Care and Social Services Inspectorate Wales

Transcription

1 Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Convent of Mercy Nursing Home 15 Lansdowne Road Colwyn Bay LL29 7YD Type of Inspection Focussed Unannounced Date(s) of inspection 11 th March 2013 Date of publication 24 April 2013 You may reproduce this report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers Please contact CSSIW National Office for further information Tel:

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3 Version /2012 Summary About the service The Convent of Mercy is registered with Care and Social Services Inspectorate Wales (CSSIW) to accommodate thirty one persons requiring nursing care. The service currently has full occupancy. The registered provider is the Institute of Our Lady of Mercy ; the responsible individual is Sister Philippa Kohlbecker. The registered manager is Ms Jane McAulay; Ms McAulay is a registered general nurse, she has the appropriate management qualification and is registered with the Care Council for Wales. The Convent of Mercy is located in Colwyn Bay in a residential area which is near to local shops and amenities. What type of inspection was carried out? A focussed unannounced inspection visit was carried out on the 11 th March 2013 between 09.50am and 13.30pm. We (CSSIW) focussed on the theme Quality of Life however our findings will be recorded under the four quality themes for ease of reference. A Self Assessment of Service form was issued and returned to CSSIW in May 2012 which provides the registered persons with an opportunity to report what the service does well and what could be improved. We issued questionnaires in April 2012 to obtain feedback from people using the service and stakeholders as follows: People using the service, ten were issued and three were returned. Relatives, ten were issued and three were returned. Staff, ten were issued and one was returned. Visiting professionals, two were issued and one was returned. We viewed documentation to be kept by the service in accordance with regulations as follows: A care plan and the risk assessments. The activity record book and monthly timetable. Staff training matrix. We spoke with people using the service, staff, the manager and the deputy manager. We viewed the food safety report dated 15/02/13, which rated the service as 5 which gives a description rating of very good. What does the service do well? We did not identify anything that could be considered to be above the National Minimum Standards 3

4 Version /2012 What has improved since the last inspection? The manager confirmed that all but one area of non compliance have been addressed in respect of the last inspection report. We have discussed this and a non compliance notice will be issued. There is now a designated activity room and as well as activities, coffee mornings are also held which encourages people living here to socialise. What needs to be done to improve the service? Although the service is not registered to accommodate people with a diagnosis of dementia, some people using the service have dementia but the manager asserts their nursing needs outweigh this care need. The registered provider is advised to consider the recommendations in CSSIW s Older People with Dementia Handbook (2009) in respect of the findings of this report. The Care Homes (Wales) Regulations 2002, 12 (3). Some people are not always given a choice and some care delivery is not always person centred. This is a serious issue and we have issued a non compliance notice to the provider. National Minimum Standard 9. Although activities are offered in a general sense more could be done to encourage people to maintain their individual hobbies and interests. Activities which are appropriate for people with a diagnosis of dementia must be provided. We advised the manager to obtain guidance from the Alzheimer s Society and Bangor University. We trust the registered provider will ensure that this is addressed and therefore we will not issue a non compliance notice in respect of this. The Care Homes (Wales) Regulations 2002, 15 (1). Care plans are generic and do not contain enough detail to assist staff in providing appropriate care. This is a serious issue and we have issued a non compliance notice to the provider. The Care Homes (Wales) Regulations 2002, 13 (2). The manager must ensure that staff responsible for the administration of medication adheres to the Royal Pharmaceutical Society and Nursing Midwifery Council guidelines to ensure that practice is safe. According to the staff training matrix, accredited medication training has not been undertaken. This is a serious issue and we have issued a non compliance notice to the provider. National Minimum Standard 20. Qualified and unqualified staff must be employed in sufficient numbers appropriate to the assessed needs of people using the service. Consideration must also be given to the size, layout and purpose of the home. The manager told us that an extra member of care staff was required to work in the mornings. We have requested that the manager provides CSSIW with a risk assessment in respect of this. A timescale of the 15 th April 2013 has been afforded to provide this evidence. National Minimum Standard 32. We strongly recommend that the manager completes a Protection of Vulnerable Adults Level 3 course to ensure that she understands what constitutes abuse and report incidents accordingly, thus safeguarding people using the service. The Care Homes (Wales) Regulations 2002, 13 (5). People requiring nursing care are accommodated on the second floor. There is currently no suitable storage space to keep equipment required to assist staff with care delivery. This may increase the risk of poor manual handling practices. This is a serious issue and we have issued a non compliance 4

5 Version /2012 notice to the provider. 5

6 Version /2012 Quality of life Overall some people living here are not given a choice in respect of some activities of their daily living. There are general activities provided but people would benefit from more purposeful recreation to help maintain their individual hobbies and interests. Some people using the service cannot always expect to receive person centred care. This is because people are not always provided with a choice in respect of some activities of their daily living. We spoke with people who told us they have designated bath/shower days. People told us that care staff pick out their clothes for the day which makes some people feel that they are unable to choose an alternative. One person told us they were not asked if they would like to go down stairs which they would have preferred to have done today and although this person was assisted with personal hygiene care they remained in their nightclothes and in bed. One person told us they had discomfort and were embarrassed about their oral hygiene and that they had reported this to staff but staff had not followed this up. In effect people may feel their individual preferences are not considered and that they have no real choice. Most people using the service can expect to be positively occupied for the most part but this could be further developed. There is a designated activity room and a person is employed who has the sole responsibility for providing activities. There is a monthly activity programme in place, this is flexible and used as a guide only. We spoke with people who told us that they were aware that activities were provided but not all had participated or were aware that coffee mornings were regularly held, which they showed interest in when we talked about this. We viewed the activity record book but noted entries were limited. One person told us they go to the activity room and commented it s alright. One person told us they like to watch mass but that there is something wrong with the cable in their room therefore they can t partake. We spoke with one person whose interest was crocheting but this person no longer had the inclination to crochet for themselves but did show enthusiasm about teaching the skill to others, however this has not been considered. One person enjoyed gardening but due to restricted mobility now finds this difficult but support to maintain some sort of interest has not been explored such as planting up pots, which could be done sitting down at a work bench. Another person told us they feel cut off from the convent. One person is unable to effectively communicate their feelings/thoughts, we noted there were limited opportunities in respect of one-to-one activities offered, and this may be attributed to the communication barriers. Some people have a diagnosis of dementia alongside their nursing needs but appropriate activities are not currently offered. We evidenced that some people may need encouragement and support to maintain their individual hobbies and interests albeit in a different way. People using the service cannot always expect staff to anticipate or respond effectively to their care needs. This is because care plans were not person centred; they were generic and did not contain enough detail to assist staff in providing appropriate responsive care. We viewed one person s care file and the manager confirmed that all care files are of the same calibre. The care plans viewed were not detailed in respect of communication and epilepsy. Behaviour charts are not utilised which would assist staff in identifying potential triggers and help them to implement appropriate coping strategies and distraction therapies. The manager confirmed that a pain assessment tool is not always used which would assist staff in assessing someone s pain and no care plans are in place in respect of pain management. We noted the term wandering which was 6

7 Version /2012 typed in the care plan and the use of such language does not enhance people s wellbeing. Some people using the service cannot expect some staff to adhere to safe medication administration guidelines. This is because we noted that one person had not taken two tablets, they were under a piece of paper on their table. We asked why these were there and this person told us oh they re old and stale just leave them there it doesn t matter. We discussed this with the manager and highlighted that this practice contravenes the Royal Pharmaceutical Society and Nursing Midwifery Council guidelines. We noted that accredited medication administration training was not evidenced on the staff training matrix provided. Following the inspection visit we were told by the manager that some staff have undertaken accredited training in accordance with the Nursing Midwifery Council Guidelines on the day of the inspection visit, we have requested evidence to support this. 7

8 Version /2012 Quality of staffing We did not focus on the theme Quality of Staffing but during the inspection visit we discovered the following: Overall the manager is reviewing staffing levels and CSSIW has requested a risk assessment in respect of this, which must consider the size and the layout of the building, the dependency of the people living here and the staff skill mix. Two registered nurses are employed to work a morning shift but this reduces to one registered nurse thereafter. The home currently accommodates seven people who require Continuing Health Care (CHC) funding; people who receive CHC funding require extra support and care as their nursing needs are complex. Seven people require assistance with their meals and fourteen people require the assistance of two care staff in respect of their mobility. 8

9 Version /2012 Quality of leadership and management We did not focus on the theme Quality of Leadership and Management but we noted the following: Overall the manager is receptive to feedback and acts quickly to address any issues. The manager raised a concern with us in respect of someone s palliative care needs and a local general practitioner s (GP) practice and their attitude of apathy in respect of this. We discussed the duty of care and the importance of nursing staff and the manager acting as people s advocates. The manager should have reported these concerns to the Protection of Vulnerable Adults (PoVA) authority at the time but hadn t realised this was a safeguarding issue. We also spoke about involving the commissioning authority if appropriate. We reported these concerns to PoVA on 13/03/13 and a referral form was faxed on the 14/03/13. When the manager s application to register with CSSIW was being considered we discussed that a PoVA Level 3 course would be beneficial to assist with safeguarding people using the service. The manager told us she has not been able to undertake this training, this is recommended as the manager is uncertain about what constitutes abuse as the aforementioned example demonstrates. 9

10 Version /2012 Quality of environment We did not focus on the theme Quality of Environment but we noted the following: Some floor areas are worn and some carpets need replacing. The manager told us that these are going to be replaced. Most people can be confident that their wellbeing is promoted because there is a range of equipment provided to meet their care needs. However we noted in the last inspection report that additional storage space was required on the second floor to store equipment such as hoists. People requiring assistance with nursing care are still accommodated on this floor. Staff have to resort to manoeuvring the hoist using the lift between the first floor and the second floor, this not only delays care delivery but also hinders it and may increase the risk of poor manual handling practices. The manager explained that they have identified a suitable storage area but need the funding to carry out the works and replace the carpet before this can be done. 10

11 Version /2012 How we inspect and report on services We conduct two types of inspection; baseline and focussed. 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. Focussed 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. Focussed inspections will always consider the quality of life of people using services and may look at other areas. Baseline and focussed 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. 11

12 Version /2012 Care and Social Services Inspectorate Wales Non Compliance Notice Care homes for older people Care Standards Act 2000 This notice sets out where your service is not compliant with the regulations. You, as the registered person, are required to take action to ensure compliance is achieved in the timescales specified. The issuing of this notice is a serious matter. Failure to achieve compliance will result in CSSIW taking action in line with its enforcement policy. Further advice and information is available on CSSIW s website Convent of Mercy Nursing Home 15 Lansdowne Road Colwyn Bay LL29 7YD Date of publication -24 April 2013 You may reproduce this Notice in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers 12

13 Care Homes for Older People Report (GIRPT01E ) Version 8.0 January 2012 Care and Social Services Inspectorate Wales North Wales Region Government Offices Sarn Mynach Llandudno Junction Conwy LL31 9RZ Home: Convent of Mercy Nursing Home Contact telephone number: Registered provider: Registered manager: Philippa C M Kohlbecker Jane Alison McAulay Number of places: 31 Category: Dates of this inspection from: Care Home Nursing - Older to: Dates of other relevant contact since last report: Date of previous report publication: 26 th June 2011 Inspected by: Marie Tait Page 1

14 Care Homes for Older People Report (GIRPT01E ) Version 8.0 January 2012 Quality of life Non compliance identified at this inspection and action to be taken Action to be taken The registered provider must ensure people are given a choice in respect of their activities of daily living to ensure that people receive person centred care. The registered provider must ensure that all care plans are reviewed to ensure they are person centred. Care plans must contain sufficient detail to assist staff in providing appropriate and responsive care. The registered provider must ensure that staff responsible for the administration of medication adhere the guidelines and that accredited training in respect of this is undertaken. Timescale for Regulation number completion 15/04/13 12 (3) 22/04/13 15 (1) 15/04/13 13 (2) The service is non compliant with The Care Homes (Wales) Regulations 2002, 12 (3). This is because people are not always given a choice in respect of some activities of daily living. The evidence for this is: One person told us they had not had a bath/shower for some time but that they had spoken with staff about this and as a consequence they now receive assistance with a bath/shower once a week. We asked if this was their preference and they told us that they would like more but that they didn t think this was possible. One person told us they have desginated bath/shower days and receive assistance with their personal hygiene care on a Tuesday and a Saturday, they stated the carer had told them this. One person told us there was a problem with their shower but that the maintence person had been informed of this. One person told us they have discomfort and are embarrassed of their oral hygiene, commenting I m just looking at your teeth and mine are all broken and some are missing; they re horrible. They also explained that they were in discomfort as one of their teeth was digging into their gum. They said they had reported this to staff but that staff had not got back to them. One person told us they would have liked to have gone down stairs today but staff had not asked them. Although this person was assisted with their personal care they remained in their nightclothes and in bed. We discussed our findings with the manager who confirmed that staff may not always give people a choice. The manager explained that this may be attributed to the way in which staff ask. A questionnare repsonse from a person using the service in respect of going out when they choose, reported this as never. Page 2

15 Care Homes for Older People Report (GIRPT01E ) Version 8.0 January 2012 One person told us that staff did not wait for a response when knocking to enter their room but that this had been resolved because they had spoken with the manager about this. A questionnaire response from a person using the service reported the same selecting not always on the questionnaire. The evidene indicated that some people s preferences may not always be considered. The impact for people using the service is people may feel they have limited or no choice in respect of some of their activities of daily living and because of the way in which staff may ask it may leave people feeling that in effect they have no real choice. People who are well and wish to get ready and go downstairs to socialise with others may not always be able to do this. The service is not compliant with The Care Homes (Wales) Regulations 2002, 15 (1). This is because care plans are generic and do not contain sufficient detail to assist staff in recognising signs, symptoms, behaviours and triggers. This would assist staff in helping people as they would be able to identify appropriate health care needs and implement coping strategies and distraction therapies specific to an individual. The evidence for this is: We viewed one person s care file and the care plans did not contain sufficient detail which would assist staff in providing appropriate and responsive care in respect of their dementia, communication difficulties and epilepsy. We spoke with the manager who confirmed that all care plans are of the same calibre. The manager comfirmed that the care plans are dated and are not person centred. We discussed with the manager about care planning in gerneral and not containing sufficient detail in respect of other medical conditions such as diabetes and challenging behaviours. The manager confirmed that no behaviour charts are used, pain asessment tools or care plans in place in respect of pain management. The impact for people using the service is they may not receive responsive or anticipated care from staff who know their individual care needs. Care plans lack suficient detail and tools to assess pain and identify behaviour triggers are not employed as a consequence people may suffer from undesired symptoms, discomfort and pain. People may feel responible for their behaviours which are mismanaged. The service is not compliant with The Care Homes (Wales) Regulations 2002, 13 (2). This is because some staff responsible for the administration of medication do not adhere to the Royal Pharmaceutical Society and Nursing Midwifery Council guidelines. The evidence for this is: We spoke with one person using the service who moved a piece of paper from their table revealing two tablets. When we asked why these were there they told us oh they re old and stale just leave them there it doesn t matter. We viewed a copy of the staff training matrix which does not evidence that up-todate accredited training in respect of the administration of medication had been undertaken by staff responsible for this. We spoke with the manager who confirmed this practice contravenes the guidelines. Page 3

16 Care Homes for Older People Report (GIRPT01E ) Version 8.0 January 2012 The evidence indicated that medication administration is not undertaken in accordance with guidelines and may result in harm to people using the service. The impact for people using the service is they may suffer from undesired symptoms, ill health, discomfort and pain. Page 4

17 Care Homes for Older People Report (GIRPT01E ) Version 8.0 January 2012 Quality of staffing Non compliance identified at this inspection and action to be taken Action to be taken Timescale for completion Regulation number We have not focussed on this theme; therefore we have not issued non compliance notices. Page 5

18 Care Homes for Older People Report (GIRPT01E ) Version 8.0 January 2012 Quality of leadership and management Non compliance identified at this inspection and action to be taken Action to be taken Timescale for completion Regulation number We have not focussed on this theme; therefore we have not issued non compliance notices. Page 6

19 Care Homes for Older People Report (GIRPT01E ) Version 8.0 January 2012 Quality of environment Non compliance identified at this inspection and action to be taken Action to be taken The registered provider must ensure that there is sufficient storage space to keep equipment required to assist staff with care delivery. Timescale for Regulation number completion 22/04/13 13 (5) The service is not compliant with The Care Homes (Wales) Regulations 2002, 13 (5). This is because people requiring nursing care are accommodated on the second floor and there is no suitable storage space to keep equipment required to assist staff in the safe delivery of care. The evidence for this is: The last inspection report identified that people requiring assistance with nursing care were accommodated on the second floor. The manager told us that storage space had been identified but works had not yet commenced as funding was required to undertake this work. People requiring nursing care are accommodated on the second floor. Staff have to obtain a hoist from another floor. The evidence indicated that staff have to share equipment between two floors which is not acceptable and may encourage poor manual handling practices as a consequence people may be at risk of injury. The impact for people using the service is people may have to wait for assistance with care and may suffer harm due to poor manual handling practices. Page 7

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