Care and Social Services Inspectorate Wales. Care Standards Act Inspection Report. Ceris Newydd Nursing & Residential Home

Transcription

1 Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Ceris Newydd Nursing & Residential Home Treborth Bangor LL57 2RQ Type of Inspection Post Registration - Baseline Date(s) of inspection January 2016 Date of publication 17 March 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.

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3 Summary About the service Ceris Newydd is located in Treborth with views over the Menai Straights and Anglesey. It is surrounded by garden and wooded areas and has parking to the front of the building. The home is divided into two main units- Ceris, which caters for general nursing needs and comprises of four main areas; Ceris Up, Ceris Down, Telford and Oaklands, and Glyn Menai which is a service catering for those with a diagnosis of dementia on either Dwynwen or Tryfan units. The service is registered to provide nursing care for up to 77 people over 65, including people with a diagnosis of dementia or mental infirmity. The registration also permits the service to care for three younger adults between the ages of 18 and 64 requiring nursing care, including those with a diagnosis of dementia/ mental infirmity within the overall number. The Registered Provider for the home is a company called Fairways Care Ltd. The Responsible Individual for the company is Mr Mark Bailey. The Registered Manager is Mrs Julie Powell. Mrs Powell is registered with the Care Council for Wales, and the Nursing and Midwifery Council. The service is offered as detailed within the Statement of Purpose. What type of inspection was carried out? A scheduled, unannounced baseline Inspection was carried out on Monday 25 th of January, 2016 between the hours of 09:30 and 17:20.This visit was also linked to a concern as received by Care and Social Services Inspectorate Wales. We (Care and Social Services Inspectorate Wales), used the following methods to inspect the service: We (CSSIW), spoke with six people living in the home A tour of the premises including all units and some service user s rooms. Review of three service user s care files in Glyn Menai and two in Ceris View of two staff files View of computer based care plans A copy of the Statement of Purpose was supplied Review of other pertinent documentation as kept by this registered service. Interview with two staff members in Glyn Menai and one in Ceris Observation of people using the services in Glyn Menai using the Short Observational Framework for Inspection (SOFI) tool. The SOFI tool enables inspectors to observe and record life from a service user s perspective; how they spend their time, activities, interactions with others and the type of support received. What does the service do well? The service has made a considerable effort to research and introduce physical adaptations to the environment to promote a positive effect on activities of daily life for people with dementia. What has improved since the last inspection? The service has invested in numerous improvements since the last inspection, this also Page 3

4 forms part of the provider s quality assurance. The improvements are: An appointment of an Audits and Standards Officer (who is also responsible for ensuring that the staff training matrix is maintained). This benefits the service by ensuring that the care given is evidence based, audited, and that the staff are updated in their training Use of the CareSys mobile software system. These mobile computer pads aid staff to deal with episodes of care quickly and safely. Use of the Book of You life history books on the mobile computer tablets. This enables people living in the home to give their loved ones a lasting reminder of their life story, photographs and quotes can be uploaded onto the page which families can also access. Families can also add to the on-line page (via a pass-word) and add further family photographs and memories. A continuing maintenance programme which has seen the redecoration of Glyn Menai, an upgrade to the decorations of bedrooms in Ceris Newydd, and some new furniture being purchased for both units. This ensures the comfort of people living in the home, and adds to the feeling of homeliness. The induction packs for new staff have been updated. This ensures that staff starting to work at the home do so with support. Induction enables staff to become familiar with the home s processes so that they are able to care for people safely. A new fire alarm system has been fitted; this will ensure the safety of people in the home in the event of fire. The catering within the home has been contracted out to a company called Elior. This will be monitored via the provider s quality assurance audits. This will benefit the people living in the home by providing a varied menu of nutritious foods. The Snoezelen room has been rewired- this is a sensory well-being room which has been designed to enable the people living in the home gain enjoyment and relaxation. What needs to be done to improve the service? The service is non compliant with Regulations 13(3); 13(3) (d); 16(2) (g); 17(1) (j); and 24 (2) (d) of The Care Homes (Wales) Regulations 2002 (The Regulations). This also relates to National Minimum Standards (NMS) 40.1; This is because the kitchenette on the first floor of Ceris (used to provide snacks and beverages), was found to lack hygiene and is in need of maintenance. This is a serious matter and we have issued a non compliance notice to the provider. The following areas of non compliance have been drawn to the Registered Person s attention to ensure that they are addressed, in addition to areas where improvement is needed. The areas of non-compliance will be reviewed at future inspections. We notified the provider that the service was not compliant with Regulation 13(4) (c) and NMS 18.1 and 18.3; This is because windows on the first floor did not have closure restrictions which were sufficient to comply with the Regulations and the Health and Safety legislation. Some small convector heaters were found in people s rooms with no electricity PAT testing stickers or guards in situ. These issues need to be remedied to ensure the health and safety of people living in the home. We did not issue a non-compliance notice in this instance because the provider gave assurances that these will be remedied immediately. The maintenance person was to be contacted regarding the issues with the convector heaters on the day of inspection. We informed the provider that the service was not compliant with Regulation 13(2); 13 (3) and NMS This is because creams and lotions were found in people s rooms with other service user s names on, or no name at all. The sharing of personal creams and lotions is an infection control risk, barrier creams should be administered to the correct Page 4

5 person and as per prescription. We have not issued a non compliance notice due to the fact that creams were removed from people s rooms on the day of inspection, and name labels and opening dates were to be supplied. Page 5

6 Quality Of Life Overall, people living in the home are treated with dignity and respect. People were seen to have a relaxed, friendly relationship with staff members. We observed the interactions between staff and service users in Glyn Menai using the SOFI tool. We found that people were addressed appropriately and with respect. People living in Glyn Menai were observed to have fun with the staff members and were seen to be responding positively to the use of humour. There was a sense of belonging and warmth to the interactions observed. Staff members sat along-side service users and enabled the participant s engagement in tasks. People cannot always be assured of being supplied with their own individual creams, topical ointments and lotions. The sharing of creams and topical lotions is an infection control risk, creams and lotions should be supplied by individual prescription and have the service user s name clearly displayed upon it. We observed that creams and topical ointments belonging to other service users were in several people s rooms. Whilst noone was receiving a cream they were not prescribed, staff need to ensure people receive the cream that has their own name on it. The staff removed these creams on the day of inspection and were to supply a fresh container as per the prescription to the correct persons, whilst ensuring the correct name was clearly displayed on the said container. People feel that their individual (diverse) needs are recognised and catered for. Individual care plans and risk assessments are computer based and are regularly updated; the soft-ware provides prompts to remind staff when updates are due. The Service has provided the staff with CareSys mobile computerised pads which enable staff to record individual episodes of care quickly. Ceris Newydd also use the Book of You life story application which allows the home to upload photographs of people that their family can view, family can also share their loved one s photographs from home on the system. This forms a lasting visual life story site that families can keep. The safety of the site is ensured with pass-word protection and allows access to an individual person only, i.e. their own family member People benefit from a healthy diet and attention to nutrition and hydration. People were seen to have frequent beverages and snacks, if so desired. The catering for the home has been outsourced to a company called Elior. People spoken with were happy with the quality and variety of the food provided. One person commented that the food was fine, but the presentation of the food sometimes lacked finesse. These comments were shared with the management team, who stated that they were aware of the problem, and that it was being addressed. We spoke with the catering manager who told us of the training being undertaken by catering staff in relation to the improvement of special diets required by people who have swallowing difficulties. People experience warmth, attachment and belonging in the home. People s rooms were seen to have their personal photographs, pictures and belongings in place. The service has invested in providing updated dementia care, and memory boxes were seen outside people s rooms with personal photographs and memorabilia contained within them. People spoken with stated that the home was homely, and the staff were friendly. We were able to evidence warm interactions and banter between staff and people living in Glyn Menai by use of the SOFI observational tool. Page 6

7 Quality Of Staffing Overall, people feel confident in the care they receive because staff are competent and confident meeting their particular needs. The staff training matrix is frequently audited and maintained. Staff spoken with state that they were given mandatory training annually, and were encouraged to attend extra training to enhance the updated dementia care given in the home. Staff spoken to said that they were supported in bringing new ideas into daily practice that would enhance people s care. We evidenced this by seeing art work by the staff along the walls of the Glyn Menai unit, which was bright and interesting for the people to look at. The use of the Book of You is championed by one staff member who updates and trains colleagues as to it s use. People are cared for by friendly, approachable staff that add to the warmth of the home and help people feel attachment and belonging. We observed that staff were relaxed, and responsive to the people s needs. The people living in the home stated that the staff were kind, and considerate of their needs.a family member commented that the standard of care given by the staff was good, and that the staff were very approachable. People receive timely support and care. We observed that staff were attentive to the people living in the home. Call bells were seen to be answered in a timely way. People living in the home felt that they received prompt, consistent care. People with complex needs receive skilful care. Ceris Newydd specialises in caring for people with a diagnosis of dementia. We observed that the Glyn Menai unit was bright and colourful with memorabilia of past decades along the corridors. Walls and furniture had differing textures and colours to stimulate the senses, and memory boxes were placed outside bed-rooms. Staff wear their own clothes, be they day-time or night time wear to help orientate people as to time and place. The sensory rooms had been rewired, and provided aromatherapy and light-sensory therapy to enable people to relax. Page 7

8 Quality Of Leadership and Management Overall, people using the services can be confident that they were safe because the service was well run. Administration systems were well organised and all the required records were being maintained. Policies and procedures were being reviewed regularly and updates made as necessary. The staff spoken with were aware of, and able to tell us about the aims and principles of the service. People can be assured that the staff delivering their care have been through a robust recruitment and induction process. We reviewed two staff files and saw that all of the required checks have been undertaken and recorded and that there is an auditing system in place. We saw that a thorough induction programme had been devised and staff spoken with felt that they had sufficient training and support. The Care and Social Services Inspectorate (Wales) had received a concern regarding the response to staff members raising a concern. The managerial team were able to show us an trail of their responses to concerns, and the resolutions that they had offered. We evidenced supervision sessions and follow up in the Staff files. The staff members spoken with felt that they were well supported, and that the management team were approachable, and proactive regarding problems and concerns. Staff stated that they were confident that the management team would keep issues confidential where appropriate. People feel that they get reliable, good care. People were seen to be relaxed in the home, they were appropriately dressed, and were seen to receive frequent beverages and snacks if they desired them. People and a family member spoken with were very happy with the care and support received in Ceris Newydd. People see visible accountability and know that there are people who are over seeing the service. The management team were very helpful and responsive during the inspection visit. Staff members spoken with were aware of the manager s responsibilities, and felt that they were accessible and approachable. We saw that the management were monitoring staff rotas and were proactive in their leadership. People experience an improving service which they can rely upon. The statement of purpose and service user guides show a commitment to an improving evolving service, and detail the service which people living in Ceris Newydd can expect. People spoken with were very happy with the standard of services delivered. The appointment of the Audits and Standards Officer shows a commitment to auditing the care provided to maintain and improve upon the standards already achieved. The officer will also review and update the training matrix so that people can be assured that staff caring for them are updated in their training and can give safe, evidence based care. Page 8

9 Quality Of The Environment Overall, people feel uplifted by the environment they live in. Ceris Newydd provides a homely environment with lovely views of the Menai Straights and Menai Bridge, providing a focal interest for the people living there. The home has garden and wooded areas that people can walk in or sit in, and have a potting shed for those interested in gardening. People s rooms have personal photos and effects, making them homely. Some of the bedrooms observed had been left in an untidy condition, the beds insufficiently made, and some bathrooms had debris left over from staff attending to people s hygiene needs, this disrupted the clean, homely ambience of the rooms. These observations were highlighted to the manager who stated that these practices would be addressed as soon as possible. People can explore freely as they are able, or with assistance, go outside and be inside as they so desire. The outside spaces had areas of interest for people, seating, ornaments hanging in trees, bird feeders, and opportunities to do some gardening. People spoken with said that they had visits from friends and family and were able to go out with them for the day if they so desired. People s wellbeing is promoted because of the range of facilities and equipment provided to meet their particular needs. Ranges of equipment designed to aid with care needs were noted throughout the home, staff were updated as to mandatory training, and equipment had updated PAT testing stickers upon them. Sensory rooms were noted with people relaxing within them. The units each have several lounges designed either for socialisation or quiet spaces as required by the people living there.the provider has an ongoing maintenance and replacement programme, some areas have already been redecorated and new furniture provided. Other areas of the home which have well used furniture and fittings are now due to be upgraded. This will be monitored at the next inspection. We observed that a kitchenette on the first floor of the Ceris unit did not meet hygiene standards. This is because a dirty food thermometer probe was found hanging by the door, the dishcloth in use was not clean, a rusty can opener was found amongst the cutlery container which itself was uncovered- and mould was seen on the windows and tiles. The crockery shelves had peeling paint on them. This is an infection control and contamination risk which is an unnecessary risk to people s health. The provider has been notified and has stated that the area will be renovated as soon as possible. People can be confident that the premises are physically safe. The main door is monitored by a receptionist. Units have closed doors with numbers locks in situ. Staff asked to see our identification badges and asked us to sign in and out of the home. Page 9

10 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 10

11 Care and Social Services Inspectorate Wales Care Standards Act 2000 Non Compliance Notice Adult Care Home - Older 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 Ceris Newydd Nursing & Residential Home Treborth Bangor LL57 2RQ Date of publication: 17 March 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.

12 Quality of The Environment Non-compliance identified at this inspection and action to be taken Description of Non Compliance / Timescale for Regulation number Action to be taken completion 13(3); 13(3) (d); 16(2)(g); 17(1)(j); 24(2)(d); NMS The Kitchenette on the first floor was found to have mould on the windows and tiles. A soiled cloth was found on use. The can opener was rusty and kept with other cutlery in an open container on a work top. The shelves had peeling paint on them. A dirty food temperature probe was found hanging on a hook by the door. 30th March, (3); 13(3) (d); 16(2) (g); 17 (1) (j); 24 (2) (d). It is the opinion of CSSIW that you are not compliant with regulations 13(3); 13 (3) (d); 16(2) (g); 17 (1) (j); 24 (2) (d) of The Care Homes (Wales) Regulations This is because a kitchennette on the first floor of the Ceris unit was found to not meet hygiene standards causing an unnecessary risk to people s health and well being. The evidence for this is as follows; During the inspection visit on the 25 th of January, 2016, we found that the kitchennette oposite room 11 of the Ceris unit was not hygienically clean.peeling paint was found on the crockery shelves, which could cause contamination to the crockery stored on them. A food probe with old, dried food on it was found hanging by the door. The dishcloths used were found to be dirty, mould was seen on the tiles and window. A rusty can opener was found amongst the cutlery container destined for people s use. These elements of concern could cause food contamination and cause a health risk to people living in the unit. These findings were shared with the Registered Person on the day of the inspection. The Registered person also viewed the room and agreed that it was not satisfactory, and that it would be rectified as soon as possible. Page 12