Care Home: Coombe

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What the care home does well A creative and enthusiastic activity co-ordinator and staff make sure people are given frequent chances to do stimulating and enjoyable things. These are done individually or in groups. Attention is clearly paid to peoples` individual hobbies or interests. Activities happen daily and the atmosphere at this visit was warm and inclusive of everyone, whatever their abilities. The internal fabric of the home has been properly kept up and all areas were in good repair. The home is pleasantly decorated and communal and personal areas were exceptionally clean and hygienic at this visit.From our surveys we asked `what does the care home do well?` Relatives said: `It has laughter and is a pleasant place to visit that`s down to the staff and their genuine caring skills. These are due to experience` and: `It always seems to be busy and friendly which is excellent. Taking everything into consideration I believe they are doing a great job`. Staff commented: `It meets peoples` needs and some staff work well. A GP that visits the home commented: `they respond to constructive criticism and follow instructions well. I do genuinely feel they have the residents` interests as top priority and they do care`. Meals at the home are of a high standard, tasty and nutritious. Peoples` likes and dislikes are made clear and their choice of meal respected. Records are kept in good order that makes it easy to track how peoples` needs are met. What has improved since the last inspection? All twelve requirements and one good practice recommendation from the last visit in July `07 had been met. Evidence was available to show how they had been met and this is reported on under each group of standards below. In particular care plans were more person-centred and clearly detailed to show positive outcomes for people. In addition activities happened over the two days of our visit that showed people have lots of stimulation and enjoyment. The meeting of all requirements shows that people are kept safe, protected and the home is run in a positive way that meets their needs. What the care home could do better: One requirement was made. This was about making sure the medication fridge temperatures are recorded daily and that a better way of checking the temperature is put in place. This will make sure people are given medication kept at the right temperature so that it continues to benefit them. Three good practice recommendations were made: The staff group is currently doing a two-day, person-centred care for people with dementia course. Permanent staff have either done it or have definite dates to do it. However agency staff that have regularly worked at the home for months or years haven`t been booked on it. This could lead to differences in approach to caring for people with dementia that may have a negative affect on them. All staff should therefore do the training wherever possible. The manager has a regularly updated development plan for the home. However none of the issues raised from the home`s own quality assurance survey are included in it. The manager was able to give information about actions she had taken but no evidence was available to show this.Actions from the survey should therefore be added to the plan so that people and their relatives can be sure that their concerns or ideas are acted on. Whilst care records were generally good, too much emphasis on bodily functions was being recorded. Unless there is a clear medical reason for this care records should be more person-centred and focus on peoples` well-being and life in the home. CARE HOMES FOR OLDER PEOPLE Coombe 321 Canford Lane Westbury-on-Trym Bristol BS9 3PS Lead Inspector Sandra Garrett Unannounced Inspection 21 and 22 May 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe Address 321 Canford Lane Westbury-on-Trym Bristol BS9 3PS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0117 3772580 0117 3772581 Bristol City Council Mrs Patricia Vera Willis Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2007 Brief Description of the Service: Bristol City Council runs Coombe. The home is registered with the Commission for Social Care Inspection (the Commission) to provide personal care and support for up to 30 people with dementia who are over 65 years old. It’s situated in the leafy area of Westbury on Trym, in a quiet road with parkland behind. The nearest shops are 1/2 mile from Westbury village and a local bus route runs nearby. The building itself is laid out over two floors with a lift to the top floor. All bedrooms are single and include washbasins although not full en suite facilities. There are lounges on both floors and a dining room on the ground floor. There are several toilets and bathrooms near to communal areas. The building itself is based on a long corridor that doesn’t lend itself to small group living. However good use has been made of the large entrance hall that doubles as a sitting area for people. The secure and private garden has a ramp that makes it accessible to wheelchair users. It also has a pergola, garden table and chairs for people to sit out in during warm weather. The fees are £603.00 per week and extra charges are made for chiropody, hairdressing etc. Currently this information is provided verbally prior to admission and then confirmed in writing within a new contract. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority fees payable are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk http:/www.oft.gov.uk A copy of the latest inspection report was seen in the home. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key or main inspection was done over two days. The manager Mrs Pat Willis was available on both days and was welcoming and open to the inspection process. Before the visit, all information the Commission for Social Care Inspection (the Commission) had received about the service since the last inspection was looked at. We also sent our ‘Have Your Say’ surveys to relatives before the visit and any comments made are included throughout this report. We spent a period of time observing the experiences of people living at the home. This was to check that they were getting a positive and person-centred quality of care and to make sure their well-being was being kept up. Person centred care means that the aim for people with dementia is to keep ‘personhood’ in the face of declining mental powers. This means being treated as valuable individuals in their own right and being given every opportunity to have choice and control over their lives. Twenty-five people were living at the home at this visit. Three were ‘case tracked’ during the inspection. Case tracking is another way we assess whether people who use services receive good quality care that meets their individual needs. We also looked at a range of records. These included: Care and daily records, health and safety, complaints, the home’s last independent quality assurance survey report and staff records including supervision and training. We spoke to several people living at the home and all the staff. What the service does well: A creative and enthusiastic activity co-ordinator and staff make sure people are given frequent chances to do stimulating and enjoyable things. These are done individually or in groups. Attention is clearly paid to peoples individual hobbies or interests. Activities happen daily and the atmosphere at this visit was warm and inclusive of everyone, whatever their abilities. The internal fabric of the home has been properly kept up and all areas were in good repair. The home is pleasantly decorated and communal and personal areas were exceptionally clean and hygienic at this visit. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 6 From our surveys we asked ‘what does the care home do well?’ Relatives said: ‘It has laughter and is a pleasant place to visit that’s down to the staff and their genuine caring skills. These are due to experience’ and: ‘It always seems to be busy and friendly which is excellent. Taking everything into consideration I believe they are doing a great job’. Staff commented: ‘It meets peoples needs and some staff work well. A GP that visits the home commented: ‘they respond to constructive criticism and follow instructions well. I do genuinely feel they have the residents’ interests as top priority and they do care’. Meals at the home are of a high standard, tasty and nutritious. Peoples likes and dislikes are made clear and their choice of meal respected. Records are kept in good order that makes it easy to track how peoples needs are met. What has improved since the last inspection? What they could do better: One requirement was made. This was about making sure the medication fridge temperatures are recorded daily and that a better way of checking the temperature is put in place. This will make sure people are given medication kept at the right temperature so that it continues to benefit them. Three good practice recommendations were made: The staff group is currently doing a two-day, person-centred care for people with dementia course. Permanent staff have either done it or have definite dates to do it. However agency staff that have regularly worked at the home for months or years haven’t been booked on it. This could lead to differences in approach to caring for people with dementia that may have a negative affect on them. All staff should therefore do the training wherever possible. The manager has a regularly updated development plan for the home. However none of the issues raised from the home’s own quality assurance survey are included in it. The manager was able to give information about actions she had taken but no evidence was available to show this. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 7 Actions from the survey should therefore be added to the plan so that people and their relatives can be sure that their concerns or ideas are acted on. Whilst care records were generally good, too much emphasis on bodily functions was being recorded. Unless there is a clear medical reason for this care records should be more person-centred and focus on peoples well-being and life in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 & 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People and their relatives benefit from being given clearer and more accessible information about the home, including terms and conditions, when they come into it. Satisfactory arrangements for people coming into the home make sure their needs are met. People are looked after well in respect of their specialist needs by staff that are suitably trained and experienced. EVIDENCE: Two requirements made at the last visit were met. The Statement of Purpose that’s common to all local authority care homes has now been changed. Information about meeting peoples needs, particularly that of people with Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 10 dementia is now clearer. This gives relatives a better idea of how the person’s needs will be met. Further, the Statement now includes information on equalities and diversity i.e. how the home will seek to meet the needs of people from different groups in society that may have more specialist needs. The manager showed us a new sheet of information for people. This had photos and pictures of people, places and things to help people understand what was being said. The sheet that will form part of the service users guide, had information in picture form about the local area, bedrooms and furniture, food and mealtimes, social events, activities and outings among other things. Whilst the picture format is good we advised the manager to make the text larger and in a more accessible font so that people would be able to see it better. People each have contracts and these are kept in their files. Each contract has the room number, fee payable and by whom and is signed by either the person if they are able to understand it or by their relative. The requirement to make sure advocates are found for those residents who do not have a representative was no longer applicable. The manager said that no-one was in need of an advocate as everyone has relatives or representatives that will act in that capacity if necessary. Pre-admission social work information was seen for each person we casetracked. Case tracking means looking at all the information kept on people including pre-admission assessments, care plans and daily records, activities, healthcare information and medication sheets. As part of case tracking we also speak to key workers and other staff. People we case tracked had either come from home or from other places where they had been spending time such as in respite and day care services. Information on peoples backgrounds and personal histories had been transferred into their care plans and added to by the home’s staff. Coombe is a home that is run to meet specialist needs of people with dementia. Information about such needs was seen transferred from assessments into care plans and staff have had training in dementia awareness so that they know how to work with this group of people. A new two-day course is currently being offered to all staff and those we spoke to that had done it said it was ‘brilliant’ as it focusses on supporting people to remain independent in a person-centred way. The home is accessible to disabled people and although not specifically designed for people with dementia efforts have been made to help people find their way around more easily. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Keeping of good and detailed care and health records show that people with dementia are well cared for in a more person-centred way that respects their rights and choices. Whilst medication practice is good, failure to keep up essential tasks in relation to it could put peoples health at risk. Being treated as valuable individuals, with dignity and respect benefits people with dementia living at the home. EVIDENCE: Three requirements made at the last visit had been met. Two of these were about making sure care plans are more person-centred with information about preferred routines and likes and dislikes being included. Further, plans were clearer about actions taken to meet individual needs, including the way people Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 12 make decisions, their health care needs and triggers that could show mental health getting worse. We looked at three peoples care records. These were all person-centred and detailed. We saw the difference for one person whose earlier care plan wasn’t person centred at all. However a more recent one was much better and gave lots of information about the person’s needs, how s/he wanted them to be met and positive outcomes for her/him. Care plans gave a clear picture of a person’s life in the home and what they needed to make them happy, relaxed and calm. Keytime records i.e. records of time spent with each person by their individual key or main care worker, were kept separately and were also very detailed about things done with the person. These included chatting about hobbies and interests, looking at photos and reminiscing, taking them out for drives or to the local shops and looking at magazines etc. Staff also give hand and arm massages and manicures that help relax people. Care plans are checked monthly for any changes and records were seen that showed they’re done regularly without any gaps. Full care plan reviews happen every six months and include relatives wherever possible. One person was due a review but her/his relative couldn’t attend. S/he had however, left information about what was to be discussed that had been properly recorded. Risk assessments were in place. Everyone has a moving and handling risk assessment that shows the effects of their dementia on movement, their abilities and needs e.g. getting in and out of bed and risk of falls etc. Some had specialist risk assessments to do with falls, behaviours and pressure sores. All were properly dated and showed evidence of regular review. Care plans were also clear and detailed about prevention and treatment of pressure areas, particularly for frailer people who can’t move about easily. Information about applying barrier creams, turning at night and use of pressure relieving mattresses was recorded in care plans and daily records although for one person records of turning at night weren’t being kept regularly enough. Healthcare issues were also properly recorded including foot care, checking of lumps, sores and mouth care. A medical visits sheet was in place in each person’s file that showed when GP’s and district nurses were called and visited. Messages from healthcare professionals about individual peoples treatments were recorded and carried out. Lots of general messages about healthcare were seen in the management team’s communication book that showed staff were quick to pick up any new issues affecting people e.g. sudden swellings or painful joints. A healthcare professional filled in one of our surveys and commented: ‘The home is managed well and the residents are looked after. The staff work so hard and are so kind to the residents – nothing is too much trouble for them’. Some people need assistance with eating because they’re unable to feed themselves. Staff were seen helping discreetly and giving people full attention Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 13 whilst they were doing so. One person was having a softer diet and liquid medication and staff spent time making sure s/he had enough to eat. A clear food and fluid chart was seen for this person that showed s/he was getting good nutrition and food that s/he liked. Weight records were seen that confirmed peoples weights were being kept up even if they were unable to feed themselves or had eating difficulties. We checked medication. All medication administration sheets were properly filled in and signed with no gaps. A requirement made at the last visit about making sure medication is handled safely was met. All records were clear including controlled medication. Returns to the pharmacy were properly recorded with date, quantity returned and reason for it. The pharmacist had signed to say s/he had received the returned meds. We checked the medication fridge. This is kept in a locked room and only used for things such as eye drops, suspensions and creams that have to be kept at low temperatures. All the eye drops that had been opened were dated so that they could be discarded within 28 days as per instructions. The fridge had a simple thermometer inside it that just showed the temperature rather than a minimum/maximum one that is recommended. Fridge temperatures seen were regularly showing 8°c that’s at the top end of the recommended range (between 2 and 8°c according to the Royal Pharmaceutical Society’s guidance). Further, fridge temperatures although recorded regularly, showed gaps of one/two days each week. This may mean that peoples meds aren’t being kept at the right temperature to make sure they stay effective. From our structured observation people were seen being treated with dignity and respect at this visit. Generally staff showed person-centred attitudes and approaches to people and regularly asked their opinions or choices when talking with them. Staff knocked on bedroom doors and waited to be invited in. No doors were locked. Where a person became talkative or excited at lunchtime and wanted to do other things rather than eat, staff were calm and gentle and used positive techniques to help the person focus on the meal. People were using the home in a positive way and not aimlessly walking about. Staff engaged people positively and tried to give everyone some contact but left them alone if they showed this was what they wanted. From what we saw people had good levels of well-being and the whole atmosphere was warm, positive and jolly. This is commended. From the home’s quality assurance survey report a relative had commented: ‘Staff treat all the residents with respect, dignity and kindness’ (two similar comments also). Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living at the home get lots of opportunities to have a stimulating and varied life where formal and informal activities happen all the time both individually or in groups. Peoples contact with the local community is kept up by staff that take them out regularly. Few restrictions placed on people living at the home gives them lots of choice in a relaxed atmosphere. Meals at the home are well managed and provide daily choice, variation, good nutrition and social contact for people. EVIDENCE: One requirement from the last visit about more regular activities was met. Coombe benefits from having an activities co-ordinator who’s worked at the home for many years. This person is enthusiastic and creative and said she loves working with people with dementia. She showed lots of ideas, some of Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 15 which she’d been able to put into action. One of these is to paint an outside wall as a beach scene. She showed us the picture of how she wanted it to look and had been able to get support from Dulux ‘Colour in the Community’ charity to give the paint needed. She had also been able to get a boat, shells and driftwood that would form part of the scene and said she hoped some of the more able people living at the home would be able to join in with the painting. The occupational therapist from the ‘In-Reach’ team (that’s made up of mental health professionals who offer support to homes) had been involved in setting up person-centred activities for people with staff. The psychologist from the team is also planning a piece of research at the home looking at peoples involvement with objects. This is to try and find out why some people with dementia need things such as dolls, cuddly toys or fabric to comfort them and also what else they get comfort from. The findings of this piece of work can then be used to add to peoples daily activities and improve their quality of life, which is good practice. The research will only happen with people if they have the capacity to agree with it and relatives were also asked for their agreement to the research going ahead. Rummage boxes had been put in place with labels on them inviting people to look and touch freely. The objects are then used as discussion and reminiscence topics. An activities room upstairs is used so that small groups of people can do crafts, baking, painting or other things. The activities coordinator said that she runs a ‘lunch club’ there where three or four people gather for lunch and help lay the table and clear away afterwards. This happened on the first day of our visit and people were also doing some gardening with her – potting up plants and enjoying time in the garden on a sunny day. People were seen being taken out for walks by care staff and records also showed when this happened. There’s a park nearby and a local shopping area with a café where they can go for drinks and meals. The handyperson has now done mini-bus training so is able to take small groups out for trips. We observed an hour before lunch in the entrance lounge. People were given a choice of music from CD’s and one person chose Glenn Miller. Some people cuddled toys or fur fabric and staff told us about these. Staff also included the dolls in conversations with people. Records of activities were seen that were person-centred and showed the various ways staff engage with people even if they are less able to join in. Reflexology and massages are offered that staff said people really enjoy. The activities co-ordinator said she regularly plans ‘themed’ events and showed us the dining room that had recently been decorated for a ‘country and western’ event. Cowboy clothes and memorabilia were displayed on walls and even a ‘wanted’ poster featuring a photo of and a ‘reward’ for the manager was seen! Lots of photos of various events were displayed in the entrance area together with photos of a person that had just come to the home. His details were Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 16 written under the photos with the name he preferred to be called. This made it easy for people to get to know him. People were seen moving about the home freely and choosing to sit where they wanted and to talk to who they liked. The hairdresser was in on the first day we visited and people were taken for their ‘appointments’. We saw an activities programme that included regular church services held in the home by a local vicar and also from a church group. Lots of visitors were in and out of the home on the first day of this visit and spent time with people. A relatives meeting had been held and minutes showed that activities were discussed. Barbeques are planned for July on different days and times so that relatives can come. A summer fete is also planned for 2nd August. We discussed bedroom door nameplates with the activities co-ordinator as many of the photos of people on the doors are of them as they are now. People with dementia may not recognise themselves as older people but could recognise themselves when younger or by their own special interests or hobbies. The activities co-ordinator said that one person loves anything to do with trains. We discussed this. Later while the person was having lunch the activities co-ordinator brought in some photographs of trains that she had mounted and was about to laminate for his door. They talked about the photos and whether he liked them. The activities co-ordinator then went away to find out more details about one of the photos for the person and came back to tell him. This is very good practice. Nameplates had also been discussed at the relatives meeting and relatives had given ideas for multi-photo frames and asked to bring in more photos or things that would help people recognise their own rooms. This is a good way of making sure people find their rooms and don’t go into other peoples. We observed the lunchtime experience for people in the home and sampled the meal of roast pork or lamb with vegetables. On both days of the visit meals were well prepared, hot, tasty and nutritious. People showed their enjoyment of the meals and ate well. Different desserts were available including those for people with diabetes. Peoples food likes and dislikes were recorded in their care records and on their personal profiles. However a staff member commented in our survey: ‘better food (is needed). Many have difficulty eating the current food and it can be very unhealthy which causes further problems’. Staff told us that mealtimes can be hard to manage, as a number of people need help with eating and there aren’t always enough staff for this. We observed staff including the manager, helping people discreetly, sensitively and in a person-centred way. We did however see that where there were two staff at one table there was a tendency to sometimes ‘talk over’ people. The manager said she was aware of this and would take action to make sure it didn’t go on happening. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 17 Menus showed traditional English meals are served although curries, pasta and garlic bread and beef chilli and rice are also offered. No-one at the home currently needs a cultural diet although the acting cook said she would like to do a cultural diets course. A Caribbean evening had recently been held with Caribbean food. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory complaints management and recording ensures people living at the home or their relatives can be confident in raising concerns about any aspect of their care. Arrangements for protecting people living at the home makes sure that they are protected from restraint, risk or harm as far as possible. EVIDENCE: Two requirements about restraint from the last visit were met. The team that supports all the local authority homes and the safeguarding adults from abuse co-ordinator had developed a new policy on restraint. The Commission had also been asked to comment and add its views on the policy, that had been developed over time. The policy had been reviewed to make sure it follows the Department of Health Statutory Guidance. No evidence of restraint was seen at this visit and staff were clear about their responsibilities about making sure people aren’t restrained. Wherever possible doors are kept unlocked so that people are free to go where they choose. Only rooms that have clear health and safety issues such as electrical equipment or things that could be dangerous are kept locked. At the last visit hair washing practices were of concern. The way people were having their hair washed could itself have been abusive or restraining to people Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 19 who may not understand what is happening to them. At this visit we saw the hairdresser at work and people were calm and relaxed. The hair-washing sink that was part of the problem had been raised so that people didn’t have to bend so far forward. Where people aren’t happy about using the sink the manager said that they now have their hair washed in their bath the night before and the hairdresser then just has to wet and set it. We looked at the complaints file but no new complaints had been reported since the last inspection. The file was orderly and all complaints that had been made had been recorded properly with clear investigation and outcomes. Staff we spoke with were clear about having had training in safeguarding adults from abuse. Those that hadn’t were identified on a training list. New staff said they were about to have it and others had dates planned. Those staff that had done the training more than three years ago had been identified as needing to do a refresher and training would take place when places became available. Staff were clear about what abuse is and how they would know if a person wasn’t happy or could have been abused. They told us how they were able to detect changes in mood. They were clear about talking to people about what might be troubling them if they were able to. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a comfortable, clean, safe environment that is well decorated and looked after, physically accessible and meets their needs. Good, proper cleaning and hygiene makes sure residents are protected from risk of infection as far as possible. EVIDENCE: One requirement had been made previously that was met. This was about a programme of maintenance work including plans to repair/repaint window frames and refurbishment of the kitchen. The building, though purpose built in the sixties, doesn’t lend itself to small group living and is built on a traditional model. However, inside staff have used Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 21 the space to good effect without it having too much of an institutional atmosphere. This is helped by having pieces of furniture and ornaments from times gone by and decoration that is cosy and homely. The activities room is laid out like a family dining room with bookcases, ornaments, rummage and a lace tablecloth. Each person’s bedroom is decorated differently and has lots of personal touches. Although none of the rooms are en suite, each has a washbasin and is close to toilets. Toilet doors are painted bright red to make them stand out from other doors. They have framed sketches of toilets with high-level cisterns on them so that people can recognise them easily. The home has been kept in an adequate state of repair and any necessary works have been done promptly. The manager said that where necessary windows had been repaired and the kitchen refurbished. The manager said that further works to improve the premises are unlikely to happen in the near future as local authority homes are subject to possible closure. However she said that essential repairs would continue to be done, that includes re-decoration of peoples rooms. From the home’s quality assurance survey report the environment scored 75 - the lowest of all the areas asked about. Positive comments about the location, garden, cleanliness and rooms were seen although a lot of comments were made about the building itself i.e. ‘the building is not perfect and in need of remedial work’, ‘the internal design of Coombe is fundamentally unsatisfactory’ and ‘building layout perhaps limits what could be done regarding living conditions – it’s oldfashioned and needs updating’. Toilets are accessible to disabled people with grab rails and some are big enough for wheelchairs to be turned easily. Equipment such as hoists and assisted baths are in place and used frequently. The home was exceptionally clean at this visit and smelled fresh and pleasant. Staff were seen cleaning all areas. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care staff are employed in sufficient numbers to meet peoples’ needs. Progress with National Vocational Qualification in Care training makes sure people are looked after well. Proper checks on staff before they come into the job keeps people living at the home safe and protected. Failure to make sure all regular care staff, whether permanent or agency, are given training in person-centred dementia care means people may not get a consistent quality of care that meets their needs. EVIDENCE: Three requirements from the last visit had all been met. One was about staffing levels. There were lots of staff on duty at this visit and they told us that they felt there are enough on each shift. The only problem they have is with the number of people that need help with eating. The manager told us that staffing has been increased to six in the morning and four in the afternoon and evening. The activities co-ordinator also does care tasks and was seen helping someone to eat when we arrived. From our survey staff commented: ‘We have one on key time between 10–11am then another 11–12noon. Two on Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 23 activities and three staff to do teas, care/personal needs and laundry. Altogether we have six staff in the morning and five staff at weekends’. Staff were very positive about working at the home. One person said she finds it fun and another agency staff member said she wouldn’t want to work anywhere else. From our survey a staff member commented: ‘Staff are affectionate to residents and give them a lot of freedom. Also most staff work extremely hard to make sure the home looks presentable and is nice for the residents’. Staff said they had enough key time to spend with people. However one person commented: ‘I have spoken to the manager about joint meetings between day and night staff but nothing happened’. S/he went on to say that ‘we have regular staff meetings but always the same staff turn up’. National Vocational Qualification in Care training continues. Eleven care staff have Level 2 and others have started it. New staff will start to do it as soon as possible. Three cook or domestic staff have Level 1. A second requirement about making sure staff records demonstrate that they’re suitable to work with vulnerable people, was met. We saw details of each staff member’s Criminal Records Bureau disclosure and for new staff recently taken on the proper check was done to enable them to start quickly before the full disclosure was received. Having staff that have been properly vetted makes sure people are protected. From the training sheet and individual records seen staff have had training in moving and handling, first aid, food hygiene and person centred care. A third requirement about setting up a rolling programme of dementia care training was met. A new two-day course is ongoing and some staff had done it whilst others are booked for future days. Staff said they enjoyed the course and had gained a lot from it. The course is about person-centred approaches to supporting people with dementia. However we noted that only permanent staff have been able to do the course. From our observation agency staff who have worked at the home for some time didn’t always display person-centred ways of working with people and should have the same opportunities to do the course as others. If not all staff do the training, differences in the way staff work with people with dementia could affect the overall quality of their lives. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33, 35,36,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and experienced manager who understands peoples needs makes sure they are well cared for. Failure to record actions from the home’s quality assurance survey shows that people may not have a chance to help change the way the home is run that will benefit them. Proper management of peoples money makes sure they are protected from financial risk or abuse. People get consistent care from a staff team that have opportunities to regularly reflect on their working practices. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 25 Proper recordkeeping makes sure people are respected and the quality of their lives within the home can be regularly checked. However too much focus on bodily functions implies an institutional approach rather than a person-centred one. Improved fire safety and checking of water temperatures makes sure everyone at the home is kept safe from risk. EVIDENCE: Management and staff scored the highest in the home’s quality assurance survey at 88 . One comment seen was that ‘managers and staff are to be congratulated on their approach, commitment and dedication (three similar comments). A number of other comments were also very positive. One person who filled in our own survey answered the question ‘What do you feel the care home does well?’ by saying ‘they are kind to my relative – they look after physical needs’. The manager, Mrs Pat Willis is trained to National Vocational Qualification in Care Level 3 (mental health) and Level 4 (management). She has many years experience of working in care settings. She and all the staff team were welcoming and open to the inspection process. Staff responded very quickly to comments we made and took action to change or improve things. The manager was available to staff and visitors and helped out in the dining room at lunchtime. Staff told us that they feel the manager is approachable and has an ‘open door’ policy. They also felt the same about other members of the management team who they said sometimes work alongside them. The manager was clear when talking to us that the people living at the home are the main focus and their welfare is of prime importance to her. However one staff member that filled in a survey for the inspection stated: ‘It would be nice to see the manager in on weekends and ‘on the floor’ as the deputy does, instead of being in the office’. Another staff member commented: ‘more effective management is needed – it’s rare for me to see my manager in work!’ The deputy manager was also praised in staff surveys: ‘The deputy manager works very hard and many staff (if not all) believe that Coombe would fall apart without her!’ and: ‘We have good officers and a good deputy manager who listens to concerns and tries to help’. The home’s quality assurance survey had been done in July 2007 and the next one is due shortly. The manager was also in the middle of filling in the home’s Annual Quality Assurance Assessment (AQAA) that we send them yearly. This is designed to help staff focus on what they’ve done well, what could be done better and how they are going to improve things. The manager has a development plan for the home that’s updated yearly. This, though comprehensive, doesn’t include action points from the home’s survey report. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 26 The manager told us about actions she’d taken to improve things but no evidence was available to show this. We recommend that actions from the survey are added to the plan. This year an action sheet will be added to the report template that will help managers achieve this. A check of peoples cash was done at this visit. All balances held against individual cash sheets were right with no mistakes. Two signatures were seen particularly for balance checks. A sheet has been added for staff to sign when they take money from peoples cash to buy them things. This is good practice. The manager said that relatives are usually good at bringing in money so that people are able to have the right amount of their weekly allowances. We looked at a sample of staff supervision records. Staff are supervised in ‘key groups’ by members of the management team who are in turn supervised by the manager. Staff said they get regular supervision. From records we saw that staff average five or six sessions a year including their yearly appraisal (a review of their work) and a half-yearly check of it. Staff meetings are also held regularly that have a supervisory part to them. Care and other records were kept in a way that made them easy to follow. Care records were detailed and properly reviewed and updated. Both night and day staff write daily records although we saw more night staff records. Daily records were largely person-centred and gave a good indication of the care and quality of peoples lives. Enjoyment of Christmas and birthdays was also recorded positively. Key time records were particularly good as they showed the enjoyment people get from one to one time with their key or main care worker. However, in several of the records looked at we noticed an emphasis on bodily functions. This didn’t necessarily correspond with a medical reason for recording them and could be interpreted as overly institutional. We recommend that unless there is a clear medical reason for recording bodily functions included in peoples care plans, the practice should stop. Health and safety records were also in good order and easy to track. Fire safety training and drills had happened regularly and were written up with the number of staff attending. The fire safety officer had recently inspected and made some recommendations under the new Regulatory Reform Order that has replaced fire safety regulations. The manager said she had met all the recommendations and amended the recent fire safety risk assessment to show this. A good practice recommendation made at the last inspection had been partly adopted. This was to record water temperatures more regularly. We saw that this had been done but the recording didn’t show accurate temperatures – just a range between 37-42°c. Further, the records didn’t show room numbers where the testing had been done. Temperatures should be tested randomly in Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 27 different bedrooms so that any differences can be picked up quickly. The manager said she would make sure the handyperson more accurately records the temperatures in future. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 3 Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement A minimum-maximum thermometer must be put in place to make sure the medication fridge is kept within the proper temperature range. The temperature must be checked and recorded daily. This will make sure people are kept healthy from use of medication that is stored properly. Timescale for action 01/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations Agency staff that have worked at the home regularly over a number of months or years should be given the same dementia awareness and care training as permanent staff. This will make sure that people are cared for by staff that are all properly trained in the needs of people with dementia. DS0000035952.V361809.R01.S.doc Version 5.2 Page 30 Coombe 2. OP33 3. OP37 Action points highlighted in the home’s own quality assurance survey report should be added into the manager’s development plan so that any concerns raised will all be dealt with. This will make sure people have a say in how the home is run that will be to their benefit and in their best interests. Care records should be more person-centred. Unless there is a clear medical reason records should not regularly focus on bodily functions. This will make sure records written about people are dignified and respectful. Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Coombe DS0000035952.V361809.R01.S.doc Version 5.2 Page 32 - 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. 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