Random inspection report
Care homes for older people
Name: Address: Winterbourne Winterbourne London Road Salisbury Wiltshire SP1 3YU two star good service 30/06/2009 The quality rating for this care home is: The rating was made on: 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 review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Susie Stratton Date: 0 9 1 0 2 0 0 9 Information about the care home
Name of care home: Address: Winterbourne Winterbourne London Road Salisbury Wiltshire SP1 3YU 01722428210 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Gillian Brinkley Type of registration: Number of places registered: Conditions of registration: Category(ies) : Caring Homes Healthcare Group Limited care home 80 Number of places (if applicable): Under 65 Over 65 41 80 dementia old age, not falling within any other category Conditions of registration: 0 0 Service users whose primary care needs on admission to the home relate to their dementia may only be accommodated to receive personal care and nursing care. The maximum number of services users who can be accommodated in 80. The registered person may provider the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories Old age, not falling within any other category (Code OP) - maximum of 80 places Dementia (Code DE) maximum of 41 places Date of last inspection
Care Homes for Older People 3 0 0 6 2 0 0 9 Page 2 of 16 Brief description of the care home The Winterbourne Care Centre is registered to provide nursing and personal care for up to 80 people. It was purpose-built and first registered on 5th February 2009. Accommodation is provided over three floors. The home is divided into six units. At the time of this inspection, four units were opened. One unit on the ground floor to the right of the entrance area provided personal care to elderly people, the unit above this on the first floor provided nursing care to people who were medically frail. The two units to the left of the entrance area on the ground and first floor provided dementia care. The home is owned by Caring Homes Healthcare, a national provider of care. The registered managers post is currently vacant, but there is an experienced manager acting into the role. This person leads a team of registered nurses, carers and anciliary staff. The home is on the London Road, leading into the city of Salisbury. There is ample car parking on site, a bus stop close by and a train station about 10 minutes away by bus or car. Care Homes for Older People Page 3 of 16 What we found:
This random inspection took place on Friday 9th October 2009 between 9:25am and 3:05 pm. It was carried out by two regulatory inspectors. We reviewed a range of documentary information and discussed issues with different members of staff, including the head of care. We concentrated mainly on standards of care in the nursing unit as we had received information about standards of care on this unit. At the end of our visit, we fed back to the acting manager. We looked at pre-admission assessments of residents on the nursing wing. We found that until the new head of care had come into post, assessments of need for people admitted for nursing care had been performed a senior carer, not a registered nurse. This meant that not all factors relating to nursing care had been adequately considered. This included, among other areas, information relating to catheter care and tissue viability. In two of the cases reviewed, the residents should not have been admitted to the home, as not all the registered nurses on the unit had the clinical skills to meet certain of their complex nursing care needs. This had not been considered prior to the persons admission. Now that the head of care is in post, this situation has been addressed and all people to be admitted to for nursing care will have an assessment performed by a person qualified to do so. The pre-admission assessment documentation will also be revised to expand assessments relating to people needing nursing care. We met with six people who needed nursing care and reviewed documentation in detail relating to four people who needed nursing care and discussed their needs with the head of care. The head of care reported that when they came in post, they found that junior carers were not given a report regularly on residents conditions. They had now set up systems to ensure that carers did receive regular reports on residents conditions and was further developing documentary systems relating to this. They also reported that they had identified that some carers needed further training in how to support residents. They had set up supervisory systems to carers to address this. We found a variability in assessments and care plans. Some people had full assessments and care plans, so that staff could know what a persons needs were and how they were to be met. One person had a detailed assessment relating to their manual handling needs and a clear care plan to direct staff on how the persons needs were to be met and risk reduced. Another person had a care plan promptly put in place when they developed a fungal infection. However other peoples care plans were not clear. One persons care plan stated that their urinary catheter bag was to be emptied regularly with no description of how often regularly was. Another person had a care plan about topical applications to be used for them but they also had additional used topical applications in their en-suite and it was not clear if and when they were to be used. Some people had care plans which were only partially completed. One person had a care plan about a urinary catheter; it did not include information on meeting the persons personal care needs in relation to cleanliness in the light of this catheter and did not document how often the catheter bag was to be changed. Another person had a care plan about their breathing, they had a clear care plan about the administration of Oxygen via a concentrator but the care plan did not document how often the nasal canulae needed to be cleaned or how often any tubing needed to be changed. The person also had a nebuliser in their room, which the resident reported they were given three times a day
Care Homes for Older People Page 4 of 16 but their care plan did not mention the use of the nebuliser or its effects on the resident. Some care plans which should have been drawn up were not in place. One person experienced pain in a range of different parts of their body and was prescribed medication both regularly and on an as required basis about this. Medicines records showed that the person was being administered these medicines and when and daily records showed that the person did experience pain, however no care plans had been drawn up about this persons pain or interventions to be taken by staff to ensure that the person did not experience pain. Another person had particular needs relating to their meals, which they told us about but they reported that some staff met these needs but others did not. This need was not documented in their care plan. There was limited evidence that staff were meeting individual care needs. One person was assessed as being both at high risk of pressure ulceration and needing to be encouraged to take in fluids. They had monitoring charts which had not been completed for two days before the inspection, so it was not possible to assess if the person had had their position changed two to three hourly, as directed in their records or had taken in adequate fluids during the 24 hour period. This was not an isolated occurrence and was repeated across all residents in the nursing unit. This is of concern as all of the people visited were frail and were at risk of pressure ulceration and could have been at risk of dehydration if they were not given adequate fluids. This matter was identified at the previous ubspection and the requirement has not been addressed within timescales. None of the fluid charts were observed to have been totalled every 24 hours as was recommended at the previous inspection. Where a resident had a catheter, there was limited documentary evidence of changes of catheter bags and the clinical indicator for use of the catheter was not documented as was recommended at the previous inspection. This was discussed with the head of care, who reported that they were trying to establish routines to ensure that residents needs were met, for example they had delegated the role of ensuring that all residents were weighed at least monthly to one of the care staff. We observed that all residents on the nursing wing had been left with access to their call bell. One person reported that staff usually comes when they rang their bell and that staff speed of attendance was variable. Another person reported Oh yes, they come if I ring my bell and another that staff come nice and quick when they rang their bell. One resident reported that they tended to slide down their bed and become uncomfortable. We asked them how staff met their needs when this happened. They reported that carers would put their arms under their arms and yank up the bed. The person did have a slide sheet in their en-suite. A second person reported to us that it took two carers to move them up the bed, they described how some carers put their hands under their arms and pulled them up the bed. This person also had a slide sheet in their en-suite. Manually pulling a person up the bed is not appropriate practice as it can put the resident and member of staff at risk of injury. It can also put the resident at risk of a sheering injury. Appropriate manual handling aids must always be used. We discussed how relatives and other people could raise complaints and issues of concern, with the head of care. They were able to describe how they had listened to one person who felt their relatives nursing care could be improved and showed us how they had documented this in the persons record. The record was clear and reflected what the head of care told us. They also reported that they had discussed the matter with the acting manager and had advised the persons involved to meet with the acting manager. Care Homes for Older People Page 5 of 16 The environment of the home remained at a high standard, with equipment to meet residents needs. Standards of cleanliness were also high and there was clearly a ready supply of disposable gloves and aprons. Some rubbish bins contained stuck-on debris which needed removing. Equipment to meet disability was largely available. However people who were assessed as having a high risk of pressure ulceration sat out of bed on cushions which were consistent with a medium risk of pressure ulceration, but their records did not clarify why this was indicated for the resident. Risk of pressure ulceration does not reduce when a person is cared for out of bed. Several of the people who had topical applications in their room did not have these named or dated, as was recommended at the previous inspection. This is recommended to reduce risks of communal use of such creams and prevent them from being used for extended periods after they are opened. As part of the inspection process we sampled the off duty staffing rota for the nursing unit, over a period of one month. The rota does not currently clearly identify which staff are working on specific units within the home. We suggested that the rota would be clearer if the nursing unit was separated from the rest of the units. The acting manager immediately put this into action. The rota demonstrated that there is always a registered nurse, (sometimes two) on duty. They are now supported on the nursing wing by two carers. This was not the case until recently. Previously there was one registered nurse and one carer on the nursing unit. The home has experienced some difficulties in recruiting permanent staff, however the acting manager reported that this has improved with regard to the nursing unit and they are almost in the position where they have an established team working on the nursing unit. Several appointments have been made and the acting manager reported that they were waiting for several newly appointed members of staff to complete notice periods in their previous posts. The head of care reported that if the registered nurse had to leave the nursing unit to support the residential units, that they and their nurses now always complete an incident form so that the extent of supports required by the other units can be monitored. We discussed the use of agency staff and were informed that the home generally use the same agencies to ensure that the carers have a good knowledge of the unit and the residents. This provides a consistent approach. The head of care reported that the agency staff they currently had were very good and liked coming to the nursing unit. One permanent member of staff commented all of the agency staff that I have worked with all know what to do but will ask if they are unsure. We use agency but they do not work alone, there is always a registered nurse with them. One agency worker we met with told us that they were currently working an average of four or five shifts a week. They confirmed that they had received an induction into the home. We asked the agency worker to explain how they obtain information about peoples needs when they come on duty. They told us everyday I look at the care plans and keep up to date. The registered nurse and the full time carers will also pass information on to me. They told us about the daily recording they complete to pass on information to the next shift. There are currently four separate daily records to be completed by staff. We suggested that this be reduced to incorporate all information on fewer records. The head of care confirmed that they and their staff are piloting improved systems in relation to this. Care Homes for Older People Page 6 of 16 We spoke to the two care staff on duty during our visit. Both confirmed that they felt there were sufficient staff on duty with the current numbers of people accommodated on the nursing unit. Both carers told us that they had time to chat to individuals while they deliver personal care. One person commented the residents always look for me as they like me to chat with them. We looked at staff induction and training on the nursing unit. One member of staff told us that they had worked at the home since January 2009. They told us that they had previously worked in retail and had no previous experience of working within a care home. They added that they love it and it was the best decision they had made. We asked them to explain about the induction process and if they felt competent to carry out their duties. They reported that their induction had consisted of training in all mandatory subjects such as, manual handling, safeguarding, first aid, basic food hygiene and catheter care. They added that they have also attended training in pain relief and palliative care at Salisbury hospital. They confirmed that they felt competent and by working alongside a registered nurse they could always ask if they need advice. The carer told us that there were two permanent staff on the unit who were half way through completing their National Vocational Qualification (NVQ) level 2. The agency staff we spoke to confirmed that they held an NVQ level 2 also. The acting manager introduced us to a member of staff who works on the dementia unit. They are a qualified manual handling trainer. They told us that they are planning to start training throughout the home in the near future and were intending to work alongside lesser qualified staff until they were deemed competent. We discussed residents reports of inappropriate manual handling with the head of care and acting manager and stated that they must ensure that staff always use safe practice when performing manual handling. The home currently hold profiles for all the agency staff used at the home. We looked at the profiles and saw that their qualifications are listed and proof of a check being carried out with the Criminal Records Bureau (CRB). Letters are kept on file from the agencies to confirm that all of their staff meet CQC minimum standards and a copy of their Statement of Purpose. The acting manager confirmed that they will not use an agency that does not provide the relevant information when requested. On the 14/5/09 records demonstrated that thirteen staff attended safeguarding training. On 30/6/09 three staff attended manual handling training. Some training is provided by E learning. This is where staff members complete workbooks on line and are presented with a certificate when successfully completed. Subjects were E learning is used include, the principles of care, fire awareness and health and safety. The acting manager explained that the Primary Care Trust (PCT) provide training in subjects such as catheter care and continence care. They added that if, during an initial assessment specific training needs were identified, they would arrange for this to take place. What the care home does well:
The Winterbourne provides a modern, comfortable home environment. There are a wide range of different communal rooms for residents to use if they wish. Residents bedrooms
Care Homes for Older People Page 7 of 16 are large and residents can bring in items of their own. One person had brought in their own recliner chair. One resident described the home as gorgeous. We met with one recently admitted resident who had been supported in bringing in a range of their own items, this gave their room a highly personal appearance, reflecting their likes and preferences. Residents can choose to eat their meal in their own room or the dining room on their floor or other areas of the home. Safe facillities for residents who wish to smoke have been provided. High standards of nursing equipment are provided, including profiling beds and a range of equipment to meet their manual handling needs. One person described how comfortable their bed was. Air mattresses are readily available. Where residents needed safety rails, assessments of need were consistently made and regularly reviewed. We met with a resident who had been recently admitted to the home from another care home with nursing. They reported that their family had come and seen their room on their behalf before they were admitted. They reported that the home provided much improved supports in comparison with their previous placement and that they particularly liked the size of their room, reporting that it was much bigger than my last home. The head of care reported on how this persons condition had improved since they had been admitted and that they were now sitting out of bed more and taking more of an interest in their surroundings and the home life. One person reported that they appreciated being able to have a shower every day if they wanted it. Another person reported that they were not a bath person and they they appreciated staff not trying to pressurise them into having a bath if they did not want one. A resident who had an existing condition relating to their leg reported they look after my leg properly. Another person who was assessed as being at high risk of pressure ulceration reported they do turn me at night. What they could do better:
When assessing a person for admission, assessments should consider if the home can meet all of the persons nursing care needs. These assessments should include consideration of if the current registered nurses employed by the home have the technical skills to meet all of a residents specific nursing needs. Care plans must be in place for all of a residents nursing and care needs. Care plans need to be specific and precisely describe how a persons needs are to be met. Plans need to include details of care such as how catheters are to be cared for by carers and when tubing for such items as Oxygen needs changing. There must be full written evidence that care is being provided to people in accordance with their care plans. Monitoring records must be completed at the time care is given. Staff must always perform manual handling in a safe manner in accordance with care plans and good practice guidelines. Where a resident is prescribed a medicine on an as required basis, there must always be a care plan or protocol to direct registered nurses on when the person is to be given such medication. Where a person is prescribed a medication which can affect their daily lives, such as a nebuliser, this must be included in their care plan and the nebuliser chamber must always be left clean and dry, to prevent risk of re-infection. Care Homes for Older People Page 8 of 16 Management needs to take prompt action to ensure that our requirements and good practice recommendations are acted upon. This inspection shows that one of the requirements at the last inspection relating to accurate monitoring records had not been addressed within timescales. Parts of two other requirements, one relating to care planning and the other to as required medication care plans/protocols had also not been addressed within timescales. Also three recommendations had not been addressed. We are aware that the home have experienced difficulties with the recruitment of staff and the acting manager reported that they anticipated that action would be taken to ensure residents needs were met, now they had established staff in post. The acting manager was advised that if this inspection had been a key inspection, outcome areas relating to health and personal care would have been considered to be adequate, not good as at the previous inspection. We will perform a random inspection before the homes annual service review, to ensure that standards have improved. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 9 of 16 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, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 7 12 Where a person is unable to 31/07/2009 change their position or give themselves fluids or meals, monitoring records must show that care has been given in accordance with care plans. Monitoring records must be fully completed at the time care was given. This requirement was identified at the previous inspection. It has not been met within timescales. Monitoring records are needed, so that staff can assess if a persons needs have been met and managers can monitor effectiveness of care plans. 2 26 13 The home must ensure safe 31/07/2009 practice in the laundry, including the correct handling of items for laundering, the availability of disposable gloves, aprons and rubbish bins and the marking of residents own items. This requirement was not reviewed at this inspection. Care Homes for Older People Page 10 of 16 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, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action If there are not safe systems in the laundry, there will be a risk of cross infection. Care Homes for Older People Page 11 of 16 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, 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 7 15 All residents must have full and detailed care plans put in place for all of their care needs. Parts of this requirement was identified at the previous inspection, with a timescale of 31/07/09. This part has not been addressed within timescales by this inspection. Care plans are needed so that residents can have their needs met in an appropriate and consistent manner. 30/10/2009 2 8 23 If a person is assessed as 30/11/2009 being at high risk of pressure ulceration, pressure relieving equipment which is consistent with this assessed degree of risk must be provided when the person is sitting out of bed. Risks of pressure ulceration do not reduce when a person is sitting out of bed. 3 9 13 Where a resident is 30/10/2009
Page 12 of 16 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 prescribed a medication on an as requred basis, a care plan or protocol must always be put in place. Parts of this requirement were identified at the previous inspection, with a timescale of 31/07/09. This part has not been addressed within timescales by this inspection. Residents need to be given their medications in a safe and consistent manner by staff. 4 26 13 Nebuliser reservoirs must always be left clean and dry after administration is completed. If a nebuliser reservoir is not clean clean and dry, there is a risk that micro-organisms will grow in the reservoir and the resident be at risk of reinfection when they use the nebuliser. 5 38 13 Staff must always undertake 30/10/2009 safe manual handling when assisting residents to move up their bed. Moving a person up the bed by not using appropriate manual handling aids can put the resident and the member of staff at risk of injury. 30/10/2009 Care Homes for Older People Page 13 of 16 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 3 Pre-admission assessments should provide written evidence that all of a persons nursing needs can be met by the home. Care plans should be written in clear and measurable terms and the use of generalistic wording be avoided. Where a person is having their fluid intake measured, the amount taken in should be totalled in 24 hours. This was identified at the last inspection. It has not yet been actioned. 2 3 7 7 4 8 Where a person has a wound photographed, the date should be included on the photograph and a signing off/archiving system be developed for healed wounds. This was identified at the last inspection. It was not reviewed at this inspection. 5 8 Where a person has a urinary catheter in place, the clinical indicator for the catheter should be documented. This was identified at the last inspection. It has not yet been actioned. 6 9 Written additions to the medication administration record should be signed, dated and checked by two members of staff. This was identified at the last inspection. It was not reviewed at this inspection. 7 9 Records for the use of creams and lotions should be made by the staff applying those products. This was identified at the last inspection. It was not reviewed at this inspection. 8 12 All activities participated in by residents should be documented and the home should develop systems so that they can review and document how successful or not activities have been for people. This was identified at the last inspection. It was not reviewed at this inspection. Care Homes for Older People Page 14 of 16 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 9 26 All topical creams should be named and dated on opening. This was identified at the last key inspection. It has not yet been actioned in full. 10 38 The fire risk assessment should be further developed. This was identified at the last inspection. It was not reviewed at this inspection. Care Homes for Older People Page 15 of 16 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.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) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 16 of 16 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
