Inspection on 14/08/07 for Trowbridge Oaks Nursing Home

This inspection was carried out on 14th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Trowbridge Oaks Nursing Home 19/01/07

Trowbridge Oaks Nursing Home 07/12/05

Trowbridge Oaks Nursing Home 24/05/05

Trowbridge Oaks Nursing Home 02/12/04

Trowbridge Oaks Nursing Home 20/05/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Trowbridge Oaks Nursing Home West Ashton Road Trowbridge Wiltshire BA14 6DW Lead Inspector Susie Stratton Key Unannounced Inspection 14th August 2007 and 9:30 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 Trowbridge Oaks Nursing Home DS0000015947.V342320.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. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Trowbridge Oaks Nursing Home Address West Ashton Road Trowbridge Wiltshire BA14 6DW 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) 01225 - 774492 01225 776965 www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Keeley Simpson Care Home 60 Category(ies) of Old age, not falling within any other category registration, with number (60), Physical disability (8), Terminally ill (5), of places Terminally ill over 65 years of age (5) Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 5 service users with a terminal illness may be accommodated at any one time The staffing levels set out in the Notice of Decision dated 16 June 2003 must be met at all times 19th January 2007 Date of last inspection Brief Description of the Service: Trowbridge Oaks is registered to provide nursing and personal care for 60 people. At the time of the inspection, there were 58 persons resident in the home. The home admits persons who are frail and many of them have complex nursing and care needs. While the home may take up to eight persons with a physical disability, these persons will also have complex nursing and care needs. The home is owned by BUPA, a national provider of care homes. Mrs Keeley Simpson is the manager and is supported by a deputy, a team of registered nurses, care assistants, administrators, activities coordinator and ancillary staff. The home was purpose built, providing single and double rooms with en-suite facilities and a variety of different sitting and dining areas, on two floors. There is a passenger lift between the floors. At the front of the building, there is a large patio area, which is easily accessible for residents, beyond this there is a lawn which is shaded by mature trees. Car parking is available on site. There is a bus stop close to the entrance. The centre of the Wiltshire market town of Trowbridge is a short ride away. Trowbridge has a railway station and the M4 can be reached in about 30 minutes. The fee range is £477 per week (Residential: Social Services) to £790 per week (Nursing: Self Funding). Items not included in the fees are hairdressing, chiropody, newspapers and telephones. Copies of the service users’ guide are available in the front entrance area and all residents are also given their own copy in their room. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, 50 questionnaires were sent out to residents and their relatives and 38 were returned. Questionnaires were also sent out to social workers and GPs and four were returned. Comments made by residents, their relatives, social workers and GPs in questionnaires and during the inspection have been included when drawing up the report. The home provided an improvement plan following the last inspection and an annual quality assurance assessment was also submitted prior to this inspection. Both documents provided much information to inform the inspection. As Trowbridge Oaks is a larger registration, the site visits took place over two days, on Tuesday 14th August 2007 between 9:30am and 3:30pm and Friday 17th August 2007 between 12:15pm and 3:00pm. The registered manager, Mrs Keeley Simpson, was on duty for both site visits. As the home had produced such a detailed improvement plan and quality assurance assessment and so as many people had responded in detail in questionnaires, the site visits concentrated on meeting with and observing care for people with communication difficulties, those who had complex nursing care needs and meeting care and nursing staff. During the site visits, the inspector met with twelve residents and observed care for nineteen further residents for whom communication was difficult. The Inspector reviewed care provision and documentation in detail for eight residents. As well as meeting with residents and visitors, the inspector met with four registered nurses, five carers, the deputy manager, the activities coordinator, a domestic, a laundress and three administrators. The inspector toured all the building and observed the lunch-time meal and two activities sessions. Two medicines rounds were observed and systems for administration of medicines and the clinical rooms were inspected. A range of records were reviewed, including staff training records, staff employment records, maintenance records and financial records. What the service does well: Trowbridge Oaks provides a wide range of recreational activities to meet the needs of people living in the home. The activities coordinator is highly motivated in his role and is keen to develop and extend his service. He is currently in the process of recruiting more volunteers to support him and further extending and developing links with the local community, so that he can meet the diverse needs of people in the home. The chef is keen to ensure that residents’ dietary preferences and requirements can be met. She showed Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 6 a flexible approach and the popularity of her meals was shown by the very small amount of meals disposed of at the end of a meal. The manager has worked hard and efficiently to develop her service following the last inspection. Staff have worked together to improve care provision and documentation, to ensure that residents needs can be met. Residents and their supporters expressed their appreciation of the services offered. One person reported “There is always a happy feel to the home with the staff making my relative very much part of the home”, another “I am happy to live at the Oaks with my friends” and another “I’m happy here. I couldn’t be any happier”. People expressed their appreciation of the staff, one reported “They always ask – What can I do for you – when I ring my bell”, another “There is one particular young lady who is always so cheerful and squats down beside my relative’s bed, which is delightful to see because he breaks out into a big smile. It makes my day too” and another “My relative’s physical needs (particularly pressure relief) are well documented and carried out”. What has improved since the last inspection? Fourteen requirements were identified at the previous inspection, all had been addressed. Twenty five good practice recommendations were made and twenty two had been addressed in full and three showed progress. The systems for pre-admission assessment has been developed and improved. Where a person is assessed as having a nursing or care need, a care plan is consistently put in place to direct staff on actions to take to meet these needs, particularly where people are assessed as being at risk of pressure damage. All residents with health care needs have a care plan and monitoring system to direct staff on how the condition is to be managed. Where a person needs thickening agent to enable them to swallow safely, there are now systems in place to ensure that staff use the agent and care plans relating to the use of thickening agent state how much of the agent is to be used for each individual. Precise, measurable wording is now being used in care plans. The amount of fluids taken in by a resident is now totalled every 24 hours. Where residents have care plans relating to their dietary needs, this includes their likes and dislikes. Where a resident has a urinary catheter, their care plan documents the clinical indicator for its use. Where a resident is not able to comment on their care plan, the home is developing systems for regular review of the person’s care plan with their relatives. All limited life prescribed items have the date/time when they were opened documented and instructions about storage complied with. The home has put in systems to ensure that prescribed tablets are no being crushed. Out of date items are promptly disposed of. Larger Controlled Drugs cupboards have been provided. Where residents are prescribed drugs which can affect their daily lives, such as painkillers, aperients or mood altering drugs, care plans have Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 7 been drawn up so that staff can monitor their effectiveness and advise their prescriber of the effectiveness of the treatment. A review of activities provision has taken place so that there are sufficient staff hours provided to meet resident need. Systems have been put in place to ensure that all staff have ready access to records about resident’s diverse social needs. The activities coordinator regularly meets with other activities coordinators within the BUPA group, to exchange ideas and provide mutual support. The registered manager and her deputy no longer support another BUPA home in the area, so that they can now fully discharge their duties. Systems for reporting of complaints and concerns have improved. The providers’ standard risk assessment document for bed safety rails is fully completed for all residents who need such rails and staff comply with company policy and individual care plans, when using bed safety rails. All equipment used to prevent risk of pressure damage is now used appropriately, taking into account the person’s condition and manufacturer’s instructions. The area behind the washing machines and dryers as been fully cleaned and monitoring systems put in place to ensure cleanliness. All cracks in the walls and ceiling of the laundry have been repaired, providing a fully wipable surface. The manger has developed an auditing system to ensure that all staff are complying with company policy on the handling of laundry. Improved systems have been put in place for the marking of residents’ clothes. Oxygen cylinders are now securely stored in appropriate carriers. Improved systems for checking equipment to ensure that no deteriorated items are in use and articles disposed of and re-ordered promptly, when needed. Systems have been put in place for the regular checking of the fridge in the first floor kitchenette. The fire risk assessment for the laundry has been revised to take into account current practice. What they could do better: Three requirements and twelve good practice recommendations were identified during this inspection. The home must ensure that all registered nurses always comply with all parts of the company policy and procedure on administration of medicines. All residents who have complex manual handling needs must be cared for in height-adjustable beds. All staff must always wear disposable gloves when cleansing sanitary items. The home’s statement of purpose should be updated to detail all areas of nursing and care where the home provides a service. The home should set up a system for auditing accidents to residents, to identify any trends and assist them in developing strategies for prevention for reduction in accidents. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 8 Where a resident is not able to comment on their care plan, the home should continue to develop its systems for regular review of the person’s care plan with their relatives. Records of dietary intake by residents should state what foods were in the liquidised diets, to enable staff to effectively assess a person’s dietary intake. All instructions relating to meeting resident healthcare needs should be dated and signed by the person who drew up the instructions. All relevant information relating to wound care and dressings provision should be included in residents’ wound care plans. Where a resident is prescribed Warfarin, the home should request that the resident’s GP puts each change of dose in writing. The index of the Controlled Drugs Book should be kept fully up-to-date. Consideration should be given to the conversion of the small bathroom on the first floor into a wet room. All commode chairs should be labelled with the resident’s name and used only for that person. A system should be put in place to inform laundry staff of residents who have an infection, and other matters which may affect their service provision. A larger laundry or a separate area to sort clothing and laundry should be provided. 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. Trowbridge Oaks Nursing Home DS0000015947.V342320.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 Trowbridge Oaks Nursing Home DS0000015947.V342320.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, 2 & 3. The home does not admit people for intermediate care, so 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People are offered enough information about the home and able to visit it, so that they can decide if the home can meet their needs. Residents are protected by comprehensive assessments, to ensure that the home can meet their individual needs. EVIDENCE: Residents and their relatives responded to the pre-inspection questionnaires, commenting on the admission process. Several people reported that they had been too unwell to visit the home before admission and that members of the family had done this on their behalf. One relative commented on how they had visited on at least two occasions, both of them unannounced, before they decided on admission. Several people commented that they knew about the home already, having been previously admitted for respite care or having a friend or family member living there. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 11 The home provides people with a comprehensive range of information. A few areas need up-dating. The statement of purpose needs to be revised, to reflect the current, not previous registration body. More detail should be included about the home’s skills in providing services to people with terminal care needs and those who have a physical disability. Details of the homes staffing levels should also be included in the document, to fully inform people. Of the 38 people who responded to this section of the questionnaire, 32 reported that they had received enough information about the home to decide if it was the right place for them or their relative. Contracts have been revised by BUPA, to reflect current regulations and guidelines. One person stated that they were “happy” with their contract. A new administrator has recently been appointed; She is undergoing an induction period. Since her appointment, she has identified that not all newly admitted residents had been issued with a contract. She has taken steps to identify shortfalls and was aiming that all residents’ contacts would be fully upto-date by December 2007. During the site visits, the Inspector met with a range of people, some of whom had recently been admitted. The manager reported that she or a deputy always goes out to meet with a person prior to admission, and completes an assessment of need. One person reported that they remembered the manager visiting them before admission. The manager was also able to describe in detail an individual’s home circumstances when they performed the assessment. Assessments seen were individualised and completed in detail and related to what the person described. Where additional information, for example from the Hospice nurses were required, this was obtained. One newly admitted resident reported “It is early days and things are still settling in and I am having to get to know the staff. I have raised a couple of issues and asked for assistance and have felt staff responded positively.” The home admits people for respite care, funded by Wiltshire Social Services. Recently one admission had taken place without prior warning and at a weekend. No information about this person or their needs had been provided prior to or at admission. This was followed up promptly by the manager after the weekend. It is much to the credit of the staff on duty, that they completed effective assessments of the person’s need, based on the limited information available at the time, to ensure that they could meet the individual’s needs. Following this, after the weekend, as more information became available, more detailed assessments and care plans were drawn up. The home are to be congratulated for all the efforts that they made to meet the person’s nursing and care needs, considering the circumstances relating to their admission. Trowbridge Oaks Nursing Home DS0000015947.V342320.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, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Residents’ nursing and care needs are supported by a home which has recently much improved its systems for delivering care. Compliance with the home’s polices and procedures on administration of medicines need improvement in one specific area, all other areas showed good practice. EVIDENCE: At the previous inspection, a range of requirements and recommendations were identified relating to shortfalls in delivery of nursing and care. After that inspection, the home submitted a detailed action plan, which outlined how they were planning to make improvements. The quality assurance assessment sent in as part of this inspection indicated that the home had succeeded in addressing their action plan in all areas. This was supported by the site visits to the home, where a wide range of improvements were noted, showing that all requirements from the previous inspection had been addressed in full. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 13 All people now have full assessments of need completed, in a prompt manner. These are revised when nursing and care needs change. Where a resident is assessed as having a nursing or care need, a comprehensive care plan is now put in place to direct staff on how these needs are to be met. Care plans are now written in measurable wording, which assists in evaluation of care plans. For example, where a person had needs relating to diabetic care, their care plan stated the blood glucose levels needed by that person and actions to be taken if the person was outside these levels. As well as documenting complex nursing care needs, care plans also document small, but significant areas of need for the individual, for example exactly how much sugar they liked in their tea or the type of footwear they preferred to wear. One newly employed care assistant reported on how useful these care plans were, as when she started in her role, there was so much to remember and she knew that if she could not remember something about a person’s specific needs, she could look at the care plan and be sure it was documented. Another care assistant reported on how it helped her when agency staff on duty, as she could direct them to use the care plan to ensure that a person’s needs were met. Of the people who responded to this part of the questionnaire, 9 reported that staff always, 22 usually and only 7 that staff sometimes met their needs. Comments included “They help me when I need it” another “99 of the staff are helpful” and another “They’re looking after me beautifully”. One person reported specifically on improvements in care provision, reporting “The standards are better than it was.” The home have made major improvements in the monitoring of care provision to very frail persons. All such persons now have fully completed monitoring records in place. These are regularly reviewed by the nurse in charge of the floor. Records showed that people were receiving the care that they needed, as directed in their care plan. Where people needed thickening agents added to their fluids to support them in swallowing, the thickness of the fluids needed for each person was always documented. Some specific medical instructions were made available in peoples’ rooms. Generally these were dated and signed, but not all. It is advisable that all be dated and signed, so that it can be clear that such documents are current directives and what professional had drawn them up. Where residents needed to have their dietary intake measured using a food chart, some charts stated what liquidised meal the person had been given but not all. This is indicated so that the home can ensure that frail residents are given choice in what they like to eat. Where a resident had a wound, there were clear monitoring systems in place, including photographs of the wound. These clearly showed the wound’s response to treatment. One resident had a chronic wound, which varied in its response to treatment. A registered nurse knew about the wound’s response to treatment in detail, however not all this known information was documented and it is advisable that this takes place, to ensure that all clinical information is available to all staff. The home’s quality assurance assessment indicated a higher than would be anticipated number of residents with pressure damage. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 14 However when this was assessed during the site visits, it was clear that the majority of people who had sustained pressure damage had been admitted with the damage and were now responding to treatment. All pressure ulcers were superficial. Since the previous inspection, the home have begun more formalised systems for consulting with residents and their relatives about their care plans. For example, the home had discussed with one relative the removal of safety rails where an assessment indicated that they were not longer needed. Several relatives reported in questionnaires that they would welcome this, so that they could feel more involved in supporting their relative. The home has clinical rooms on each floor for the storage of medicines. All medicines were appropriately and securely stored. New Controlled Drugs cupboards had been provided since the previous inspection. All records relating to Controlled Drugs were correctly maintained. On one floor of the home, the index of the Controlled Drugs Register needed to be kept more up-to-date. Where a person is prescribed Warfarin, a registered nurse was able to report on the systems in place to ensure that they were correctly informed of changes in dose following routine blood testing. Not all GPs follow this up in writing and it is advisable that GPs are encouraged to do this, to prevent risk of error, which can occur when messages are given verbally. Where medications are given via PEG feeding systems, the home has ensured that all medication is in liquid form. The home has also developed clear care plans where people are described medications which can affect their daily lives, such as painkillers or aperients. This means that the effectiveness of such medication can be assessed. One care assistant reported on how helpful she had found such care plans and that it enabled her to inform Registered Nurses if such drugs were working for individual residents. One resident reported that they had felt unwell on the morning of one site visit. This had been observed by a care assistant, who had fetched the Registered Nurse. She had assessed their clinical need and given them a prescribed drug, which was beginning to help them to feel better. Drugs rounds were observed, these were noted largely to be performed in a safe manner. However on one occasion, the registered nurse left the medicines trolley with a stack of medicine packs on top of it. This is a risk, as the home has on occasion admitted people who suffer from confusion and they might inadvertently give themselves such drugs, if they are not securely stored. It is also contrary to the home’s policy and procedure on administration of medicines. All residents, including very frail residents appeared to be well cared for, with brushed hair and clean finger nails. Several residents commented on how they enjoyed their baths and that staff worked with them to make them feel comfortable and clean at such times. One said “I love my bath”. The laundress commented that following the previous inspection, much effort had been put in Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 15 by staff to ensure that residents’ clothing was properly marked and returned promptly to them. This was evidenced by the “lost items” basket in the laundry which included very few items. All personal care was provided behind closed doors. One person commented “I like my privacy and they let me have that”. Trowbridge Oaks Nursing Home DS0000015947.V342320.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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence, including visits to this service. Much support is given by the home into encouraging residents to continue living their lives as they wish, this particularly relates to contacts with the local community and families, meeting social care needs and meals. EVIDENCE: This home employs a full-time activities coordinator. He is supported by several volunteers. Of the 15 people who responded to this section of the questionnaire, 13 reported that there were always or usually activities arranged by the home which they could take part in. One person reported “Because of my health I can only come for a couple hours a day, which I enjoy very much”, another “I am happy with the activities as I come along most days” and another “The activities coordinator is very good and makes every effort to chose activities which all can join in with.” Where the person was not able to or does not wish to come down to the lounge, the activities coordinator visits the person in their room and arranges longer visits from volunteers. One person reported “I am very happy to see the activities organiser. I do not go down but he comes to me and sent a volunteer to see me” and another “I like Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 17 to see the activities man; he comes to me every day”. The activities coordinator maintains records of peoples past lives and interests. Care plans relating to social engagement are prepared for all residents. This reflected what the residents reported. A wide range of different activities are provided from large group (BINGO was taking place on the afternoon of the first site visit), small group (one person described how the activities man had recently led a small story reading group) and 1:1 activities. One person reported on how they enjoyed the PAT dog visits. On the first site visit, a person brought their kittens in for residents to look at, which was clearly much enjoyed. Residents are taken out of the home on trips. Several commented on a recent trip to Weston super Mare. One described the trip as “Very, very nice” and another as a “lovely day” and another said “I’ve never enjoyed myself so much.” Residents commented that their relatives could visit whenever they liked. One relative commented “I am always welcomed to see him by the staff”. Several people commented on how much they had enjoyed the home’s recent fete. Where residents are not able to go out, the home works to bring people into the home. There are close links with the main churches in the area and residents who wish to receive communion may do so on a regular basis. The activities person has forged links with other local groups, for example on the second site visit, three retired members of the armed forces were visiting the home. Records showed regular visits by volunteers from local schools. The activities person has received guidance on equality and diversity from BUPA and was able to describe how he had met the needs of people from different religious groups and ethnic backgrounds when they had been admitted in the past. He also commented on how the diverse staff groups had been a resource in developing such areas when needed by individual residents. Residents and their relatives reported that they could live the lives that they wanted, considering the restrictions imposed on them by the medical conditions. One relative commented “She likes her own space and likes to stay in her room” another person reported “If I want something different, the chef will always try and arrange it for me” and another commented “My relative cannot make choices but she seems to be well content with her situation”. As would be anticipated in a large home, there were a range of comments made about the meals. Of the 25 people who responded to the questionnaire, 15 reported they always, seven usually and only three, sometimes liked the meals, none reported that they never did. This is a higher proportion of favourable comments about meals than is usually reported in homes of this size. Comments varied from “There’s lots of problems with the meals”, through “very nice”, to “I always look forward to my meals” and “excellent food”. One mealtime was observed and it was noted that the receptacle for unwanted food at the end of the meal, was nearly empty. Much work has been put into developing individualised documentary systems about residents’ Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 18 preferences for meals, their likes and dislikes. These documents are highly individualised and reflect a range of matters which are important to the resident. The chef reported that they had performed a full audit of menus, to ensure that they complied with principals of healthy eating. She reported on how she had consulted with residents by going to meetings arranged by the activities coordinator, to receive their views on the meals provided. The chef clearly knew many of the residents individually and was able to describe how she provided meals to suit their individual tastes. She reported that she was given flexibility by BUPA, within a standard budget, to order foods according to what the residents liked. Meals are provided in the main dining room on the ground floor, a smaller dining room on the first floor or in residents’ own rooms. The dining rooms are attractively laid out, with tablecloths and cloth napkins. Trays taken to residents’ rooms are nicely set out, including tray covers. Residents who wish to have sherry, wine or beer with their meals can do so. Staff are available to support residents at mealtimes. Where residents needed assistance with eating staff sat with them doing their best to make it a pleasurable, social occasion. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People are protected by a management ethos, which actively seeks comments and where safeguarding adults is regarded as a significant area in care provision. EVIDENCE: The home has a complaints procedure, which is displayed in the entrance area and is made available in the service users’ guide to all residents in their own rooms. Since the last inspection, one complaint and one matter of concern has been raised with the CSCI. Both have been investigated in full by the home in accordance with their procedures. Of the 38 people who responded to this part of the questionnaire, 33 reported that they knew how to make a complaint. People reported that they would raise issues with the staff or the manager. Two people reported that they had raised issues with the head office and had received a reply. One of these people reported “When I had to correspond with BUPA direct, they replied by return of post and the matter was investigated without delay resulting in further correspondence informing me of the outcome.” People reported that they would raise issues with staff if they had concerns, citing the carers, registered nurses or activities coordinator. One person commented “They seem to know if I’m not happy about something by my expression”. Some people did comment, as at the previous inspection that when matters were raised, that improvements were not sustained. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 20 However there were far fewer such comments than at the previous inspection. At the last inspection there was evidence that peoples’ complaints or concerns were not always listened to or reported on to management. Following this, a concerns record has been put in place at each nurses’ station. Staff can document individual concerns raised by residents in this book and report on how they have resolved the issues. Both books were clearly being used by staff at all levels. The home are to be congratulated for developing this record, which should improve how staff respond to issues of concern and ensure that management are made aware of issues affecting residents. The manager of the home is aware of the local vulnerable adults’ procedure and has jointly worked with external agencies in the past when issues have arisen. Since the last inspection, one issue has been raised by an external person. It was investigated in full by the home and no further action indicated. Staff spoken with at all levels were aware of the importance of safeguarding vulnerable persons and ensuring that relevant information was passed on to appropriate persons. One newly employed person was able to report on how she had been trained in this area as part of her induction. A review of training records showed that staff are all regularly trained in safeguarding adults. The home have recently performed a full audit of the use of bed safety rails and where indicated, it was noted as good practice that these restraints have been removed. Where bed safety rails were assessed as being needed by individual residents, there was documentary evidence that staff regularly checked on resident’s safety when the rails were in use. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People live in a pleasing, well-maintained environment. Nearly all equipment needed to meet residents’ disability needs is provided, but some deficits in one area continue. They are generally protected from risk of spread of infection, apart from some lack of consistency when using personal protective equipment. EVIDENCE: Trowbridge Oaks is a well maintained home. BUPA has established systems for ensuring that maintenance of the building, services and equipment takes place. This is regularly monitored by the parent company. The maintenance man is keen to ensure the safety of people when works are taking place. For example on the first site visit, when it was extremely rainy, drips were noted coming from the ceiling in one specific area of the first floor. The maintenance man Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 22 ensured that warning signs were put in place promptly and that any electrics to the area were turned off. Staff were also prompt in raising issues. For example, one registered nurse was observed to discuss with the maintenance man that the weighing scales had started to show probable inaccurate weights and that it needed re-calibrating. Different types of sitting areas are provided in the home, with a large lounge on the ground floor, two smaller lounges on the first floor and the ground floor dining room. Several people commented on how much they liked the garden area. One relative reported “He likes it in the garden” and another commented on how her daughter always took her into the garden, which she enjoyed. A range of different bathing facilities are available. On the first floor, there is one smaller bathroom, which is seldom used as most residents prefer the larger disabled bathroom. A shower is available on this floor, but it is not a walk-in type. Discussion with care assistants indicated that many newer residents prefer to have a shower to having a bath and they felt that choice to residents could be improved by the provision of a wet room in this small bathroom. A range of equipment is provided to meet the needs of residents with a disability. All residents at risk of pressure damage were provided with equipment to reduce risk; this related to their assessed degree of risk. All such equipment was being correctly used. A range of hoists were provided for residents with manual handling needs. Further adjustable height beds have been provided to the home; however the number supplied is still not enough to meet the needs of all residents with complex manual handling needs. Three of the eight people considered in detail had complex manual handling care needs, but were not cared for in height adjustable beds. Where residents have complex manual handling needs, to prevent risk to residents and staff, they need to be cared for in beds where the height can be adjusted. The home was clean throughout, with no dust or debris visible on high or low surfaces. A domestic was observed performing her role, and she paid attention to detail, such as routinely dusting small items belonging to residents, like pictures in frames. Domestic staff reported that there was a good supply of cleaning chemicals and equipment. Of the 25 people who responded to this section of the questionnaire, 15 reported that the home was always and 10 that it was usually fresh and clean. One person reported that staff were “Very good with the cleaning”. Discussions with registered nurse indicated that there were supplies of sterile gloves for performing aseptic procedures. Care staff also reported that there was a ready supply of disposable gloves and aprons to use when performing personal care. One recent complaint indicated that on one shift, staff had been observed not to use disposable gloves when performing personal care. This was not supported by discussions with some staff. However one carer was observed to clean a used commode chair, which showed some brown staining on it, without putting on gloves first. This could present a risk to cross infection and further training Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 23 is indicated to ensure consistency from all staff. At present commode chairs are used communally. Observations indicated that the home has a good stock of commode chairs and on discussion with the manager it, was felt that there were enough commode chairs for each resident who needed one to be allocated one of their own. This would be seen as a good practice measure to further reduce risk of cross-infection to residents. The laundry room was much improved since the previous inspection. All cracks in the walls had been repaired, presenting a wipable surface. The areas behind the machines and dryers were free of dust and debris. The laundry itself remains small for the amount of work to be performed and it has been recommended at previous inspections that developments to the laundry be considered to improve the service to residents. The manager reported that a meeting has been booked for September 2007 to consider how the laundry facilities can be improved. Staff were observed to place laundry in correct receptacles, in accordance with the home’s infection control policies. The laundress reported that staff performance has improved since the last inspection and that laundry is nearly always placed in correct containers, in accordance with the home’s infection control policy. The laundress did report that she would find it easier to provide an effective service if a system were set up to routinely inform laundry staff of when residents had an infection or other significant matters which they may need to know about. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 24 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 visits to this service. People are supported by a stable team of staff, who are correctly recruited, with systems in place to help staff develop their skills base. EVIDENCE: Trowbridge Oaks employs a range of staff, including registered nurses, care assistants, ancillary staff and support staff, such as administrators and an activities coordinator. At least two registered nurses are on duty throughout the 24 hour period and for some day shifts there are more registered nurses on duty. Care staff are supported in developing their skills and over 50 are trained to NVQ 2 or equivalent. Many of the staff have worked in the home for several years and while the home does need to use agency staff to ensure that adequate numbers of staff are on duty, this has reduced since the last inspection. No agency staff were on duty for any of the site visits. Of the 28 people who responded to this part of the questionnaire, 3 reported that staff were always, 16 usually and 9 sometimes available when they needed them. This represents an improvement from the previous inspection and while some residents continued to consider that staff took time to answer call bells, reporting for example “They come after a while”, far more now made comments such as “As a busy home there are times when the staff are doing other tasks that I have to wait but I understand this” and others reported “It’s Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 25 really well answered” about response to their call bell. The manager reported that since the last inspection, she and her senior staff had put much effort into monitoring staff performance when call bells are used, and that this increased monitoring of staff was beginning to have an effect. BUPA has established systems for staff recruitment, which the home keeps to. The files of three newly employed members of staff showed that police checks had been performed, two satisfactory references obtained, a full employment history and a health status questionnaire completed on all staff before employment. All staff are interviewed, using an interview assessment tool and are given standard terms and conditions of employment, which they sign. All staff work supernumerary when they commence their duties. Care staff are allocated to one senior carer and a registered nurse, who will act as their mentor. All newly employed staff have a standard induction programme, which complies with current guidelines. One newly employed care assistant reported that they had found their induction period supportive and that all staff had been very approachable and willing to support her as she gradually took on her role. Staff spoken with reported on how supportive BUPA were of training. One carer reported on how she was to start NVQ training shortly and how she was to be supported in this. One registered nurse was able to describe the supports they had in their role and that where more detailed training was needed for specific clinical matters, that BUPA provided appropriate support. Clear, individualised records of training are maintained for all members of staff, this included certificates where relevant. Records provide evidence of the range of training opportunities offered to staff. Of the eight relatives who responded to this part of the questionnaire, two reported that the home always and six usually met the needs of people. One person reported “the newcomers are ready to learn” and another “My relative and nursing and care staff seem to have a helpful and happy relationship” Of the 27 people who responded to this section of the questionnaire 22 reported that people always and five usually received the medical support that they needed. One person reported “I am happy with this treatment.” Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 26 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. People are protected by an effective manager, who has set up systems to ensure that staff are supported in their roles and principals of health and safety up-held. EVIDENCE: The manager of the home is an experienced manager and registered nurse. At the previous inspection, she had been spending a period of time supporting another home within the BUPA group. This meant that she had not been able to concentrate on the services provided by this home. The previous inspection showed a range of matters which needed to be addressed, to ensure that nursing and care was being effectively provided to residents. Following that Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 27 inspection, the manger put a comprehensive improvement plan in place. This inspection shows that the improvement plan has been effective in improving service provision and it is much to the credit of the manger that the systems she has put in place have ensured that all of the 14 requirements identified at the previous inspection had been addressed in full and that of the 25 recommendations, 22 had been fully addressed and three showed progress. BUPA has standard systems for reviewing quality of service provision, across a range of areas. All managers provide monthly returns on areas such as pressure damage or infection control. Regular internal audits are performed; the most recent was an audit of the laundry and housekeeping. A health and safety audit was to take place shortly. All such audits are submitted to BUPA, as part of their quality audit process. BUPA sends out questionnaires to service users and their supporters and issues a report on the findings to each home. The home is also visited regularly by a senior manager, who makes a report. The administrator is responsible for managing residents’ moneys. BUPA has a standardised computerised system for the management of individual resident accounts. There is a full audit trail of additional charges, for example hairdressing or chiropody. These are charged to individual residents and full receipts kept. Very few residents are able to pay their own accounts directly to the home and all residents have a named person, generally a relative, who is able to support them in management of their finances. Staff are supported in their roles. All staff receive annual appraisal and regular supervision. Full records are maintained, these are individually completed. Discussions with staff indicated that they felt supported in their roles. All care assistants spoken with reported that if they had concerns, for example about a resident, they were able to report it to the registered nurses and that they were confident they would be listened to and action taken. Two carers reported that registered nurses were happy to provide individual support if, for example if a resident was admitted with a medical condition which they were unfamiliar with. Registered nurses spoken with reported that managers listened and that if they had an issue, for example with a staff member’s performance, which they could not deal with themselves, they could approach the manger, who would take appropriate action. The home has systems in place to ensure that staff are regularly trained in areas relating to health and safety. A matrix is available outside the staff room, where staff can easily identify which areas of mandatory training they or their colleagues need. The deputy manager reported that up-take was generally good and that she had systems in place to ensure that staff were reminded when they needed up-dating in certain areas, for example manual handling. Observations showed that staff largely complied with current good practice guidelines to ensure health and safety, apart from one area of infection control (see standard 26 above). The fire risk assessments for the home are regularly reviewed, including the laundry, following Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 28 recommendations at the previous inspection. BUPA has fully established systems to ensure that all equipment and services are regularly maintained and full records were maintained. BUPA also regularly monitors staff accidents; however it does not do this for resident accidents and it was discussed with the manager that it may be advisable for her to set up individual monitoring systems so that she can monitor accidents to residents and identify any matters which may need attention, to improve safety and reduce risk of accident. Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 3 x 3 Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 30 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 OP9 Regulation 13(2) Requirement All registered nurses must always comply with all parts of the company policy and procedure on administration of medicines. All service users who have complex manual handling needs must be cared for in heightadjustable beds. All staff must always wear disposable gloves when cleansing sanitary items. Timescale for action 31/08/07 2. OP22 13(4)(c) 01/01/08 3. OP26 13(3) 31/08/07 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. Refer to Standard OP1 OP7 Good Practice Recommendations The home’s statement of purpose should be updated and detail all areas of nursing and care where the home provides a service. Where a service user is not able to comment on their care plan, the home should continue to develop its systems for DS0000015947.V342320.R01.S.doc Version 5.2 Page 31 Trowbridge Oaks Nursing Home regular review of the service user’s care plan with their relatives. This was recommended at the previous inspection of 19th January 2007. It is in progress. Records of dietary intake by service users should state what foods were in the liquidised diets, to enable staff to effectively assess a service user’s dietary intake. This was recommended at the random inspection of 17/8/06. It is in progress. All instructions relating to meeting service user’s healthcare needs provided in service user’s rooms should be dated and signed by the person who drew up the instructions. All information relating to wound care and dressings provision should be included in service users’ wound care plans. Where a service user is prescribed Warfarin, the home should request that the service user’s GP puts each change of dose in writing. The index of the Controlled Drugs Book should be kept fully up-to-date. Consideration should be given to the conversion of the small bathroom on the first floor into a wet room. All commode chairs should be labelled with the service user’s name and used only for that service user. A system should be put in place to inform laundry staff of service users who have infection, and other matters which may affect their service provision. A larger laundry or a separate area to sort clothing and laundry should be provided. This was recommended at the previous inspection of 19th January 2007. It has not been addressed. The home should set up a system for auditing accidents to service users, to identify any trends and assist them in developing strategies for prevention for reduction in accidents. 3. OP8 4. OP8 5. 6. 7. 8. 9. 10. 11. OP8 OP9 OP9 OP21 OP26 OP26 OP26 12. OP38 Trowbridge Oaks Nursing Home DS0000015947.V342320.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 - 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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