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Inspection on 07/01/09 for Uplands Nursing Home

Also see our care home review for Uplands Nursing Home for more information

This inspection was carried out on 7th January 2009.

CSCI found this care home to be providing an Poor service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Uplands provides an adequately maintained environment for the residents, and provides a welcoming atmosphere for visitors. Some of the residents are able to move around the dementia care unit in safety and pursue their time as they particularly chose. There is a small and inclusive lounge in the nursing unit. There is a good standard of nutritious food served here, and residents all seemed very satisfied with their meals. There are some positive comments from the staff regarding the teamwork and peer support that they experience.

What has improved since the last inspection?

A new spacious front porch and door has been completed, which not only enhances the front entrance to the home, but also provides additional security.

What the care home could do better:

Although residents are admitted to the home on the basis of an assessment, the home needs to ensure that it thoroughly understands any complex needs a person may have before giving them an assurance that their needs can be met. We saw some examples of satisfactory care planning based on individual needs and risks, however generally the existing system was inadequate to meet residents` needs. The home`s arrangements to address this were too slow and required much speedier improvement. The review of residents` care was infrequent, and there were examples where staff had failed to ensure the necessary health care interventions when health concerns had been identified. Care staff were not reading residents` care plans and were reluctant to acknowledge any responsibility in this area. Many of the care records were undated and unsigned. The systems for managing residents` medications were unsafe and required major improvement. Although we saw examples of respect being shown towards residents` privacy and dignity there were occasions when this was not always the case.Residents` `end of life` wishes were not recorded in their notes, and there were no specific plans of care for this eventuality. Many of the residents were not stimulated socially, and were left unattended for significant periods. At times like this the impact of some people`s challenging behaviour upon other residents was not being adequately managed, and more regular monitoring of the communal areas would have ensured greater attention was given in this regard for the benefit of all. When asked for information in the course of a complaint investigation the home had not provided it concisely and clearly, and had drawn out the process unnecessarily, and this had not been to anyone`s benefit. The procedures adopted by the home to protect the vulnerable residents were not in any way robust, and a warning letter had already been issued to the home prior to this inspection by CSCI. Improvements in relation to the staff`s understanding of the issues and the needs of the vulnerable resident group, to share information with the relevant authorities openly, and to adhere to good practice are now required. This was fully acknowledged by the registered provider, and there was a declared intent to improve this immediately. Some issues for attention in relation to the environment regarding maintenance records, the heating system, fire safety and minor points of decoration were identified. The staff were very busy throughout this inspection trying to cater to the needs of the residents. There was no key-worker system, and it was judged that this was adversely affecting carers` attitudes and skills. There were many gaps on the staff rota that required filling, either by existing staff offering to work extra, or by the regular use of agency. There were some very good examples of a sound recruitment process, however, the home`s failure to supervise a new worker whilst still awaiting the return of a full Criminal Records Bureau (CRB) disclosure had posed a degree of risk to residents. There was an ongoing National Vocational Qualification (NVQ) training programme, but progress with this was slow, with the home not achieving the 50% level of qualified care staff recommended in the National Minimum Standards. New staff had received a very inadequate standard of induction to the home, and staff were not receiving a good standard of ongoing training for their roles in the home and for their professional development. There have been no arrangements in place to provide staff with structured and meaningful supervision and appraisal. There has been no structured approach towards monitoring quality in the home, with standards generally declining since the last inspection.Uplands Nursing HomeDS0000016643.V373520.R01.S.docVersion 5.2Page 8There has been inconsistent management over the past year, with some inadequate leadership in place. However the home now has a new nurse manager, who although not yet registered with CSCI, has taken the necessary steps to apply for this, and now has a clearly identified agenda for improvement following this key inspection. The registered provider and the new manager fully acknowledged that improvements were needed, and that they would be addressed.

CARE HOMES FOR OLDER PEOPLE Uplands Nursing Home Church Road Maisemore Gloucester Glos GL2 8HB Lead Inspector Mrs Ruth Wilcox Unannounced Inspection 7th January 2009 08:30 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 Uplands Nursing Home DS0000016643.V373520.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. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Uplands Nursing Home Address Church Road Maisemore Gloucester Glos GL2 8HB 01452 505629 01452 307399 uplandsnursinghome@lineone.net Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Graham James Rigby Manager post vacant Care Home 54 Category(ies) of Dementia (38), Old age, not falling within any registration, with number other category (16) of places Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate three (3) service users under the age of 65 years but a minimum of 55 years in either category OP or DE(E) To accommodate an additional named service user under 55 years. When this service user reaches the age of 55 years or leaves the home, the condition will revert to the original category with the above condition. 2nd April 2008 Date of last inspection Brief Description of the Service: The care home is an extended house within the village of Maisemore, near to the River Severn. It sits back directly off the main road and has car parking to the front and rear of the building. There is a small-enclosed garden within the centre of the building, and a church and public house are nearby. The home is also on a main bus route from Gloucester City. A number of care needs for older people are catered for in this home; these include general personal and nursing care, and care of those with dementia within a designated unit. Information about the home is available in the Service User Guide, which is issued to all prospective residents. The home does not display its previous CSCI inspection report, although does display a notice confirming it is available, and inviting people to request a copy to read if they wish. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience Poor quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. Two regulatory inspectors and one pharmacy inspector carried out this unannounced inspection over one full day in January 2009. The inspection schedule was brought forward to January 2009 following identified concerns about the service. Care plans and associated records were inspected, with the care of six residents being closely looked at in particular. As part of this key inspection, one of our (The Commission for Social Care Inspection) pharmacist inspectors looked at some of the arrangements for the management of medicines. This included looking at some stocks and storage arrangements for medicines and various records about medication. We saw how staff administered some medicines to people living in the home. The pharmacist spoke to the acting nurse manager and one of nurses, as well as two people living in the home. A number of residents and one visitor were spoken to directly in order to gauge their views and experiences of the services and care provided at Uplands. The quality and choice of meals was inspected, and the opportunities for residents to exercise choice and to maintain social contacts were considered. The systems for addressing complaints, monitoring the quality of the service and the policies for protecting the rights of vulnerable residents were inspected. The arrangements for the recruitment, training and supervision of staff were inspected, as was the overall management of the home. A tour of the premises took place, with particular attention to health and safety issues, the maintenance and the cleanliness of the premises. We gave full feedback after the inspection to the registered provider, the acting nurse manager and other management personnel. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although residents are admitted to the home on the basis of an assessment, the home needs to ensure that it thoroughly understands any complex needs a person may have before giving them an assurance that their needs can be met. We saw some examples of satisfactory care planning based on individual needs and risks, however generally the existing system was inadequate to meet residents’ needs. The home’s arrangements to address this were too slow and required much speedier improvement. The review of residents’ care was infrequent, and there were examples where staff had failed to ensure the necessary health care interventions when health concerns had been identified. Care staff were not reading residents’ care plans and were reluctant to acknowledge any responsibility in this area. Many of the care records were undated and unsigned. The systems for managing residents’ medications were unsafe and required major improvement. Although we saw examples of respect being shown towards residents’ privacy and dignity there were occasions when this was not always the case. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 7 Residents’ ‘end of life’ wishes were not recorded in their notes, and there were no specific plans of care for this eventuality. Many of the residents were not stimulated socially, and were left unattended for significant periods. At times like this the impact of some people’s challenging behaviour upon other residents was not being adequately managed, and more regular monitoring of the communal areas would have ensured greater attention was given in this regard for the benefit of all. When asked for information in the course of a complaint investigation the home had not provided it concisely and clearly, and had drawn out the process unnecessarily, and this had not been to anyone’s benefit. The procedures adopted by the home to protect the vulnerable residents were not in any way robust, and a warning letter had already been issued to the home prior to this inspection by CSCI. Improvements in relation to the staff’s understanding of the issues and the needs of the vulnerable resident group, to share information with the relevant authorities openly, and to adhere to good practice are now required. This was fully acknowledged by the registered provider, and there was a declared intent to improve this immediately. Some issues for attention in relation to the environment regarding maintenance records, the heating system, fire safety and minor points of decoration were identified. The staff were very busy throughout this inspection trying to cater to the needs of the residents. There was no key-worker system, and it was judged that this was adversely affecting carers’ attitudes and skills. There were many gaps on the staff rota that required filling, either by existing staff offering to work extra, or by the regular use of agency. There were some very good examples of a sound recruitment process, however, the home’s failure to supervise a new worker whilst still awaiting the return of a full Criminal Records Bureau (CRB) disclosure had posed a degree of risk to residents. There was an ongoing National Vocational Qualification (NVQ) training programme, but progress with this was slow, with the home not achieving the 50 level of qualified care staff recommended in the National Minimum Standards. New staff had received a very inadequate standard of induction to the home, and staff were not receiving a good standard of ongoing training for their roles in the home and for their professional development. There have been no arrangements in place to provide staff with structured and meaningful supervision and appraisal. There has been no structured approach towards monitoring quality in the home, with standards generally declining since the last inspection. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 8 There has been inconsistent management over the past year, with some inadequate leadership in place. However the home now has a new nurse manager, who although not yet registered with CSCI, has taken the necessary steps to apply for this, and now has a clearly identified agenda for improvement following this key inspection. The registered provider and the new manager fully acknowledged that improvements were needed, and that they would be addressed. 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. Uplands Nursing Home DS0000016643.V373520.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 Uplands Nursing Home DS0000016643.V373520.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&4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Despite some omissions, the pre-admission assessment process should give prospective residents an assurance that their needs can be met by the home, although due to unforeseen circumstances in at least one case this has not continued to be the case. EVIDENCE: As part of the pre-admission phase for prospective residents the home had recorded an ‘Admission sheet’, which was held within the person’s care notes thereafter. This had included the person’s personal details, their next of kin, their past medical history, any dietary requirements and medications, and any power of attorney arrangements. The section to record individuals’ chosen religion had not always been completed and was blank in some cases. We inspected the pre-admission arrangements for three residents in particular. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 11 Their pre-admission assessments had been recorded on the home’s standard assessment tool for the purpose, with the date of the assessment and the assessor identified; the location where the assessment was conducted was not consistently recorded. Assessments were comprehensive and had taken account of the person’s safety and environment; personal care; dressing; routine; continence and aids; diet and meal patterns; sleep routines; likes and dislikes; equipment; vision and hearing; oral health; foot care; mobility and dexterity; falls; communication; sexuality; spiritual needs; behaviour and aggression; cognitive behaviour; medication; past medical history; allergies; any wandering habit; hobbies and interests. Previous health or social care interventions in any case were recorded, and there were records of information from the discharging ward at the hospital, plus copies of the placing authority assessments and care plans where relevant. In one case the date of the assessment corresponded with the date of admission, the resident having been admitted as an emergency. This person was already known to the home, as his wife was already a resident here. All the new care documentation was ready in this person’s file, but written care plans had not been devised on the basis of the assessment at the time of this inspection. The person had been weighed on admission. This was also the case with another two people who had been assessed prior to admission. We discussed these particular shortfalls with the acting nurse manager and the proprietor, and it was fully agreed that these plans would be drafted on the basis of the assessments by the end of the following day. There have been occasions when the home has conducted pre-admission assessments over the telephone where the prospective resident has lived at some distance. There has also been an occasion recently when the behaviour of one particular resident, admitted to the home some months ago, could no longer be accommodated due to the risks it posed to other residents. It is imperative that the home discusses the person’s care and health needs in full with other professionals involved in cases such as this, and that copies of the placing authority assessments and care plans are obtained in advance, so that the home’s representative can be assured that Uplands can meet the needs of the individual before accepting them for admission. Uplands does not provide intermediate care. Uplands Nursing Home DS0000016643.V373520.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 & 11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although there are plans to address an otherwise inadequate care planning system, people living in this home are at risk of not having their health and care needs met through the current weaknesses in care planning and monitoring, and the arrangements and practices for medication. EVIDENCE: New care planning documentation had been in the process of being phased in for approximately two months, but progress to date had been unacceptably slow with only 50 of the plans revised. Despite this the new system showed great potential with areas of risk and care fully taken account of. The acting nurse manager stated that progress was slow because of constraints upon her time, but that she and the deputy manager were working through them. We stressed the importance of the completion and implementation of this work in order that residents’ needs were fully taken account of and met accordingly, and agreed a timescale of the end of February 2009 for the home to complete the project with her and the proprietor. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 13 We case tracked six residents and looked more closely at their particular care and circumstances. In the case of one particular person in the dementia care unit where the new documentation was in use, an assessment was recorded based on the person’s activities of daily living. A ‘Strengths Based Assessment’ was also recorded which took account of their values, beliefs and feelings; thinking and communication; contact and activity; maintaining control; environment; physical health, and any behaviours that could pose difficulties for others. A ‘Whole Person Picture’, although not yet completed, was to take account of the person’s strengths and abilities, and their strengths upon which to build. A dependency profile was also recorded, and records generally showed that a high level of support would be needed for this person. A risk assessment was in place for manual handling needs, and this incorporated the persons’ ability in terms of their mobility, standing, sitting, limbs, falls, vision, and behaviour. A risk assessment was also in place for mobility such as it related to the environment. This included the influence of environment and others, and incorporated choices, decisions, and social contacts. A falls risk assessment tool was ready in the file but was incomplete, although there was a documented plan of care to address the risks in place. An assessment based on the Waterlow tool showed there was no risk of pressure sores developing, with no equipment necessary. Despite this there was a fully documented care plan in place to address any needs in this area. A nutritional risk assessment was in place, showing a degree of risk, and there was a full care plan in place to address this. The person’s weight had been recorded on admission and had been repeated two months after with the body mass index (BMI) calculated. There were fully detailed care plans in place to address the person’s mental health issues, with the risk of their wandering habit and their associated medication included, although this seemed to be a standard printed care plan and was not really personalised to this person. A behaviour-monitoring chart was in place. There was a plan to address the action needed in this case in the event of a fire, and the rationale regarding the home’s locked door policy. There was a documented care plan to address their personal care needs, and this was appropriately detailed and encouraged some independence. There was an acute care plan for some scar tissue breakdown, which the community nurse was addressing, with general practitioner (GP) intervention and hospital referral. The care records included specific forms to record any medical visits, but only the community nurse visit had been recorded on here. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 14 A full review of the person’s care had been undertaken between the home, the resident and their family a few weeks after their admission. We visited this person, and although they were reluctant to speak to us, was walked about independently and appeared comfortable, clean and well dressed. In the case of a second dementia care resident, concerns had been raised prior to this visit about the overuse of sedation during a review by the placing authority. Following this the home had consulted with a GP at the request of the authority, and there was a record that the GP had visited and had reviewed the dosage and use of the sedation medication. We met this person and they were now up and about and mobile, and were very cheerful and responsive to us. They appeared happy, clean and well dressed. They told us that they ‘felt fine’. All the new records were in their care file ready, but were not yet completed. An old assessment based on the activities of daily living model had been updated for continued use. Despite these reviews, this identified the person as ‘self-caring’, which was not accurate to the current circumstances. Neither had the assessment been altered to take account of the person having been nursed in bed whilst over sedated. There was a long-standing care plan for their particular behaviour and agitation, which had been regularly reviewed; this reflected their increased frailty. However the ‘action part’ of the plan was completely out of date, and still reflected their previous wandering habit, and cleaning of cuts and grazes from when they absconded from the home approximately two years ago. A risk assessment for pressure sores showed there was no risk of the person developing a pressure sore. In a third case, the person had moved into the dementia unit, and their care had been reviewed since then by a social worker, with a new care plan devised. This identified that this person’s behaviour had caused concern to others, and that they had agreed to move rooms. The Mental Health Nurse from the Care Home Support Team (CHST) had visited them, as had the Community Psychiatric Nurse (CPN), although there was no actual record of these visits. This person was under regular observation due to their habit of going into other residents’ rooms. We saw this resident in the dementia unit lounge and also in the nursing lounge at different times. This person appeared quiet and withdrawn, but was pleasant and responsive when we approached them. A behaviour chart showed they had shown aggressive behaviour towards staff. The care plan to address this resident’s personal care needs had not been reviewed for nearly four months. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 15 A pressure sore risk assessment showed there was a low risk in this area, and a care plan with support equipment was in place, but had not been reviewed for nearly four months. The general assessment of this person’s needs, and the care plan for maintaining safety in this case had not been reviewed and updated for nearly four months. The acting nurse manager told us that this resident was due to be re-assessed, possibly for dementia care as a consequence of the recent review. In the fourth case the new care plan format was in use, although the ‘life history’ section was not completed yet, as was the case in other people’s records. In general the care plan contained a good level of detail and guidance to staff on how care and support should be managed. There was some information recorded in behaviour monitoring charts that was not dated or signed; this indicated that incidents were being recorded second hand and not by the person who witnessed incident or dealt with it. This resident’s weight had fallen significantly within a specific six-month period in 2008, but there was no record of a recent weight. Their BMI was rated as 15, which the home’s policy said that the person should be weighed weekly, but this had not happened. There was no record of what action had been taken in relation to the weight loss. We met this resident, and they were fairly uncommunicative but appeared happy and settled. Staff appeared to know them well and said the resident was “having a good day”. The new care plan system was not in place in the fifth or sixth case. In the fifth case an entry on a behaviour-monitoring chart indicated the resident’s habit of shouting. We observed staff dealing with the resident in their room, being reassuring, but there was be no clear method of responding to this resident’s behaviour that calmed them down. We later observed this resident being disruptive to other residents in the lounge, as the apparent absence of staff meant that the shouting was not being addressed. The resident eventually calmed after staff intervention, and staff did not remove the resident from the communal lounge. The acting nurse manager told us the home had asked for this resident to be reassessed, and that they were unsure what the cause of the shouting was. In the sixth case a care plan entry from 2008 said ‘consider the need for a 1st level mattress’; there was no follow up record made in reference to this. The resident had not been weighed for nearly four months. An entry in the care records in December 2008 recommended various actions and a later entry stated, ‘care plan implemented’, however there were no other details in place. We met this resident, and they appeared happy and settled, but fairly uncommunicative. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 16 Daily records were in place. Although undated, there were daily allocation sheets, including personal care and room checks signed by the person responsible. The home did not operate a key worker system. Care staff seemed to carry on with their care work with little supervision, with the nurse’s time being taken up with other tasks. Our interviews with staff showed that the majority of them did not read the residents’ care plans, but relied on information from other staff during induction and handover meetings. Generally only senior staff wrote up notes, often with verbal information passed to them from the care staff. Lots of the entries in records were not dated or signed. This practice was posing a risk to the robustness of the information that was actually recorded and followed up, or acted upon ultimately. The acting nurse manager confirmed that carers did not read the care records, but received direction at handover. We advised the acting nurse manager that even when the care plan renewal project was completed, it was in danger of being just a paper exercise under those circumstances. We met or observed a number of other residents, some of whom were quietly spending time in their room or lounge, whilst others were walking about the home freely. Two of the residents did not have much to say to us, but appeared fairly settled, seemed clean, well dressed, safe and comfortable. One resident in the nursing lounge had a bruised right eye; they told us that they had fallen out of bed, and were prone to falling. They said they ‘felt OK but it had been sore before’. We spoke to one relative who was visiting, who told us that they were ‘happy with care and the home’, and that ‘dad was OK’. Registered nurses were responsible for the management and administration of medication for all people living in the home. At the time of the inspection no one was assessed as able to self-administer any medicines, so people living in the home were totally dependent on the nursing staff to manage their medication on their behalf. For each person living in the home there were arrangements for recording medication received, administered and leaving the home or disposed of (as no longer needed). Complete and accurate records are important so that there is a full account of the medication the home is responsible for on behalf of the people living here, and so that people are not at risk from mistakes, such as receiving their medicines incorrectly. We looked at a sample of these records in more detail and found a number of serious concerns. We found examples of inaccurate medicine records. For example, we saw some gaps on some medicine charts. In some cases the tablets were missing from the packs (but it was not possible to check this for all examples) so the people may have received their medicines, but it was not possible to tell if this was so. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 17 In one case the nurse was able to confirm that she had in fact administered a dose that morning but not signed to confirm this. There were other examples when medicines were signed as though administered on the morning of the inspection, but the nurse told us she had not yet administered these even though the records were signed to confirm administration. This was poor practice and must not continue. The directions for some medicines such as eye drops or creams and ointments were not always specific. Examples were, as to which eye the treatment was for, or where or how often a cream or ointment was to be applied. In one example the printed directions for eye drops were for use in both eyes but the nurse told us these particular drops were only used in the right eye. Two containers of eye drops for this person had no date when opened to use but had been dispensed on 03.12.08. This meant staff were not able to change the containers after 28 days in use as is required to prevent risks of infection from contaminated drops. There was new stock in the home and we told the acting nurse manager to bring these into use. For another person there was a bottle of eye drops on the medicine trolley that had an opening date of 26.11.08 so this also needed replacing. We saw examples of records where the actual dose of medicine administered was not noted where a variable dose (one or two tablets for example) was prescribed. This again meant we did not know what medication these people had received. A course of 42 capsules of an antibiotic was signed as received for one person yet the doses signed as administered amounted to 48 capsules. This indicated that some of these records were incorrect. Just over two weeks before this inspection one person had transferred to the home from another care home. There were poor procedures for dealing with this person’s medicines on transfer to Uplands. The medicine records from the previous home were still in use. Uplands should have started their own records when this person was admitted and the previous home should have retained their own records, as they are required to by law. There were gaps on this person’s medication records. Records for some medicines indicated these had not always been available to administer. For one medicine records showed this had not been administered since the person was admitted to the home. This was a medication error and should have been notified to us as this could adversely affect the health of this person and placed them at risk. There were handwritten additions and changes to this chart but these were not always clear or signed and dated by the staff responsible, with evidence of a check by a second nurse as is good practice, to make sure records are clear and accurate. We looked in the care plan for this person for further information about medicines that were prescribed to use as required but the whole care plan was largely uncompleted. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 18 We saw another example of a medicine not being available, as paracetamol tablets had been given to one person instead of co-codamol 8/500, which were marked as unavailable. A number of medicines were prescribed to take ‘as required’. We could not find any protocols or written information in care plans to provide clear direction to the staff about how to make a decision to administer each of these medicines. The acting nurse manager confirmed that this information was not recorded but that she wanted to introduce individual protocols. Clear guidance for staff is needed to help make sure people receive medicines prescribed to take as required in a consistent way to meet identified needs, and in accordance with the provisions of the Mental Capacity Act 2005. Each medicine chart has a space to record information about any known allergies but these were not completed. We looked at medicine records for another person and found these indicated that significant changes a doctor had made for use of two of these medicines on 19.11.08 had not been properly actioned by staff all of the time. One of these tablets had been discontinued by the doctor and the other one was to be given very occasionally when required. On the medicine records for the period 08.12.08 to 04.01.09 these directions had not been correctly changed, and there was evidence of continued administration sometimes during this period for the tablet that was discontinued, and administration of the other tablet which was for occasional use. We could find no information in care plans giving clear directions about using these tablets, or records to explain why the doses were administered. One person needed staff to apply a number of different creams, ointments and lotions to him or her. We found printed directions for using these in one of the bathrooms but there were no records to confirm what had been applied and when. Some of the containers of these products were found in a bowl in a communal bathroom. There was no date of opening on the containers, so staff would not know when to replace the container after it had been in use for the recommended time. This is to prevent risks of cross contamination. One of the containers had a manufacturer’s expiry date of 11.12.08 yet it was still apparently in use. There were several other containers of this cream but they were all outside of the manufacturer’s printed expiry date. We visited another bedroom where there were two containers of creams stored in a cupboard below the basin. These had a recent date when opened but there were no records of when and where the creams had been applied; (the last entry seen on the chart in the bedroom was 08.10.08). The risks of storing some of these creams and ointments in bedrooms and bathrooms must be assessed to make sure the arrangements are safe and secure for everyone living in the home. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 19 We watched the nurse administer some medicines at lunchtime from 1pm onwards in the dining room. One person had returned from hospital that morning and was given some tablets from a supply on the trolley. The nurse was sure that this person was still taking these tablets but when we looked at the discharge letter from the hospital these particular tablets had in fact been stopped. The medication needs for this person should have been thoroughly checked before any further medicines were administered. For another person the nurse left two tablets with one person to take. He or she was sitting at a table with three other people eating lunch and left the tablets on the table whilst going off to the toilet. This is poor and potentially unsafe practice in a home such as this and must stop. Anyone could have helped themselves to these tablets. We spoke to one person who told us about a particular problem experienced. We suggested that this was discussed with the doctor. Staff told us this person does see the doctor but the last entry in the GP record in the care plan was 24.04.08. We found that the proper warning notice was not in place outside a room where an oxygen cylinder and concentrator were in use. This needs attention. There were arrangements to store medicines safely but we found some issues that need attention. Temperature records for the medicine fridge showed this had been a little above 8°C (the maximum for a medicine fridge). The thermostat must be adjusted to reduce the temperature to the range 2 to 8°C. We were concerned that in addition to the clinic room there was a more general store room where we saw large amounts of some medicines were kept. This was evidence of poor stock control of medicines as this was overstocking, but we had also seen examples of medicines being out of stock or out of date. The special cupboard for storing controlled drugs (as required by the Misuse of Drugs (Safe Custody) Regulations 1973) was too small and not properly secured to the wall with two rag or rawl bolts. Three packs of controlled drugs were not kept in this cupboard and there would not have been space for them. We looked at the controlled drug record book and found some inaccurate entries. On page 15 the last entry for a particular 10mcg medicine was booked in on wrong page, as the stock recorded did not agree with what was in the cupboard; this should probably have been entered on page 26. Also on page 15 explanations were needed about a dose on 3.12.08 at 1730 but crossed out; the stock balance was reduced by one but not corrected by the crossing out so it looks as though one patch was not accounted for. There was also confusion between entries on pages 10 and 11 as we were unable to find stock as recorded; it appeared the explanation might be that items on these pages were subsequently entered as received on other pages Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 20 so entries may be duplicated. These issues must be investigated so that completed and accurate entries are made in the controlled drug record book. There were correct arrangements in place for the disposal of medicines no longer needed, with a recording system. It is important that the records for the disposal of any medicine, but particularly controlled medicines, are witnessed and this is included on the records as two signatures as a safeguard that proper practices are followed. There were three glass medicine bottles on the medicine trolleys containing loose tablets or capsules. These had handwritten labels indicating Uplands Nursing Home stock with the name of the medicine (but not always the strength). One of the items should not have been a stock item. There was no way of checking the batch numbers or expiry date for any of these. This is not the way that a registered pharmacy would provide these medicines. This is poor and unsafe practice and must stop. The only medicine reference book we saw in the office was a September 2006 British National Formulary; this should be updated as the current edition is September 2008. We did not find a copy of the policy and procedures about medication in the clinic room where we would expect to find them so that they are readily available to staff. The findings from this inspection indicate that this may need reviewing, with training provided to staff to make sure that they fully understand the good practices for the management of medication that must be followed whilst working in the home. After the inspection we discussed with the registered provider the concerns we had found with the arrangements for medication. We emphasised the large amount of work involved in safely managing medicines for a home of this size and for the administration of medicines in the morning in particular. One nurse on duty in the morning for the home as well as administering and following safe arrangements for medicines for up to 54 people in an accurate and timely way was not sufficient. We overheard staff on numerous occasions being polite, offering choices, with some friendly interactions witnessed. Several residents we spoke to said they ‘liked their rooms’ and confirmed that their privacy was respected. We saw staff knocking on doors before entering. However, one of the inspectors was taken to a bedroom to conduct some interviews with staff, under the impression that the room was not currently occupied, only to later find out that this was not the case; the inspector was told that the ‘person would not mind’. It was the inspector’s view that this was a lack of understanding rather than poor attitude on the part of the staff. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 21 We witnessed a member of the cleaning staff taking their coffee into a resident’s room for their work break (the resident was not present). We stopped this, and advised the home that this would constitute a breach of the occupant’s privacy. There was no dividing curtain between the two beds in one of the shared rooms in the interest of the individuals’ privacy and dignity. This room was currently being used for single occupation, but until recently had been occupied by two residents. There was no curtain track on the ceiling for one to be fitted either. The staff office was extremely small and claustrophobic, and consequently the door was left open all of the time. The home must remain mindful of this, as this practice had the potential for breaches of residents’ confidentiality. Care records contained a ‘Spiritual Needs’ section on the assessment forms, but these were not filled in and there were no ‘end of life’ wishes recorded or care plans to address this area. There had been no staff training in ‘end of life’ care. The acting nurse manager and deputy manager were scheduled to attend an ‘Early recognition of the sick and deteriorating resident’ training course the following month. The acting nurse manager confirmed to us that, in the event, relatives would be welcome to stay with their dying relative if they wished and would be fully supported by the home. There was no designated ‘quiet room’ for relatives in the home under these circumstances, and the acting nurse manager expressed some concern about this. We discussed a recent case of a deceased resident, and the home had liaised with their relative regarding the resident’s wishes, but the acting nurse manager confirmed that there had been no specific care plan to address this. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. Although people living in this home have a good choice of nutritious diet and can receive their visitors, there are factors here that impact on the ability of people to make choices and to remain socially stimulated in their daily lives. EVIDENCE: The social activities co-ordinator had recently left their employment, and the home was in the process of carrying out pre-employment checks on a new person who, we were told, would work across the three homes owned by the Registered Provider. The acting nurse manager told us that carers do bingo and games with the residents sometimes, but several staff told us about a lack of time to sit and chat with residents, and run or organise social activities for them. We saw that the care staff were very busy in the afternoon, and had no time to do this. We saw residents sitting in the lounges, sometimes with staff around, but with minimal social interaction between them and with very little going on. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 23 Two televisions were switched on in the dementia unit lounge, both vying to be heard within a few feet of each other; one of the televisions was tuned into children’s programmes. There was no actual activities programme, but there was evidence of some entertainment being booked occasionally, and a weekly music and movement session. There were piles of books, puzzles and games in the dementia unit lounge. There was a box containing ‘memory diaries’ in smaller dementia unit lounge but, although would be a good initiative, were not filled in. We saw examples where a resident’s social interests and hobbies had been identified in their care records, with a family tree and history; as good as this was, the home needed to build on this information for the resident’s social benefit, and this had not been done in all cases anyway. The home had an open visiting policy, with visitors free to come into the home as they or their relative chose. One visitor told us that they visited their relative regularly and that they always felt welcome here. We witnessed a friendly and positive exchange between staff and two other visitors. We saw a number of residents walking about the home freely, and one resident seemed to be doing chores as she saw it. The resident was smiling and very happy, and clearly benefited from being able to do this; they said that they ‘loved it here’. Some of the residents who had chosen to use the dementia unit lounge were obviously finding the shouting habit of one of the residents particularly disturbing to them, and for some it was impossible to avoid it as they were reliant on staff to help them out of the lounge. Residents were able to introduce personal items of their choice into their private space, and as a consequence some rooms were more personalised than others. We saw the service of breakfast and lunch, and meals were being delivered to all areas of the home where residents were. Cooked breakfasts were served if wanted, and one gentleman said that he ‘always had a full cooked breakfast’. Residents had chosen their lunchtime meal from the menu, assisted by a member of staff, and their lunch was served according to their particular selection. The senior carer was checking the menu choices and directing service from hot trolley in main lounge. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 24 The choices for lunch included chicken casserole or gammon and parsley sauce, with assorted vegetables. The meal was hot, and looked wholesome and plentiful. There was evidence of good portion control. The menus showed that there were three choices at supper, examples being hot soup, assorted sandwiches and another hot choice, such as beans on toast. There were tablecloths on the dining room tables, with plentiful drinks, however there were no condiments. We saw staff regularly encouraging fluids with people, and witnessed carers helping more vulnerable residents to eat their meal. One carer in particular was very encouraging, and was gently coaxing the reluctant resident to eat and drink. Residents indicated to us that they had enjoyed their meal. The kitchen was tidy and clean. Catering records were kept, but refrigerator and deep-freeze temperatures had not been recorded since 3/1/09. The kitchen assistant was very helpful, was clear about her role, and was knowledgeable about some of the residents’ preferences. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 25 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 poor. This judgement has been made using available evidence including a visit to this service. The home’s failure to adhere to safeguarding procedures has resulted in the people living here being placed at risk of harm and abuse. EVIDENCE: A copy of the home’s procedure for addressing people’s complaints was written in small print, and was posted high up on the wall in the entrance hall. This still contained details of the previous registered manager who had left the home approximately nine months ago, and still had the CSCI contact details that were out of date by over one year. The acting nurse manager had a designated complaints’ folder for a complaints recording system, but there was nothing of significance in here, with the acting nurse manager saying that no complaints had been received. The recorded minutes of a staff meeting however showed that a complaint had been raised by a nursing agency, despite the acting nurse manager saying none had been received. We discussed this with Human Resource Manager, who said that she had dealt with incident at the time, but on exploring it with the complainant the complaint was withdrawn. We spoke to one visitor who said that they found staff in the home ‘approachable’ and that they had had ‘no cause to raise any concerns’. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 26 The local authority was investigating a complaint raised by a relative concurrently with this inspection. Although this had yet to be resolved at the time of this visit the home had been supplying conflicting information to the authority in the course of its investigation, which was not helping the fact finding process, and was having the ultimate effect of making the process unnecessarily drawn out. On the advice of CSCI prior to this inspection the home had reviewed its Safeguarding Vulnerable Adults policies, including the Whistle Blowing procedure. The policy continued to state that safeguarding referrals would be made ‘with the consent of the resident’. This piece of policy is not considered appropriate and should be amended, as the home has a duty of care to report any incidents of abuse so that the local safeguarding procedures can be implemented for the protection of vulnerable residents. Most staff received training on Adult Protection and Abuse during their induction-training day. This had consisted mainly of watching a video and a holding a discussion. The Care Services Manager told us that additional training had been arranged for staff who had missed this part of the induction, and that safeguarding information was given to all workers. Despite this, staff did not recall the booklet they had allegedly been given about safeguarding. Staff appeared generally to have a limited understanding of the broader aspects of protection, the various terms and processes and how this should be underpinning the quality of care provided. Some staff said they had had no training in this area, but this may have been just that they could not remember the video from their one day’s induction. Also some staff appeared to understand the issue after some explanation of the context from the inspector. We received varying responses to questions about how or when they would report any concern or suspicion of abuse. Also one staff member said they would be reluctant to put anything in writing and that this would have to be done by the management. Two staff were aware of the Whistle Blowing policy and one said they had read it as part of their induction. The rest of the staff spoken to had no idea what the inspector was referring to, but were clear that they had a responsibility to report concerns. A copy of the Mental Capacity Act 2005 (MCA) Easy-Read version was in the staff office. The acting nurse manager said she had last had safeguarding training in 2008 from the Care Services Manager, and had also done MCA training with the local authority. She said the safeguarding training had included a video presentation showing types of abuse, recognition of abuse, what staff were to do if any concerns were identified, and that there had been a role-play exercise. Prior to this inspection there had been some incidents of alleged abuse in this home by residents upon other residents, which have been the subject of some Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 27 scrutiny and investigation by CSCI and the local authority. There had been instances when the necessary reporting of such incidents had not been carried out, as required, by staff in the home to the relevant authorities. In response to these circumstances CSCI issued a warning letter to the home regarding their failures and breaches of regulation in this area. We discussed these concerns again during the course of this inspection, and the proprietor acknowledged that the home had failed to share information and make the necessary reports and referrals where concerns had arisen, but that they had done things correctly since, and that they would continue to do so in future. The acting nurse manager told us about a particular area of concern she had had in relation to four particular residents who were assessed as being incapable of giving informed consent. She told us that she had contacted the local Adult Protection Unit to discuss the situation and that she had discussed it with the relevant families; copies of associated letters in these cases were seen. We were also told that care plans were in place for these situations, but we did not see these directly. We saw no evidence in residents’ care records about their ability to make informed choices, or regarding their mental capacity and ability to consent. Power of Attorney and representative arrangements were recorded. The acting nurse manager told us that consent had been sought from residents and their representatives where applicable regarding influenza vaccinations. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 28 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 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Apart from some minor concerns people living in this home are generally provided with accommodation that is suitable to meet their needs. EVIDENCE: There was a stale smell on entering the home, however the environment appeared to be reasonably clean and, apart from a couple of rooms, was free from any pungent odours. All bedrooms we saw were adequately decorated and furniture and fittings were in reasonable order. Some of the bedrooms we visited seemed cold; two did not have the radiators switched on, and two were cold despite the radiators being on. Some residents said they preferred them cooler and some said the rooms were not hot enough. We reported this to the proprietor who said he would address this. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 29 A new front door and porch had been completed to a good standard, and this provided additional security as well as enhancing the entrance to the home. The ground floor corridor carpet in the dementia unit looked well worn, but the acting nurse manager told us that she thought this ‘may be scheduled for replacement’. The curtains remained partially drawn in the smaller dementia unit lounge throughout the day. There was still adequate daylight in the room, but no-one could say why the curtains remained partially drawn on a fairly dull day. The window frames in here were slightly dirty with some dust build up in parts. The home was generally in a satisfactory state of decorative repair, although there were some areas of damaged and rough paintwork around the ground floor corridors. The laundry facilities were provided in a small and cluttered room. The emulsion paint on the walls was flaking off in places, and could do with some attention. The laundry equipment was capable of sluicing and disinfecting foul laundry. The experienced laundry assistant was aware of the necessary infection control procedures, and foul items were being appropriately segregated for laundering. Hand washing facilities with liquid soaps, alcohol sanitising hand gels and paper hand towels were available, and there were plenty of gloves and aprons available for staff. However, the laundry room had run out of liquid soap, and a normal bar of soap was being used in here; we pointed out that this was not advisable as it could pose an infection control risk. We spoke to one of the cleaners, who was aware of the importance of locking chemicals away. The cleaner told us that staff did not use the sluice machine for cleaning commode pans, as they preferred the manual one adjacent to the nursing unit. The home had two cleaners on duty on five mornings of the week, rising to three on three days, with one on a Saturday. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 30 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 poor. This judgement has been made using available evidence including a visit to this service. The shortfalls in the way that staff are recruited and supported to train and develop professionally are posing risks to the care and wellbeing of the people living in this home in relation to staff suitability, skills and competencies. EVIDENCE: The staff rotas showed that in general there were eight carers on duty in the mornings, six in the afternoon and evening, three at night, with one registered nurse on duty at all times. There were occasions where there were nine carers on duty at weekends, which was reported to be an extra one to cover laundry duties, as there was no laundry assistant provided at the weekend. We saw that there were some gaps on the rota when staffing had reduced to seven and five carers when late or unavoidable absences could not be covered. On the latest rota there were a large number of shifts left to be covered. We were told that these would be filled by offers from the existing staff team or by an agency otherwise. Care staff told us that they felt ‘over-stretched’ at times, and we could see that staff were very busy throughout the day. Because of this there were times when residents sitting in the main lounge were unsupervised and unattended. We met at least two care staff, one of whom had come from an agency, who were each working an early and a late shift on the same day. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 31 Despite this particular agency carer saying that he regularly worked here and knew the home and its residents well, the regular and significant use of agency staff could give rise to inconsistency and unfamiliarity for the residents. For the purposes of working with groups of residents the staff team was divided into sections of the home, namely the ‘house’, the ‘corridor’, and the ‘dementia lounge’. Staff appeared to be caring and motivated but they clearly saw a large number of tasks around recording, care planning and assessing as being the responsibility of the management. There was no key-worker system, and this appeared to contribute to an apparent de-skilling of staff and the removing of accountability and the lack of encouragement for care staff to use their initiative and imagination. We interviewed or spoke with eight members of the care team. All seemed generally positive about teamwork and peer support, and were pleased that staff meetings were starting again. All spoke positively about quality of care and the commitment of their colleagues. However several mentioned difficulties that had been caused on previous occasions when there was reportedly a high number of foreign staff working at the home whose lack of understanding of the English language caused problems within the team. We saw minutes of a staff meeting held in September 2008 that contained a clear reminder for staff to use English when dealing with residents and not their native language. One visitor told us that she ‘thought there was a good team’. There were four care staff who had just started or were about to start the National Vocational Qualification (NVQ) training, whilst two other staff already held this qualification; this current level does not meet the national minimum standard of at least 50 of carers being qualified to NVQ level 2. There appeared to be a lack of clarity about the route for this training and the expectation upon staff about when they would undertake it. There was no NVQ assessor on the staff team although the Care Services Manager told us that the deputy manager would be undertaking the necessary assessor’s training. Two staff files of recently recruited carers were inspected. In each instance, the prospective employee had completed an application form providing details of their employment history. In one case this history was only brief, and the person had not worked since 1996, having retired at that time. The employment history had reportedly been explored at interview with the Human Resources (HR) Manager during interview, however the interview notes had not been kept, as would be good practice. This history of employment, with none reported for many years, had presented a slight problem in terms of obtaining references. The person had no history of working with vulnerable adults at any time, and character references were sought from three professional people in reputable positions. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 32 A full Criminal Records Bureau (CRB) disclosure and Protection of Vulnerable Adults (POVA) check had been obtained prior to employment commencing, and a copy of the disclosure was shown to us. In the second case there was a very full employment history recorded on the application form, and this person had previously worked with vulnerable adults. Appropriate professional references had been obtained, including from the employer for whom the person had worked with vulnerable adults, and the reasons why they had left that employ had been sought and obtained on the reference. The home was not in receipt of the full CRB check for this person at the time of this inspection, evidently due to an incomplete declaration of the home address history, but we saw evidence that a POVA First check had been done prior to employment commencing. However, this person was working largely unsupervised in the absence of a full disclosure having being received. The acting nurse manager said that she did not know that the person’s full CRB had not been received. We made it absolutely clear to the acting nurse manager and the HR Manager that this was a breach of regulations. Clear guidance on recruitment matters has been given to the proprietor on previous occasions. We advised that the acting nurse manager must have some method of communication with HR in the company office, to be certain of the suitability of people starting work in the home, and to decide whether additional supervision would be necessary. Proof of identity and evidence of medical fitness had been obtained in both cases. The HR Manager was very helpful and professional towards the inspection process, and told us that she brought job applicants over to the home to look round and meet people. Job descriptions, contracts, equal opportunities forms, and a pack of health and safety and fire safety information was issued to all staff, and a copy of the General Social Care Council’s Code of Conduct was also issued to all carers. The Care Services Manager told us that staff received an induction training on one day when starting at the home. Most of those we spoke to said they had had one day’s induction and then had shadowed other staff for between three to five days. Two people told us they had had no induction and had started shadowing more experienced staff straight away. Some staff were unaware of what the term ‘induction’ referred to. The acting nurse manager said that all staff had an induction booklet that had to be completed. These different perceptions of the induction process were concerning. No staff mentioned the Common Induction Standards (CIS) or recalled the induction booklet itself. A mixed induction over a three day period including observation of staff, reading of policies, care plans and more training on Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 33 dementia concluding with supervision meetings to establish areas of concern or weakness would be much better. The induction training over just one day appeared to be too intense and we stated that in our judgement there was a need for a more structured and planned induction that would include competency based assessments from senior staff, which could be monitored and followed through during supervision. It was particularly poor that there was no formal supervision for new staff or assessment of their competence or attitude or understanding. Staff confirmed that they had not undertaken moving and handling tasks until they had undergone specific moving and handling training, which was a one day course that included information about the use of hoists and moving equipment. One staff member explained how the need for some different slings and sliding sheets was brought to the attention of the managers, which the carer was surprised were not in place already, but after speaking directly to the proprietor these had now been ordered. Some staff said they had received training in dementia care, but others were a little vague about this, and again this seemed to be mainly a video presentation and discussion. Some staff said they had not had any training in dementia, although the records indicated that they had; in our view this was more of a reflection on the quality of the training rather than on any mistakes in the training records. When we asked an agency carer about their level of training they told us that they had received moving and handling training, and did not mention anything about induction or dementia care. The planning and monitoring of training was not very well organised as there was no matrix system in place for planning and targeting training, and there was no system for getting feedback on the workers’ experience or effectiveness of the training. Any training that was delivered seemed to be provided internally by the Care Services Manager, with little contact with accredited external training providers, which would be of much greater benefit to the staff, home and residents. In general, induction, ongoing training and supervision needed to be planned professionally and systematically, particularly for the first twelve months, and greater clarity needed to be given towards the expectations for staff to undergo training. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 34 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 poor. This judgement has been made using available evidence including a visit to this service. There needs to be greater commitment and consistency with the management and monitoring of standards in this home so as to prevent risks to the interests and wellbeing of the people who live here. EVIDENCE: There has been a degree of instability with the management of Uplands over the past ten months following the departure of the registered manager early in 2008, with a newly appointed manager after that leaving after only a short time in post. The home’s long standing deputy manager has now been appointed to this role, although she has not been registered with CSCI; she confirmed to us that she had submitted her application to CSCI for consideration. She appeared to Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 35 have no clear autonomy for managing the service, with the Registered Provider and the Care Services Manager maintaining control over certain aspects of the running of it, and its strategic and financial planning. The appointed nurse manager is a first level nurse. She does not have the Registered Manager’s Award or a specific Dementia Care qualification. The recently appointed deputy manager is a qualified mental health nurse. The acting nurse manager has worked at the home for a long time, and appeared genuinely caring, pleasant and helpful. She fully acknowledged the significant shortfalls that we identified during this inspection, but could offer us no real explanation as to why these existed. The proprietor told us that the outgoing manager had been a factor in this and that the new manager had not had the time to start to rectify things. When asked, the proprietor declared his confidence in the newly appointed manager to address the enormity of the task facing her at Uplands to improve standards. We stressed the importance of how the home had clearly suffered from poor leadership and that an improvement in this area was going to be crucial to the life of the home, residents and staff. We also told the proprietor that in our view the acting nurse manager needed more supernumerary time in which to go about implementing an improvement programme; she currently has eighteen hours each week. The deputy manager works full time but has no supernumerary time. The proprietor declared his very clear intent to us to put things right in the home, and do whatever it took to achieve this. He stated that the acting nurse manager could have a second nurse in the mornings, and that she only had to say what she needed and she would get it. We spoke to one visitor who said that they ‘found the management approachable’. A satisfaction survey was last done for residents and visitors in September 2008. There was recorded evidence of the collated results, with plans to address areas of concern seen for that period, but nothing since. The Care Services Manager acknowledged that provider visits to check standards and circumstances in the home, as required under Regulation 26, had not been carried out consistently. We saw no evidence of any other auditing tools in the home. Recorded minutes of a relatives’ meeting were seen for September 2007 when information was discussed and shared, but there was no evidence of anything since. We saw recorded minutes for a staff meeting held in September 2008. There was very little evidence that much had been done regarding quality monitoring, with standards generally having fallen since the last key inspection. The proprietor and acting nurse manager acknowledged that this was the case and accepted and listened intently to all our feedback in all areas. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 36 The management of residents’ monies placed with the home for safekeeping was not inspected on this occasion, with no changes to the systems having taken place since records were seen to be in order at the last inspection. There was no staff supervision-planning matrix in place, with no formal programme in progress. We saw that the previous manager had compiled appraisal forms into a folder, but none had been carried out. The acting nurse manager acknowledged that formal staff supervision and appraisals had not taken place, but that she was aware of the requirement to do it, and of the standard for at least six formal sessions in each twelve-month period. The acting nurse manager stated that she and the deputy manager were planning to implement a programme. All staff we spoke to confirmed to us that they did not receive formal supervision and none could recall having any sort of appraisal. Maintenance records showed that fire extinguishers had been serviced in July 2008. The fire alarms and emergency lights had been checked for electrical safety in January 2007, although there were certificates on file for when the new accommodation opened a year ago. There were automatic door closers fitted to the doors for the event of fire, and there were battery stocks available when needed. One of the fire exits on the ground floor had a piece of string attached to the fire door bolt, with a temporary gate in front of the door. When this was pointed out to the acting nurse manager she removed it immediately and acknowledged that this was unacceptable and dangerous. She told us that it was due to one particular resident repeatedly breaking the ‘break glass tube’ on the security lock of the fire door, and that they required replacing each time. Some staff said they had received fire safety training but others said they had not. Some said the training was in the form of being given a document about fire safety procedures, some said they had been shown the alarm system and evacuation points. Management told us that the fire service comes once a year to train staff, but records of this were not seen directly; staff we spoke to did not mention this. The home had at least two first aid kits, but care staff were not trained in first aid, with the home reliant on the skills of the qualified nurses in this area. The home must reconsider this provision of first aid skills. The resident call bell system was last serviced in July 2008; the passenger lift was last serviced in September 2008; the laundry equipment was last serviced in July 2008, and resident hoisting equipment was last serviced in June and October 2008. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 37 The records showed that the home’s maintenance person last checked the portable electrical appliances for safety in May 2006. The proprietor confirmed the maintenance person had regularly done this since, as well as doing regular safety checks on the hot water system, although he could not locate the recent records for inspection. There was evidence that an electrical safety installation check had been carried out within the past five years, although there was no actual certificate. The gas boiler had not been serviced for some time, with records indicating the last check was in March 2007. When asked about the servicing engineer’s CORGI (Council of Registered Gas Installers) registration the proprietor confirmed they were so registered. Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 38 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 1 X 2 Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 39 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The registered person must complete the review and implementation of the new care planning system for all residents. This is in order that residents’ needs can be clearly identified so that they can be met in full. The registered person must revise and update the care plans on the basis of regular reviews, so that residents’ changing needs are reflected and can be appropriately catered for. The registered person must ensure that the home maintains a full record of all medical visits and treatments to all residents. The registered person must ensure that the home monitors the weight of those residents who are at risk nutritionally, and takes appropriate actions to address the risks and concerns, so that their nutritional health needs can be met. The registered person must take action to ensure that there are effective arrangements in place to monitor stock levels and DS0000016643.V373520.R01.S.doc Timescale for action 28/02/09 2 OP8 15(2b) & 12(1a) 28/02/09 3 OP8 17(1) Schedule 3(k) 12(1) 28/02/09 4 OP8 28/02/09 5 OP9 13(2) 28/02/09 Uplands Nursing Home Version 5.2 Page 40 6 OP9 13(2) 7 OP9 13(2) 8 OP9 13(2) expiry dates and to reorder medication and prescribed items in sufficient time so that medicines of the correct quality are always available to administer to people in the home in accordance with the doctor’s directions. This is to protect people from risks of not having their prescribed treatments available and within date when needed. The registered person must 28/02/09 ensure that when any medication (including prescribed treatments for external use) is administered or applied to people who live in the home it is always clearly and accurately recorded. (This particularly relates to the shortfalls in records seen at the inspection and included in the text of the report). This is to help to make sure people receive their prescribed medication correctly and to help reduce risks of mistakes. The registered person must 28/02/09 ensure that when medication is administered to people who live in the home this is in accordance with the doctor’s directions, with arrangements in place to make sure changes to these directions are effectively implemented. (This particularly relates to lack of effective arrangements for the correct medication as included in the text of the report when people were transferred from hospital or another home or following a change in prescription.) This will help to make sure people receive the correct levels of medication. The registered person must 28/02/09 ensure that the home tells us the DS0000016643.V373520.R01.S.doc Version 5.2 Page 41 Uplands Nursing Home 9 OP9 13(2) 10 OP9 13(2) 11 OP10 12(4a) outcome of its investigations to determine the reasons for the discrepancies noted in the controlled drugs record book. This is to make sure that these arrangements fully and accurately account for all medicines and there is a robust audit system in place. The registered person must 15/03/09 ensure that for any medication labelled for use when required, as directed or with a variable dose, there is always clear written direction for staff on how to make decisions about administration for each person and medicine and in accordance with the Mental Capacity Act 2005. This will help to make sure there is some consistency for people to receive the correct levels of medication in accordance with their needs and planned actions. The registered person must 31/03/09 ensure that storage arrangements used for all controlled drugs is in accordance with the Misuse of Drugs (Safe Custody) Regulations 1973. This is to make sure all these medicines are stored securely and in accordance with the law. The registered person must 28/02/09 ensure that there are full arrangements in the home to ensure the privacy and dignity of all residents in all areas. (This particularly relates to the shortfalls seen at the inspection and included in the text of the report). The registered person must ensure that residents’ needs and wishes are ascertained regarding their ‘end of life’ care, and DS0000016643.V373520.R01.S.doc 12 OP11 12 (1,2,3) 31/03/09 Uplands Nursing Home Version 5.2 Page 42 13 OP12 16 (m,n) 14 OP14 12(3) 15 OP16 22(7) 16 OP18 13(6) & 18(1.ci) 17 OP18 13(6) 18 OP18 13(6) recorded in specific plans of care. The registered person must ensure that the home provides a social activities programme that meets residents’ needs and abilities. The registered person must ensure that the home takes account of residents’ wishes and feelings. (This is in relation to other residents’ behaviour impacting on them in a negative way) The registered person must ensure that the Complaints’ policy and procedure is reviewed and updated, so that interested parties have access to the correct contact details should they need them. The registered person must ensure that all staff receive updated training in safeguarding vulnerable adults, so that all are equipped with the necessary skills and knowledge to protect the vulnerable residents in their care. The registered person must ensure that all staff adhere to the policies and local protocols to protect vulnerable residents and prevent abuse taking place. The registered person must ensure that care records are made and kept regarding residents’ ability to consent and make informed decisions, so that their rights and interests can be upheld at all times. In circumstances where new staff commence employment pursuant to the receipt of a Criminal Records Bureau disclosure the registered person must: DS0000016643.V373520.R01.S.doc 31/03/09 28/02/09 31/03/09 30/04/09 28/02/09 31/03/09 19 OP29 19 (11) 28/02/09 Uplands Nursing Home Version 5.2 Page 43 • Appoint an appropriately qualified and experienced ‘staff member’ to supervise the new worker, pending receipt of a satisfactory disclosure So far as is possible, ensure that the ‘staff member’ is on duty at the same time as the new worker; and Ensure that the new worker does not escort service users away from the care home premises unless accompanied by the ‘staff member’. • • 20 OP30 18(1.c)(i) & (2) (This is to ensure that only suitable people are employed to work with vulnerable residents, and to promote their safety). The registered person must ensure that structured induction training is delivered in line with the Common Induction Standards for all care staff, and that they are regularly supervised during this period. (This is to ensure that new staff are equipped with skills for their role, to ensure their performance is monitored, and for the protection of the vulnerable residents) 31/03/09 21 OP30 18(1ci) 22 OP31 9 (2.bi) 18 (1.ci) The registered person must ensure that all relevant staff receive updated training in Dementia Care and Managing Challenging Behaviour, so that staff are equipped to deal with the needs of the vulnerable residents. The registered person must ensure that the recently DS0000016643.V373520.R01.S.doc 31/05/09 31/05/09 Uplands Nursing Home Version 5.2 Page 44 23 OP33 24 (1) 24 OP33 26(1), (4c) & (5.a) 25 OP36 18(2a) 26 OP38 23(4.d.e) 27 OP38 13(4) appointed nurse manager has arrangements in place to obtain the necessary qualifications for managing the home and the specific needs of the residents accommodated. The registered person must establish and maintain a system for monitoring and evaluating the service, in order that the quality of the service can be improved for the benefit of the residents. The registered person must carry out visits to the home and compile written reports required under this regulation and provide such reports to CSCI every month. The registered person must ensure that a structured staff supervision programme is implemented, so that staff can receive clear direction and support in their work, and so that their performance can be monitored for the benefit of the residents. The registered person must ensure that all staff receive fire safety training on a regular basis, which must include regular fire drills, so as to ensure their safety, and that of the home and the residents. The registered person must risk assess the current level of First Aid qualified staff to ensure that it can meet the needs of the residents in the home. 31/05/09 28/02/09 31/03/09 31/03/09 31/03/09 Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 45 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 OP8 Good Practice Recommendations The registered person should ensure that: • Information in relation to residents’ life histories is recorded in full • Entries on all monitoring charts relating to the home’s residents is made, signed and dated by the relevant person • Residents are weighed at least monthly • The home operates a key-worker system for the benefit of residents. The registered person should ensure that: • Medication records are reviewed to make sure that the allergy box on each medicine chart is always completed accurately and that any handwritten entries on medicine charts are signed and dated by the member of staff writing this with a check by second member of staff that the information is complete and accurate • Where creams or ointments are stored in bedrooms written risk assessments are carried out to make sure the arrangements are safe for everyone in the home • Staff write the date on containers of any medicines when they are first opened to use and record the quantity of any stocks of medicines that are carried forward to the next medication cycle. This is to help with good stock rotation in accordance with the manufacturers’ or good practice directions and to enable audit checks that medicines are being used correctly and the right quantities remain in stock • The home reviews and updates the medicine policy and local procedures so as to provide all staff with clear direction about the way medicines are safely managed and handled in this home • Proper warning signs are placed in areas where oxygen cylinders are stored or in use • Recording arrangements for witnessing inactivation or disposal of all medicines includes records being signed by two authorised members of staff. The registered person should ensure that all staff are DS0000016643.V373520.R01.S.doc Version 5.2 Page 46 2 OP9 3 OP11 Uplands Nursing Home 4 OP12 5 6 7 8 OP14 OP15 OP16 OP18 9 OP27 10 11 12 OP28 OP29 OP30 13 OP36 14 OP38 given training in ‘End of Life’ care for dying residents. The registered person should ensure that the home keeps detailed records of residents’ social interests and hobbies in order to inform the development of the social activities programme. The registered person should ensure that staff maintain a presence in the dementia care lounge in order that a fuller account can be taken of residents’ wishes who sit in there. The registered person should ensure that condiments are provided on the dining tables for residents’ use. The registered person should ensure that the Complaints’ procedure is displayed more accessibly on the notice board. The registered person should ensure that all staff receive: • The Alerter’s training for safeguarding vulnerable residents • Mental Capacity Act (2005) training. The registered person should ensure that the home: • Employs higher numbers of its own regular staff so as to reduce the use of temporary agency staff and the contracted staff working additional hours • Adopts a key worker system in order to enhance staff accountability. The registered person should ensure that at least 50 of the care staff are qualified to at least NVQ 2 level or equivalent. The registered person should ensure that copies of interview notes are kept following interviews with prospective employees. The registered person should ensure that there is: • Ongoing competency assessments for staff, particularly for new staff • A training matrix to plan, implement and monitor a suitable training and development programme for all staff • Training for staff is sourced from accredited external training providers. The registered person should ensure that there is: • Staff supervision being given at least 6 times each year • A matrix being devised to plan and monitor the progress of the programme. The registered person should ensure that: • The gas boilers are serviced annually • Clear records are maintained and available of all maintenance undertaken and of all checks on utilities and equipment. DS0000016643.V373520.R01.S.doc Version 5.2 Page 47 Uplands Nursing Home Uplands Nursing Home DS0000016643.V373520.R01.S.doc Version 5.2 Page 48 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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