Inspection on 19/01/07 for Trowbridge Oaks Nursing Home

This inspection was carried out on 19th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Trowbridge Oaks Nursing Home 14/08/07

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 10:05 19 January & 13th February 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Trowbridge Oaks Nursing Home DS0000015947.V320789.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.V320789.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 (CFCHomes) 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.V320789.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 7th December 2005 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 56 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, administrator, 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 £336.99 per week (Residential: Social Services) to £735.38 per week (Nursing: Self Funding). Items not included in the fees are hairdressing, chiropody, visitors’ meals, physiotherapy, 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.V320789.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. A random inspection took place to this service on 17th August 2006, in response to a complaint raised by the supporter of a resident. That inspection showed that while the home had addressed some areas of the complaint, others had not been fully investigated or acted upon. Following the drawing up of the random inspection report, the home manager responded with an action plan. As part of this inspection, 25 questionnaires were sent out and 20 were returned. Comments made by residents and their relatives in questionnaires, during the inspection and from relatives, GPs and social workers, who were contacted after the first site visit, have been included when drawing up the report. The home also provided information requested by the CSCI prior to the inspection, relating to residents and staff. As Trowbridge Oaks is a larger registration, the site visits took place over two days, on Friday 19th January 2007 between 10:05am and 5:20pm, and Monday 12th February 2007 between 9:15am and 2:40pm. The first site visit was unannounced. The registered manager was on duty for both the site visits. During the site visits, the inspector met with fifteen residents, four visitors and observed care for twenty-one residents who were unable to communicate. The Inspector reviewed care provision and documentation in detail for ten residents, three of whom had recently been admitted. The relatives, GPs and social workers (if applicable) of these residents were written to, to gain their opinion of the quality of care provided. As well as meeting with residents and visitors, the inspector met with the deputy manager, six registered nurses, five care assistants, a catering assistant, the chef, two housekeepers, both laundresses, the maintenance man, the activities coordinator and two administrators. The inspector toured all the building and observed two lunchtime meals, an activities session and two medicines rounds. 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 is a purpose-built home, which provides a range of accommodation for residents, so that they can choose where they sit during the day. On a cold winter’s day, it was warm and comfortable throughout. The Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 6 home are mid-way through developing a new record-keeping system and those records which have been completed were very detailed, documenting individual preferences, across a range of care needs. As Trowbridge Oaks is owned by a national provider, there are clear, established systems and policies and procedures, to guide and support staff when providing a service to residents. The manager and her deputy are both very committed to the service and had already taken action to effectively address a range of issues by the second site visit. Residents expressed their appreciation of the service. One person said “I am very happy here. I get good care and attention.” another person reported “I love it here and I’m not easy to please” and another “The care [my relative] receives is good.” Residents expressed their appreciation of the staff. One person said “The staff are very helpful”, another “All the staff are nice”, another “The night staff are just the same as the day staff.” and another “The qualified nursing staff are always very approachable, and very caring,” What has improved since the last inspection? What they could do better: Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 7 Fourteen requirements and twenty five good practice recommendations were made at this inspection. Of these requirements, one had not been addressed in full since the previous inspection of December 2005 and another other had not been addressed in full since the random inspection of August 2006. One recommendation had not been addressed since the previous inspection and four recommendations had not been addressed since the random inspection. The home needs to improve its system for care planning. This is particularly in relation to residents who are at risk of pressure damage, who have health care needs relating to diabetes, urinary catheters or wound care, who show complex behaviours, have communication needs and bowel care needs. Care plans need to be clear and precise and fully direct staff on the actions to take to meet the resident’s needs. Monitoring systems need to be put in place for all residents who have increased needs. Where monitoring systems are in place, staff need to ensure that full records are kept, in accordance with directions in care plans and the resident’s needs. This is particularly the case for frail service users who are unable to change their positions or eat or drink independently, those who show complex behaviours, have bowel care needs or experience falls. Staff need to ensure that residents who have swallowing difficulty and need thickening agents have these added to their drinks in accordance with instructions. Pre-admission assessments should be improved, to detail matters such as who the assessment was obtained from, baselineinformation on bowel care and assessments from clinicians. Records of fluids taken by residents should be totalled every 24 hours. Where residents have care plans relating to their dietary needs, this should include their likes and dislikes, to support staff in encouraging service users to eat. Records of dietary intake by residents should state what foods were in the liquidised diets, to enable staff to effectively assess a resident’s dietary intake. Where a resident has a urinary catheter, their care plan should document the clinical indicator for its use. Where a resident is not able to comment on their care plan, the home should set up a system for regular review of the resident’s care plan with their relatives. Some matters were identified at the previous or random inspection, particularly in relation to record keeping. Improvements are indicated in some areas relating to the management of prescribed items. Care plans are needed to direct registered nurses on actions to take when crushing tablets. Limited life products need to be dated when opened and stored appropriately. Care plans should be drawn up so that staff can report back to residents’ GPs on the effectiveness of prescriptions. Out of date medicines, testing equipment and other items must be disposed of at their expiry date. A larger cupboard is needed for the storage of controlled drugs. The home should ensure that where a service user may need a drug to be administered in an emergency, that they have a current prescription on their medicines administration record. Residents would benefit if more hours were available for the provision of activities. The activities coordinator would benefit from supports in their speciality similar to that provided by BUPA to the chef and maintenance man. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 8 Records relating to residents’ past lives and diverse needs should be available to nursing and care staff. Attention is needed to the safe use of equipment and compliance with company policies. Staff must ensure that the providers’ standard risk assessments are fully completed for all residents who have safety rails in place. They must comply with company policy and individual care plans, when using safety rails. All equipment provided for residents must be in a safe condition, taking into account the person’s individual assessment of risk. Staff and service users must be protected from the risks presented by unsecured oxygen cylinders. All equipment used to prevent risk of pressure damage must be used appropriately, taking into account the resident’s condition and manufacturer’s instructions. All equipment used in care must be intact and easy to wipe down if contaminated. Staff need to comply with company policy when handling used linen. The fire risk assessment for the laundry should be reviewed and BUPA should consider a larger laundry room or provision of a separate area for sorting and ironing linen. The area behind the washing machines and dryers in the laundry must be clean and dust-free and cracks in the walls and ceiling repaired, to reduce areas where micro organisms can grow. The fridge in the support kitchen on the first floor must be regularly checked to ensure that any old items of food are disposed of. Management support and systems need to be improved. The registered manager and her deputy must be enabled to devote all their time to Trowbridge Oaks and not support another home, to ensure that they can fully discharge her duties. Staff should ensure that all issues of concern raised with them are documented. Systems need to be put in place to ensure that all residents’ clothes are marked. A range of issues have been identified at this inspection, some of which have been identified previously. However, the manager and her deputy made improvements between the two site visits and it is to be anticipated that all matters will be addressed once they are able to devote all their time to management of this home. 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.V320789.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.V320789.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): 3. The home does not provide 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. All residents have an assessment of their nursing and care needs prior to admission. This process ensures that their needs can be met. EVIDENCE: The Inspector met with and received comments from several residents and their relatives who had recently been admitted to the home. One person said that they were “happy” to have chosen Trowbridge Oaks. Another person commented “I looked at another home but I think the ambiance of T Oaks is much better.” One relative reported that their relative “looks so much better here than when [the person] was at home”. One resident could remember the manager coming to meet with them in hospital, prior to admission. Another person said that they had previously come to the home for respite care and therefore knew about it before they decided on admission. Another said that Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 11 they lived close by and so had visited to meet friends and relatives before they decided to be admitted. All prospective residents are assessed, using a standard assessment methodology, prior to admission, by the manager or her designate. All assessments were performed by registered nurses. The assessments reviewed included reference to a wide range of areas and were fully completed. One resident had been admitted from a distance and documentation showed that a telephone assessment had been performed. The assessment documentation did not show whom the assessment was obtained from. It was therefore not possible to assess if all relevant persons involved in the prospective resident’s care had been approached. One resident had an assessment indicating that they had bowel care needs, however it did not state their normal habit. This is indicated, so that staff can assess if they are meeting a resident’s bowel care needs after admission. One recently admitted resident had complex nursing and care needs. After their admission, it became clear that they had had their needs assessed by a clinician. In order to ensure that the home can meet the person’s needs, they should obtain a copy of the assessment from the clinician, not rely on a verbal report from a third party, who may not be a clinician themselves. Registered nurses spoken with reported that they received copies of assessments and a verbal report prior to the resident’s admission. This enabled them to prepare for the resident’s admission. They also reported that residents were nearly always accompanied by a relative or other person and that they gained further information from such persons as well, to ensure that they could meet the resident’s needs. Trowbridge Oaks Nursing Home DS0000015947.V320789.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 adequate. This judgement has been made using available evidence, including visits to this service. Many residents’ nursing, health and care needs are met by the home. However an inconsistent approach to care planning and monitoring of these needs may put certain residents at risk. Systems are largely in place to ensure the safe administration of drugs and medicines, however practice in a few areas could put residents at risk. Staff work to ensure that resident’s needs for privacy and dignity are up-held. EVIDENCE: Residents and their supporters gave a range of comments about the nursing and care provided in the home. One reported “I find the staff generally very obliging and cheerful” and another “If I ask them to do something, they do it”. One relative reported “My [relative] is always clean and tidy” and one resident reported “They wash and dress me and do it properly”. However other people did report some concerns about the care. One person reported “It’s a bit Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 13 mixed” and another “They listen but what is requested is not always done or if it is done it seems to be for a short time only”. The home uses a standard system for assessing nursing and care needs and most residents are assessed for risk such as manual handling, pressure damage, falls and nutritional risk. Where a risk is identified, care plans are generally put in place to reduce risk. The home are currently developing revised care plans, relating to a wide range of areas. These new care plans were very detailed and of a high standard. Where residents need topical applications, these new care plans all detailed what application was to be used and where. They also documented significant details for the individual. For example one noted that the resident was reluctant to take a bath, but would do so, if they had bubble bath in it. Care plans relating to residents with mobility needs documented small, but significant issues such as what they should wear on their feet to safely move. All residents now have end of life care plans, documenting their wishes. The standard of other care plans and record keeping was not so high, some were detailed and directed nursing and care, others were not. A recommendation was made about this during the random inspection of 17/8/06 but this inspection shows it has not been addressed. One resident clearly had complex nursing and care needs relating to their behaviours, this was both observed during the inspection and reported by staff. Their documentation did not reflect these needs and there was no monitoring system in place to inform external professionals about the extent of these complex needs. On the second site visit, one resident who had complex nursing and care needs still had no care plans to direct staff on actions to take to meet their nursing and care needs, five days after their admission. One resident had an assessment which documented that they experienced bowel care needs, their daily record indicated that their bowels had been opened only three times in the previous three weeks. They did not have a care plan about these needs. The person would not have been able to inform staff of when they had last moved their bowels. A similar requirement was identified at the inspection of 7/12/05. Constipation can be very uncomfortable to older persons, make them eat less well and can make any confusional state more complex. One person had a communication aid, they showed the Inspector how it worked effectively for them. This was not documented in a care plan. As the resident found communication without the aid difficult, such information needs to be documented, so that staff over the full 24 hour period know how to support the resident. Care plans for prevention of pressure damage did not state how often a person’s position was to be moved. One service user who was assessed as having a high risk of pressure damage was observed to be highly mobile when in bed, but other persons did not move from the position they had been put in. The latter persons would currently be at more risk of pressure damage if their Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 14 position was not moved, than the former person, but this was not evident from their care plan. Many of the residents who were at risk of pressure damage spent varying periods of time sitting out in a chair. A standard phrase was used in care plans relating to limiting the amount of time a person spent sitting in a chair. One such resident informed the Inspector that they preferred to get up early, did not return to bed in the afternoon for a rest and went to bed after supper. They said that they could not move themselves and needed a hoist for all transfers. The care plan to reduce risk to this person therefore did not consider how this person’s risk was to be reduced in the light of how they preferred to spend their day. Residents who were unable to move themselves or were assessed as being at high risk of pressure damage generally had monitoring systems in place to ensure that their positions were changed to prevent pressure damage. However as none of the residents’ care plans stated how often they were to be moved, these charts did not provide evidence that residents’ needs were being met in a planned, systematic way. All of the charts examined on the first site visit showed that there were times when their positions were not changed for periods of over six hours. This was improving by the second site visit but had not been addressed in full for all residents. On the first site visit, one resident did not have a movement chart in their room, however they were observed to remain on their back throughout the whole inspection. Such practice could put residents at risk of pressure damage. If a person does develop pressure damage, resultant wounds can take a considerable period of time to heal, are painful and can be a source of infection. Many of the residents were very frail and needed assistance to take in adequate diet and fluids. Some such residents had monitoring charts in place to assess their fluid and dietary intake, but not all. One resident was observed to have a tray with breakfast on it left with them until lunch-time. This was taken away at lunch-time but their lunch tray remained with them until 5:00pm, largely untouched until the Inspector showed this to the manager. Three residents were observed to be left with drinks, such as tea or coffee, at various times during the first site visit, these residents were not assisted or reminded to drink these drinks, which then became cold. The levels in beakers of drinks such as water or fruit juice left out for these three residents did not change during the day. None of these three residents had fluid monitoring charts visible in their room. A similar observation was made on the second site visit. One resident had an opened nutritional supplement drink in their room. The container of supplement clearly stated that it was to be discarded 24 hours after opening and be stored in a fridge when not being used. The box of fluid did not feel cold and there was no date/time of opening documented on it. So it was not clear if the resident was being given a fresh supplement drink. Other residents did have food and fluid monitoring charts in their room, these were variably completed, some were completed in full, others were not. Some Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 15 charts continued on the first site visit, as at 17/8/06, to state fluids in nonmeasurable terms, such as “half a cup”. This had been rectified by the second site visit. None of the fluid charts were totalled at the end of the day. Two care plans for residents indicated the total amount of fluids aimed at for them, however if their fluid charts were not totalled, it was not possible to assess if they had managed to take this amount of fluids in. On both site visits, some food charts indicated what the resident had eaten, however some continued to state wording such as “liquidised diet”. The home had already been advised, during the inspection of 17/8/06, that such records do not provide evidence that a resident has been given a well balanced diet or offered choice (which the chef was clear did taken place), so such wording should be avoided. Some care plans relating to dietary needs continue not to document resident’s likes and dislikes. This was recommended at the random inspection so that staff could support residents who were reluctant to eat. Some residents were assessed as having difficulty in swallowing. Several residents with swallowing difficulties were noted to have thickening agents in their rooms, to support them in taking in fluids. The use of such agents was variable. One resident was observed to have thickening agent in their afternoon tea, however two other residents were not observed to have thickening agents in the beakers of drink in their room. One person who had a care plan stating that they needed thickening agent in their drinks did not have any in their room. None of the care plans relating to thickening agent documented how thick the drink was to be made for the resident, according to their individual need and preference. Where residents had wounds, generally they had clear documentation relating to the treatment of the wound. They also had a monitoring system, including photographs, to assess the wound’s progress. This was not the case for all residents. One resident had a dressing visible. It was clear from their notes that this had been reported to their GP, but there was no care plan to direct staff on what was to be used on the wound and how often the dressing was to be changed. It was noted as good practice that the home used very few urinary catheters and where they did, there were generally clear records of the changes of catheters, which included all information relevant to the management of invasive equipment. However one resident who had been admitted five days before the second site visit did not have any records relating to their urinary catheter. As good practice, it is expected that care plans should state the reason for use of a catheter. One resident’s care plan stated a reason for use of a catheter which is not a clinical indicator for its use, so it was not clear if the catheter was being used in the best interests of the resident. One resident was being fed via a PEG feeding system. They had very clear records relating to this system, which directed care and were fully completed. Two of the residents considered in detail were diabetics. One had a very clear care plan, which fully directed care, the other person did not have a care plan. It appeared that their blood sugar levels had not been monitored Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 16 for over a month and when they were last monitored, that they were higher than would be anticipated to ensure effective management of their condition. Residents reported that staff contacted external healthcare professionals when needed. One said “They got the doctor in quickly when I had a bad chest” and one relative reported “GP and outside help all called in as soon as problems arise.” Clear records of contact with GPs and external healthcare professionals were in place. One resident had very clear information on how their communication needs were to be managed from a speech and language therapist. Another resident with additional mental health care needs had been seen by an appropriate clinician, who had given directions on their treatment programme. The home has two areas for the storage of drugs, one on each floor. All drugs were securely stored and there was a full record of drugs received, administered to the resident and disposed of from the home. An additional medicines refrigerator had been purchased since the previous inspection. One resident had a preparation stored which was to be administered to be given in an emergency. They rarely needed this treatment and it was no longer documented on their medicines administration record. This would mean that staff would find it difficult to administer this medicine in an emergency as there was no current written prescription for it. All records relating to administration of medicines were maintained in full. Where a resident was prescribed one to two tablets, the amount given was documented. Where a resident was prescribed a medicine which could affect the heart rate, records of the resident’s pulse were maintained and there were clear directions on what actions to take if the resident’s heart-rate fell below certain levels. The Controlled Drugs were checked. All such drugs were correctly stored and records maintained. One service user was prescribed a Controlled Drug to be given every third day, this had not taken place on one occasion and the drug had been given on the fourth day, this was investigated following the inspection and evidence was available to show that relevant action was taken. This must be investigated. The ground floor Controlled Drugs cupboard is small and if a further resident were admitted who was prescribed Controlled Drugs, the home would have difficulty in appropriately storing it. This had been recommended for the past four inspections and the manager reported that it is being considered. One resident was reported to be having their tablets crushed. The registered nurse was able to report in detail how this was done and how the medication was then to be administered to the resident. However none of this was documented and as medicines may be administered by an agency registered nurse at times, this is needed so that any agency nurse is aware of how to meet the resident’s medication needs. The resident’s records should also document any discussion with GPs about prescriptions for medication in a liquid form, so as to prevent crushing of tablets, which can be less effective method of giving medication. No out of date preparations were found in Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 17 residents’ rooms, as was found at the random inspection, however a storage cupboard showed a range of testing reagents, which had expired a considerable period of time ago, which would be likely to give an incorrect result if used. These had been disposed of by the second site visit. One medicines refrigerator had injectables stored in it relating to a resident who had died in 2006. These should have been disposed of. The presence of out of date prescribed items and reagents was discussed with the manager and it was recommended that one member of staff was delegated with the task of regularly reviewing all such items and disposing of them. Many residents were prescribed drugs which could affect their daily lives, such as mood-altering drugs, painkillers or aperients. None of the residents had care plans about the use of such drugs. This is recommended so that staff are able to assess the effectiveness of these treatment regimes and advise the prescriber accordingly. All care was provided behind closed doors. All staff were observed to routinely knock prior to going into a resident’s bedroom. Staff called residents by their own preferred name. For example two of the residents considered in detail preferred to be called by a name other than their first name. This was documented in all their records and was observed to be followed by staff. Residents were dressed in their own clothes. However, as at the previous inspection, a store of washed, but previously used, net underwear and socks were found in a laundry room on the first site visit. These had been disposed of by the second site visit. The manager agreed to remind staff again that such stores of clothes for communal use must not be used and that such items should be promptly disposed of, if the owner of the clothes cannot be identified. Trowbridge Oaks has several double rooms, all are provided with screening, which were used by staff when caring for residents. One resident reported that they did find it difficult sharing a room if the other resident died, as they could not avoid hearing what was happening. One other resident said that they liked sharing as it gave them company. On the first site visit, there seemed to be a confused system for identifying which wash bowl was to be used for which resident in double rooms. This had been addressed by the second site visit and all wash bowls had been labelled with the resident’s name. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence, including visits to this service. The home has a varied activities programme, led by an enthusiastic activities coordinator, however residents need more support in this area when the activities coordinator is not on duty. Contact with friends and family is supported. Residents are enabled to choose how they live their lives. Meals were attractively presented and residents are generally supported at mealtimes. EVIDENCE: A range of opinions were expressed about activities provision for residents. Of the 15 people who completed this section of the questionnaire, 3 said that there were always, 7 that there were usually, 4 that there were sometimes and 1 that there were never activities that they could take part in. Trowbridge Oaks employs a part-time activities coordinator. The manager reported that there were a range of plans currently being considered to increase staffing for activities. The activities coordinator clearly works hard within the hours that he is available to provide a range of supports to residents. He visits all residents every day that he is on duty, including those who cannot or unwilling to come Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 19 out of their rooms. One resident described the activities coordinator as “marvellous”, another reported “I couldn’t praise him enough” and another “I look forward to going down to the lounge”. Other people were not so positive, generally feeling that when the activities coordinator was not on duty, residents were not supported. One person reported that he “does a marvellous job when he is there but the other days they are usually left to sit around, falling asleep most of the time, they need stimulating.” and another “it’s very, very boring”. Care records maintained in the nurses’ stations included a personal history and activities document, but very few were completed even partially. The activities coordinator maintains clear and detailed records of residents’ past lives and needs for activities, as well as what activities they have taken part in. Residents would benefit if all staff had access to these records, so that diverse factors relating to residents’ past lives could be taken into account when providing care. BUPA has standard management systems for the support of services in the home such as catering and maintenance, but they do not do so for activities. This is advised, so that activities coordinators in different homes in a similar locality benefit from learning from each other and from mutual support. Residents and their relatives reported that they could visit when they wished. Visitors were observed coming into and leaving the home throughout the inspection. At least two visitors came specifically at mealtimes, so that they could support their relative when eating. One resident said that they had liked trips out of the home during the past year. Several relatives commented on how well staff kept them informed of changes in their relative’s condition. Where residents were not able to be involved in care planning, relatives support them in this. One relative reported that they would find it easier if they could arrange agreed times with staff to do this, rather than trying to find a member of the nursing staff when they visited and had something to ask about or discuss. It is recommended that this takes place, as self-funded residents will not otherwise have the same supports from regular reviews, as socially funded residents. Residents reported that they could choose how they spent their day. One said how much they disliked having breakfast in bed and that staff were aware of this and always got them out of bed before breakfast, so that they could eat sitting in their chair. Many residents commented that they appreciated not being pressurised to go do the dining room or down to the lounge if they did not want to do so. Several residents had brought in a range of their own items and many of the rooms were highly individualised, reflecting their likes and preferences. As would be anticipated in a large establishment, there were a range of opinions expressed about meals. Of the 19 residents who responded to this part of the questionnaire, 6 reported they always liked the meals, 10 that they usually did, 2 that they sometimes did and 1 that they never did. Comments varied from “The food is always appetising and of high quality”, “The food is Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 20 very good and I was always so fussy”, “The food is lovely” through “The food is reasonable” to “Depends on the cook”. The chef reported that BUPA were currently developing their meals service, using a quality points system when reviewing menus, to ensure that residents are given a well balanced diet. She reported that nearly all meals provided were cooked from raw ingredients. She also reported that many of the residents were very frail and approximately one third of them needed their meals to be liquidised. Two meal times were observed. Meals were served by catering staff. This meant that they could ensure that meals were attractively presented. The catering staff were also able to manage the serving of meals, to ensure that every person was given the meal that they had chosen. It was observed that one resident decided that they did not want what they had chosen, so the care assistant brought the meal back and the resident was given a different one. One relative reported “the staff do give [the person] bread and butter (her favourite) when [the person] asks.” Meals are kept in a hot trolley and continued to be hot when taken to the residents. Many residents needed full assistance from care staff to eat their meals. Discussions with staff showed that more residents needed such assistance than there were staff on duty. Carers spoken with were aware of this and reported that they planned their work together, to ensure that residents were given their meal in a timely manner. However, as noted in Standard 7 above, one frail resident was observed not to be assisted to eat their meal or have their tray of food taken away in a timely manner. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 21 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 visits to this service. The home has a complaints policy, however it is not clear if it is always complied with by all staff on all occasions. Systems are in place for the protection of vulnerable adults, however failure to fully comply with some company policies could put certain residents at risk. EVIDENCE: Trowbridge Oaks has a complaints policy, which is on display in the entrance area and is available to all residents in the service users’ guide. One person approached the CSCI since the last inspection, as they were not satisfied with the response to a range of issues raised by them. The person had received a reply, which was brief and did not respond to all the areas that they had complained about. When the matter was investigated by the CSCI, while certain matters had been dealt with appropriately by the home, other areas had not been, and several requirements and good practice recommendations were identified, mainly relating to personal care and cleanliness. Of the 20 people who responded to this section of the questionnaire, 15 reported they always, 3 usually, 1 sometimes and 1 never knew who to talk to if they were not happy. Several people said that they had never needed to complain. One person reported “Responses from the Home Manager are generally very good”. However one person reported “I see the manager and it Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 22 is then dealt with – hopefully” another “The manager always acts immediately, unfortunately the staff quite soon revert to their “old ways” and another “I told the staff but they were so busy”. The manager maintains a log of all complaints received and sends in a return to BUPA monthly. Several people reported to the Inspector about the laundry (see Standard 26 below), other residents commented on staff performance when they used their call bell (see Standard 27 below). The manager was not aware of these problems, so it was not clear if residents and their supporters had reported these matters or if staff had not reported them on to the manager, so that she could take action to address such concerns. At the random inspection, it was recommended that staff should document all issues of concern raised with them, to ensure that staff consistently respond when issues are raised. It would appear from this inspection that this is not taking place. The manager and her deputy reported at this inspection that they were planning to introduce a daily report system, to be completed by the person in charge of each floor, so that they are promptly informed of issues raised by residents and others. The manager of the home has experience of working within local vulnerable adults procedures. One issue had been reported since the previous inspection. This had been reported by the manager of the home in support of a vulnerable adult. The home has a policy on abuse awareness, which is on display in staff areas. Two cleaners and two laundresses spoken with were fully aware of their responsibilities towards vulnerable adults and clearly knew what to do if they had any concerns. One resident showed bruising to their face. There were clear records relating to how the bruising was sustained. Reports from different members of staff agreed with this written record. However another resident’s records showed an incidence of unexplained bruising to a limb and that medical opinion had been deemed necessary. No accident record had been made in relation to the bruising and neither the manager nor her deputy had been informed of the situation. There was evidence that this matter was fully investigated following the inspection. Residents who needed restraints such as safety rails or lap belts usually had assessments for use of such restraints completed. One person had had their assessment for use of such a restraint reviewed and its use discontinued and other measures put in place, when their condition changed. Two residents who had safety rails on their bed had not had a risk assessment completed. This is contrary to company policy. When one of these resident’s bed was looked at, the rails used on their bed meant that there was a gap between the rail and the side of the bed, where a limb could be entrapped. Staff were observed on two occasions moving the residents’ limb to prevent entrapment and the Inspector also did this on one occasion. This is of concern, as the home were not complying with their own established policies and procedures, thereby placing the resident at risk. One resident was documented as needing protection on their safety rails to prevent risk of bruising to their limbs. The resident was observed to have thin, frail skin. The resident was in bed Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 23 throughout the first site visit but no protection had been placed over their safety rails. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 24 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 adequate. This judgement has been made using available evidence, including visits to this service. Trowbridge Oaks provides an environment, which generally meets the needs of its residents. It is well-maintained, clean and provides comfortable furniture and equipment, to give residents a homely setting in which to live. More attention needs to be paid to the laundry and certain smaller items of equipment, to ensure appropriate standards of facilities. Some residents who are at risk of pressure damage could be put at risk by the home’s incorrect use of equipment. EVIDENCE: Trowbridge Oaks is largely well maintained. Where small deficiencies were noted during the inspection, the maintenance man knew about them and had plans in place to address them. BUPA regularly reviews the quality of the environment and develops plans where deficits are identified. For example, Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 25 the stained carpet in the upstairs dining room/lounge is to be replaced shortly and it was reported that ten new variable height beds were to be provided during the current financial year, to ensure that all residents with complex manual handling needs are cared for in such beds. The home was purpose-built as a care home, all bedrooms have en-suite facilities and a range of assisted baths and showers are available. The home was registered prior to the Care Standards Act coming into effect, so there are also some double rooms in the home. There are two sitting/dining rooms on the first floor, a dining room and sitting room on the ground floor and a large patio garden area. Some residents also like to sit in the front entrance hall. All communal areas were warm and comfortable. The kitchen is small but staff are used to working within the environment and manage the space available effectively. There are a range of bathrooms and showers in the home, which are suitable for disabled persons. Equipment such as hoists and pressure relieving mattresses are provided. It was noted that at least two of the dials on pressure relieving mattresses were not set at the correct level for the resident’s weight on the first site visit. This continued for at least one resident on the second site visit. Where pressure relieving mattresses are not set at the correct level for the resident’s weight, they can present an increased risk to residents. The records for both these residents showed that the resident had sustained pressure damage. Such practice was identified at the previous inspection and a recommendation made. It is of concern that the home have not taken action to rectify matters and that residents have gone on to sustain pressure damage. One resident was observed to have a Kylie sheet placed over a pressure-relieving low airloss mattress. Manufacturers’ instructions show that the use of such sheets reduces the effectiveness of low airloss mattresses and can increase risks of pressure damage to the resident. This is a factor which the home should have known about and taken action on. All residents had been left with access to their call bell and there is an electronic monitoring system for response times, which is audited, to ensure that staff respond promptly when the call bell is used. Three days were reviewed at random during the site visit; these showed that occasional long response times were taking place, generally at different times during the waking day. The manager reported that she had already identified this as an issue of concern and had ordered ten more bleeps for staff to carry, so that staff in different parts of the building could be alerted. Five had already been delivered and all registered staff in charge of a floor now carried them, to ensure that they could review staff performance. She reported that this was a matter which she will regularly audit, and hopefully will be addressed, following the delivery of the next five bleeps. Of the 20 people who responded to the questionnaire, 12 said the home was always and 8 usually clean. One person reported “It never smells unpleasant, Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 26 unlike some other homes I have visited.” The domestic staff were observed performing their roles. They were careful, including the wiping down of skirting boards and lamp-shades, as well as more obvious areas. Both said that they had a good supply of chemicals for cleaning and that the equipment they used was well-maintained. All clinical waste was properly disposed of. There was an ample supply of gloves and dressing packs and the registered nurses reported that all wounds and other clinical procedures were carried out using aseptic technique. One of the deteriorated washer disinfectors was to be replaced during the next financial year. At the random inspection, one commode bucket was observed not to have been left in a clean state. During this inspection, a range of commode buckets and bed pans were observed to show staining and needed to be replaced. Stained sanitary items are unpleasant to look at, may put residents off using them and can present a risk of cross infection. Staff need to understand that they need to report such items promptly and take them out of use. Other deteriorated items were observed during both site visits, including bags for potentially infected laundry, bed safety rail protectors and clipboards for charts. Such items need to be in a good condition and cleanable, to prevent risk of cross infection. By the second site visit, the manager reported that she had delegated the role for observing of the condition of such items to a senior carer, who would take on responsibility for disposal and re-ordering. The home has a kitchenette on the first floor. During the first day of the inspection, an old stale sandwich, and a dessert and items of fruit which appeared to be old, were observed in the fridge. These were not disposed of until pointed out by the Inspector. By the second site visit the manager had delegated the responsibility for checking this fridge daily to the domestic staff. On the first site visit, a carer was observed not to be complying with company policy for the prevention of spread on infection and management of laundry and placing all categories of laundry into the same container for used laundry. The laundresses confirmed that this was not an isolated occurrence. On the first site visit, one carer was observed during the inspection to carry used bed linen by holding it to the front of their uniform, while carrying it to the laundry skips. The carer was not wearing an apron or gloves. To prevent risk of cross infection, residents’ bed linen must be handled using gloves and an apron. These must then be disposed of on completion of the task. By the second site visit, the manager reported that staff involved had received training on infection control, particularly in relation to laundry. This was confirmed by staff spoken to. The manager was also in the process of setting up a documentary system for the laundresses to complete, to support them in auditing staff performance in relation to company policy for used laundry. The laundry is cramped and the laundry staff have difficulty in organising their working environment due to the limited working space available. One person Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 27 commented, “This is an area where the high standard cannot be maintained. This is a real shame as the staff are being let down by poor facilities. I am sure that when a member of Head Office looks into this area, they will agree that an upgradation on this area is vital.” On the second site visit, a range of clean items were awaiting ironing and folding, they were stacked in piles on the equipment. Given the cramped space, it is complex to see how this could be avoided. In the light of how staff have to mange such roles, there could be a fire risk, so the room’s fire risk assessment needs to be reviewed, to ensure the safety of staff and residents. To improve the space available for laundry, the home either needs a larger laundry facility or a separate area identified for ironing and folding of laundry. It is difficult to clean the area behind the washers and dryers. On both site visits, dust and debris were visible behind the washing machines and dryers, particularly on the pipes, where it gave the appearance of being encrusted. The laundresses reported that they regularly vacuum behind the machines but it is very difficult to reach, given the tightness of the working area. Several cracks were observed in some of the walls and the ceiling near both the driers and the limited area for sorting laundry. Micro-organisms can live and develop in the warm environment presented by a laundry and be transported on footwear, in dust or in the air, so the areas behind the machines need to be clean and all debris removed. All walls need to be intact and free of damage, to enable effective cleaning. This will prevent risk of cross infection. There was a container of unmarked clothes by the dryer. This is not ideal but there seemed to be limited alternative space available. Several persons commented on lost laundry, one person said “The laundry is very good but I am missing things all the time.” Staff should explain to residents and their supporters when they are being admitted, the need for all clothes to be marked before they are worn. Where a person cannot mark their own clothes, this needs to be identified early, so that effective action can be taken by the home, to ensure that items are not lost in the laundry. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 28 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. A full range of staff with a skill mix to meet residents’ needs are in post. Some residents felt that sufficient staff were not available to meet their needs but this is likely to relate to factors other than the numbers of staff. Residents are supported by the home’s system for recruitment of staff. Training is encouraged by the home’s managers. EVIDENCE: Trowbridge Oaks is required to staff the home in accordance with a Condition of Registration set out by the Commission. They were meeting and often exceeding the requirements of this Condition. A registered nurse manages each floor of the home, these nurses are supervised by the deputy manager, who is supported by the home manager. A range of senior care and care staff are in post. A full team of ancillary staff are employed, including domestic, catering, laundry and maintenance staff. A part-time activities coordinator and two administrators support the home. Observations made during the site visits and discussions with staff indicated that the dependency of residents has increased. Only eight of the 56 residents in the home used the dining room on the ground floor for lunch. All the other residents ate in their own rooms and many of these were unable to leave their Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 29 rooms. Many of the residents spent much of their time in bed and needed to have their positions moved by staff and were unable to give themselves food or fluids independently. Many of the residents could not communicate effectively, to inform staff of their needs. Staff agreed that the number of highly dependant residents had increased during the past year and that they had to plan their days carefully so as to meet residents’ needs. Of the 20 people who responded to the questionnaire, 6 reported there were always, 10 usually and 4 sometimes staff available when they needed them. A range of comments were received about staffing of the home, they included, “The care my [relative] receives is good”, “They do anything you ask”, “I get good care and attention”, “The night staff are as helpful as the day staff” other comments included “The home always seems to be short of staff. Those that are there (or some of them) do try very hard”, “You don’t see much of the staff here” and “Sometimes difficult to locate a nurse (as opposed to a carer) to talk to.” Comments were made on the response times to the call bell. Residents generally felt that staff attended quickly when they used them, but reported that staff promised to come back as soon as they were free, but did not always do so. One person reported “They do come when you ring the bell, they say they will come back in just a minute but sometimes it takes them an hour to come back” and another “They come and turn your bell off and then don’t come back”. Records showed that there had been a turnover in staff recently. The manager reported that newer staff and many of the older staff showed an improved skills base, so she hoped that responses from residents and their supporters would improve, now that they had a more motivated staff team. Issues of concern about staffing may relate to management changes (see Standard 31 below) and some staff turnover, rather than an actual shortage of staff. Reviews of files relating to recently employed staff showed that all required pre-employment checks take place, including police checks, at least two references, proof of identity and health checks. All staff are interviewed using a standard interview assessment tool. Staff records also show that where issues relating to performance are identified, that the manager takes action within BUPA’s established systems, to improve performance. Training is supported and records relating to training were fully documented. BUPA has a standard system for induction of new staff, which complies in full with Skills for Care. All new staff are allocated to a mentor, who is responsible for ensuring that all parts of the induction programme are covered. All staff have an individual training record. Over 50 of carers are trained to NVQ 2 or above and the home has recently recruited carers who already hold this qualification. Other training is supported. Recently training on dementia care and nutritional care have taken place. Registered nurses are also supported in extending their skills and the deputy manager reported that they had enough nurses with technical skills, such as male catheterisation, to meet residents’ nursing care needs. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 30 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 adequate. This judgement has been made using available evidence, including visits to this service. The manager for the home is appropriately qualified but as she is currently supporting another home, there is evidence that she is not in a position to fully discharge her duties. BUPA has systems established for the reviewing of quality of service provided. There are safe procedures for the management of resident’s moneys. Staff are supervised in accordance with company policy. Appliance of the principals of health and safety was variable. EVIDENCE: The manager of the home has been in post for over two years and has gained the managers’ award. She is also a registered nurse, who has regularly updated her skills. The manager and her deputy have been supporting another Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 31 home in the locality, while a recruitment process for a new manager is being carried out. This has continued for an extended period of time. BUPA has maintained contact with the CSCI to inform them of the situation. This support to another home has meant that the manager and her deputy may not have been able to discharge their responsibilities fully to Trowbridge Oaks. Parts of the shortfalls noted at this inspection had been identified at the previous inspection and others at the random inspection. An action plan was submitted after both inspections, which stated that all the areas would be addressed. The home which the manager was supporting did not show similar concerns to that raised by this inspection, so the manager and her deputy are clearly able to effectively mange a home. Evidence therefore suggests that the concerns identified at this inspection are most likely to relate to the manager having to cover two complex areas for nursing and care provision. Action needs to be taken to ensure that the manager can fully discharge her responsibilities to Trowbridge Oaks so that residents’ nursing and care needs are met and staff appropriately managed. BUPA has standard systems in place for reviewing quality of service provision to residents by way of an external quality control audit team. The last audit was performed in 2006. Managers are also required to perform monthly audits of certain topics, such as care plans or administration of medicines. Complaints returns are made to the parent company monthly. Accidents are reviewed quarterly. Service user and supporter satisfaction surveys are produced annually. The home is visited monthly by a senior manager from BUPA, and a report made. Where issues are identified, the manager is required to submit an action plan to the parent company detailing how service provision is to be improved. BUPA has established systems for the management or residents’ moneys. No residents’ cash is held on the premises and all moneys relating to such matters as hairdressing, chiropody or newspapers are dealt with by invoice. Clear records are maintained and hard copies can be run off for residents or their supporters when requested. A full audit trail of all transactions is in place. There is also a clear documentary system for items handed in for safekeeping and returned to the resident or their supporters. There are established systems for supervision of staff. One registered nurse reported on how they observed and supervised staff on their floor while they were on duty. One NVQ qualified carer also reported on how they supported new staff in their role. All new staff are supervised three months after taking up their role. Supervision then takes place on a regular basis. Records showed that the home has a flexible approach to supervision, with some supervisions taking place individually and others in groups. Supervisions relate to residents’ nursing and care needs. The training matrix showed that all staff were regularly trained in areas such as manual handling and fire safety on a regular basis. Standards relating to Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 32 health and safety were variable. The home has a range of hoists to assist manual handling, which were observed to be being correctly used by staff. Residents also reported that staff moved them correctly. Concerns about practice relating to prevention of spread of infection were identified during site visits (see Standard 26). Other issues related to conforming to fire safety principals. During the first site visit, a door which was clearly marked as a fire door, with an additional notice on it to state that it was not to be held open, was held open throughout the morning and was not closed. The door was in a main area of the home on the first floor, passed by staff several times during their duties. Other equipment continued to be used (see Standards 22 & 26 below), which was in an deteriorating state and could present risk to service users or staff. This had not been reported to the managers, who once they were alerted to such matters, took prompt action. On the first site visit, two residents were prescribed oxygen, both had appropriate warning signs on their doors but of the five oxygen cylinders observed during the inspection, only one had been appropriately placed in a carrier. By the second site visit, there were only two oxygen cylinders noted, neither had been secured. Oxygen cylinders must always be fully secured. This is because they are very heavy and, due to their shape, can over topple easily, unless secured. If they do so, there is much potential for serious injury to residents, visitors or staff. The home were advised of this matter over a year ago and a requirement made. The deputy manager reported that new oxygen carriers had been ordered. One resident had a fall documented in their daily record but not in their falls monitoring record, therefore the home would not have an up-to-date record for that person of the frequency of their falls to assist in reducing risk to the resident. Another resident, as noted in Standard 18 above, had records relating visible bruising but an accident form had not been completed. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 33 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 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 2 x 3 X 3 3 x 2 Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 34 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement All service users who have been assessed as having a risk of pressure damage must have a full and detailed care plan in place. Care plans must relate to the individual’s needs and be specific about all interventions to be taken by staff to prevent pressure damage. All frail service users who are unable to change their positions, eat or drink independently and/or have bowel care needs falls must have a documented monitoring system in place. This record must be fully completed by staff, to provide a full audit trail, to evidence that their individual needs are being met and enable review by relevant persons. Parts of this requirement were identified at the inspection of 7/12/05, with a compliance date of 31/1/06. This part has not yet been addressed. Where a service user has a nursing or care need, full assessments of their needs must DS0000015947.V320789.R01.S.doc Timescale for action 30/04/07 2. OP7 OP8 17(1)(3)S 3(3)(k) 31/03/07 3. OP7 15(1) 30/04/07 Trowbridge Oaks Nursing Home Version 5.2 Page 35 4. OP8 12(1)(a) 5. OP8 OP38 17(1)(3)S 3(3)(k) 6. OP8 17(1)(3)S 3(3)(k) 7. OP9 13(2) 8. OP9 17(1)(3)S 3(3)(m) 9. OP18 OP38 13(4)(c) be made and a care plan put in place to direct staff on actions to take to meet these needs. Where a service user is prescribed or needs thickening agent to enable them to swallow safely, there must be evidence that there are systems in place to ensure that staff meet this need in every case. If a service user shows complex behaviours, including falls, they must have a monitoring system in place, so that the extent of behaviours and effectiveness of interventions can be assessed. All staff must ensure that they always correctly document in such records in accordance with the company policy and procedures. All service users with health care needs, such as wounds, urinary catheters or diabetes must have a care plan and monitoring system put in place to direct staff on how the condition is to be treated and enable assessment of the stability of their condition. All limited life prescribed items must have the date/time when they were opened documented and instructions about storage must be complied with at all times. Where prescribed tablets are being crushed, a care plan must always be drawn up to direct registered nurses on the actions to take to ensure that the drugs continue to be effective. Staff must ensure that the providers’ standard risk assessment document is fully completed for all service users who have safety rails in place. Staff must ensure that they DS0000015947.V320789.R01.S.doc 28/02/07 30/04/07 30/04/07 28/02/07 28/02/07 28/02/07 Trowbridge Oaks Nursing Home Version 5.2 Page 36 10. OP22 13(4)(c) 11. OP26 13(3) 12. OP26 13(3) 13. OP31 10(1) 14. OP38 13(4)(a,c) comply with company policy and individual care plans, when using safety rails, All equipment used to prevent risk of pressure damage must be used appropriately, taking into account the service user’s condition and manufacturer’s instructions. The area behind the washing machines and dryers must be fully cleaned, and remain dust and debris-free at all times. All cracks in the walls and ceiling of the laundry must be repaired, to present a fully wipable surface. The registered manager and her deputy must be enabled to devote all their time to Trowbridge Oaks and not support another home, to ensure that they can fully discharge their duties. Oxygen cylinders must always be securely stored and transported about the home in oxygen cylinder carriers. This requirement was identified at the inspection of 7/12/06, with a compliance date of 31/1/06. It has not been addressed. 28/02/07 31/03/07 31/03/07 12/03/07 28/02/07 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. Refer to Standard OP3 Good Practice Recommendations Pre-admission assessments should indicate who the assessment was obtained from. DS0000015947.V320789.R01.S.doc Version 5.2 Page 37 Trowbridge Oaks Nursing Home 2. 3. 4. OP3 OP3 OP7 5. 6. OP7 OP7 7. OP8 8. OP8 9. 10. OP8 OP9 11. 12. 13. OP9 OP9 OP9 14. OP9 Service users’ assessments should state what their usual bowel habit is, so that staff can fully assess any variance for the service user. Where there is evidence that a service user has been assessed by a clinician, the home should obtain a copy of the clinician’s assessment, rather than a third party report. Precise, measurable wording should be used in care plans and generalistic wording avoided. This was recommended at the random inspection of 17/8/06. It has not been addressed. The amount of fluids taken in by a service user should be totalled every 24 hours. Where service users have care plans relating to their dietary needs, this should include their likes and dislikes, to support staff in encouraging service users to eat. This was recommended at the random inspection of 17/8/06. It has not been addressed in full. 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 has not been addressed. Care plans relating to the use of thickening agent, should state how much of the agent is to be used for each individual, to detail the thickness needed, to meet the service user’s individual needs. Where a service user has a urinary catheter, their care plan should document the actual clinical indicator for its use. One member of staff should be given the responsibility for checking expiry dates on all prescribed and other items and ensuring that all out of date items are promptly disposed of. Larger Controlled Drugs cupboards should be provided. This is an unmet recommendation from the past four inspections, it is reported to be under consideration. The home should provide evidence that it has discussed the prescription of liquid preparations for service users who need have their tablets crushed. Where service users are prescribed drugs which can affect their daily lives, such as painkillers, aperients or mood altering drugs, care plans should be drawn up so that staff can monitor their effectiveness and advise their prescriber of the effectiveness of the treatment. The home should ensure that where a service user may need an drug to be administered in an emergency, that they have a current prescription on their medicines DS0000015947.V320789.R01.S.doc Version 5.2 Page 38 Trowbridge Oaks Nursing Home 15. 16. OP12 OP12 17. 18. 19. OP12 OP13 OP16 20. OP26 21. 22. 23. 24. 25. OP26 OP26 OP38 OP26 OP26 OP26 administration record. A review of activities provision across the home should be made, to ensure that there are sufficient staff hours provided to meet service user need. Systems should be put in place so that care staff have ready access to records of service users’ past lives, so that they can be aware of significant matters when caring for residents. A management system should be put in to support the activities coordinator, similar to that for the maintenance man and chef. Where a service user is not able to comment on their care plan, the home should set up a system for regular review of the service user’s care plan with their relatives. All staff should ensure that all issues of concern raised with them are documented. These should be reviewed regularly by the home manager, to ensure that staff are consistently responding when issues are raised. This was recommended at the random inspection of 17/8/06. It has not been addressed. One person should be delegated with the role of regularly checking all smaller items of equipment, such as bedpans, safety rail protectors, storage boxes in cupboards or laundry bags for potentially infected laundry, to ensure that no deteriorated items are in use and articles disposed of and re-ordered promptly, if needed. The fridge in the first floor kitchenette should be regularly checked and any old items of food disposed of. The fire risk assessment for the laundry should take into account current practice in the laundry for the sorting, folding and ironing of items. The manger should develop and auditing system with the laundry staff to ensure that all staff are complying with company policy on handling of laundry. A larger laundry or a separate area to sort clothing and laundry should be provided. A member of staff should be delegated with the role of ensuring that new service users and their supporters understand the importance of marking items of clothing prior to laundering and identifying if service users need support with this. Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 39 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 Trowbridge Oaks Nursing Home DS0000015947.V320789.R01.S.doc Version 5.2 Page 40 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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