Inspection on 09/10/08 for Waverley Nursing Home

This inspection was carried out on 9th October 2008.

CSCI found this care home to be providing an Adequate 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.

Other inspections for this house

Waverley Nursing Home 08/12/08

Waverley Nursing Home 23/03/08

Waverley Nursing Home 07/05/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

Inspecting for better lives Random inspection report Name: Address: Waverley Nursing Home 14/16 Waverley Road Liverpool Merseyside L17 8UA The quality rating for this care home is: The rating was made on: one star adequate service 13/02/2008 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Julie Garrity Date: 0 9 1 0 2 0 0 8 Information about the care home Name of care home: Address: Waverley Nursing Home 14/16 Waverley Road Liverpool Merseyside L17 8UA 02085315737 Telephone number: Fax number: Email address: Provider web address: phillippa.hoxha@btconnect.com Name of registered provider(s): Type of registration: Number of places registered: Daughters of Mary Mother of Mercy care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category 0 Over 65 20 Conditions of registration: The registered person may provide the following categories of service only. Care home only - code PC, to service users of the following gender:- Either. Whose primary care needs on admission to the home are within the following categories: - Old age not falling within any other category - Code OP. One named service user who is under 65 years old within the overall total of 20 The maximum number of service users who can be accommodated is: 20 Date of last inspection Brief description of the care home The Waverley provides nursing care and personal care For a maximum of 20 individuals. The home is a converted building on four floors, there are two lounges one on the lower ground floor and one on the ground floor. Bedrooms are located on the ground floor, first and second floors. There are gardens at the rear that are accessible from the main building and parking to the front and the side. The Home is located in a residential part of Liverpool near to the shopping areas of Lark Lane and Sefton Park Page 2 of 15 area. There are frequent buses to this area and a train station within 15 minutes walk. Fees are charged in the home in accordance with those paid by Liverpool Social Services. Private clients fees are based on their individual assessment and the support that they need. There are several areas not covered in the fees such as hairdressing and newspapers. Page 3 of 15 What we found: The manager raised concerns with us regarding the practice of some of the nursing staff in particular their ability to manage a pen injection system for diabetes. At the same time concerns were raised from social services concerning five people living in the home who were admitted to hospital. During our discussions with the manager she advised that in a short period of time three people with complex nursing needs had been admitted. The manager had anticipated that the nursing staff would be able to appropriately manage the necessary nursing care. In further discussion the manager told us that in hindsight this had not been the case and staff had struggled to attend to individual nursing needs. As a result of these concerns we attended the home on the 9th of October to undertake a random site visit into the concerns raised. A pharmacist inspector was included in this site visit to look at medications management. We looked at staff competency, medications management and the services ability to meet the health and welfare needs of people living in the home. A code B (which identifies and protects the rights of the manager and provider) was issued to the manager and provider informing them of the regulations we suspected had been breached. A list of the items we photocopied or files we removed was left with the manager. Four care files for people in hospital were removed and returned to the home on the 17th of October 2008. The main findings from this site visit including some examples are detailed below. We looked at medicines record keeping. We found that medication changes, particularly on discharge from hospital were not well managed. Records of healthcare professional visits and advice were not always kept up to date. As such it was not always possible to confirm what medications people living in the home should be taking. We saw one example where nurses had not got written confirmation of someones Warfarin dose on admission to the home. This is contrary to current guidance about the safe handling of Warfarin, and increases the risks of making mistakes. We saw two examples where dose changes recorded on a hospital discharge note had not been accurately carried forward to the homes medication administration records (MAR). This meant the medication changes made in hospital were not happening in the home. We looked at a sample of MARs and found these did not list currently prescribed medicines. We found that where medicines were not given the reason was not always recorded. For example, we saw one record that showed prescribed nebules (for breathing) had been missed because the person was asleep. The records viewed showed hat the person had take all their other medicines at that time. This shows that the record was inaccurate as it indicates that the person was awake for some of the medications and asleep for others. All the medications were recorded as being given or refused at the same time. To help ensure medicines are safely administered as prescribed, records need to be completely and accurately maintained. We also saw that a care plan for someone who needed mouth care did not refer to the use of three medications (gels and a spray) prescribed for them. Their MAR showed that one gel was to be given three times a day. This was recorded as being applied in Page 4 of 15 the morning, no reason was recorded when the gel was not used. A second gel was not listed on the MAR. It was not possible to tell whether the person received the mouth care they needed. As previously seen we saw that records for the application of creams were poorly completed. There was no written information about where the creams should be used, or for how long. Records were only ticked and not signed by the person who had actually applied the cream. As such the records did not comply with the homes policy on recording medications. We looked at how medicines to be taken when required (PRN) were managed. As previously seen, medications such as painkillers that were to be given PRN had no written instructions as to when to give or in what circumstances. This information is needed to help make sure that staff have proper instructions as to when to give the medication. Without these instructions the person is at risk of not receiving this medication correctly. At the previous inspection we noted that; better systems were needed for ordering medicines outside the normal delivery times. This system needs to be in place to make sure that people always have the correct medications available. During this visit we found that one person had not been given three of their medicines because there was none left to give. An initial fax, sent after the first medicine had run out had not been received by the surgery. The order had not been followed up by the home until seven days later. To make sure people receive the treatment they need, sufficient stocks of medication need to be kept at the home, without overstocking. We looked at how controlled drugs were managed. We were concerned to find that a recent handwritten administration record showed the wrong dosage instruction, and that although the Controlled Drugs register had been competed; the administration record had been left blank. This poor record keeping increases the risk of medication errors. The manager had identified this concern when administering medicines and had taken steps to make sure nursing staff now know how to correctly record the safe handling off controlled drugs. We looked at the ways in which staff communicated with external professionals. We found that instructions from external professionals were not always recorded or carried out. One example included an instruction for staff to make sure that an individual received a litre of water a day. We noted that this instruction was not recorded or passed on to other staff on the day it was received. This information was recorded the day after at the instigation of the community matron who informed staff of this instruction. We looked at the homes fluid balance charts, which record the amount of fluids that the individual received. These showed that this individual had not received a litre of fluid a day for the rest of their stay in the. The homeowner informed us that the individual did receive the fluids and this was likely to be a recording error. The homes policy and procedures follow the nursing and midwifery guidance which state that if its not written down it did not happen. The fluid balance record had not been monitored to make sure that staff both supplied the correct amount of fluids or dealt with poor recording. Another example concerned an individual who needed their blood pressure (BP) monitoring on standing and sitting once a week. This was not carried out. The records showed that for 11 weeks the persons BP was measured on five occasions and not once a week. The care plan did include this information. This showed that nursing staff had failed to carry out instruction that they had received and were written in the individuals care plan. Page 5 of 15 The records in the home where looked at these showed that staff were not contacting external professionals as needed. Daily records for two different people showed that staff had identified that an external professional was needed to review individual pressure ulcers and wounds. A further review of the records showed that this action had not occurred and staff within the home had not referred the individuals to external professionals. Another example included on person who lost over a stone in weight in 10 days. Staff had recorded the persons weight on both occasions but had not contacted the persons doctor for advice. The lack of appropriate action placed this person at significant risk. We reviewed how the home monitored individuals condition and what action they took for changes in condition. We noted thats staff did not always monitor individuals condition appropriately or take action when changes in condition were indicated. Examples of this included a lack of recording blood monitoring (BM) for people with diabetes. These were not consistently recorded. We noted that one record detailed that the BM needed to be recorded four times a day. When we reviewed the records available recording of this varied from twice a day to not at all. There was no system in place that monitored this correctly and support staff to take action. Care plans did not detail a range that the BM should be within or what action to take if the BM was beyond this range. Other examples of this included the monitoring of wounds. Records were very confusing and as such made it impossible for staff to fully recognise and deal with changes in individuals condition. Where issues had been identified in daily records that showed the persons condition had deteriorated no action had been taken. The lack of clear monitoring and action taken when changes in individuals condition occurred, placed people receiving this support at risk. Care plans reviewed were not individual, person centred, specific and did not always plan to meet individual needs. Records were disorganised, incomplete and in some cases inaccurate. Examples of this included a lack of a care plan for an individual identified as needing mouth care. This is mentioned above and may have resulted in them not receiving mouth care as needed. Another example included lack of planning for infection including hospital acquired infection such as MRSA. One person had confirmation of MRSA included in their discharge notes from the hospital, they also has a wound. There was no plan for the wound or how staff would manage the MRSA infection. Assessment records and risk assessments were incomplete and one member of staff had filled out all nutritional assessments called MUST inaccurately and without the proper information. This had resulted in an inaccurate assessment of their nutritional need. In three cases people were identified as at risk, but no clear plan had been put into place. Information was confusing as to whether they were at risk and if so what actions the service had taken. We looked at the skills of staff. As above several examples have been identified when staff have not demonstrated that they are competent to deliver nursing care and meet health and welfare needs. Examples include, not checking that they know how to use an injection system for an insulin pen. Not giving out medications correctly. Not monitoring peoples conditions appropriately and referring to external professionals when their advice is needed. Not passing on instructions verbally or in writing in daily records and care plans. On one occasion one individual with diabetes had not eaten or drunk for over 18 hours. Staff did not check their BM and proceeded to given them Page 6 of 15 insulin. This is dangerous practice and could have resulted in serious risk to the person. Another example included an individual with diabetes who on two occasions appeared very sleepy to staff. Sleepiness can be an indicator of unstable diabetes, but can be due to other causes. Staff had supported the person to return to bed but had not checked their BM to make sure that this need was not as a result of changes in the condition. We looked at other records in the home such as staff meetings, staff training records and staff supervision. Training records were disorganised and out of date it was not possible to determine what training staff had received. The training matrix shown to us did not describe training in diabetes, wound care, prevention of pressure ulcers, nutritional needs, MUST scores, care planning or record keeping as examples. All of these areas have been identified within this site visit as not meeting the needs of people living in the home. What the care home does well: The manager had carried out medicines audits and had highlighted some concerns about medicines record keeping. In response to audits the manager had started to carry out competency checks, to help make sure that peoples medication needs will be met. The Primary Care Trust pharmacist had visited the home to review peoples medicines. They and the Community Pharmacist will be supporting additional safe handling of medicines training at the home. We watched part of the lunchtime medicines round. This was done with care and the records were signed immediately after the medicines were given. We saw that people were now offered a cold drink (water) to help swallow their medicines. We looked at medication storage and found that all medicines including controlled drugs were safely locked away. This helps to prevent the miss handling or misuse of medicines. The manager identified the initial concerns and reported this to the external stakeholders such as social services and the commission. Appropriate action was taken including a review of the competency of the staff in the home and action taken for two members of staff identified as not demonstrating competency. The staff have on several occasions recognised the need to consult with external professionals. The manager has arranged for medications that are for return to meet the correct legislation and passed this information on to the staff in the home. What they could do better: A lack of clear records including those on a PRN basis does not support the safe administration of medication or make sure that people receive their treatment as prescribed. Not maintaining sufficient stock of medications prevents people from having their proper treatment available. Page 7 of 15 The homes medication policy and procedures do not provide staff with sufficient instructions to support them to give out medications safely. Staff records do not identify training or competency in medications, nutritional management, record keeping, care planning, management of wounds and monitoring of practice. There is no supervision in place for staff that supports them to identify the skills they need to develop. Records in particular care records are very disorganised. Staff have not completed some assessments and other assessments done at the same time conflict with each other. This resulted in vital information not being included in plans of care. There is no consistency in formats of plans of care. Plans of care are not person centred, specific or meaningful as a consequence care needs have not been identified or actioned. In other instances where needs have been identified staff have not had sufficient instructions to meet the individual needs. On occasions actions have been identified in care plans that have not been carried out. Staff have identified issues that need external professionals and failed to obtain their input. On other occasional external professionals have given instructions that staff have failed to carry out. Both these aspects are poor practice and place people living in the home at risk. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Page 8 of 15 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set. No. Standard Regulation Requirement Timescale for action 1 1 4 (1) (a) (b) Information in the home (c) (2) (3) (a) such as a statement of (b) purpose and a service users guide needs to be written and readily available in a format to suit the individual needs of people living in the home. 27/09/2008 2 3 14 (1) (a) (b) All residents need to have a 27/03/2008 (c) full assessment that determines their needs and supports staff to plan on how to meet their needs before they are admitted to the home. Outstanding from 16/02/08 3 7 15 (1) (2) (a) It is essential that residents 27/04/2008 (b) (c) (d) health and welfare needs are recognised and staff have clear written instructions that supports them to be aware of and meet the residents health and welfare needs appropriately. This includes up to date care plans that provide staff with clear instructions on how to meet resident?s needs. Care plans for the residents need to be reviewed and Page 9 of 15 monitored in order to determine that they fully respect the support that is to be provided by staff. Outstanding from 16/02/08 4 9 13 (2) Medications must be 27/04/2008 appropriately managed to maintain the safety of the residents. Staff need to give out medications in accordance with the homes own policy and make sure that they follow the prescription given by the GP. Outstanding from 31/10/07 5 14 16 (2) (m) The opportunity to explore, 27/04/2008 find out and put in place actions to meet residents personal preferences and choices. This is of particular importance for residents less able to voice an opinion whose equality and diversity needs are not being explored or addressed. Outstanding from 31/10/07 6 16 22 (3) (4)(5) A record of any complaint 27/04/2008 made, details of any investigation, action taken and outcome must be kept at the home in order to make sure that all concerns are fully addressed and prevented from happening again. Outstanding from 31/10/07 7 26 13 (3) The lack of good practice to prevent cross infection and the usage of equipment is insufficient to prevent the 27/04/2008 Page 10 of 15 spread of disease. This will need to be reviewed and appropriate measures taken such as audits of environment, correct equipment, policies and procedures and staff training put into place. Outstanding from 31/10/07 8 27 18 (1) (c) Staff training is not sufficient 27/05/2008 to fully safeguard residents needs. Training that is specific to the residents needs will need to be put into place. A plan that details what each individual member of staff training needs are and how they are to be developed will need to be put into place. This will need to include all the areas identified within this report Outstanding from 31/10/07 9 27 18 (1) (a) Staff competency regarding 27/04/2008 medications, communicating with residents effectively and protection of vulnerable adults is not sufficient to safe guard the residents. Arrangements that review staff competency and address any concerns will need to be developed. A system that regularly monitors staff skills and addresses any shortfalls needs to be included. Outstanding from 31/10/07 10 33 24 (1) (2) (3) Arrangements to monitor the 27/04/2008 quality of the service provided that also takes into account the views of the Page 11 of 15 residents needs to be developed in order to increase the quality of the service. This will need to identify the strengths and the areas to be improved in the home and a plan as to how this will be accomplished put into place. Outstanding from 31/10/07 11 38 13 (4) (b) Risk assessments for 27/04/2008 residents individually are either insufficient or not in place this includes, smoking, mattresses next to beds as examples, falls. In order to make sure that residents are fully protected these will need to be reviewed and put into place. Outstanding from 31/10/07 12 38 13 (4) (a) Environmental risk 27/04/2008 assessments such as equipment and potential fires need to be updated. This will need to include when and how specific equipment are to be tested, maintained and used. Outstanding from 31/10/07 Page 12 of 15 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 13 Clear, up-to-date and 07/11/2008 accurate medication records must be maintained to support the safe administration of medication and to ensure people receive their treatment as prescribed. To maintain the safety of the people living in the home. 2 13 The health and welfare needs 07/11/2008 of people living in the home need to be determined. Where a need is identified staff need to take appropriate action such as monitor the persons condition and referring to external professionals as needed. In order to meet the health and welfare needs of people living in the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. Page 13 of 15 No. Refer to Standard Good Practice Recommendations Page 14 of 15 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards – can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: 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 We want people to be able to access this information. 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