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Inspection on 21/11/08 for Westbury Nursing Home

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

This inspection was carried out on 21st November 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 23 statutory requirements (actions the home must comply with) as a result of this inspection.

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

The Westbury is situated on a main road, leading into the Wiltshire town of Westbury, with parking on site, a bus stop close by and for the able-bodied, is a short walk from the centre of town. This means that visitors can access the home with ease and can pop in and out to suit both them and the resident. Many of the residents and staff are from the Westbury area and this helps in making sure that the home can be part of the local community. The home is fully wheelchair accessible, including the patio garden area. The home has the benefit of being part of a large group of homes and so has access to a wide range of supports from the provider. People commented about the home. One person reported "its very nice and I`m very comfortable", another "lovely, the best move I`ve ever made", another "I`m very contented with the surroundings and care given to me". People also commented about the staff. Comments included "staff do their utmost to keep residents happy", "the staff are very nice and polite", "I can have a laugh with them" about the staff, "agency staff are very, very nice generally", "the nurses are lovely - she sorted out my bed" and "some staff offer that "extra mile" to please residents".

What has improved since the last inspection?

At the previous inspection, three requirements and nine good practice recommendations were made. Of these, one requirement had been addressed in full and one showed progress. Of the recommendations, four had been addressed in full. People commented on recent changes in the home. One person reported "the new manager is making a difference, trying to run the home for the people who live there". Since the last inspection, the providers have recruited a manager, are in the process of recruiting a deputy manager and an administrator is to take up post shortly. The provider has performed a recruitment drive, to reduce reliance on agency staff. New documentation systems have been introduced to support staff in assessing and planning care. Documentation seen was clear and highly individual in tone. Where residents needed records relating to monitoring of their conditions, these were fully completed, at the time care was given.

What the care home could do better:

At this inspection, 24 requirements and 17 good practice recommendations were made. Residents reported on how the home had changed from the past. One person reported "its all a bit of a mish mash from what it used to be" and another "the quality of [my relative`s] care has significantly declined". The home needs to review staffing levels, particularly in the light of resident dependency, to ensure that residents` needs are met, that their ability to choose can be up-held and staff can provide care in a correct, safe and timely manner, in accordance with care plans. Staff need to be supervised in their roles, to ensure that they can meet resident need. Training needs to be improved. At the previous inspection, it was required that staff training records must be fully up-dated to reflect training undertaken. If deficiencies were identified, an action plan must be developed and submitted to the CSCI. This hadnot been actioned by this inspection. It was not clear if staff had been trained in the principals of health and safety, including infection control or first aid. There was no evidence that staff had been trained to meet resident needs relating to conditions experienced by older people such as prevention of pressure ulceration, stroke care or dementia care. This lack of training means that there was evidence from a range of sources, including residents and their relatives, observations of care and reviews of records that not all their nursing and care needs were being met. Not all recruitment policies were being fully completed in accordance with the company`s polices, this could put residents at risk. There was limited evidence that the home`s induction procedures, including induction of agency staff, were being followed, so new staff would not be fully aware of their roles and safety procedures. The home needs to improve its systems for ensuring that all complaints are listened to, documented and fully investigated. Staff also need to be trained in their responsibilities for safeguarding vulnerable people, including local procedures, to ensure that residents are fully protected. Improvements are needed in the home environment, including provision of appropriate equipment to meet residents` needs. Attention needs to be paid to cleanliness of basic equipment. The principals of health and safety need to be up-held, including risk assessments, fire safety, use of bed safety rails and home security systems.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Westbury Nursing Home 86 Warminster Road Westbury Wiltshire BA13 3PR     The quality rating for this care home is:   zero star poor service 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. Lead inspector: Susie Stratton     Date: 1 1 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 51 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 51 Information about the care home Name of care home: Address: Westbury Nursing Home 86 Warminster Road Westbury Wiltshire BA13 3PR 01373825868 01373825013 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): BUPA Care Homes (CFC Homes) Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 51 Number of places (if applicable): Under 65 Over 65 51 0 old age, not falling within any other category physical disability Additional conditions: 0 5 The staffing levels set out in the Notice of Staffing dated 9 January 2004 must be met at all times. This can be reflected in the Statement of Purpose. Date of last inspection Brief description of the care home The Westbury Nursing Home is registered for 51 people. The building was purposebuilt as a care home and opened in December 1993. Accommodation is provided over two floors with a passenger lift in between. The home aims to meet the needs of frail/elderly people, those with a physical disability and those who need care in the terminal stages of life. It also offers respite care for people living in the town of Westbury. A new manager was appointed in the Spring of 2008, she is to be assessed in accordance with our processes. A team of registered nurses, care assistants, activities coordinator and ancillary staff are employed in the home. The Westbury is Care Homes for Older People Page 4 of 51 Brief description of the care home situated on the A350, leading into the small market town of Westbury. Car parking is available on site and a bus stop is situated close to the entrance. Westbury also has a main line railway station. The fee range is 650 pounds to 900 pounds per week. Items not included in the fees are hairdressing, chiropody, visitors meals, physiotherapy, newspapers and telephones. A copy of the service users guide is provided in each residents bedroom and a copy is also available in the main entrance hall. Care Homes for Older People Page 5 of 51 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: As part of the inspection, 30 questionnaires were sent out and 25 were returned. Comments made by the people in the questionnaires and to us during the inspection process have been included when drawing up the report. As part of this inspection, the homes file was reviewed and information provided since the previous inspection considered. We also received an annual quality assurance assessment from the home. This was their own assessment of how they are performing. It also gave us information about what has happened during the last year. We looked at the quality assurance assessment, the surveys and reviewed all the other information that we have received about the home since the last inspection. This helped us to decide what we should focus on during the visit to the home. Care Homes for Older People Page 6 of 51 As The Westbury is a larger registration and a range of issues of concern had been identified in questionnaires and at the first site visit, the site visits took place over three days. Both the site visits were conducted by two inspectors and these people are referred to as we throughout the report, as the report is made on behalf of the Commission for Social Care Inspection (CSCI). The first site visit was on Friday 21st November 2008, between 8:45am and 5:10pm. The second site visit was on Friday 5th December, 2008 between 9:45am and 3:35pm. The third site visit was on Thursday 11th December 2008 between 9:50am and 1:00pm. The first two visits were unannounced. The prospective manager was on duty for some of the first two days and all of the third day of the inspection. Both the regional manager and the prospective manager were available for the feedback at the end of the site visits. During the site visits, we met with sixteen residents, six visitors and observed care for fourteen residents for whom communication was difficult. We toured all of the home and observed care provided at different times of day. We reviewed care provision and documentation in detail for six residents and reviewed certain aspects of care and documentation for a further four residents, across all parts of the home. As well as meeting with residents, we met with four registered nurses, twelve carers, the activities coordinator, the chef and a laundress. We observed lunch-time meals and an activities group. We reviewed systems for storage of medicines and observed medicines administration rounds. A range of records were reviewed, including staff training records, staff employment records, and complaints records. What the care home does well: What has improved since the last inspection? What they could do better: At this inspection, 24 requirements and 17 good practice recommendations were made. Residents reported on how the home had changed from the past. One person reported its all a bit of a mish mash from what it used to be and another the quality of [my relatives] care has significantly declined. The home needs to review staffing levels, particularly in the light of resident dependency, to ensure that residents needs are met, that their ability to choose can be up-held and staff can provide care in a correct, safe and timely manner, in accordance with care plans. Staff need to be supervised in their roles, to ensure that they can meet resident need. Training needs to be improved. At the previous inspection, it was required that staff training records must be fully up-dated to reflect training undertaken. If deficiencies were identified, an action plan must be developed and submitted to the CSCI. This had Care Homes for Older People Page 8 of 51 not been actioned by this inspection. It was not clear if staff had been trained in the principals of health and safety, including infection control or first aid. There was no evidence that staff had been trained to meet resident needs relating to conditions experienced by older people such as prevention of pressure ulceration, stroke care or dementia care. This lack of training means that there was evidence from a range of sources, including residents and their relatives, observations of care and reviews of records that not all their nursing and care needs were being met. Not all recruitment policies were being fully completed in accordance with the companys polices, this could put residents at risk. There was limited evidence that the homes induction procedures, including induction of agency staff, were being followed, so new staff would not be fully aware of their roles and safety procedures. The home needs to improve its systems for ensuring that all complaints are listened to, documented and fully investigated. Staff also need to be trained in their responsibilities for safeguarding vulnerable people, including local procedures, to ensure that residents are fully protected. Improvements are needed in the home environment, including provision of appropriate equipment to meet residents needs. Attention needs to be paid to cleanliness of basic equipment. The principals of health and safety need to be up-held, including risk assessments, fire safety, use of bed safety rails and home security systems. 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 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 51 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 51 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People will be given information about the home. This information would benefit from more detail. There is a clear admissions process, however information systems to inform care staff about new residents needs would benefit from more development. Evidence: All of the fifteen people who responded to this section of the questionnaire reported that they felt they had had enough information about the home, so that they could make a decision about admission. Residents are given a copy of the service users guide in their own room. One person reported that they had been admitted for respite care and had decided to stay, another this is the right place for me, one wouldnt find a better home, however another person did qualify their response by reporting that they had been admitted quite a while ago and that the home was all so different now. Care Homes for Older People Page 11 of 51 Evidence: We reviewed the information in the homes Statement of Purpose and Service Users Guide and noted that it complied with Regulations and guidelines. However the information was brief and would not fully inform an external person of how, for example the home was able to meet the needs of a person with complex nursing needs or needs relating to terminal care. Additionally while it gave an overview of the numbers of staff, it did not detail the numbers and skill mix of staff throughout the 24 hour period and how these numbers and skill mix could meet residents needs. The statement of purpose stated that the home was Dedicated to training and developing our staff, this was not supported by the evidence of our inspection (see Staffing below). We reviewed records relating to two newly admitted residents. Both were generally fully completed, providing a good basis for the development of care planning. Where a prospective resident had complex needs, the assessment was completed individually and in detail. One persons assessment did not have the section on beliefs and cultural interests completed. The assessment did not indicate if the prospective resident had been unable to respond or if this was a matter to be followed up after admission. Both of the recently admitted residents were very frail and were not able to comment about their experience of the admission process. A relative of a recently admitted person reported that they did not have any concerns about their relatives care in the home. We spoke to three registered nurses and one carer, who reported that they were given a full report on people who were to be admitted to the home so that they could meet their needs. The manager reported that she ensured that where people had specific needs, for example complex manual handling needs, that an adjustable bed was always available for them. Registered nurses reported that occasionally they had had to move such equipment around, to meet the needs of people who were admitted, as there were not yet enough adjustable height beds to meet the needs of all residents who had complex manual handling needs. We discussed with more than 10 carers about how they found out about recently admitted residents needs and also considered responses in questionnaires from staff. Most carers reported that they were given a report when they came on duty, to inform them about residents needs. However all carers commented that this report tended to be very brief. This meant that they had to learn how to meet the specific needs of residents as they went along. Several care assistants commented that if they had been off duty, they might not be informed that a person had been admitted whilst they had been away and so not be aware of their specific needs. All carers reported that the care plans were very useful as they fully detailed how residents needs could be met. However they also commented, that they only rarely had time to read care plans, due to the high dependency needs of residents in the home. Care Homes for Older People Page 12 of 51 Care Homes for Older People Page 13 of 51 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have some clear, individualised assessments and care plans. However there is evidence that not all care is being provided in accordance with care plans and that residents dignity is not always up-held, this may relate to staffing numbers and training. People at risk of pressure ulceration may be put at risk as the home are not providing care in accordance with national and local guidelines. Evidence: During the inspection, we spoke to a range of people, including residents, their relatives, registered nurses and care staff, as well as the manager, to assess how the home met residents health and personal care needs. Prior to the inspection, we reviewed peoples comments in questionnaires. Many of the comments from people related to a perception that the home did not have enough staff on duty to meet the needs of individual residents. Comments included sometimes there arent enough staff to meet my personal needs, little time, if any, is given to checking on [my relative] and providing care, support, welfare and reassurance, I am usually well cared for, but really it all depends on who is on duty and the girls are really nice to Care Homes for Older People Page 14 of 51 Evidence: me. Several people reported that they felt that significant matters were missed. One resident reported, I would like my false teeth put in every day. One relative reported that their relatives hearing aids were not always put in and if they were, were not always put in correctly. Additionally, staff did not regularly check and change the batteries or check the tubing for build-up of wax. Two relatives reported that staff did not appear to always understand how to position a person who had had a stoke or how a stroke affected a persons communication. One person reported that they did not think that staff understood how their relatives medical condition affected their continence of urine. Staff training records showed no evidence that they had been trained in continence care, care of hearing aids or stroke management. Staff agreed that that they had not had any training in these and other areas relating to resident care (see Staffing below). All the staff we spoke to know about their residents needs. Some staff stated that at times, because they were rushed due to the high dependency of the residents, they were aware that matters could be missed or forgotten. Many carers reported that they did not feel that they had enough time to perform the key worker role properly. Some carers reported that the brevity of the handover in the morning meant that they did not always feel that they could meet residents needs. One carer reported information about service users does not always get passed on in full at staff handovers between shifts. All residents had very clear and detailed care plans, which mainly reflected their individual nursing and care needs. People we spoke to reported that care plans reflected individuals needs. Care plans were evaluated regularly and were available to residents in their rooms. Staff agreed that the care plans were highly useful documents. One member of staff reported that care plans cover everything we need to know about the resident. Another member of staff reported on the benefits of the new documentation system, in ensuring that staff considered residents needs on an individual basis. However, as noted in the section on Choice above, carers reported that they did not always have time to benefit from reading the care plans. It was noted as good practice that carers completed records relating to care given. These records were fully completed and included relevant details of care given. Where residents were unable to move themselves or give themselves drinks, monitoring records were in place. It was noted as good practice that these were completed in full at the time care was given and records for previous days and weeks showed the same standards of completion. Where residents had complex needs, for example were assessed as being at risk of Care Homes for Older People Page 15 of 51 Evidence: pressure ulcers or needed a urinary catheter, care plans were in place. It was noted as good practice that one resident who had had several urinary infections had had their urinary catheter removed to reduce risks of repeated urine infections. The home does not consistently include the clinical reason for use of a urinary catheter in their documentation. As urinary catheters are associated with higher risks of urinary infections, this is indicated, so that urinary catheters are only used when they are in the best interest of the resident. All people who were assessed as being at very high risk of pressure ulcers had care plans relating to reduction in risk in place. Some people who were assessed as being at high risk of pressure damage had care plans drawn up, but not all and this is needed to direct staff on how risk is to be reduced. Most people who had care plans relating to risk of pressure damage had their assessments reviewed regularly, but this did not happen in every case. This is indicated, as changes in peoples conditions can affect their risk of developing pressure ulcers. The National Institute for Clinical Excellence (NICE) guidelines, the European Pressure Ulcer Advisory Panel (EPUAP) and local guidelines all state where a person is assessed as being at risk of pressure ulcers, that as well as providing pressure relieving aids, in order to prevent risk of developing pressure ulcers, people at risk also need to have their positions changed at least four hourly and for those people at higher risk, they need their positions changing more frequently. The guidelines also state that if a person has pressure ulceration, that time sitting out of bed needs to be limited to two hours. It is anticipated in a care home with nursing that pressure ulcers will improve and generally not develop or only be noted for a short period of time. It was noted during the inspection that the home had a higher than would be anticipated number of people who had sustained pressure ulcers whilst in the home. We had not been informed in writing of any of these incidents as is requred in relation to events which can affect a persons well-being. One person had remained with a complex pressure ulcer for an extended period of time. During the inspection, we observed that whilst some people had their positions changed four hourly, most people at risk of pressure ulcers had their positions moved six hourly. One person who had sustained pressure ulcers in the home was only put on four hourly changes of position a month after the pressure ulcer was first noted. Two registered nurses spoken with were not aware of why the home was changing peoples positions six hourly rather than four hourly. There was no written evidence that staff had recently been trained in prevention of pressure ulcers. This was confirmed when we discussed training in this area with staff (see also Staffing below). Records showed that the home had good working relationships with external Care Homes for Older People Page 16 of 51 Evidence: healthcare professionals. The office diary showed a planned approach to contacting such professionals, to ensure that residents needs were regularly monitored. One resident reported staff all so kind when unwell recently. By the third site visit, the tissue viability nurse had been contacted about all people with pressure ulcers. She has also previously visited the home regularly to review people who had wounds, such as leg ulcers. Where residents needed thickening agent to assist them in swallowing, there was evidence of consultation with speech and language therapists, with clear care plans in place. It was observed that the speech and language therapists directions on the thickness of fluids were followed. All residents who were assessed as being at dietary risk, had an assessment performed in accordance with local guidelines. One relative did report that they considered that some registered nurses may need more training in the use of the assessment document. Reviews of training records did not indicate that all relevant staff had received recent training in this area (see Staffing below). During the inspection, we observed four medicines rounds. All were conducted in a safe manner, in accordance with the homes policies and procedures and Nursing and Midwifery Council (NMC) guidelines. There were safe systems for the storage of medicines. There was up-to-date information for registered nurses on the actions of medicines they were administering. Where residents had chosen to self-medicate there were clear risk assessments relating to this, which were regularly evaluated. One resident reported that they appreciated being able to remain in charge of their medication. Where resident were administered diabetic drugs or Oxygen, there were clear care plans relating to this. Residents reported that registered nurses were supportive in meeting their medication needs. One person reported My legs are very painful, they ARE helping, theyve just put me on stronger painkillers and another Im not really comfortable, they offer me painkillers but I try and avoid it. Where residents are prescribed medication which can affect their daily lives, care plans are being put in place to direct staff, however these need more development. For example one persons pain management care plan noted that the person was to have analgesics to meet their needs. However the person was prescribed a range of different painkillers and their care plan would benefit from documenting which painkillers were to be given and when, to assist in evaluating the effectiveness of such interventions. Another person was prescribed a major mood-altering drug but the reasons for its introduction were not included in their care plan, so evaluations of its effectiveness could not take place. Some people were prescribed topical creams and lotions. Some care plans documented their use, but not all. There was also a lack of clear documentation relating to the actual application of topical creams. This needs to be developed, so that the home can Care Homes for Older People Page 17 of 51 Evidence: demonstrate that prescribed topical creams and lotions have been applied in accordance with the residents needs and the prescribers instructions. During the inspection, we observed that staff consistently knocked on residents doors prior to entering a room. All personal care was performed behind closed doors. Residents consistently reported that when staff did answer the bell, they were helpful. One resident reported oh yes they are helpful when they come, they make you feel youre the only patient, they are so good and another the girls are very nice, we always get on well. The laundress was aware of the importance of returning residents own clothes to them and had clear systems for ensuring that residents clothes were marked, so that they did not go astray. Some staff spoken with reported that they felt that at times residents privacy and dignity could be affected by the availability of staff on duty. During the inspection we observed one resident shouting very audibly that they needed the toilet, their distress was so evident that what they were saying could be heard throughout the corridor that their room was on. There was only one carer allocated to this section of corridor and they were observed to very kindly and gently advise the resident that they would need to get a hoist and another member of staff to assist them. This took some time, as other carers on that floor were busy, so during all this period, everyone in the area would have been aware of the residents needs and distress. This matter will also be dealt with in the section on Staffing below. Care Homes for Older People Page 18 of 51 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents ability to choose in relation to their social care needs may be limited by a lack of staff available to support them. Meals have shown improvement in choice and quality, however meals for people who are very dependant, do not reflect the same standards as for people who are able to eat without assistance. Evidence: Residents have a profile of their lifestyle and interests, and records of activities participated in. Communion is arranged regularly and several residents reported that this was important to them. It was noted as good practice that one resident who was from an ethnic minority had clear records that they did not want to be involved in their former religion. The activities person is able to work flexibly, to meet the different needs of residents, for example at weekends. There is an activities list displayed in public areas and this list is sent round the residents rooms. One resident reported I know whats happening with activities and another I go to the arts and crafts on Thursdays. The activities person reported that residents do not often go out. This is due to their frailty, additionally pushing a person into the centre of the town is complex, due to the Care Homes for Older People Page 19 of 51 Evidence: quality of the pavement and quantity of traffic on the main trunk road, which goes past the home. The activities person felt that she was limited in what she could provide, as staff do not have time to support her, so that when residents needed support from a person to engage or to meet their immediate personal needs when participating in activities, staff are not always available. It was also felt that staff were not good at encouraging residents to come down to activities. Care assistants reported that they were not able to be involved in social care due to time. Some care assistants spoken with felt that activities programmes related to more able people, and that many residents just need a chat. Care assistants reported that they could not do this due to time constraints. One carer reported sometimes the only time you get to talk to a resident is when youre washing them. Matters relating to staffing levels will also be dealt with in the section on Staffing below. Many carers felt that residents choice was limited because there were not enough staff. For example they reported that some residents would not be up until just before lunch-time. On one of the days of the inspection, two residents had to wait to be assisted with theri personal routines until after lunch, as staff had not had the time during the morning. Staff reported that residents started going to bed from 6:30pm, not through choice but so that they were ready for bed before the night staff came on duty. One carer reported day staff want night staff to get a certain number of people up, there is not a list or a quota as such but peoples requests are not listened to. Preferences for getting up are not clear in the care plan. Another carer reported that they would like to be able to meet service users daily requests i.e. when they want to come to the lounge and join in activities or just to get out of their room for a change of scenery, these needs are often not met. Several carers reported that they could not bath residents more than once a week, due to shortage of staff and that sometimes residents missed their bath days, due to shortage of staff. Staff also reported that there was not enough time to talk to people or encourage independence, therefore some residents may loose some self-care skills, for example washing their face, as it was quicker for a carer to do this for them. Several carers reported that an emphasis was placed on speed of provision of care, not quality of care provision to the resident. The home also needs to consider equipment provision. There are not enough specialist chairs for people who are not able to sit in conventional chairs and two people shared one specialist chair and they therefore got up every other day. This did not relate to an assessment of their individual needs. We met with a range of relatives during the inspection. Residents and relatives commented that they could come into the home whenever they wished. Some records are made of contacts with residents relatives but this is not consistently the case. For Care Homes for Older People Page 20 of 51 Evidence: example, the records relating to one resident who had sustained a pressure ulcer whilst in the home, did not show if their relative had been informed of this. We received a range of comments about the meals service. One person reported the food is very good, I need help to feed, they liquidise my meat, through the food varies, on the whole its reasonable to the food is my biggest complaint, the food is very, very poor. One person reported that their relative is not always asked what they want for their meals, resulting in food being provided that they dont like and a resident reported not enough food is served promptly. However another resident reported if I dont fancy anything, they give me something else. The other day, I was not very hungry and I said I fancied scrambled egg and they did it in no time. During the inspection, we met with the chef and observed mealtimes. The chef had only recently come in post. He reported that he goes round to meet residents and also attends residents meetings to receive their comments. Nearly all meals are cooked from raw ingredients. The chef reported that he was finalising reviews of menus at the time of the inspection. Staff reported that the food had improved since the new chef started. Some staff felt that the rest of the catering staff did not yet show the same abilities as the new chef in food preparation, for example some of the liquidised meals still had lumps in them. For people who needed liquidised meals, it was reported that when the chef was not on duty, the variety was limited and it was reported that sometimes residents who needed liquidised meals had the same meal for lunch and tea. The chef reported that he is planning to start staff supervision in the New Year to improve the consistency in quality of the meals service. Very few residents went to the dining room for their meal. It was reported that this was because of the high dependency of residents in the home. Many of the residents ate in their own rooms and many also needed full assistance from staff to eat their meals. We observed that there was a management system to ensure that residents got the meals that they ordered. However some relatives reported that this was not always the case and that there had been occasions when residents did not get what they asked for and on occasion had not had a meal at all. We observed that staff sat with residents when they assisted them to eat. Staff, although they had several people to assist to eat their meals, were observed not to hurry residents, helping them to eat at their own pace. Care assistants were observed to try to engage residents in conversation whilst they assisted them, to try to make the mealtime a social occasion. Care assistants were observed to use different sizes of spoons, depending on the residents ability to swallow. The type of spoon to be used was documented on residents care plans. Care assistants we spoke with were aware that some residents could vary in their need for support and that some residents Care Homes for Older People Page 21 of 51 Evidence: needed prompting as they could loose concentration when eating. We observed that at mealtimes there were not enough staff to assist all people who need assistance, to eat at the same time. The residents meals were kept in a hot trolley whilst staff were assisting other residents to eat their meals. We observed that meals in the hot trolley for people who had to wait to be given their meals tended to become dry. Staff agreed with this observation. One resident had a care plan which stated that their meals must be moist to enable them to swallow. We noted that their records stated that they refused their lunch-time meal and this may have been because their meal became dry as it had needed to remain for so long in the in meals trolley. Carers reported that some residents took an extended period to eat their meal and that they felt that not all carers had the time to do this. Care Homes for Older People Page 22 of 51 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their supporters will not have all their complaints noted and investigated. Lack of training in safeguarding means that residents have the potential not to be protected by systems in the home. Evidence: The home has a complaints procedure, which is on display in the main entrance area and is available to residents in the service users guide. During the inspection, we received a range of comments about raising matters of concern with the home. One relative reported that they had no hesitation in making a complaint if they needed to, another relative reported I can always speak to the sister & carers, if I have a complaint regarding [my relatives] welfare. However other people had different opinions. One person reported that their relative has confidence in certain members of staff who will try to allay their fears. This is not the case with other members of staff and another if I go to management with a complaint I dont always get the result I was hoping for. During the inspection, we met with several people, some of whom felt that they had raised complaints about a range of matters. However when we reviewed the complaints file, there were only records made of formal, written complaints, not other matters which had been raised verbally. One of the people who had put in a written complaint stated in their letter that they had raised a number of concerns before, Care Homes for Older People Page 23 of 51 Evidence: however there were no records of what these matters were in the complaints folder. We met with another relative who reported that they felt that they kept raising a range of issues but that no action had been taken. There were no records of this persons concerns on the complaints file. Carers reported that they received complaints from relatives. One reported we very often take complaints from residents relatives and another relatives can sometimes be very rude and abusive to ourselves. We understand and we would feel the same if it was one of our loved ones not receiving the care they need and deserve. During the inspection, we observed one relative bring up a matter directly with carers, raising their voice as they did so. Discussions with staff indicated that such occurrences are not reported to senior management for them to address and manage. Some people felt that even if matters were reported, that action did not take place. One carer commented concerns never really get sorted. When we reviewed the complaints file. There was evidence of the complainants letters and copies of the homes response to the complainant, however there was no evidence of how the complaint was investigated, including statements from staff or other matters relevant to the investigation, apart from a couple of pieces of paper with hand-written annotations. In the absence of an audit trail to show how a complaint had been investigated, it is not possible to assess if the home has followed its procedures or if the conclusions reached were valid or not. We reviewed systems for safeguarding people in the home. Since the last inspection, there have been two safeguarding referrals made under local procedures. Both of them were made before the prospective manager came into post. A review of the homes file showed that the home assisted the investigators fully at the time of the referrals. During the inspection, we discussed training in protection of vulnerable people. All of the care staff spoken with reported that they had not received any training recently in the area. This was supported by records, which showed that last training had been in 2007. The training at that time consisted of a DVD, with a question format at the end. There was no evidence that training took into account local procedures. We discussed actions to take in the event of suspected abuse with staff. All carers were clear that they would report any matters of concern to the person in charge. The registered nurses, who will be in charge of the home, when the manager is not available, all reported that they would inform the manager. None of them knew what actions to take under local procedures. On the second site visit, the manager was not in the home and staff were not clear as to where she was. On such occasions, staff in charge of the home would need to know what actions to take under local procedures, to ensure that vulnerable people were safeguarded. The prospective manager reported that they had Care Homes for Older People Page 24 of 51 Evidence: not had specific training in local procedures but that they had ensured that they had met with key people in Social Services since they came in post, to familiarise them with local procedures. Care Homes for Older People Page 25 of 51 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home environment supports residents in some areas, however there is a shortfall of equipment to meet resident need in certain areas and the state of facilities and cleanliness in parts of the home may present a risk of cross infection. Evidence: The Westbury was purpose-built as a care home with nursing, some years ago. During the inspection, we observed that many of the homes corridor walls and doors were scraped. This reduced the homely atmosphere of the home. The previous maintenance man left his post in 2007, a new person was appointed in the summer of 2007, with a gap of about two months when maintenance was performed by other maintenance people from within the group. During this period, records indicated that none of the standard planned maintenance had taken place and only urgent issues were attended to. All other maintenance logs were clear and fully completed. The home has invested in some equipment to meet the needs of the residents. We observed that not all people with complex manual handling needs were cared for in variable height beds. The prospective manager reported that two more profiling beds were on order. Even with these two new beds, there would continue to be residents with complex manual handling needs being cared for in fixed height beds. This has the potential to put both residents and staff at risk, as all people who have complex Care Homes for Older People Page 26 of 51 Evidence: manual handling needs, need to be in height adjustable beds, to ensure safety when manual handling. We did observe, as good practice, that the type of profiling beds that had been provided lowered close to the floor. This reduces the need for safety rails, which can be regarded as a risk to residents safety. As noted above, not all residents who had complex seating needs had chairs provided to meet their needs and two residents alternated the use of one chair every other day. The home has a range of equipment to prevent risk of pressure ulceration. Some of these mattresses were the older type and on two occasions, the weight indicator on the dial did not relate to the persons weight as documented in their records. If such air mattresses are not on the correct setting, this can mean an increased risk of pressure damage for the resident. As there was no evidence that staff have been trained in the prevention of pressure ulceration and use of equipment, this may relate to lack of knowledge amongst staff relating to the importance of correctly using equipment. During the inspection, we met with a laundress and visited the laundry. The laundry was clean and looked well managed, with no dust or debris visible behind any of the machines. The laundress reported that staff conformed in full to the homes policies on management of infected and potentially infected laundry. She also showed a good awareness of her role in the prevention of spread of infection. One resident commented the laundrys quite alright and another the laundry is not an issue. Several people raised issues relating to cleanliness in the home. One person commented I dont think the home is very clean at all, another I get the smells morning, noon and night and another this home stinks. During our three site visits, we did not observe issues relating to odour or general cleanliness and one resident commented that their cleaner who does the rooms, shes very good. During the inspection we did note that several of the sanitary items such as urinals and bedpans, showed staining, including lime-scale deposits. All of the lids of clinical waste bins in sluice rooms were deteriorated, with old sticky tape, half torn old signs and the like. As such the lids could not be properly cleaned. Several of the sluice rooms showed cracks to tiling. Some of the inner door surfaces in sluice rooms were not clean. One of the hoists was not clean in places, with debris visible and parts mended by sticky tape. Most of the undersides and backs of bath hoists were not clean, with in-grained yellow/brown deposits in top of lime-scale. Such hoists will be used communally, so they must always be clean and free of lime-scale. Several of the safety rail protectors were no longer intact showing holes in their surfaces and so as such could not be wiped down. All areas and equipment which may be used communally or touched by residents or staff must be clean, intact, wipable and free of Care Homes for Older People Page 27 of 51 Evidence: lime-scale, to prevent risks of cross-infection. Where residents were cared for in double rooms, there were not clear systems for separation of their topical creams. As communal use of topical creams is a significant factor in spread of infection, there must be full systems to ensure that all such applications are clearly labelled and used only for that person. It should be noted that none of the staff training records evidenced that any of the staff had been trained in infection control during the past year, so they may not have been aware of the significance of such matters as observed above, in the prevention of spread of infection. Care Homes for Older People Page 28 of 51 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are not supported by the homes numbers of staff and there is no clear evidence that staff have been trained to meet resident need. Residents are also not protected as not all recruitment processes have been completed in full. Evidence: We received many comments about the numbers of staff available to support residents, from residents, relatives and staff. Some of these matters have been referred to in sections above, as they have a direct affect on residents care. Comments included at times short staffed - difficult for carers, but sometimes there arent enough staff to meet my personal needs, the home is very understaffed, we always seem to be short staffed and there arent enough staff. As well as commenting on the shortage of staff, many people reported that staff were slow or did not answer call bells. Comments included the time lapse for [my relative] ringing her bell and a response to them far too long, if I ring my bell, they come sometimes it takes 10 minutes, they are very short staffed, I spend all my time in bed, Ive got a bell but if I ring it its not very often that they come and the home is very understaffed & waiting for bells to be answered sometimes takes ages and ages. The home has a call bell system that goes into emergency mode if the call is not answered within three minutes. During one of the site visits, we observed that the call Care Homes for Older People Page 29 of 51 Evidence: bells went into emergency mode on fifteen occasions. Residents did comment that when staff did attend to them, that they were supportive. One person reported they are very good, oh yes they are helpful when they come, they make you feel youre the only patient, they are so good. The length of time taken to respond to call bells means that residents may be placed at risk if they become unwell or fall, as well as not having their care needs met in a prompt manner. We looked at systems for recruitment of staff. The home does not currently have an administrator in post, so the prospective manager reported that some documents were awaiting filing in individual staff records. One file that we asked for could not be located on the first day we asked for it. It was subsequently found. Many staff photographs were copies of photographs from passports and driving licences and as such were not clear or able to provide clear proof of identity. One newly employed member of staff only had one reference on file and this was limited, not providing evidence of the persons suitability for their role. There was no evidence that a further reference had been sought. One person showed gaps in their previous employment records but there was no evidence on their file to show that this had been probed at interview. Two peoples files showed references which were different from the person stated on their application form, with no evidence as to why this was or in what ways the referee had known the persons performance in the past. One persons employment dates on their application form were different from those on a reference letter from their previous employer. There was no evidence that this had been probed. If full checks on a persons suitability for their role are not sought, residents may be put at risk by the employment of staff who are not able to fulfil their role. All people had had police checks. However the records maintained in the home did not show the date, record number or any issues identified. A checklist system is needed to clarify these matters. Under our Regulations, staff may be employed to work in the home supervised, until the Criminal Records Bureau (CRB) check is returned. The prospective manager reported that when a person is working prior to return of their CRB, that this is designated by a star by their name on the off-duty. None of the staff spoken with were aware of this system for ensuring that people worked fully supervised until the check had been returned, so systems for supervision need to be more clearly developed. We received many comments about the systems for staff induction. The Westbury uses a standard format induction booklet, which complies with accepted policies and procedures, however it was not at all clear that the providers policies and procedures for induction of new staff were being followed. One member of staff, who had commenced their role in August 2008, had one of the standard format induction booklets in their folder. This had not been completed. Another member of staff who Care Homes for Older People Page 30 of 51 Evidence: had commenced working in the home in January 2008 had a range of records not completed in their file, including equipment training, fire safety and safeguarding adults. The chef did report that he had had a comprehensive induction, had been provided with an appropriate mentor and had felt supported. Residents, relatives and staff commented on the induction. One person reported new carers are very lovely lasses, some are SO young, they need to go to school first and be taught what to do, lovely kids though, another at present I feel that the induction process urgently needs looking into. New staff are given brief inductions on what to do with residents in terms of care. This is because we are nearly always short staffed, another given induction pack, but left to sort out myself and another any new carers which start now have a poor induction. During the inspection, we met with newly employed carers and more experienced carers. They reported that a new member of staff would be allocated to work with a more senior person, but that newly employed staff only worked supernumerary for two days and they felt that this was not enough, particularly if someone had not done care work before or if their first language was not English. People also reported that new staff could be placed with different senior carers every shift and that this could be confusing for newly employed people. Newly employed staff need full and detailed inductions into their roles, these need to be built round the member of staffs needs, to ensure that they are able to properly fulfil their role. As noted above, the home has been using high levels of agency staff. There was an agency induction programme, to ensure that agency staff were informed of significant procedures such as the fire policy. However no records had been completed in this file since 2007 and none of the names of people on this file related to agency staff currently employed. The homes policy is that agency care staff are allocated to work with a permanent member of staff. However staff were not able to confirm that they were always able to supervise agency staff, as the dependency needs of residents was high in the home. Records showed that agency registered nurses may be in charge of the home at times. The lack of evidence of agency induction is of concern and the home needs to ensure that all temporary staff are fully aware of all relevant procedures, particularly emergency procedures. We reviewed the staff training file. The file was not clear and was complex to follow. It provided no evidence that the requirement from the previous inspection that Staff training records must be fully up-dated to reflect training undertaken. If deficiencies are identified, an action plan must be developed and submitted to the CSCI had been addressed in any way. The file indicated that not all staff had been trained in mandatory areas relating to Health and Safety (see Management below). It also provided no evidence that staff had been trained in the range of needs for people in Care Homes for Older People Page 31 of 51 Evidence: the home, including prevention of pressure damage, management of the care of people who have had strokes, management of hearing loss, management of continence, dementia care, management of people who have dietary needs or swallowing problems. Staff spoken with confirmed that they had not been trained in these areas. All staff spoken with expressed a desire for training, so that they could meet residents needs. One person reported although a disability may be written up in a care plan training in a range of areas relating to disability and diversity would be really useful and another due to continual changes training is usually left out. Evidence from this inspection, particularly in areas relating to health and personal care above show that staff need to be trained in a range of areas to ensure that they can meet resident need. Discussions with carers indicated that they were performing certain extended roles, such as changing stoma bags. They reported that they had been trained in such tasks by people who had experience. The prospective manager reported that if a resident was admitted with a new clinical need, that she ensured that staff were trained and that training was cascaded as relevant to other staff. There were no records on file to support this and this is advised to ensure that the home can demonstrate that staff are fully trained in relevant areas to meet resident need. Care Homes for Older People Page 32 of 51 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are not fully protected by management systems to ensure that quality of care is fully reviewed, that staff are protected and that all principals of health and safety are up-held. Evidence: The Westbury has been without a permanent manager for a period of time. At the last inspection, there was an acting arrangement by a manager from another home, whilst a recruitment process was carried out. After this, a manager was appointed and they were approved in accordance with our processes. However this person did not remain in post and a second recruitment process was carried out. The current manager designate was appointed in the spring of 2008 and the regional manager reported that she will be put forward to us to be the registered manager of the home. During the same period, the home has also not had a deputy manager, two people have been appointed to the role since the last inspection but neither person remained in post and a recruitment process for this role was taking place at the time of the inspection. The Care Homes for Older People Page 33 of 51 Evidence: home also does not currently have an administrator and had been without an administrator for a period of time, with once a week support being provided by an administrator from another home. This means that a range of management and training processes had not taken place and the manager designate has had to perform a range of roles, not only the home manager role. These management issues were reflected in comments in questionnaires from residents and staff. One person reported I do find that with each successive manger (& there have been quite a few) we seem to see less and less of them, another our manager is also very busy and I do not feel she is to blame for not meeting her staff regularly and she seems to have a lot on her plate. As part of the inspection process, the home submitted an annual quality assessment audit. This audit was submitted after the deadline for reply. This audit did not recognise or report on the requirement from the previous inspection in relation to staff training and comments made indicated that there were no issues in relation to staff training. The audit also did not comment on residents, relatives and staff perception of a lack of staffing in the home , although it did comment on actions taken to reduce agency staff in the home. In the section on complaints and protection, the audit indicated that training in safeguarding adults was taking place. This was not reflected in records or evidence from staff in the home. The section on the environment did not note the lack of height adjustable beds and specialist chairs or actions being taken to address such shortfalls. The home is visited by a senior manager on a monthly basis and a report is drawn up, which is kept in the home. These reports were very brief and none of them documented issues relating to training, staffing and equipment. They also did not document the deficiencies in documentation relating to recruitment and complaints investigations, as observed at this inspection. The regional manager was present for the feedback at the end of the inspection and she reported that she completes a much more detailed report into the conduct of the home when she visits. These reports were more accurate and did reflect some of the areas identified by this inspection. The manager of the home also makes returns relating to matters such as infection rates, accidents and incidences of pressure ulcers. It was noted that this homes higher than would be anticipated number of pressure ulcers had been noted by the providers quality audit processes and the prospective manager had been asked to account for the situation. We reviewed some of the homes policies and procedures. The infection control procedures relating to urinary catheters was clear but did not document the risk of urine infections associated with urinary catheters or direct that the reasons for their Care Homes for Older People Page 34 of 51 Evidence: use and regular evaluations of need should take place. The policy on prevention of pressure ulcers does not state guidelines on how often a person with pressure ulceration or risk of pressure ulcers should have their position moved, in accordance with NICE and EPUAP guidelines (see section on health and personal care above). The home has revised its security policy in relation to the front door. The current policy is that when the manager is in their office, that the door should be unlocked. It appeared that this procedure was not always being kept to. On one of the site visits, the prospective manager was not in the home, however the door was not secured and we met with a delivery person who reported that they had rung the bell several times, had had no response and so had opened the door and come into the building to look for a person to receive the delivery. This person reported to us its always like this - cant find staff. On another occasion, the front door was locked but was opened to one of us by a resident. This has the potential to put residents at risk. As noted above, the home does not have an administrator in post at present. BUPA has standard systems for management of residents moneys and an administrator from the provider company attends the home once a week to ensure that are records are kept fully up-to-date. If items are handed in at other times, there are systems to ensure that there is a documentary record. This has clearly been complex whilst the home does not have an administrator and whilst systems were in place, they needed some work to ensure that there was a clear audit trail. It is to be anticipated that this will be dealt with when the new administrator is in post. We looked at the systems for supervision of staff, including reviewing records and discussions with staff. Supervision records need to be confidential but the records were open for any person to access in a general staff office. There was no evidence of an on going system to ensure that supervision was taking place. Records showed no order, consistency or evidence of professional development and records were not signed. Some records showed that poor practice/attitude was discussed, but there was little evidence of subsequent follow up. There was no evidence of discussing work role, peoples needs and other such issues. The records which were available showed no evidence of the next supervision date or any action plan. There was no evidence that any appraisals had taken place since the last inspection and at that point, they had not been up to date. Staff reported that there were no systems for formal supervision and that they were only told if they were doing something wrong. Five of the care assistants reported that they had not recently received supervision. Some staff reported that they felt on their own, just having to find out what to do for themselves. Many carers reported that they felt unsupported and several care assistants reported that they were not aware of who their supervisor was. Registered nurses were also not clear about supervision. Care Homes for Older People Page 35 of 51 Evidence: One described supervision in terms of the key worker/lead nurse role. Registered nurses also reported that they had not recently had any clinical supervision. One member of staff commented I have not had an appraisal for a long time and have not received any supervision for several months. I feel that this is because there is never enough time. Nurses and carers are seeming to be overworked, stressed and rushed of their feet! Records showed limited evidence of health and safety training, particularly first aid, infection control and food hygiene. Five care assistants spoken with reported that fire safety and manual handling training was taking place. There was evidence from both residents and carers that care assistants were occasionally using hoists on their own. This is contrary to the homes policy. The reasons for staff occasionally hoisting on their own was reported to be because a resident needed urgent manual handling assistance, for example to use the toilet, and the member of staff was not able to find another person who was able to assist them. Using a hoist with one person has the potential to put residents and staff at risk. During the inspection, we reviewed the fire folder, which is kept in the main entrance hall. The information in this folder was out of date, many of the records related to 2007. On the day we reviewed this folder, the main fire log book was locked away in the managers office and so would not have been available to fire authorities in the event of a fire. We asked to review the records of fire drills. Although a search was made for fire drill records, they could not be identified, therefore the home cannot evidence that regular fire safety training is taking place. The fire risk assessment was dated 22/1/04. There was no evidence that it had been up-dated since then. One resident was prescribed oxygen. A British Standard warning sign was not placed on the door, as is needed to ensure fire personnel are correctly advised in the event of a fire. Oxygen was also stored in the nurses office but the British Standard warning sign had come off the door and was propped up on a window. Matters relating to fire safety have been reported to the Fire Brigade. The home has diverse generic risk assessments completed for areas such as the boiler house, portable fans, use of electric razors and display screen equipment. These had last been reviewed in 2002. There was a risk assessment relating to automatic door closures which was dated 13.3.07. It stated individual assessments were needed. But there was no evidence of these. The risk assessment re toiletries was dated 13.3.07 and stated staff were to have regular COSHH updates. There was no evidence of this. The violence and aggression risk assessment stated that staff would benefit from briefing on aggression and how to deal with aggression from a resident. There was no evidence of this. Risk assessments need to be regularly reviewed. Where action plans are indicated in risk assessments there must be evidence that this has taken place. Care Homes for Older People Page 36 of 51 Evidence: The current situation has the potential to put residents, visitors and staff at risk. Residents who need bed rails had assessments for their use. These were regularly evaluated. One resident had safety rails on a divan bed. These bed rails were loose in their fixings. This was not noted in their safety rail assessment. The homes policy on checks on bed rails states that visual checks need to take place but there is no mention of a physical check. Where residents have non-integral bed rails, full assessments of their safety need to take place on a regular basis. Care Homes for Older People Page 37 of 51 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 30 18(1)(c) (i) Staff training records must 30/04/2007 be fully up-dated to reflect training undertaken. If deficiencies are identified, an action plan must be developed and submitted to the CSCI. This requirement is unmet from the inspection of 8/1/07. All staff will need to be trained in their role, so that they can meet the needs of residents. In a care home with nursing, some residents will have complex needs and all staff need to be made aware of how to meet such needs. Records need to be maintained so that managers can identify areas for development. Care Homes for Older People Page 38 of 51 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 8 37 The CSCI must be informed of any complex pressure ulcers, in accordance with Regulation 37. As a regulator, we need to be aware of any incidents that may seriously affect a residents well-being so that we can ensure that the home is in a position to meet residents needs. 27/02/2009 2 8 12 People assessed as being at high risk pressure ulcers must have a care plan in place, as well as those assessed as being at very high risk. Care plans must be reviewed regularly or if the persons condition changes. If people are assessed as being at risk of pressure ulceration, there must be written evidence that their positions have been changed, in accordance with national and local guidelines 27/02/2009 Care Homes for Older People Page 39 of 51 Pressure ulcers are painful and complex to heal, they also present a risk of infection to the person. An emphasis needs to be placed on prevention of pressure ulcers and there is a large body of research-based information on how they are to be prevented. In the absence of care plans, which are evaluated when indicated, staff will not be consistently directed on the care they are to give to ensure that pressure ulcers are prevented and if they do occur, actions are taken to ensure an effective healing process. 3 14 12 Residents must be able to exercise choice in fundamental areas, such as when they wish to get up, when they wish to have a wash or go to bed and be supported in maintaining their independence in activities of daily living. Residents in a care home must be able to chose how they spend their days, as they would in their own home. Independence needs to be fostered, so that residents do not loose abilities to care for themselves and become increasingly dependant on staff. 27/02/2009 Care Homes for Older People Page 40 of 51 4 15 16 A full review of the meals system must take place, to ensure that residents consistently receive the meals that they want to have, in a timely manner. Where residents need assistance to eat their meals, there must be systems in place to ensure that the quality of the meal does not deteriorate whilst they are awaiting supports from staff. Residents nutrition is a key area for their health and welfare as well as being part of a normal activity of daily living. To encourage residents to eat, meals provided must be appetising given to residents promptly in accordance with their individual needs. 27/02/2009 5 16 22 All complaints must be 27/02/2009 received by management, fully documented and there must be written evidence of how complaints were investigated and any actions points following complaints investigations. Frail people and their supporters may raise complaints in a range of ways and not always in writing. Management needs to know when residents and their supporters are not happy with service provided, so that they can take action Care Homes for Older People Page 41 of 51 to ensure that residents needs are met. If matters are not documented, they cannot be reviewed and any trends identified. Complaints files need to show how a complaint was investigated, so that review of the process can take place. 6 18 13 All staff must be fully trained 27/03/2009 in abuse awareness. This must include training in local protection procedures. Residents in care homes need to be protected from being abused. Abuse can take a variety of forms and staff need to be aware of what may constitute risk. Local procedures have been established to protect vulnerable people. Referrals needs to be made in accordance with local procedures to ensure that matters are correctly investigated and vulnerable people safeguarded. 7 22 23 All equipment needed to meet resident care needs must always be provided and be correctly used. Residents in care homes with nursing will have complex physical needs. Equipment to meet these needs must always be provided, so that residents can be cared for in a safe manner and to ensure that they are comfortable and 27/03/2009 Care Homes for Older People Page 42 of 51 able to exercise choice. To ensure that complex equipment is correctly used, manufacturers instructions must always be taken into account. 8 26 13 Systems must be put in place to prevent the communal use of topical creams in double rooms. Jars of topical creams provide a climate in which micro-organisms can grow. Therefore there need to be clear systems where residents are cared for in double rooms to ensure that topical creams are not used communally to prevent risks of cross infection. 9 26 13 All equipment and all sluice rooms must have intact, wipable surfaces and be clean. Where surfaces are not intact, micro-organisms can find places to grow. Sluice rooms where potentially contaminated equipment is managed and equipment which is used communally in care can present a risk to cross infection, unless all surfaces are intact and fully wipable. Where discolouration, staining or debris are visible, there is likely to be some microorganism growth, which can present a risk of cross infection. 27/02/2009 27/02/2009 Care Homes for Older People Page 43 of 51 10 27 18 A full review of staffing 27/02/2009 levels and skill mix must be undertaken, taking into account resident dependency, to ensure that residents needs can be met. In a care home with nursing, residents are likely to be highly dependant and have complex needs, therefore there must be enough staff, with a correct skill mix, to meet their needs. 11 29 19 There must be evidence that 28/02/2009 all gaps and discrepancies in employment history have been probed. If a prospective member of staff does not have a clear employment history, this needs to be investigated, to ensure that the person is honest and suitable to perform their new role. 12 29 19 All staff must have two satisfactory references before they commence employment, if different referees are used from that documented on the persons application form, the reasons for this must be documented. Residents will be at risk if a correct recruitment procedure for new staff is not carried out. Before a person commences employment, the home need to satisfy themselves by 27/02/2009 Care Homes for Older People Page 44 of 51 having a reference from their former employer and one other person, that the person is suitable for their role. If the reference is not from the designated person, the home needs to be able to demonstrate why this is, to ensure that a person who did know the prospective employee has commented on their performance. 13 30 18 There must be a review of the induction systems for newly employed staff, including agency staff, to ensure that there is evidence that all staff are fully inducted into their role. Inductions must be flexible to meet different staff needs. The induction of new staff is a key area, to ensure that people are fully informed of how to perform their role. All staff, including agency staff need to know actions to take in the event of an emergency and where relevant records that they may need to use are kept. Different newly employed staff will have a different skills and knowledge base, so inductions must take this into account, to ensure that residents are protected. Written evidence is needed, so that it can be referred back to by staff and 27/03/2009 Care Homes for Older People Page 45 of 51 managers when reviewing performance. 14 36 18 Systems for staff supervision 27/03/2009 must be developed in accordance with the providers policies. All supervisions must be securely stored. All staff who supervise others must be trained in their role. Staff need to be supervised, to ensure that they are supported in their roles. Supervision needs to take place regularly. Supervisors also need to be aware of effective ways of supervising staff. As the contents of supervision may be confidential, all such records must be securely stored and not be available for other people to look at. 15 38 13 Systems must be put in place to ensure that nonintegral bed rails are regularly physically checked and prompt action taken to address any deficiencies. Incorrect use of bed rails can present a risk to residents, therefore systems must be put in place to ensure that where these devices are assessed as being needed for residents, that they are used in a safe manner. 16 38 13 The policy and systems for 27/02/2009 entry into the home must be reviewed, to ensure that 27/02/2009 Care Homes for Older People Page 46 of 51 residents can be kept safe, visitors supported and deliveries promptly attended to. Whilst the home had a policy for entry into the home, there was evidence that this was not being kept to and this is needed, to ensure that residents and staff are not put at risk and ensure that the home is able to appropriately welcome visitors and other people. 17 38 18 The home must evidence 27/02/2009 that all staff have received mandatory training in areas relating to health and safety. Staff need to be trained in all relevant areas, to ensure the health and safety of themselves and all people in the home. 18 38 13 British Standard signage 27/02/2009 must always be used on all room doors where Oxygen is used or stored. In the event of a fire, the fire brigade needs to be fully informed of where there is an additional risk presented by oxygen, to ensure that appropriate actions can be taken to ensure peoples safety. The only acceptable way to do this is by the use of standard, agreed signage. Care Homes for Older People Page 47 of 51 19 38 18 The home must be able to evidence that staff are regularly trained in fire safety, including fire drills. Staff need to be trained regularly in fire safety so that in the event of a fire they are fully aware of actions to take to ensure the safety of people. 27/02/2009 20 38 23 The home must up-date its fire risk assessment. Fire risk assessments are required to be drawn up, to identify areas of risk and how they are to be reduced. As risks of fire can vary over time, risk assessments need to be regularly reviewed to ensure that risk to people is reduced. 27/02/2009 21 38 23 The fire log book must 27/02/2009 always be kept up-to-date and be available for relevant persons to review. Fire authorities need the log book to be available and to include all information required, to ensure that in the event of a fire that people can be protected. 22 38 13 The home must ensure that 27/02/2009 enough staff are on duty so that staff do not have to use hoists on their own. Where a resident needs a hoist, there need to be two people to support the resident, to ensure that risk Care Homes for Older People Page 48 of 51 to the resident and staff is reduced. 23 38 13 General risk assessments 27/03/2009 must be regularly reviewed and there must be evidence that actions identified in risk assessments have taken place. Risk assessments are needed to ensure that risk is reduced to residents, visitors and staff. As risk may change over time, they need to be regularly reviewed to ensure that they are relevant and to make any changes needed. If management has identified actions to take to reduce risk, to ensure that people are protected, they must ensure that these actions have taken place. 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. No. Refer to Standard Good Practice Recommendations 1 1 The Statement of Purpose and Service Users Guide should be further developed, to detail to people how the home is able to meet the needs of people with complex needs. The systems for informing care staff of the specific needs of newly admitted residents should be reviewed, so that all staff are given the information and guidance they need to meet residents specific needs. The section in the assessment form on lifestyle and beliefs should not be left blank. If the person experiences difficulties communicating or if the assessor cannot identify the information, this matter should be stated, so that this so can be followed up after admission. 2 3 3 3 Care Homes for Older People Page 49 of 51 4 9 Care plans relating to medicines which can affect daily lives should state which drugs are being used and reasons for their use. Where a resident is prescribed external creams or lotions, there should always be a care plan in place relating to their use and a documentary system should be developed, to evidence that they have been applied as prescribed. The clinical indicator for use of a urinary catheter should always be documented Sufficient care staff should be on duty to support the activities person in their role. Relatives need to be informed of significant changes in residents conditions and written records should be maintained. A range of different teaching methods should be used to train staff in safeguarding vulnerable adults. Corridor areas should be re-decorated. All items that may be used communally, such as sanitary items and bed rail protectors should be reviewed and any that are old, stained or not intact, be disposed of and replaced. Improved systems should be developed to ensure that staff are fully supervised until their police checks have been returned. All staff photographs should be clear. A checklist should be developed so that the home can evidence that policies and procedures in relation to Criminal Records Bureau checks have been complied with. There should be written evidence of training in extended roles for care assistants. More detailed reports into the conduct of the home should be available for inspection. Policies and procedures on pressure ulcers and infection control should be revised, to reflect national and local guidelines. 5 9 6 7 8 11 12 13 9 10 11 18 19 26 12 29 13 14 29 29 15 16 17 30 33 33 Care Homes for Older People Page 50 of 51 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. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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