Inspection on 09/05/05 for Warrens Hall Nursing Home

This inspection was carried out on 9th May 2005.

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

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

Other inspections for this house

Warrens Hall Nursing Home 23/05/09

Warrens Hall Nursing Home 20/08/08

Warrens Hall Nursing Home 11/06/07

Warrens Hall Nursing Home 05/06/06

Warrens Hall Nursing Home 07/11/05

Warrens Hall Nursing Home 10/01/05

Warrens Hall Nursing Home 14/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Warrens Hall Nursing Home 218 Oakham Road Tividale West Midlands. B69 1PY Lead Inspector Cathy Moore Unannounced 9 May 2005 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 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. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Warrens Hall Nursing Home Address 218 Oakham Road Tividale West Midlands. B69 1PY 01384 455202 01384 240068 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) ANS Homes Ltd. Pauline Starrs Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56) of places Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/13.01.05 Brief Description of the Service: Warrens Hall Nursing home is part purpose built which is attached to another converted buidling which was formerly a farmhouse. The home has been a registered care home since 1990. The home is owned and managed by ANS and is registered primarily to provide nursing care to a maximum of 56 older people. The home is close to Dudley golf course and adjacent to riding stables . There are pleasant views from the back of the home of open fields. Accommodation is spread over two floors and has three distinct units known as Rowley, Malvern and Clent. There are 40 single ensuite rooms , 4 single rooms without ensuite facilities and 6 double rooms. The home provides three lounges and two dining rooms. The home has a lift enabling residents access to all floors. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day between 08.00 and 20.30 hours. The inspection involved two regulation inspectors, one pharmacy inspector and a contracts officer from the main funding authority. The inspection was conducted in part as a routine statutory inspection and part due to on-going concerns. Five residents files were scrutinised in detail, others examined in less detail. Four residents were spoken to at length. Four staff were interviewed and four staff members personal files were examined. The premises were randomly assessed, to include lounges, bathrooms, toilets and a number of bedrooms. Health and safety and infection control aspects and records were assessed. Complaints documentation, menus and were examined. A full audit of the home’s medications and medication systems were observed and scrutinised by the pharmacy inspector. What the service does well: The home is owned by a large organisation, which operates over forty other care homes and offers a potential for support and advice. The home is located in a pleasant residential area, which offers panoramic views to the rear. A number of the care staff have been in post for several years providing consistency to the residents. A number of residents comments were obtained during the inspection and included “ They are all really nice to me”, “The food is good “, “couldn’t wish for a better place”, “can’t express my thanks”, “carers have been golden to me”. Staff comments obtained included, “we have time to get to know the residents”, when I came here I did not have any qualifications, now I have got some”, “everybody is friendly”, “ I like the friendly atmosphere, whatever grade of staff, homely type”, “Scope for training, training dates known in advance”, “manager at other end of line, accessible and supportive”. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: The home has been given over eighty requirements following this inspection, a number of these remain outstanding from previous inspections. Record keeping, adherence to procedures, staff training, direct nursing and care delivery and health and safety issues remain very concerning. Lessons have not been learnt by this home and organisation. There have been three situations in the last year where policies have not been followed, practices questioned: situations have arisen that have been referred for local authority vulnerable adult protection proceedings due to delays in obtaining medical attention, a medication error where the nurse concerned has been dismissed and referred to the Protection of Vulnerable Adults list and to the Nursing and Midwifery Council. A further, fourth incident was identified during this inspection where a resident had become unwell. There was no evidence to demonstrate that the doctor had been summoned and no evidence of fluid monitoring to prevent her becoming dehydrated. This incident was also referred for vulnerable adult protection proceedings. Immediate requirements and serious concern letters were issued by the Commission. The organisation must give priority attention to and address urgently the requirements made in this report to ensure improvements across all areas highlighted. The Commission’s prescription for improvement will be closely monitored and the Commission will work with the home to achieve the Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 7 requirements. However, if no improvement is evident or other untoward situations occur where there is evidence of non- action or no evidence of action placing residents at risk, then the Commission may take further serious enforcement action and or prosecution proceedings. 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. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4 Provision of information for prospective residents needs to be developed. Contracts and terms and conditions must be put in place for all residents and residents must be fully involved in their needs assessment. Residents and their representatives must be assured that their needs will be met by the home. EVIDENCE: A statement of purpose and service user guide were available. However, these documents are not in a format appropriate to all residents, for example large print or pictorial format. The statement of purpose did not specifically detail how the physical environment standards in respect of the home are being met. There was no evidence available to demonstrate that the home actively provides a copy of the service user guide to residents or other stakeholders. A terms and conditions document was seen to be in use. However, there was no contract available for a newly admitted resident who was self-funding his placement (D.A) and no terms and conditions document for (J.B). The fee on other documents had not always been detailed. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 10 An assessment of need process is in place for prospective residents. However, there was no evidence to suggest that the resident had been involved in this process. The assessment of need process must be more specific to ensure that the primary diagnosis of each resident is formally confirmed and recorded on their assessment of need documentation before a placement is offered. This to prevent prospective residents who have needs, for example dementia, that are not reflected in the homes registration categories being offered a placement. Two residents (R.L, E.D) records suggest that they have a diagnosis of dementia; another resident (D.H) has been admitted into hospital for assessment of his behaviour. The primary diagnosis of these three requires written confirmation from an appropriate professional. If any are confirmed as having a primary mental disorder or dementia diagnosis, then a variation application must be made to the CSCI office, as the home is not registered to care for people with these diagnoses. There was no evidence that a written acknowledgement had been given to (D.A) or (E.D) confirming their needs and how these will be met. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 Inadequate care planning processes, poor response to clinical situations and care needs, lack of instruction dissemination to staff and non-adherence to safe handling and administration of medications, has caused severe consequences for four residents in the past year. Risk to residents and potential for omissions remains high. EVIDENCE: Requirements were made following the last inspection in respect of care planning processes and documentation, examples being care plan tracking methods, content and the involvement of residents in their individual care planning and reviews. Little improvement was noted, these requirements remain unmet. The care plan system is separated into various sections, care plan assessment, summary and specialist areas. The tracking of all these sections is hard to follow, this view was confirmed by the manager. Residents needs are not all incorporated into their care plans examples being, continence promotion, aggression, risk assessment and medication. Care plan content for other areas is poor, one resident (J.B) has an indwelling catheter, and his care plan lacks specific detail of instruction of how this catheter should be cared for. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 12 Another resident (B) has a history of respiratory problems. On the 13.4.05 he had an attack where his lips were cyanosed, yet his care plan does not give sufficient detail of what staff should do if he becomes breathless or for usage of his inhaler. The care plan of a resident (D.A) who became unwell had not been updated. There was no evidence that residents are involved in the compilation of or review of their care plans. Social activity and activity care plans were not being met for (E.D and M.R). The actual activity participation did not reflect the care plan. There was little mention of (M.R) poor sleeping patterns in respect of her shouting and screaming at night. The management of falls does appear to have improved in that policies and procedures have been produced informing staff what they must do if a resident has a fall and hurts themselves, or if a doctor makes a judgement and nursing staff are not satisfied with this judgement. There was however, no evidence to demonstrate that staff have read and signed these policies. New mechanisms have been implemented that if a resident has a fall and no apparent injury is sustained then monitoring and accompanying recordings on a set template is carried out over a 48-hour period. Concerns were identified in that resident (D.A) had become unwell and had vomited ‘black stuff’ at 07.00 hours 2.5.05 medical assistance was not requested until 17.00 hours 2.5.05 when she was found to be ‘unresponsive’. Records state “ staff instructed to observe closely” but did not say how or when. From 07.00 hours 2.5.05 until the last entry made at 17.00 hours 2.5.05 (before admission to hospital) the only record of fluid intake was 100 millilitres fluid and 15 millilitres of medication. No fluid balance chart could be located in respect of this resident for the day in question, who had a history of being prone to dehydration. The resident later deteriorated, was admitted to hospital and died the next day. This incident generated great concern as this was the fourth time in a twelve month period where inadequate actions/ lack of evidence of appropriate action in response to injury, illness and nonconformance to policies has been identified. The incident was referred to the local authority in accordance with their multi-agency adult protection guidance. Other recordings in respect of changes of position (turns) were inconsistent. One resident (B.H) stated, “ they are supposed to turn me every two hours but if I am asleep they leave me alone”. (E.D) care plan states position to be moved every 2-3 hours but there was no specific recordings to demonstrate that this is being done. There was a lack of clarity identified on what pressure relieving appliances should be provided with regard to individual residents. Recording gaps were identified in the daily recording of personal care delivery for example (B.H) personal care delivery records showed that he had not had a bath for some time and did not reflect what had been provided as an alternative. Similarly, (D.A’s) personal care record revealed that only one bath had been given in the month of April 05. Weight monitoring was also identified Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 13 as being inadequate. Continence promotion was lacking. When this was raised in respect of one resident with one staff member the response was “ she uses pads”. It was difficult to establish from records available if all residents are having access to all of the main health care services or an annual review of their health from their doctor. Medication storage was observed to be safe and secure in locked cupboards. There was some evidence of medication audit undertaken. Care plans seen lacked clear reference to medication. It was highlighted that in some circumstances care staff are being asked to observe that medication had been taken by the resident or asked to give medication to residents. Care staff interviewed were able to give an account of how they ensure that residents dignity and privacy is ensured when they deliver personal care, one care staff commented “ I make sure that I have everything ready before I start bathing, I give choices, I make sure that the curtains are drawn and the door is shut, I make sure that as much of the body is covered up at all times when washing”. One resident commented, “ the staff look after me well”. Residents records identified a lack of recording of their last wishes in respect of dying and death. Training on dying and death has not been received by all staff. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 Though there are some efforts to engage residents in recreational and social activity matching these efforts to expectations and preferences needs to be developed as do resources to allow this to happen. Dietary provision appears reasonable though lack of recording of food intake hinders this judgement. Supper menu should be provided and condiments made available. EVIDENCE: It is positive that the home has a dedicated activities co-ordinator. The home had held a Victory in Europe theme day. One resident commented about the activity provision” they give me colouring to do, I like colouring”. However, she also commented “ I am lonely sometimes with nothing to do”. The activity co-ordinator records individual resident activity participation however, records of activity provision and participation when she is not on duty is poor. It was identified that insufficient one to one activity provision is aimed at those residents who have more complex needs or who spend considerable amounts of time in their bedrooms. Activity care plans are not being updated as they should, when they are not working. The home has a set menu, however supper was not detailed on these menus. A record of some residents daily food intake is being recorded, but not for all. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 15 Where food intake charts are in use the recording in some cases was inadequate or inconsistently completed .The records for the residents where food intake is being recorded lacked supper time food, thus there was no evidence to suggest that food is offered to residents between tea time one day and breakfast the next. The manager did comment “ Sandwiches are always available during the evening and night time”. Food stocks seen were ample and varied with fresh and frozen foods. The home has dedicated catering staff. One resident commented “ Dinners not very good, no salt. Don’t eat much because no salt”. Another resident said, “ The food is always good”. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 More effort must be made to raise awareness of complaints procedures amongst residents and their families. Policy, procedure, training support and management responsibilities and response require considerable development to ensure residents are protected from abuse. EVIDENCE: The home has a written complaints procedure in place which has been produced in a standard font format. There was no evidence to suggest that the complaints procedure has been produced in other formats for example, large print or pictorial format. There was no evidence to suggest that residents or relatives are reminded of the homes complaints procedure and how to access this. Complaints records were perused. No complaints have been recorded by the home for some time. The home has a number of policies and procedures in place aimed to protect vulnerable adults. A number of which do not accord with good practice or Department of Health guidance, for example the whistle blowing policy makes reference to the staff grievance policy. These two policies must be kept as two separate entities. Not all staff were aware of the whistle blowing policy. A number of staff have received adult abuse awareness training, but not all. Adult abuse polices must accord with Sandwell multi-agency adult protection guidance. Two incidents have occurred in the last six months where staff have been dismissed and referred to the Protection Of Vulnerable Adults list, one also referred to the Nursing and Midwifery Council. Whilst it is positive that these instances were reported by the home to the appropriate agencies, clear Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 17 written guidance/ training must be given to staff to prevent instances of this nature occurring in the first place. However, staff spoken to were able to give differing definitions of abusive / neglectful practice, all stated that they would report any concerns immediately. Staff spoken to were able to give an acceptable definition of confidentiality and examples of when, resident confidentiality may have to be disclosed to relevant others if there is a cause for concern. There was no evidence available to demonstrate that staff have re-read the homes confidentiality policy. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,21,24, 26 Though improvements have been made to enhance the environment these must continue and plans for improvement should define timescales for completion of work required. Attention to detail is required with regard to the environment and facilities to ensure residents’ comfort and safety and cleanliness/hygiene of the home. EVIDENCE: From observations it was identified that improvements have been made to the environment, as the external redecoration has been completed, a number of rooms internally have been redecorated and new carpets provided. However, further redecoration internally is needed and replacement of carpets. There was evidence of wheelchair damage to décor and need for carpet replacement and redecoration in a number of areas. A programme of maintenance was available, however, this document did not detail a production date. Some areas identified as requiring attention did not have a specific timescale only “ to be done “ detailed. The courtyard area is having work undertaken at the present time. The courtyard was seen however, not to be fully appropriately, accessible Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 19 as some ramps have raised areas which may present a tripping hazard or difficulty in manoeuvring wheelchairs. The security of the home was questioned as both external reception doors were unlocked, presenting an opportunity for anyone to gain access to the home. Rowley unit has a lack of bathing and toilet facilities. One bedroom has no usable toilet located nearby. The bathroom on this unit is not used, as it does not have any hoisting equipment. Storage space is lacking. Portable, electrical hoisting equipment was seen stored in bathrooms. Audit documentation of bedrooms against standard 24 has commenced but has not been completed. The wardrobe in (E.D) bedroom was not secured. Further, the floor in this room was uneven, the wardrobe tilted, presenting as a potential hazard. Bathrooms were seen to be dimly lit. There was no evidence that these rooms have been tested in respect of lux requirements. The ventilation system in the bathroom by the nurses station is not in full working order. The laundry as highlighted during the previous report is too small for the size of the home. There was a lack of protective clothing provided in the laundry, staff were seen to be using rubber gloves instead of disposable gloves. Cleaning schedules and infection control policies in the laundry were inadequate. The floor in the laundry requires replacement/ recoating. There is only one sink in the laundry instead of the required two. Clinical waste bins outside, were not locked as required from the previous inspection. The cat litter tray was seen to be part full outside. . Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27.29,30 Numbers of staff and skill mix must be matched to dependency of the resident population and accord with changes therein. Recruitment safeguards require further development. Staff training in specialist areas of care must be improved. EVIDENCE: It is positive that the organisation has employed two new nurses in the last two weeks. The manager stated, “ it is anticipated that these nurses will provide excess nursing hours to give greater support and supervision to the care staff and allow seniors and management to devote more time to processes and record keeping. The new nurses will provide greater consistency of care by reducing the need to use a agency staff”. The home was one care staff member short on the morning of the inspection. Only one nurse is on duty for the whole home during the night. There was no evidence to suggest that thorough dependency levels of the residents are being undertaken and monitored to ensure that staff numbers are adequate in terms of need and dependency in addition to the numbers of residents accommodated at any one time. Staff rotas revealed that a number of staff had been off sick, but did not always detail who was covering the staff off sick. Staffing numbers appeared to be low on the 2.5.05. Staff recruitment process in all respects have improved since the last inspection. However, a photo was not available for all staff, screening Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 21 processes for the volunteer inadequate, insufficient evidence to demonstrate that documentary evidence has been provided by agency staff to demonstrate their suitability in terms of screening, checks and identity. A lack of training/ clinical and nursing intervention updates for both care and nursing staff was identified in respect of specialist areas, examples being continence promotion, risk assessment and nursing processes, procedures and nursing interventions and treatments. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 22 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36,37,38 Staff supervision must be further developed. Recording and recording practices must be considerably improved. Policies and procedures require continual audit and updates to ensure they accord with contemporary best practice and legislation and they are disseminated amongst staff as required and that staff understand how they must operationalise these policy and procedural documents. Health and safety policy and procedure and associated recording practice is of particular concern potentially putting residents and the premises at risk. EVIDENCE: Although staff supervision has been given greater attention since the last inspection, shortfalls remain with processes in that supervisees have not received any training, senior care staff are supervising their peers and the content of the supervisions is inadequate. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 23 Due to problems highlighted in this report concerning incidents that have occurred of late, it is vital that all staff receive effective and thorough supervision on a regular basis. A schedule of planned supervision sessions was not available to peruse. There was inconsistent evidence to suggest that all staff have read, signed and dated all of the homes working policies and procedures. Although, there was some evidence to demonstrate that polices and procedures have been reviewed and updated, an example being the recruitment policy, there was little evidence to suggest that effective auditing and monitoring was taking place to ensure that staff are fully complying with these policies and procedures. There was evidence across many areas that record keeping is poor. This apparent in terms of non- use or ineffective use of forms to evidence personal care, vital observations diet and fluid input, doctor / other health care input. Blue, red and gold inked pens have been used for recording where Nursing and Midwifery Council guidance states all entries must be made in black. Care planning systems and other records examined revealed staff signatures not their full name, which could make audit trailing of who was responsible for and who did what at any time difficult. Health and safety policy, procedures and systems were concerning in a number of areas. There was no evidence of recent accident analysis, accident minimisation or prevention processes. The bedrail on (MR) bed revealed a large gap, records showed that the bed rails have not been checked since Jan 2005. The last recording of portable electrical appliance testing was in September 2003. Not all staff received fire training in February 2005. Fire drill response recordings were concerning, September 04 “ average response – complacency “? April 05 “ No response”. Where engineers have made requirements in respect of work being needed, call system, replacement of fire extinguishers and the Parker bath, there was inadequate documentation to demonstrate that this work has been carried out. Staff mandatory training was identified as lacking in respect of first aid and health and safety. Moving and handling training has been booked for May 05 all staff have received food hygiene and infection control training. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 1 COMPLAINTS AND PROTECTION 1 x 2 x x 2 2 1 STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 1 x x x x x 2 1 1 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4(1) Requirement The registered provider and manager must ensure the statement of purpose clearly identifies whether the home meets the physical environmental statndards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3, and 23.10. Timescale of 10.03.05 not met. The registered provider and manager must ensure that the statement of purpose and service users guide is produced in a format appropriate to the residents needs. The registered provider and manager must ensure that all residents are supplied with a copy of the service user guide. The registered provider and manager must ensure that: - all private paying residents are provided with a contract of residency. -alll residents funded by local authorites or Primary Care Trusts are issued with a terms and conditions document . Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 26 Timescale for action 01.07.05 2. OP1 4(1)5(1) 01.07.05 3. OP1 5(2) 02.07.05 4. OP2 5(1)(b) 15.06.05 Immediatle y for new admissions on or after 9.5.05 5. OP2 5(1)(b) 6. OP3 14(1)( c) 7. OP3 14(1)(a) 8. OP4 14(1)(a) The registered provider and manager must ensure that the fee applicable to each resident is detailed on their contract or terms and conditions of residency. The registered provider and manager must ensure that it is evidenced that prospective residents are involved in their assessment of need process. Where they are unable to participate and have no representative to act on their behalf then this must be detailed on the assessment of need documentation. The registered provider and manager must ensure that the primary diagnosis for each prospective resident ( for example, physical condition or dementia) is confirmed by an appropriate professional, for example a doctor and detailed on their assessment of need documentation. The registered manager must ask the doctor to refer (E.D) for a psychatric assessment . If a primary diagnosis of dementia is made: The manager must consider if her needs can be met. Written evidence that this has been addressed must be forwarded to the CSCI office. The manager must apply to the local CSCI office for consideration to vary the homes registration certificate. Timescale of 25.01.05 not met. 15.06.05 Immediatle y for new residents. 9.5.05 9.5.05 10.06.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 27 9. OP4 14(1)(a) 10. OP4 14(1)a 11. OP4 14(1)(d) 12. OP7 15(1) The registered provider and manager must in respect of (R.L and D.H) request written confirmation from a reliable source for example, their doctor or psychiatrist their primary diagnosis. Evidence of outcome of these diagnoses must be provided to the CSCI office. If a primary diagnosis of mental disorder or dementia is made then a variation for registration categories/ conditions application must be made to the CSCI . The registered provider and manager must apply to the CSCI to have removed from their certificate of registration the condition in respect of one resident under the age of 65 years who is no longer accommodated. The registered provider and manager must ensure that they confirm in writing to any prospective resident that the home is suitable for the purpose of meeting their needs in respect of their health and welfare. The registered provider and manager must review the current care plan documentation to make it easier to track and for it to be more effective. Timescale of 25.01.05 not met. 20.06.05 20.06.05 09.05.05 10.06.05 13. OP7 15(2)(b) The registered provider and manager must establish a system to ensure that each service users care plan is reviewed monthly or earlier if changes occur. Timescale of 10.01.05 not fully met. 01.06.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 28 14. OP7 15(1) The registered provider and manager must ensure that all health care needs are reflected in and incorporated within the service users care plan, for example diabetes and concerning behaviours. 15.06.05 15. OP7 15(2)(b) Timescale of 31.01.05 not met. The registered provider and 15.06.05 manager must ensure that care plans are specfic to needs and requirements, for example what has to be done, when , how, how often and by whom. It must also detail what to do if this plan fails. The registered provider and 06.06.05 manager must ensure that a system is implemented where delegated senior nurses or the manager randomly selects a number of residents files on a daily basis to scrutinise, ( so that every week every file is checked). to ensure that the care plans and other records required( examples being turn / change of position charts, fluid in and output charts, vital observation documentation) for those individuals are being used , are being adequatley maintained, are updated and that where concerns are raised the correct actions are being followed by all staff. A record that this has been done, by whom and when, together with the action taken to correct any non-conformance must be made. The registered provider and 09.05.05 manager must ensure service users are consulted with on a regular basis about their care Version 1.30 Page 29 16. OP7, OP8 15(1) (17(2)) 17. OP7 15(1) Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc plan. Where possible each service user must sign their plan of care. This must be at the point of admission for new service users. 18. OP8 12(1)(a)( b) 13(4). Timescale of 31.01.05 not met. The registered provider and manager must ensure that all staff read, date and sign the newly implemented policies which inform when a fall occurs what must be done and if nurses have concerns in respect of a doctors judgement. The registered provider and manager must ensure that medical attention is sought immediatley when any residents condition deteriorates or there is a cause for concern and that this can be evidenced at all times. 01.06.05 19. OP8 12(1)(a)( b) 11.05.05. 20. OP8 12(1)(a) 13(4)( c) Immediate requirement issued to this effect . The registered provider and 11.05.05 manager must ensure that measures are taken to ensure that all residents are adequatley hydrated and that this can be evidenced at all times. Fluid input / output must be evidenced at all times. Immediate requirement issued to this effect. The registered provider and 01.06.05 manager must ensure that (E.D) is referred to a dietician. Timescale of 17.01.05 not met. The registered provider and manager must establish a system whereby all personal care (examples being hygiene, oral care, hair care, foot care and incontinence care) is 01.06.05 21. OP8 12(1)(a) 22. OP8 12(1)(a)( b)) Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 30 evidenced on a daily basis. Timescale of 25.01.05 not fully met. The registered provider and manager must ensure that all residents are weighed on admission and monthly thereafter. A record of these weights must be made. The registered provider and manager must be able to evidence that all residents recieve a full health care check from their doctor at least on an annual basis. The registered provider and manager must ensure that all When required medication is supported by a written protocol to clarify their use this must be endorsed by a clinician. Their use must be reviewed on a regular basis. 23. OP8 12(1)(a)( b). 01.06.05 24. OP8 12(1)(a)( b) 01.07.05 25. OP9 13(2) 09.05.05 26. OP9 13(2) Immediate. The registered provider and 09.05.05 manager must ensure that all medication administered is accuratley documented or if not administered, the appropriate code documented and the reason recorded on the Medication administration record. Immediate The registered provider and manager must ensure that the medication policy is updated using the Royal Pharmaceutical Society of Great Britain guidance on the Administration and Control of Medicines in Care Homes and Childerns Services (June 2003) and is easily accessible to all staff. The registered provider and manager must ensure that when 01.06.05 27. OP9 13(2) 28. OP9 13(2) 01.06.05 Page 31 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 29. OP9 13(2) 30. OP11 18(a) 31. OP11 12(3) 32. OP12 16(2) 12(3) there is a choice of dosage e.g 1 or 2 tablets, that the number of tablets administered is recorded. The registered provider and manager must ensure that nurses only administer, give or witness that residents have taken their medication. This must be enforced by written instruction to all nurses. All nurses must be form reminded of their accountabilty in accordance with Nursing and Midwifery Council guidance. The registered provider and manager must ensure that all staff who have not already recieve care of the dying training. The registered provider and manager must ensure that the last wishes in respect of death and dying are explored and recorded for all residents. Where they are unwilling to discuss this subject or the information can not be obtain from an appropriate, reliable source then this must be recorded on their file. The registered provider and manager must develop an individualised activity programme to complement the existing group based activities which occur at Warrens Hall. Timescale of 10.03.05 not met. The registered provider and manager must ensure that each residents activity care plan is working for them or explore alternative activities appropriate to their needs. The registered provider and manager must ensure that the supper for any given day is detailed on the homes menu. 09.05.05 01.08.05 01.07.05 15.06.05 33. OP12 16(2) 12(3) 15.06.05 34. OP15 16(2) 15.06.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 32 35. OP15 16(2) 17(2) 36. OP15 16(2) 37. OP16 22(2) 38. OP18 13(6) The registered provider and manager must ensure that the supper residents have consumed is recorded on their food intake chart. The registered provider and manager must ensure that food is cooked and served to the residents liking, in accordance with health and risk considerations. The registered provider and manager must ensure that the complaints procedure is appropriate to the needs of all residents and that residents, relatives and other stakeholders are reminded on a regular basis of the complaints procedure and how this can be accessed. The registered provider and manager must ensure that: All polices and procedures aimed to protect vulnerable adults accord with Department of Health and local authority multiagency adult protection guidance. All staff must be made formally aware of these policies and procedures and that this be evidenced. All staff who have not already had must recieve appropriate adult abuse awareness/ protection training. The registered provider and manager must formally remind all staff of the homes confidentiality policy and their responsibility towards this . All staff must be asked to sign and date the confidentiality policy. Timescale of 30.01.05 not fully 09.05.05 09.05.05 15.06.05 15.06.05 39. OP18 12(5) 10.06.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 33 met. 40. OP18 13(6) The registered provider must 25.06.05 revise the homes whistle blowing policy. References about the homes grievance procedure must be removed. The registered provider and 20.06.05 manager must ensure that a timescale is attached to all decorating or replacement items listed on the maintenance programme This to include the glass pane window in Rowley unit.. The registered provider and manager must ensure that suitable ramped access is provided from all doors in the courtyard area. The registered provider and manager must ensure that the homes reception area is secure at all times to prevent any unauthorised access.. The registered provider and manager must ensure that all bathrooms and toilets throughout the home are in suitable working order and are provided with required equipment The registered provider and manager must ensure that the ventilation system in the ground floor bathroom( near to the nurses station) is mended and in good working order. Timescale of 31.01.05 not met. The registered provider and manager must ensure that all wardrobes are suitably secured to prevent accidents or injury. The registered provider and manager must provide appropriate and safe door locks 41. OP19 23(2) 42. OP19 23(2) 07.07.05 43. OP19 13(4) 21.05.05 44. OP21 23(2) 20.06.05 45. OP21 23(2) 20.06.05 46. OP24 13(4) 01.06.05 47. OP24 13(4) 01.07.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 34 to service users private accommodation. Advice must be sought from West Midlands Fire Service before locks are purchased / fitted. 48. OP25 23(2) Timescale of 20.02.05 not met. The registered provider and manager must carryout a documented audit against the whole of standard 24 . Where items are not wanted by service users or it has been assessed that a risk may present by certain items being provided then this must be documented and where possible verified by the service user . Otherwise all items must be provided. Timescale of 31.01.05 not fully met. The registered provider and manager must ensure that the lux lighting requirements are being met in bathrooms and toilets. The registered provider and manager mus ensure that the ventilation system in the groundfloor bathroom ( near to the nurses station ) is mended and in good working order. Timescale of 30.01.05 not met. 51. OP26 13(3) 16(2) The registered provider and manager must produce a cleaning schedule for the laundry which must be adhered to at all times. Timescale of 10.02.05 not fully met. The registered provider and manager must forward future plans for the laundry as it is 06.06.05 01.07.05 49. OP25 23(2) 20.06.05 50. OP25 23(2) 15.06.05 52. OP26 13(3) 16(2) 15.06.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 35 unsuitable at the present time in terms of size and layout. 53. OP26 13(3) Timescale of 01.03.05 not met. The registered provider and manager must ensure that disposable aprons are available in high risk areas. Time scale of 25.01.05 not fully met. Not available in laundry. 54. OP26 13(3) The registered provider and 06.06.05 manager must ensure that Now wash your hands please wash your hands signs are displayed in all toilets, bathrooms ( and laundry) Timescale of 30.01.05 not fully met. 55. OP26 13(3) No signs in laundry. The registered provider and manager must ensure that infection control procedures in respect of the laundry are clearly displayed in the laundry. The registered provider and manager must ensure that suitable disposable gloves are available and used by laundry staff. The registered provider and manager must ensure that the laundry floor is replaced or suitably recoated. The registered provider and manager must ensure that the clinical waste bins are locked at all times. Timescale of 25.01.05 not met. The registered provider and manager must make a decision 06.06.05 06.06.05 56. OP26 13(3) 06.06.05 57. OP26 13(3) 15.07.05 58. OP26 13(3) 06.05.05 59. OP26 13(3) 06.06.05 Page 36 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 to the quailty of the service provided by the clinical waste contractor. Timescale of 25.01.05 not fully met. The registered provider and manager must ensure that the cat litter tray is emptied frequently. The registered provider and manager must produce and implement an effective dependancy rating tool to ensure that staffing levels both in terms of care and nursing staff over every twenty four hour period reflect in full the needs and numbers of the residents accommodated. The registered provider and manager must ensure that adequate nursing and care staff are provided at all times in terms of comptence and numbers. The registered provider and manager must ensure that all of the required staffing documents and photo required in Schedules 2 and 4 are obtained for each staff member and retained on their personal file. Timescale of 13.01.05 not fully met. 64. OP29 17(2) The registered provider and manager must ensure that ; All written references are authentic, with their full name and position detailed. Interview questions and answers in respect of all prospective staff are recorded. Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 37 60. OP26 13(3) 27.05.05 61. OP27 18(1)(a) 10.06.05 62. OP27 18(1)(a) 09.05.05 63. OP29 17(2) 15.06.05 09.05.05 65. OP30 17(2)) The registered provider and manager must be able to evidence at all times with appropriate documentation that effective screening of agency staff has been carried out. Sufficent documentary / certification must be obtained to verify training, that they have valid CRB and POVA checks , nurse NMC registration and identity. All volunteers working at the home or in contact with the home must be screened to the same level as any paid member of staff. The registered provider and manager must ensure that all staff including nursing staff are adequatley updated in terms of training and knowledge and are able to demonstrate by certification that they have recieved training and updates to ensure that they are all fully competent to undertake all care, clinical, nursing interventions, treatments or other duties required of them. The registered provider must ensure that all supervisees are appropriatley trained and competent to to undertake the supervison of others and that undertaking supervision is appropriate to their role and job description. The registered provider and manager must produce a schedule of staff supervisions to ensure that all staff regular one to one supervision sessions at least six times per year. This to include all staff ( nursing, carers and ancillary staff ). 09.05.05 66. OP36 18(1)( a) 01.07.05 67. OP36 18(1)( c) 01.07.05 68. OP36 18(1)( c) 09.06.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 38 Timescale of 30.01.05 not met. 69. OP36 18(1)( c) The registered provider and manager must as part of the staff supervision sessions ensure that these sessions incllude : All aspects of practice. Philospphy of care in the home. Career development needs. Timescale of 30.01.05 not fully met. The registered provider and manager must ensure that all staff read, sign and date all policies and procedures in operation within the home. Timescale of 10.02.05 not met. The registered provider and manager must implement effective auditing systems/ monitoring systems to ensure full compliance with policies and procedures within the home. Timescale of 30.03.05 not met. The registered provider and manager must ensure that any documentation /forms are used when required. That these are completed , fully, accuratley with sufficient detail to demonstate what has been done in any instance. The registered provider and manager must ensure that staff signatures alone are not used on any documentation, the signature of the staff member concerned must be accompanied by their full printed name. The registered provider and manager must ensure that entries made on all records and 01.07.05 70. OP36 17(2) 01.07.05 71. OP36 17(2) 01.07.05 72. OP37 17(2) 09.05.05 73. OP37 17(2) 09.05.05 74. OP37 17(2) 20.05.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 39 75. OP38 13(4)( c) 76. OP38 13(4)( c) 77. OP38 23(4) documents are done with a black inked pen. The registered provider and manager must ensure that weekly documented checks are undertaken in respect of all bedrails used in the home. The outcome of these checks and where required actions taken are detailed. The registered provider and manager must ensure that the bedrails on (M.Rs) bed are suitable, safe and secure at all times. The registered provider and manager must provide to the CSCI evidence that recent PAT tests have been carried out and that in future: Testing of all portable electrical appliances is carried out yearly. That all electrical items brought into the home by residents are tested before use.: The registered provider and manager must ensure and be able to evidence that all staff recieve two fire training and two fire drill sessions in any twelve month period. The registered provider and manager must take action to rectify the recent staff responses/ lack of resonses to fire drills. What action has been taken , how and by whom must be recorded and be available for inspection. The registered provider and manager must inform the Commission without delay if any of the situations detailed in Regulation 37 occur. This did not happen in the case of ( D.A s ) admission into hospital or death. 27.05.05 09.05.05 27.05.05 78. OP38 23(4) 01.07.05 79. OP38 23(4) 09.06.05 80. OP38 37(1) 09.05.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 40 81. OP38 13(4)( c) 82. OP38 13(4)( c) The registered provider and manager must ensure that an accident analysis is undertaken on a monthly basis. That documented systems and processes are establised to promote/ ensure accident minimisation. The registered provider and manager must provide evidence to demonstrate that the work to the call system has been carried out. 01.06.05 09.05.05 83. OP38 13(4)( c) Appropriate records must be available for inspection to demonstare that where engineers have made recommendations that the work has been carried out. The registered provider and 05.06.05 manager must provide the CSCI with a timescale detailing when the required new wheelchairs will be purchsed. In the interim period wheelchairs in use must have been assessed as safe and have the required footrests in situ. The registered provider and manager must provide the CSCI with firm dates to demonstate when the following training will be delivered: Fire Training and drills. First aid. Health and safety. 84. OP38 18(1)(a) 05.06.05 85. OP38 13(4)(c ) Risk assessment training. The registered provider and provider must ensure that the asbestos situation is fully assessed by an appropriate engineer. 05.06.05 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 41 Timescale of 31.01.05 not met. Evidence that this has been done by means of an engineers report must be forwarded to the CSCI within the timescale set. The registered provider and manager must ensure that a copy of the homes premises risk assessment is available on the premises at all times. The registered provider and manager must undertake a full investigation on the events that occurred on the 2.5.05 involving resident (DA). Documentary evidence to demonstrate that this has been done along with outcomes and actions taken must be provided to the CSCI. 86. OP38 13(4)( C) 01.06.05 87. OP8 12(1) 13(4) 20.06.05 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 OP9 Good Practice Recommendations The registered provider and manager should improve medication audit , nursing staff should date the opening of all containers ( boxes, bottles, inhalers etc) and also carry over balances of medicines from previous cycles onto new medication administration records., The registered provider and manager should ensure that where medication administration records are handwritten that these are checked by a second person and referenced back to the orginal prescription. The registered provider and manager should ensure 2. OP9 3. 4. OP9 Warrens Hall Nursing Home E55 S4853 Warrens Hall V225496 090505 Stage 4.doc Version 1.30 Page 42 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 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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