Care and Social Services Inspectorate Wales. Care Standards Act Inspection Report. Calon Fawr Care Home. Lon Masarn Tycoch Swansea SA2 9EX

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1 Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Calon Fawr Care Home Lon Masarn Tycoch Swansea SA2 9EX Type of Inspection Baseline Date(s) of inspection Thursday, 7 January 2016 Date of publication Wednesday, 17 February 2016 Welsh Government Crown copyright You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or psi@nationalarchives.gsi.gov.uk You must reproduce our material accurately and not use it in a misleading context.

2 Summary About the service Calon Fawr Care Home is registered with Care and Social Services Inspectorate Wales (CSSIW) to provide nursing and personal care and accommodation for up to twenty three people over the age of sixty five years. Within the twenty three places, the service is registered to provide care for up to three people aged sixty five and over with a diagnosis of dementia. There were twenty three people living in the service on the day of the inspection. The service is situated in the residential area of Tycoch on the outskirts of Swansea city centre, and provides accommodation and facilities on two floors. There are nineteen single bedrooms and two double (shared) bedrooms. None have en-suite facilities. The registered provider (owner) is Calon Fawr Nursing Home Ltd. Lucille Davies is the responsible individual and Dawn Ranft is the registered manager with day to day responsibility for the service. What type of inspection was carried out? We, Care and Social Services Inspectorate Wales (CSSIW) inspected the service on 7 th January 2016 for a scheduled, unannounced, baseline inspection. To inform this report, we considered all four quality themes: the quality of life, quality of staffing, quality of leadership and management, and quality of the environment. The following methodology was used: One unannounced inspection Recommendations from the previous inspection report conducted Discussions with seven people in the service, five members of staff, the registered manager and the responsible individual Observation of two people, using the Short Observational Framework for Inspection (SOFI) tool. The SOFI tool enables inspectors to observe and record life from a person s perspective; how they spend their time, activities, interactions with others and the type of support received Examination of four people s care records Examination of three employee s personnel records Examination of the Statement of Purpose Feedback forms from people in the service and their relatives, issued by the provider Observation of care practices. What does the service do well? We did not identify any specific areas of good practice within the focus of this inspection that exceeded practice outlined in the Care Homes (Wales) Regulations 2002 or the National Minimum Standards for Care Homes for Older People (2004). Page 2

3 What has improved since the last inspection? People in the service can be reassured that all new employees are recruited with full and satisfactory information being obtained prior to them commencing employment. What needs to be done to improve the service? We notified the provider that the service was not compliant with the following regulations: Regulation 18 (2), and National Minimum Standard 24.3 of the National Minimum Standards for Older People, because staff were not receiving formal supervision on a two monthly basis. Regulation 25, because the provider has not provided documentation in the form of an annual quality of care report for the service. Regulation 27, because the responsible individual did not undertake three-monthly visits to the service. We also identified that practice could be improved if the following were put in place. We therefore drew these matters to the manager s attention, and they must take action to address these; compliance will be monitored at future inspections: People s admission documents must be fully completed. The manager must continue to develop care records to include people s life histories. The manager must instigate a formal system of group or individual meetings for people in the service and have these meetings recorded as evidence. The manager must source relevant staff training that is specific to the needs of people in this service. The manager must continue to develop plans for a shower facility in order maximise choice for people in the service. Page 3

4 Quality Of Life Overall, we found that staff demonstrated a commitment towards providing people with good quality care. The wellbeing of people was promoted and protected as much as possible and we saw people treated with respect, dignity and warmth throughout our inspection. We also observed that people who live at Calon Fawr were encouraged to feel a sense of ownership and belonging; all rooms we viewed contained clear evidence of personalisation with items such as ornaments and photographs. One person told us, It s important to be able to bring your own things in with you. Makes it feel more like home. We saw that the service took information concerning people s support needs from families where their relative was unable to contribute themselves. For example, due to dementia. We saw that risk assessments recorded people s mobility and likelihood of falls, and were linked to care plans that described the support the person required when staff were assisting them to move. We also saw risk assessments that recorded any relevant nutritional aspects were accompanied by care plans that described how the person was assisted to eat a healthy diet. In addition, we saw risk assessments that measured the health of people s skin, together with the accompanying risk of them developing pressure areas. We noted that all care records were being reviewed monthly in order to remain current. However, at the last inspection, we recommended that care records should be further developed in order to provide the staff team with more person centred information about the people they supported, such as life histories and pen pictures, which would help staff understand people in the context of the lives they had lived before they came to the service. We noted that the provider was still developing this process, and was currently introducing a booklet called This Is Me that was being given to people in the service and their families to complete. We saw that people s rights were protected at this service. The manager showed us applications that had recently been made for Deprivation of Liberty Safeguard authorisations for three people in the service with a reduced capacity for understanding safety issues in the community due to their dementia. We noted that all documentation was in place and that people and their families had been consulted about the decision. People we spoke with told us they felt safe with staff who supported them. One person told us, All the staff are very kind and lovely. Each person in the service we spoke with told us they felt listened to and believed their views were valued. However, the service does not currently arrange and record either group or individual meetings for people in this service. We therefore notified the manager that they must instigate a formal system, so that each person in the service is able to discuss issues that affect them on a regular basis, either in a group or individually, and have these meetings recorded as evidence. We found that people are supported to remain as healthy as possible because their Page 4

5 needs are being anticipated and they are enabled to access medical support. We evidenced this from people s care records, which contained appointments and records of visits to their doctor, dentist and optician. People also confirmed to us that they were able to access healthcare professionals when they needed to. One person said, The doctor s always here, and often drops by to chat. Page 5

6 Quality Of Staffing Overall, we found that people s needs are anticipated and they benefit from good, timely decisions and responsive care. All staff members we spoke with were clear about their roles. One staff member explained the specific support needs and preferences of one person in the service who was very clear about how they wished to live their life. During our inspection, people were seen experiencing warmth, attachment and belonging; staff were observed being polite, kind and caring with the people they supported. We saw that care giving is relaxed, and we observed that people in this service had time to talk to staff. Staff were not rushed and the duty rota viewed during our inspection evidenced appropriate staffing levels at all times and corresponded to the numbers of staff on duty at the time of the inspection. People in the service were also supported by familiar staff, as there was good staff retention at this service. We did note that there were occasions when bank nurses were used to cover sickness and annual leave, but the manager showed us they always arranged for nurses who had worked in the service before, for consistency of care. This was supported by viewing the staff rota, together with speaking with people in the service, who all confirmed to us that they knew all the nurses who worked at the service well. From viewing the staff training matrix, we saw evidence that staff received adequate mandatory training for their roles. However, we noted that there was no staff training available that was specific to the needs of the people in the service, such as dementia awareness. We noted that one senior member of staff has been trained to deliver some topics to their colleagues, but we recommended to the manager that they sourced service-specific training, and ensured all staff had access to it. This would ensure people were supported by a staff team who had a good understanding of their support needs. Staff members we spoke with said they felt well supported by the manager and senior staff and we saw that supervision arrangements were in place for staff members to be given the opportunity to express their views and raise any issues that affected them. However, there was some lack of clarity about frequency of supervisions. The manager told us that the aim was to provide sessions every two months, but accepted that this was not happening currently. We therefore notified the responsible individual that the service was not compliant with Regulation 18 (2) of the Care Home (Wales) Regulations and National Minimum Standard 24.3 of the National Minimum Standards for Care Homes for Older People, as staff were not receiving formal supervision on a two monthly basis. This was evidenced by supervision records we examined that indicated that staff members who worked at Calon Fawr were not being appropriately supervised, and were not being given the opportunity to express concerns they may have. The impact on people using the service is that staff supporting them have not formally identified their current training and development needs. In addition, people in the service cannot be reassured that they were supported by a staff team who were motivated and able to cope with complex needs. Page 6

7 At the last inspection, we noted that a new employee had been recruited without full and satisfactory information being obtained prior to them commencing employment. We therefore checked staff recruitment records during this inspection and we found that people in this service could now be confident that all staff members who support them had been through a robust recruitment process. This was because recruitment records we viewed confirmed that no staff member started work until all the checks we require services to have in place had been completed. Page 7

8 Quality Of Leadership and Management On a day to day basis, the service is well managed. There is an effective management team in place, with clearly defined roles and responsibilities. The manager is a registered nurse and an experienced social care manager who is registered with the Care Council for Wales and CSSIW. The Statement of Purpose clearly outlined the aims and objectives and the ethos of the service, along with all facilities and services offered. The registered manager and responsible individual were present throughout the inspection. We notified the responsible individual that the service was not compliant with Regulation 27 of the Care Home (Wales) Regulations because the responsible individual did not undertake three-monthly visits to the service. These visits are used to monitor the standard of support available to people in the service, and to discuss people s care and welfare with themselves, their relatives or representatives. This was evidenced by the lack of documentation available to view at the time of the inspection and indicated that the provider was not recording the opinions regarding standards of support from people in the service, their relatives and members of the staff team. In addition, they were not monitoring the quality of the premises or reviewing complaints that have been received. Because of this, people in the service could not be reassured that the provider was formally monitoring the quality of support they received, and could not be confident the provider was identifying improvements to the service they were responsible for. We notified the responsible individual that the service was not compliant with Regulation 25 of the Care Home (Wales) Regulations because the manager did not make suitable arrangements to establish and maintain a system for monitoring the quality of care in the service; there was no annual quality of care report available to view. This was evidenced by the lack of documentation available to view at the time of the inspection and indicated that the provider was not formally measuring the quality of the service they were responsible for. Therefore, people in the service cannot be reassured that the provider was working to provide a consistent service based upon quality improvement, and was not identifying potential improvements to the service they were responsible for. When completed, a copy of this review must be sent into CSSIW and then reviewed annually. From the care records we viewed, we also noted that people s admission documents were not complete. For example, there were no entries under the section concerning the person s capacity to make their own decisions or the person s level of ability to manage their own financial affairs. We therefore recommended to the manager that this was rectified as soon as possible, in order for staff to be clear about each person in this service s capacity to understand their situation, together with their abilities and support needs. People in this service can be confident the provider will respond positively to feedback. For example, the manager showed us how they obtained information from surveys to monitor the quality of support people received; we saw completed surveys from people in the service and their families, and both sets of responses were complimentary. In Page 8

9 addition, the manager showed us completed monthly medication audits, with actions that had been taken as a result of the findings. This showed that the service learnt from recommendations of audits and surveys, so that the risk of these being repeated was reduced to a minimum. The provider also took account of complaints and comments to improve the service. We saw that there was a complaints policy and procedure, available for anyone who needed it, and that there had been no complaints since the last inspection. People we spoke with told us they knew how to make a complaint if they needed to. One person told us I d tell any of the staff. People in the service see visible accountability and know that there are people who are overseeing the service. It was evident that the manager has an open door policy within the service; during the inspection, we saw them talking to several people in the service, and staff colleagues. We noted they were never rushed or hurried and people appeared satisfied with the outcomes of each conversation. Page 9

10 Quality Of The Environment During our inspection, we saw that bedrooms were individualised with personal photographs, pictures and ornaments. The service s communal rooms included a dining room and two lounges that people used for relaxing and eating. There was also a garden which was used during the summer months. We also viewed the laundry and found it to be satisfactory; it contained the necessary equipment to meet the needs of the people living at the service. The CSSIW Registration certificate was displayed together with the Care Council Registration for the manager together with the Employer Liability Insurance certificate. Each person in this service can be confident that they are able to live in a comfortable and warm environment which is suitable for their needs. There were no unpleasant odours in any parts of the service during our inspection, and all parts of the premises were clean and well presented. People told us they found the environment light, airy, fresh and clean. One person told us, It s not home, but it s very nice. During our inspection, we saw that people found it easy to do things for themselves or with the minimum of support, because of the design and layout of the premises. People told us they were able to meet with friends when they wished in the communal lounges, but at the same time, had private space in their rooms should they need it. During our inspection, we observed several occasions where people met up to chat. We also saw that people in the service could choose whether they wished to be in a lounge with a television, or spend time in a quieter room where people respected other people s peace. Each person we spoke with told us they liked having that choice. One person added, I always come in here to catch up with what s happening. We found that there was a comfortable, homely atmosphere throughout the premises. People said they were more than satisfied with their rooms and facilities on offer. One person said, Yes, I like my room because it has a nice view and is quiet. Another person told us they liked being with the group of people in the television lounge. They added, It s nice to catch up on gossip and what s happening. Communal bathrooms and toilets were well situated on each floor and were seen to be clean, uncluttered and well equipped. However, at the last inspection, we recommended that the service should provide a shower facility to maximise choice for people. We therefore checked on this inspection and found that the issue has still not been addressed. We spoke to the handyman, who showed us potential sites for a shower, but they explained to us that technical issues regarding plumbing had prevented a firm resolution to the issue to date. We notified the manager that they must continue to develop plans for a shower facility in order maximise choice for people in the service. People can be reassured that they are safe at this service. We saw that all personal belongings were held securely and that people s personal and confidential information is properly protected; we saw that all care records were stored within a locked filing cabinet in the manager s office and this office was locked when not in use. We also saw that all Page 10

11 information held on the computer system was available only to employees authorised to access it. People were safe from strangers entering the premises as all visitors had to ring the front door bell prior to entry and were requested to complete the visitor s book when entering and leaving the building. Page 11

12 How we inspect and report on services We conduct two types of inspection; baseline and focused. Both consider the experience of people using services. Baseline inspections assess whether the registration of a service is justified and whether the conditions of registration are appropriate. For most services, we carry out these inspections every three years. Exceptions are registered child minders, out of school care, sessional care, crèches and open access provision, which are every four years. At these inspections we check whether the service has a clear, effective Statement of Purpose and whether the service delivers on the commitments set out in its Statement of Purpose. In assessing whether registration is justified inspectors check that the service can demonstrate a history of compliance with regulations. Focused inspections consider the experience of people using services and we will look at compliance with regulations when poor outcomes for people using services are identified. We carry out these inspections in between baseline inspections. Focused inspections will always consider the quality of life of people using services and may look at other areas. Baseline and focused inspections may be scheduled or carried out in response to concerns. Inspectors use a variety of methods to gather information during inspections. These may include; Talking with people who use services and their representatives Talking to staff and the manager Looking at documentation Observation of staff interactions with people and of the environment Comments made within questionnaires returned from people who use services, staff and health and social care professionals We inspect and report our findings under Quality Themes. Those relevant to each type of service are referred to within our inspection reports. Further information about what we do can be found in our leaflet Improving Care and Social Services in Wales. You can download this from our website, Improving Care and Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW regional office. Page 12