Care Home: Old Vicarage Nursing Home

What the care home does well People have a choice of food for their meals and people who have their food pureed, have this done separately so that they can enjoy the colours and tastes of the different foods. There are staff who are allocated specifically to support people with activities. People say this has improved recently and staff feel that it gives people more stimulation and motivation. The new manager has recruited some staff and is intending to recruit further. She recognises that there is a need for more staff at peak times of day and has plans to address this. She is also aware that the duty roster had become unbalanced on some weekends and is addressing the way rosters are planned so that staff can be used more effectively. Visitors tell us that the new manager is always welcoming, answers their questions and that "she`s definitely doing her job". What the care home could do better: We know that the manager is new in post and has already made some improvements. She has needed to prioritise what she is doing and came to the home at a time when significant problems had developed. What we saw, heard and were told on this visit , information from our service review last year, and concerns from callers to our office , tells us there are things that must be done to improve outcomes for people living in the home. Care plans must set out the support needs of each individual rather that using a standard format. They must be kept under review so that staff are always clear exactly what support they should offer to meet someone`s needs. People must be enabled to make decisions about their care and to participate in review. Action must be taken to assess and minimise (as far as possible) any risks to which people are exposed. This includes in relation to falls, use of bed rails, pressure area problems, and hazards arising in the environment. This is to show how people`s safety and welfare is being promoted effectively. The Commission must be notified of specific events or incidents taking place in the home. This is so we can be confident that the management team keeps us up to date and responds appropriately to problems that arise in the best interests of people living in the home. These requirements, and some things that manager could think about doing to improve things, are set out in full at the end of the report. The manager can tell you what action she is taking to respond to these. Inspecting for better lives Random inspection report Care homes for older people Name: Address: Old Vicarage Nursing Home Norwich Road Ludham Norfolk NR29 5QA two star good service 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 assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Judith Last Date: 2 7 0 5 2 0 0 9 Information about the care home Name of care home: Address: Old Vicarage Nursing Home Norwich Road Ludham Norfolk NR29 5QA 01692678346 01692678565 ashleycaregroup1@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Hewitt-Hill Limited care home 29 Number of places (if applicable): Under 65 Over 65 29 old age, not falling within any other category Conditions of registration: 0 That appropriate care and accommodation can be provided for up to three (3) service users who are under 65 years of age. Twenty-nine (29) older people may be accommodated. Two (2) service users, named in the Commission`s records, who have a diagnosis of dementia may be accommodated. Maximum number not to exceed twenty-nine (29). Date of last inspection Brief description of the care home The Old Vicarage is a care home with nursing for older people, and is situated in the village of Ludham. Hewitt-Hill Limited owns the home. The majority of service users require nursing as well as personal care and the staffing ratios reflect this level of care. There is a nurse on duty at all times in the home. The 29 bedrooms are situated over two floors with access via a shaft lift. Some of the Care Homes for Older People Page 2 of 19 Brief description of the care home ground floor bedrooms open directly to the gardens. The communal areas consist of two lounges and one conservatory that also double as dining areas. The grounds consist of surrounding lawns, shrubs, large trees and flowerbeds, with a small patio area and pond, all of which can be accessed by residents. There is ample car parking at the front of the premises. The cost of a placement at the home is from £366 per week, and is individually assessed according to dependency and nursing needs. Copies of CSCI reports can be made available to residents and their relatives upon request from the homes office. Care Homes for Older People Page 3 of 19 What we found: Before we made our visit, we looked at all the information we had about the home. This includes information we have been sent and concerns or complaints that have been made to us. Because of these concerns Mrs Prettyman and Mrs Last (Regulatory Inspectors) carried out this visit unannounced. We arrived at the home just after 10 in the morning, and left at 4:45p.m. We focused particularly on outcomes for people in their personal and health care and some aspects of the environment, staffing and management The main method of inspection we used is called case tracking. This means we look at records and then try to find out from observation and discussion, how well peoples needs are being met. As part of this we looked at records for six people, spoke to three visitors to the home, two people living there, the manager, owner, two staff and a visiting health professional. We had permission to include the views of the doctor and two relatives. Two requirements in this report were made at the last inspection and show up as outstanding requirements. We did not check compliance with these at this visit and they will be assessed at the next key inspection. Files kept in peoples rooms set out priorities for their care. However, care plan aims are a standard format. For example - one person who has had a stroke and is assessed as requiring support with personal care but maintains some independence. There is similar information about how their personal care needs are to be met as for a person who is bed-fast and requires full support of staff to meet their needs. This means that care plans and aims for care do not reflect the specific needs of individuals and how staff are to support them appropriately. Two visitors told us they felt that the personal care for the person they visited had not been acceptable during the last three months of last year. They say that the person was not offered a bath for a considerable period. We were not able to verify from records that the care delivered matched expectations. Complaints we have received also say that people had not had personal care delivered as relatives would wish. Assessments for peoples risk of falling are incomplete in some cases. Records are also unclear about why people are identified as needing cot sides on their beds. There are risk assessments about using bed rails which do not refer to the persons risk of falling from their bed. For example one says that the person is at risk of falling out of their bed after shuffling down past cot sides. Records of accidents show that one person has had accidents involving them getting limbs caught in bed rails that have been happening since 2006. One inspector demonstrated to the manager that the existing padding was not adequate to prevent the person getting caught in the rails and sustaining skin tears or bruising. The manager says new padded bumpers are coming but the persons continuing use of Care Homes for Older People Page 4 of 19 the existing system has not been properly assessed to make sure it is safe. Action has not been taken promptly to minimise the risk of these accidents being repeated so placing the person at continued risk of injury. There is information in the home about nutritional needs. However, not everyone has a completed assessment to show what action might be needed to promote good nutrition (and so contribute to reducing the likelihood of pressure sores developing) or to achieve and maintain a healthy weight. Peoples weight is not always consistently monitored. One person was noted as losing weight in 2008 but there was no subsequent care plan to monitor this. One person had no recorded weights since the middle of last year so nutritional problems would not be identified promptly. One persons records show that they are to be on a low fat diet although there is no information about why this has been considered necessary or whether the person has been consulted about the arrangement, so being able to make their own decision about their health and diet. There was no evidence on any of the plans of care seen that people have been consulted about their care when their own care plans are being developed or reviewed. (The need to involve people is set out in our standards and regulations. It is also in the guidance produced for nurses by their professional organisation - the Nursing and Midwifery Council. Staff are not adhering to this.) On five out of six of the plans seen, the only signatures on the individual care plan aims are of named nurses who have completed them. One initial care plan had been signed by a relative. Relatives we spoke to say that they had not been spoken to about individual needs until very recently, and had not been involved in regular reviews and updates of individual plans. Some care plans had not been reviewed or updated appropriately. For example, one persons records show that the plan for delivering personal care was put into place in November and updated in December. Information was transferred to a new form in April but there was no evidence of review between December 2008 and April this year, despite the persons recorded gradual deterioration and changing needs. Observation shows some people are too poorly to be involved in agreeing their own support, but others are able to do so, based on our conversations with them. They could not confirm that they were involved in developing their own support plans although some information is accessible to them in their own rooms should they wish to refer to it or agree to their representatives doing so. One record from April this year shows that a person is unable to make informed decisions and that staff need to make decisions for her based on assessment and knowledge of... needs. There is no evidence of proper assessment of the persons capacity to make a particular decision about their care (as required by the Mental Capacity Act) or any evidence of consultation with any other relevant parties at the point this information was recorded (for example relatives, care manager, GP or independent advocate). Two out of three relatives spoken to say they have found it difficult to get information about what has been going on for the person and what has happened. However, they also say that this has improved since the new manager came into post and that she does respond properly to their questions. They say they have been spoken to about Care Homes for Older People Page 5 of 19 the most recent plan for care. We spoke to the doctor visiting the home who says that the home does refer people for advice or treatment at the appropriate stage, neither unnecessarily delaying, nor referring when there is no real need. The doctor is generally satisfied with the standard of care that patients receive. However, we have some concerns about the way things are recorded, updated and reviewed as this report explains. Peoples records show that they are referred for professional advice about continence and for any aids that might be considered necessary to promote their comfort. However, nursing records on care plans are not always clear about what should happen. This is because a standard form is in use and has not been adapted or amended to reflect specific individual needs. For example, one persons individual plan has not been completed with the type of catheter, size, or balloon fill and says Use long/short bags during day. It is unclear what sort of bags should be used because the suitable type has not been highlighted (or the unsuitable one - deleted). Two visitors to the home expressed concerns about the way someones diabetes was monitored in the past and about the regime for testing their blood sugar. They felt this was not as frequent as it should be. However, we could see from records that the frequency of testing had been reduced on the advice of the doctor following a period of stability. They would have been aware of this if they had been informed and consulted about changes and reviews. There are assessments of peoples vulnerability to developing pressure sores. However, because of the way records are kept (and where) it is not always clear when information should be or has been reviewed. This is because the records are held in different places and files. For example, one person has an assessment for the risk of developing pressure sores that was completed in November and not apparently updated until May. Another similar assessment for the same person in a different file shows that it was completed in October and reviewed in December and January. Records do not support that the assessment was reviewed monthly despite the increase in risk to the person concerned. The assessment completed when the person arrived at the home shows that although their skin was healthy, other factors meant they were at medium risk of developing pressure sores. However, records do not support that they were provided with appropriate pressure relieving equipment to minimise the assessed risk at that point. They say that on 18th December the person is on bed rest. Needs turning frequently and nursed on alternate sides. (There is no reference to equipment, techniques or frequency of turns.) The assessed risk that month was high but the first reference to an air mattress being supplied is at the end of January by which time the persons skin had broken down. Relatives feel that at the point the mattress to relieve pressure was supplied, the damage had already been done and this is confirmed by records. We have not been notified about people who have developed pressure sores since their admission and the actions that the home has taken to minimise the risk of these Care Homes for Older People Page 6 of 19 worsening. These things lead us to conclude that the service has not always responded appropriately to promote tissue viability and so to maintain peoples comfort and wellbeing. The manager says that, since being in post, the tissue viability nurse has been contacted and arrangements are being made for her to deliver training to staff. This should help them understand and respond appropriately to identified risks and so to promote peoples health better. The doors to most peoples rooms were open when we walked round the building particularly those people who were bed fast. This may not necessarily be dignified for the person if they are in bed. However, staff did close doors when they were carrying out personal care tasks and the call system can be set such that lights show above the door when personal or health care needs are being attended to, so their privacy can be protected and other staff know not to enter the room. We looked at the arrangements for serving meals. We saw that there was a choice of meals and the cook had recorded the options people had selected. There is a white board in the kitchen that provides information about special dietary needs. The information about who has diabetes is also on the clipboard used to record peoples choices. This means that the staff member who asks people what they would like can advise them of suitable choices. We asked about soft diets (where food is pureed). The cook told us that each item is pureed separately so that people can experience different tastes, colours and smells. We saw this good practice happens. We also saw that these meals were some time in the preparation and so staff taking the them round to people need to reheat them in the microwave to make sure that the food is an acceptable temperature. We heard the cook reminding a staff member to do this. However, we have had two complaints about this issue saying that the food is sometimes cold. This indicates staff may not always remember to ensure that it has been either kept hot or is heated appropriately to a safe and palatable temperature. We saw one person being assisted with their food. The staff member assisting sat with them and to one side, engaging them quietly in conversation while the person was eating. This is good practice in promoting peoples dignity. The new manager has brought in an increased programme of activities and provided dedicated staff time for this. We saw from records that some people had been able to go out and the manager says for some this is the first time in a long while. Staff say that people have something to get up for now, and that more people come out from their rooms. While we were there, some people went out for a short trip in the minibus - being offered the opportunity to go for ice cream or coffee. They are also working on a joint fete with the local church. Care Homes for Older People Page 7 of 19 We looked around the building. Wedges were being used to keep large numbers of room doors open. This means people may not be properly protected should a fire break out. There are changes of level towards the top of the home and stairs accessible to anyone who might wander. This presents a risk of trips and falls which has not been clearly documented or addressed. One door (down small step) to where the hot water tanks are is labelled to be kept locked shut. There is no lock on the door. The label indicates this area is considered potentially hazardous to service users or at risk of possible interference from unauthorised persons. One assisted bathroom was being used to store the linen bag trolley and three wheelchairs. Staff say these are removed when the bath is in use by someone and placed in the corridor. This presents a potential hazard for people or staff moving along the corridor and for evacuation in an emergency. If they are left in the bathroom it is not a pleasant environment for people. The manager says that staffing had been difficult. We know from three occasions when people contacted us since our last visit, that visitors have been concerned there were insufficient staff to properly meet peoples personal care needs and that people had to wait a long time for assistance. Two other visitors say that they have known it to take 15 minutes for staff to respond to the call bell when someone needs assistance. The people we spoke to and who contacted us anonymously say that staffing is particularly bad at weekends. We had concerns when we last reviewed the service that staff turnover was very high and the owners also confirmed to us in November that staffing levels had not been as they should as a result of illness. However, the manager has made two appointments and is looking to recruit additional part time staff for times of peak demand (morning and twilight shifts). She also says that the roster for weekends was not well balanced when she first arrived at the home. We will look at this during the next key inspection to see whether the plans she told us about to improve staffing have been made and sustained. We looked at recruitment records for three staff who have recently started work at the home. Up to date photographs need to be on file but the process shown in records provides for appropriate checks before staff start work, to ensure they are not unsuitable to work with vulnerable people. We discussed the events of last year and the things that we should have been notified about, by law. We were not told that the former manager had left (in June 2008) and of the arrangements for running the home in the absence of the registered manager. We were also not notified of the drop in staffing levels which affected peoples welfare and were not told about the outbreak of sickness that affected staff and residents. Additionally, this visit tells us we have not been notified about developing pressure ulcers and the actions being taken to address this - including assurances that the calibre of equipment provided is adequate for the condition of the person. Care Homes for Older People Page 8 of 19 There is now a manager in place who has been working at the home for approximately three months. Relatives who have visited the home since last year when things were difficult with staffing, say they have noticed an improvement, that the manager is always welcoming, does answer their questions and shes definitely doing her job. What the care home does well: What they could do better: We know that the manager is new in post and has already made some improvements. She has needed to prioritise what she is doing and came to the home at a time when significant problems had developed. What we saw, heard and were told on this visit , information from our service review last year, and concerns from callers to our office , tells us there are things that must be done to improve outcomes for people living in the home. Care plans must set out the support needs of each individual rather that using a standard format. They must be kept under review so that staff are always clear exactly what support they should offer to meet someones needs. People must be enabled to make decisions about their care and to participate in review. Action must be taken to assess and minimise (as far as possible) any risks to which people are exposed. This includes in relation to falls, use of bed rails, pressure area problems, and hazards arising in the environment. This is to show how peoples safety and welfare is being promoted effectively. The Commission must be notified of specific events or incidents taking place in the home. This is so we can be confident that the management team keeps us up to date and responds appropriately to problems that arise in the best interests of people living in the home. These requirements, and some things that manager could think about doing to improve things, are set out in full at the end of the report. The manager can tell you what action she is taking to respond to these. Care Homes for Older People Page 9 of 19 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 10 of 19 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 30 18(1)(c)(i) Training regarding dementia 30/04/2008 care and `Safeguarding Adults? must be in place for staff to ensure safe and up to date practice. Arrangements must be in 29/02/2008 place to ensure that emergency lighting tests are carried out at regular intervals. 2 38 23(4)(c) (v) Care Homes for Older People Page 11 of 19 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 Individual plans must be reviewed regularly (with the person concerned or their representatives). If care plans are not kept under review, people are at risk of not having their needs met. Regulation 15(2) of the Care Homes Regulations 2001 requires that service users plans must be kept under review and people be notified of any revision of their plan. Breach of this regulation is an offence. 24/07/2009 2 7 13 People must be properly assessed for their risk of falls, including the risk of falls from bed. This is so people are not exposed to avoidable or unnecessary risk. Regulation 13(4) of the Care Homes Regulations requires 12/06/2009 Care Homes for Older People Page 12 of 19 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 that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. Breach of this regulation is an offence. 3 7 15 Service users plans for care 26/06/2009 must set out the specific support that each individual requires to meet their health and welfare needs. This is so people receive the support they need at the right level and in the right way. This is because individuals require different levels of support and are at risk of having their independence compromised if input is not appropriate for their needs. Regulation 15(1) of the Care Homes Regulations 2001 requires that a plan be prepared as to how the service users needs in respect of health and welfare are to be met. Breach of this regulation is an offence. 4 8 13 People who are at risk of developing pressure sores must have plans setting out clearly the equipment and interventions they need to promote their welfare and reduce risk. 12/06/2009 Care Homes for Older People Page 13 of 19 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 If they do not have proper interventions to promote skin integrity, people are at risk of harm. Regulation 13(6) of the Care Homes Regulations 2001 requires that arrangements are in place to prevent people being harmed or placed at risk of harm. Paragraph 4 of the same regulations requires that unnecessary risks be identified and - so far as possible -eliminated Breach of either part of the regulation is an offence. 5 8 15 People (or their representatives) must be consulted with regard to the development and review of their own care plans. If people are not consulted, they are at risk of not having support that meets their needs in the way they require and prefer. Regulation 15 of the Care Homes Regulations 2001, says that unless it is impracticable, people of their representatives shall be consulted in the development and review of individual service user plans. Breach of this regulation is Care Homes for Older People Page 14 of 19 24/07/2009 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 an offence. Regulation 12 of the same regulations, requires that people be enabled to make decisions about the care they are to receive. 6 8 13 Where people have recurring 12/06/2009 accidents remedial action must be taken promptly. If similar accidents occur repeatedly without action to minimise risk, people will be exposed to harm or be at risk of harm. Regulation 13(6) of the Care Homes Regulations 2001 requires that arrangements be made to ensure people are not harmed or placed at risk of harm. Paragraph 4 of the same regulation requires that parts of the home to which people have access are (so far as reasonably practicable) free from hazards to their safety. Breach of either of these sections of the regulation is an offence. 7 19 13 Risks associated with 12/06/2009 changes in level and stairways must be assessed and action taken to minimise risk. This is so peoples safety is promoted. Care Homes for Older People Page 15 of 19 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 Regulation 13(4) of the Care Homes Regulations 2001 requires that all parts of the home to which people have access be so far as possible, free from hazards to their safety. it also requires that unnecessary risks are so far as possible, eliminated. Breach of this part of the regulation is an offence. 8 19 23 Risks associated with the practice of wedging open doors must be assessed and included in the overall fire risk assessment for the home. If this does not happen there is a risk that any fire breaking out would not be adequately contained and people living and working in the home would be at risk. Regulation 23(4A) of the Care Homes Regulations stipulates that the home must comply with the Regulatory Reform (Fire Safety) Order 2005. 9 38 37 Notifications of incidents 05/06/2009 must be made to the Care Quality Commission in accordance with regulations. This is so we can be sure that the management team is taking responsibility for running the home effectively 05/06/2009 Care Homes for Older People Page 16 of 19 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 and complying with the law. This is so we know what the management team are doing to address any developing concerns. Regulation 37 of the Care Homes Regulations 2001 requires that the Commission be told of certain events and incidents in the home. Breach of this regulation is an offence. 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 7 The system for recording care and filing reviews and assessments should be reviewed to ensure that the practice of holding it in different locations does not compromise efficiency and mean people do not always have access to up to date information. Where it is felt people are not able to make informed decisions about their care, a proper process should be followed to assess ability on each occasion, and to show that decisions are only made in the persons best interests. This is also to avoid the service being in breach of the Mental Capacity Act. Key staff should have training in assessing risk appropriately so they understand better about hazards to which people might be exposed and how to minimise them. The door to the room with the hot water tanks should either be secured or have the label removed if it is not considered necessary to lock it following assessment. Alternative arrangements for storing wheelchairs and laundry trolleys should be explored. This is so corridors are Page 17 of 19 2 8 3 8 4 19 5 21 Care Homes for Older People 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 not restricted and that bathing or toilet facilities are as comfortable and homely as possible. 6 29 The manager should date and sign copies of information on recruitment files, confirming that she has seen the originals of the information held. Care Homes for Older People Page 18 of 19 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –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 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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