There is help for people who are more frail with aids such as grab rails. Some rooms have adjustable beds but the majority I saw were ordinary divan beds. I visited the bedrooms of the people that I was case tracking. Some rooms have vinyl floors fitted to make the room easier to clean. There was attention to detail such as the curtains coordinating with the colours of the room. I saw that in two rooms latex gloves, wipes and continence products were on top of the dressers. These should be stored out of view. I saw the companys complaints procedure had been placed on wardrobes. This had not been done in the manner which was intended by the Manager who expected staff to place them inside the wardrobe. The bedrooms contained individual toiletries but there was not a soap dispenser or paper towels for staff to maintain their own hygiene standards and to reduce the risk of cross infection. In two of the three bedrooms people’s clocks weren’t working, presumably due to flat batteries. On the divan beds there was no valance to cover up the base of the beds. Some pillows looked quite flat and misshapen. All of the bedrooms I saw had personal mementos, pictures and photographs. The bedroom doors have a photograph of each person occupying the room to help people recognise their own room. In one instance was a photograph of the person’s dog was on the door, which also gave me a good opportunity to talk about this when meeting this person. At the end of each corridor there are areas with armchairs or padded seats of people to use if they wish to. The toilets are spacious and have grab rails and soap dispensers with paper towels. The bathrooms are also spacious and one had enough room to have a separate shower area within the same room. The bath could be used by people who needed assistance. The bathrooms were decorated attractively with a pleasant border, pictures and stencils on the mirror. I spoke with one of the domestic staff on duty about the difficulties of cleaning the corridor which is laid with vinyl flooring. They stated that had been some difficulties with this due to some continence problems, but this had improved with the purchase of different chemicals. There was a slight odour of incontinence in this area during the visit, but was much improved after it had been cleaned. Other areas of the home seen during the visit were clean and tidy. DS0000020257.V339751.R01.S.doc Version 5.2 Page 21 The home does use a bold primary colour for the communal toilet doors, as this is supposed to help the people with dementia recognise that there is a toilet behind the door. I spoke with staff about whether this was successful; they did when not feel that it made any difference. I saw that the toilet doors in peoples ensuite bathrooms are not painted in the same colour. As there has been a problem with incontinence in corridors consideration should be given to doing this. There are pictorial notices on the bathroom and toilet doors to help people recognise what the room’s function is. DS0000020257.V339751.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff numbers in the evening have been increased to make sure that the needs of the people living in the home are met. The manager is organising training for staff including the National Vocational Qualification in care. Recruitment practices ensure the safety of the people living in the home. EVIDENCE: There were several staff vacancies at the time of the visit. The manager said that he was busy trying to recruit staff to reduce the amount of overtime staff are doing, and reduce the use of agency staff. During the visit there was one registered nurse on duty for a 12-hour shift, six care staff on in the morning and then only 5 during the afternoon/evening. One survey form had commented that very often on the unit they visit in the evenings there was only one member of care staff. I observed the evening routine and noted that the unit with only one member of staff had more physically dependent people who were not as challenging for the staff to look after. DS0000020257.V339751.R01.S.doc Version 5.2 Page 23 One member of the morning staff stayed until five oclock to help her colleague with the evening meal. The staff member who was to be left on their own said that it was usually that unit that only had one member of staff. This made it difficult to deliver care in a way that was suited to the needs of the people who live there, as they had to wait for another member of staff from another unit to help them. I read in the staff meeting minutes from February 2007 which said that the staff would have to make do with five staff in the evening due to the fact that agency staff could not be authorised. This was discussed with the manager who agreed that this was not a satisfactory situation, and agreed that he would try to resolve this. This was done by the second day of the inspection and new rotas to show that wherever possible six care staff were on duty all day. The recruitment records were checked for the last three staff employed. These included a registered nurse, a kitchen assistant and a care assistant. Safe recruitment procedures continue to be used, and include the use of an equal opportunities monitoring form, a medical questionnaire, and all the appropriate safety checks which should be made before a person starts their employment. New staff undergo a six-month probationary period and have to complete a 4day company induction programme. This program was not looked at during this visit. At the end of the probationary period the manager has to determine if this time needs to be extended. This had been done in one instance and areas of weakness discussed during a formal interview. Unfortunately this was not picked up during the following three supervision sessions to show whether these weaknesses had been overcome, and whether there were any other training needs for this person. Other supervision records varied in their content, in some instances there had been generic instructions given to all staff which had been recorded in supervision notes. However again this had not been followed up in subsequent sessions. Supervision sessions need to be usefully constructed so that strengths and weaknesses are identified, and any support needed for the employee to improve areas of weakness. The organisation has a regional training organiser. There is a matrix (planner) which identifies when staff need to update themselves in mandatory topics such as fire safety, protection of vulnerable adults, moving and handling, first aid and food hygiene. I asked to see this matrix which showed that some staff are due their annual update. This is quite urgent for some staff who need updates in abuse and fire training. The manager stated that he is in the process of organising this so that staff are not behind with these updates. I saw a copy of the training plan completed by the manager of the 2007 to 2008. DS0000020257.V339751.R01.S.doc Version 5.2 Page 24 The priority of this plan was first of all to get all staff updated in statutory topics as mentioned previously, from more staff to undertake their National Vocational Qualification in care, and for all staff to be trained in dementia care using a person centred approach and also incorporating challenging behaviour. Another topic identified is the social interventions needed which can boost selfesteem and stimulate people, and this is to include the activities coordinator. I spoke with some staff about training they had received up to date for staff many of the staff had been working at the home free number of years. Some felt that training was very useful but also that they learnt a lot of their skills while actually working on the units themselves. Some felt it that it was their knowledge of the residents by working with them day after day that enabled them to meet peoples needs. The training of staff have had previously to deal with challenging behaviour they have not used so far. Some staff felt that these techniques taught you are not appropriate to the people that they looked after and other techniques such as distraction and remaining calm were very helpful. I looked at the minutes of staff meetings since February 2007 when Mr Caine the manager started in post. Some topics discussed in these meetings included information about the Mental Capacity Act, the fact that information sharing in between shifts had to improve, complaints management and the role of the key worker. The manager stated that he had posted an agenda sheet in the staffroom to be completed with suggestions to be added to the meetings. DS0000020257.V339751.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has not yet submitted an application to become a registered manager of the home. People and staff are protected by the regular fire safety tests; but staff may not be being trained often enough in fire safety. DS0000020257.V339751.R01.S.doc Version 5.2 Page 26 EVIDENCE: Mr Caine has been working at home as a manager since February 2007. He has not yet submitted an application with the Commission for Social Care Inspection to become the registered manager of the home. I informed Mr Caine that he needed to do this as a matter of priority. Mr Caine is a registered nurse in general and mental health nursing. He has a lot of experience in the care sector and has managed similar services in the past. I spoke with several of the staff on duty over the two days, many of whom had been working at the Home for several years. As mentioned above there has been a period of a couple of years where theyve had no permanent manager who has stayed more than six months. This has had both positive and negative effects on the staff group. They have become a strong workforce and have been used to doing things in a certain way, and then had to change practices with each new Manager. It was evident during the visit that this period of change has been difficult for both the staff group and the manager. The manager understood to all of the changes the staff group had experienced, but was anxious to make the changes necessary to improve the standards of care in the home. In some instances these changes have been told to the staff rather than being introduced in a consultative way. The staff I spoke with had mixed feelings about changes, some felt change was a good thing, but most had been frustrated at the amount of changes over the last two years. At the time of the visit the manager had no administrative support as the administrator had left her job. This was causing him to spend an undue amount of time dealing with phone inquiries and letting people into the building. The situation is not satisfactory and the organisation needs to offer the manager some administrative support while another administrator is employed. The fact that an inspection visit was taking place obviously added to the stress that the manager was experiencing. I checked the fire log to make sure that the regular tests of fire extinguishers, alarms and emergency lighting were taking place and being recorded. These tests were all being done regularly but the record of the emergency lights could not be found at the visit. The manager later sent these on to me after as proof that they were being done. Records showed that fire safety drills are also held regularly, and that staff undergo a fire training safety session as part of their induction. An external trainer updates the staff in fire safety every year. It was not clear from the records I saw that there is any distinction between the amount of training the night and day staff get. It is recommended that night staff receive a three monthly update as this is considered to be a high risk time due to the fact that they are less staff on duty. Day staff should receive a six monthly update. DS0000020257.V339751.R01.S.doc Version 5.2 Page 27 A fire risk assessment of the building was done in February of this year, this included the management of extra risks such as the fact that some people living in the home smoke, and that oxygen cylinders were being stored in the building. I could not see any oxygen cylinders during the visit and the deputy manager informed me that these had been returned to the pharmacist. The fire log contains a serious or imminent danger contingency plan, which includes important information such as the plan of the home with a roll call for both staff and people living in the home. This includes peoples mobility and possible co-operation with evacuation. This is commended. DS0000020257.V339751.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 2 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 X X X 2 X 2 DS0000020257.V339751.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO 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(1)(2) Requirement The registered person shall ensure that the care plans detail all aspects of the health, mental health, personal and social care needs for each service user. These should be written in consultation with the service user and/or their representative. The registered person shall ensure that written strategies are in place for staff to use for episodes of challenging behaviour. The registered person shall ensure that all service users are able to engage in social interests which are meaningful to them. The registered person shall ensure that all staff behave in a way which respects the privacy and dignity of service users. The acting manager should submit their application to the Commission for Social Care Inspection to become the registered manager of the home. The registered person shall ensure that all staff are updated in the subject of abuse. DS0000020257.V339751.R01.S.doc Timescale for action 31/10/07 2 OP8 12(1)(a) 30/09/07 3 OP12 16(2)(m) 31/08/07 4 OP10 12(4)(a) 20/07/07 5 OP31 Care Standards Act 2000. 22(2)(j) 13(6) 31/08/07 6 OP18 31/08/07 Version 5.2 Page 30 7 OP30 18(1)(a) The registered person shall ensure that all staff receive training appropriate to the needs of the service users. 31/10/07 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. 3. 4 5 6 Refer to Standard OP15 OP15 OP24 OP1 OP19 OP38 Good Practice Recommendations Those service users unable to make a verbal choice of meals should be offered a visual choice. Any service user at risk from not eating well should have this recorded, and the kitchen staff informed so that a special diet can be arranged. The key workers must ensure that they look after the possessions of their service users. The Statement of Purpose and Service user guide should be sent to the CSCI’s local office when reviewed. The home would benefit from being re-decorated. Fire safety training must be given at the intervals recommended by Avon Fire Brigade, eg night staff 3 monthly and day staff six monthly. DS0000020257.V339751.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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