Care and Social Services Inspectorate Wales

Transcription

1 Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Springbank Care Home Neuadd Went College Road Barry CF62 8HS Type of Inspection Baseline Date(s) of inspection 18 July & 1 August 2013 Date of publication 9 October 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: cssiw@wales.gsi.gov.uk

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3 Summary About the service Springbank care home is situated in an established residential area on the periphery of Barry town, close to bus routes, shops and other amenities. The care home is operated by Springbank Care Home Ltd (which is the name of the registered provider). The service is currently registered with CSSIW to provide accommodation for a maximum of 66 residents in the category of Older Persons (aged 65 years and above) who require nursing care. At the time of the inspection, there was no registered manager at the home. The registered person had designated the operational manager as the manager of the home and it was planned by the provider (at the time of the inspection) that the operational manager will apply to become the registered manager of the home. What type of inspection was carried out? A baseline inspection was carried out through two unannounced visits on 18 July and 1 August These visits followed a previous focussed inspection completed on 18 June 2013 where non-compliance notices had been issued. This inspection looked at whether the non-compliance had been addressed by the provider. We (CSSIW) therefore looked specifically at whether the following regulations had been met: 12(1) (a) - The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. 13 (1) (b) - The registered person shall make arrangements for service users to receive where necessary treatment, advice and other services. 18 (1) (a) - The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users (a) ensure that at all times suitably qualified, competent, skilled and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. 10 (1) - The registered provider and the registered manager shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the care home with sufficient care, competence and skill. What does the service do well? The service had employed a music motivation therapist to work both individually with residents and in groups. He comes to the home on several occasions a month. We observed a session where the music therapist worked with two residents in their room and carefully chose songs that connected with their past lives that they would 3

4 enjoy singing along to. We also observed a group setting, where a group of around 18 people enjoyed singing along with the therapist who was able to skilfully engage with residents. Residents told us how much they enjoyed the event. What has improved since the last inspection? There were substantial improvements to the hallways (new flooring and redecoration) underway during the first inspection visit. On the occasion of the second visit, these improvements had greatly improved the appearance of the home. These areas were presented as bright and fresh, with a positive ambience. The acting manger has revived a previous system for contacting residents relatives/representatives so that they are provided with the opportunity to attend monthly reviews with their family member and be involved in the revision of their individual care plans. There was a new carpet in the communal down stairs lounge. What needs to be done to improve the service? The service continued to be non-compliant with: Regulation 12 (1) (a); relating to health and welfare of service users. Regulation 13 (1) (b); relating to seeking medical advice where service users health has deteriorated. Regulation 18 (1) (a); relating to a lack of suitably skilled and supervised staff. Regulation 10 (1); relating to managing the care home with sufficient care, competence and skill. The evidence for this can be found within the body of this report. As stated compliance notices were issued to the provider regarding the above at the last inspection. The outstanding non-compliance is a serious matter and CSSIW is pursuing this with the provider. Other matters required to achieve improvements to the service are: Review and update the Statement of Purpose document to ensure that the content is accurate. 4

5 Quality of life Overall, people living at the home are in receipt of care and support from staff that do not have a comprehensive understanding of their individual needs and preferences. This is because the care home is operating through the use of a significant number of agency staff. An agency staff member through discussion was found to have a limited understanding of people s needs. Examination of a sample of six residents care files revealed that documentation was incomplete. Although some attempt had been made to review and update plans and risk assessments, others contained insufficient information regarding known medical conditions, fundamental daily care needs, identified cognitive impairment and some long term health conditions. This means that staff are working with limited information about how to provide residents with assistance. One file contained information about recent advice given by a speech and language therapist as the resident had an identified problem with swallowing food and fluid. We found however that the resident was being provided with fluids in an incorrect type of cup (contrary to the specialist advice given) which placed them at increased risk of choking. This matter was immediately brought to the attention of a registered nurse and remedial action taken. Generally the residents files were untidy and not readily providing staff with clear information about the care to be delivered. This was seen as especially important to address in view of the volume of agency staff working at the home at the time of the inspection. The files contained old material that needed to be archived. Further the service user plans were not always readily accessible to staff. The plans for service users on the middle floor were stored on the floor below. One care staff member commented to us during the inspection that they did not have time to read care plans. Conversation with a number of staff working at the home during the two unannounced visits, highlighted their inability to spend time familiarising themselves with the content of risk assessments and care plans. In addition, we overheard two separate conversations between care staff who were clearly uncertain as to whether residents required their drinks to be thickened, due to swallowing difficulties. The above findings have the potential to place residents health, safety and welfare at risk. These plans are crucial in keeping service users safe. The importance of addressing this was fed-back to the registered persons at the second inspection visit. Examination of records showed that an audit had been completed of accidents and falls. However, there was no detailed analysis undertaken of the audit such as whether there were sufficient care staff to provide adequate levels of supervision. Nothing in the audit referred to whether falls were observed or not, or whether risk assessments were updated, whether medical attention was sought or a referral made to a falls assessment clinic. One resident had recently moved into the home. The falls risk assessment referred to a very high risk of falls. It was evident from the accident records that this person had fallen 3 times in a period of 18 days. However, only one fall was entered in the falls diary in their file and the specific risk assessment for residents who have a history of falls was not completed and there had been no consideration of a referral to any specialist clinic/team in relation to falls. Residents do not always receive responsive care from staff at the home. This is because conversations with a small number of residents during the first unannounced visit on the 18 July 2013 revealed that they were unhappy about being left in bed until late morning 5

6 and having to wait for their breakfast until almost midday. We have since been assured by the registered provider that steps have been put in place to ensure that people do not receive their breakfast late, they are not left in bed late and that this issue is being monitored. People living at the home told us that they sometimes had to wait for long periods for assistance from staff. We have since been assured that the registered provider now has a system in place to record electronically when call bells sound, and when they are answered. However, residents described a number of instances where staff had entered their room in response to the sound of the bell, but then had not been in a position to assist them at that time. Instead staff had only been able to offer them an apology and had returned to them when possible, which in some cases was estimated to be up to 30 minutes. During the course of our first unannounced visit we observed a resident walking through the corridor who we determined was at imminent risk of falling. As there were no staff available at that time, we approached the resident to provide assistance to prevent them falling. A carer subsequently confirmed that the resident should not have been mobilising unsupervised. At the time of writing this report there were 6 Protection of Vulnerable Adult investigations underway. The outcome of these has yet to be concluded. Overall, the system in place at the home regarding the prevention of pressure damage to residents skin was found to be inadequate. Conversation with a registered nurse demonstrated that they were not using a newly introduced form for monitoring mattress settings. The nurse was also unaware that two such pieces of equipment in use in their area of the home were in need of repair. In addition, where the new form had been placed in residents rooms, a large number of those remained blank or were incomplete. We also found that four mattresses in use at the home had not been set in accordance with manufacturer s guidelines (i.e. in accordance with the recorded weight of the resident). A number of other mattresses of a different type were however in use in accordance with recommended guidelines. Scrutiny of wound documentation and audit information at the time of our second visit, highlighted a number of inconsistencies in terms of recording. Specifically, residents were not always named (and were therefore not able to be identified) and the type of wound dressing being used was unclear. We also found blank sections of the audit forms where there should have been a recorded assessment of the grade of pressure damage and there was little or no information in terms of whether wounds were improving or deteriorating. We did find some evidence of requested visits form a tissue viability nurse and one resident s wounds had been photographed to assist with monitoring of the healing process. However, the above matters together with inadequate wound care documentation in residents care files may mean that people are not in receipt of appropriate wound care/management. People do not always benefit from a healthy diet and attention to nutrition and hydration. During the first of two unannounced visits we discovered that soft drinks had been placed in communal areas on what was a very hot day, but were out of reach of the residents. Conversation with a small number of people indicated that they were in need of a drink and staff were not easily located in the areas concerned. Scrutiny of care files also showed that the malnutrition risk forms in place were incomplete in each case. The registered provider has since informed us that regular and accurate recording of 6

7 residents body weight is now taking place through the use of revised documentation and new/re-calibrated weighing scales, with instructions for staff regarding actions to be taken in relation to weight loss. However, we noted in one resident s case file (following discharge from hospital), their care plan advised weekly weighing and monitoring of diet and fluid intake daily; but there was no evidence that this had taken place. We also noted that some care files did contain information about people s meal preferences, likes and dislikes. We were informed by a provider regarding an occasion where a particular service user s dietary needs had not been identified in their risk assessment and care plan; which had led to them being given an inappropriate diet that had posed serious risks to the person involved. An investigation is on-going regarding this. We saw examples where people were positively occupied and stimulated. A music motivation therapist, employed by the company was at the home on both visits and he was positively engaging people on an individual basis and group basis in musical activities within the home and we saw people greatly enjoying participating in this activity. We also saw one person being taken to church and other people attending the hairdresser. 7

8 Quality of staffing People living at the home do not receive care from relaxed staff able to cope with more complex demands. This is because qualified nurses and care staff told us that they feel unable to meet the needs of residents due to competing priorities (providing support with personal hygiene, continence care, medication administration, and assistance with eating/drinking). During the inspection we saw that people did not receive responsive care. We observed care giving to be rushed, people receiving late care (during the first of our two unannounced visits) and a small number of people living at the home described feelings of isolation or frustration (at not being able to have a shower or a bath) at a time of their choosing or as frequently as they would prefer. However, we found care giving to be less rushed at the second inspection visit. We saw a service user being put at risk regarding their medication. Specifically, the service user was observed having been left in their room holding tablets in a medicine pot. Medication administration guidelines, (as determined by the Nursing and Midwifery Council -NMC), dictates that registered nurses, when administering medication should remain with the person to witness whether the prescribed items have been taken. An entry should then be made on the Medication Administration Record (MAR) thereafter to record whether the prescribed item has been taken, refused etc. Not taking medication could have led to serious impact on a service user s health. During our first unannounced visit we also observed that a resident s commode had not been emptied throughout the whole morning. It was a hot day and the resident s room had become malodorous. We saw the home s hairdresser stepping-in to assist service users (with reduced mobility) to enter the dining room and then serve lunch; but we saw that basic food hygiene practices were not being followed and the inspector needed to provide guidance to ensure appropriate measures were taken. During the first inspection visit one person told us that they no longer spend time in the ground floor lounge area to socialise because when they had done so in the past, staff had been too busy to facilitate her moving from her wheelchair into a more comfortable chair. This meant that the resident was confined to their wheelchair for a number of hours during which time they became very uncomfortable. We also saw a staff member rushing around the building looking for a correct piece of equipment to assist other members of staff with moving and handling a resident. On the first inspection visit, as stated, there were delays in getting people out of bed in the morning. Staff told us that 20 out of 22 residents on the top floor that morning needed 2-1 staffing ratio and that with the staffing levels it was difficult to get residents up in a timely manner. People are not always cared for by familiar staff and there is a daily usage of agency staff. Although the home try to use the same agency staff to maximise consistency, this has not always been possible. One carer told us that working with agency nurses was difficult as they were not necessarily familiar with the needs of the residents. Additionally, an agency carer told us (at the second unannounced visit) that they had not had the opportunity to read any of the residents care plans or risk assessments, yet they were observed providing care to a person who was having to guide the member of staff 8

9 as to the level of assistance they required. We were given a copy of a recently devised handover sheet which is being used as an attempt to ensure that staff are familiar with core elements of residents care. However, conversation with the agency nurse who showed us the document readily admitted that the handover sheets are not updated on a daily basis. This may mean that residents health, safety and welfare needs are not being met. The acting manager informed us following the first inspection visit that he had changed the system for staffing and increased the number of carers on shift to address the delays in attending to peoples needs. However, the nursing complement at night had been reduced from two to one. In looking at the staff rota and in discussion with the acting manager it was evident that there had been some gaps in the rota, in relation to nursing staff and care staff. The acting manager, as a Registered Nurse himself, had covered part of one shift in addition to his management duties when the home had not been able to secure an agency nurse to cover the rota. Examination of a sample of care files showed that there was a dependency tool in place. However, conversations with staff indicated that this information is not analysed to assist with determining what level of staff support is required to meet the needs of the residents. There have been a number of changes in the management of the home within the past nine months. The previous registered manager had left employment at the home in November Following their departure the home had been temporarily managed by the lead clinical nurse until another manager was appointed in May That person however left their employment at Springbank in June The home is currently being managed by the company s operational manager who is planning to apply for registration with CSSIW as manager (application form sent on 25 July 2013). Staff spoken to during this inspection told us that the above changes had created difficulties for them as each manager had tried to put their own different ideas into place. People do not receive care from properly supervised and appraised staff. We identified lack of supervision of staff as an issue during the last inspection. This had not been addressed by this inspection. The acting manager stated that he was in the process of setting up a new system for supervision and appraisal, but this had not yet been implemented. Formal supervision should cover all aspects of practice, philosophy of care in the home and career development needs as identified in the National Minimum Standards. 9

10 Quality of leadership and management At the last inspection we found that people could not be confident that they were safe because the business was not run with due care and attention to minimum standards and regulations. This was found to remain the case at this inspection. Whilst we recognise that the registered provider acknowledges a number of deficits regarding the operation of this service, are working with an action plan and are committed to addressing the identified regulatory breaches; non-compliance remains evident. This is specifically in relation to aspects of care practice, delays in seeking medical treatment and sufficient numbers of competent staff. In addition, further non-compliance was found at this inspection in relation to other areas of leadership and management. People cannot be confident that the provider will respond positively to feedback and critical incidents. This is because other agencies and the registered provider have told us that there had been a number of complaints made to the home in the past few weeks. However, there was no record of these complaints or how they had been responded to at our inspection. The acting manager acknowledged that the complaints that had arisen since May 2013 had not been logged. The complaints that had been entered in the file (prior to May 2013) did not indicate whether complainants had been advised of the outcome of the complaint. Neither were we assured that the correct timescales had been applied for dealing with complaints, as determined by the regulation. One complaint was in relation to an allegation of money that went missing. There was no indication that the complaint had been referred to the appropriate authorities (either Protection of Vulnerable Adults or the Police). We also found that the company s own internal monitoring processes had not been followed adequately so that the providers themselves were able to detect and rectify deficits. During the first inspection visit (on 18 July 2013) we were told that the three monthly monitoring visits by the provider required under Regulation 27 had not been undertaken for the last 10 months. On the second CSSIW inspection visit, records of Regulation 27 visits by one of the directors of the company were produced for visits on 12 July 2013 and 29 July 2013 that had been completed following visits to the home in response to concerns raised within CSSIW s previous inspection report. These were not comprehensive reports. Rigorous internal monitoring is an essential part of the home s own quality assurance systems. The Statement of Purpose document needs some amendment. The address of CSSIW needs amendment, as does the information about inspection which is incorrect. We found that care plans and risk assessments were not based on clinical guidelines produced by relevant professional bodies concerned with the care of older people (e.g. guidelines produced by the National Institute for Health and Care Excellence - NICE). People using the service had been actively involved in defining and measuring the quality of the service. Evidence of this was seen in the form of an annual quality of care review report published by the provider in February Their report describes the difficulties caused by changes in management and acknowledges that several managers have left Springbank after relatively short periods and the staff team has had to come to terms with these different managers and their individual styles of leadership and management. The quality report also identifies that it remains difficult to employ high quality professional nursing staff and that there is a residual (but reducing) 10

11 negative staff culture at the home. The quality report also refers mentions that the management team at Springbank is highly committed to making improvement to the service. At the time of writing this report, the service provided at Springbank residential home was being closely monitored by local social care commissioning agencies through a process known as Escalating Concerns. (This process facilitates joint working between the commissioning agencies and CSSIW to improve residents standards of care). The escalating concerns process was initiated due to a number of issues brought to the attention of the Vale Local Authority via Protection of Vulnerable Adults (PoVA) procedures. The result of the escalating concerns process to date was the production of an action plan by the Vale Local Authority (LA) which was subsequently agreed by the care home provider. The provider has voluntarily agreed to cease new admissions until improvement actions have been implemented. 11

12 Quality of environment During the first unannounced inspection visit, major refurbishment to the hallways of the home was underway. At our second visit, we found these areas to be greatly improved. The stained carpet had been replaced by new flooring and the hallways had been redecorated and these areas were looking bright and fresh. The carpet in the main lounge had been replaced. However, we still saw some areas that needed attention. There were two bedrooms that had stained carpets, a middle floor bathroom presented with peeling paint on the wall-tiles which would be difficult to keep hygienic and a toilet handrail was bound with stained and soiled tape. This may pose infection prevention and control risk. We also observed that there was a toilet seat on the floor. However, it was evident that since the home had been purchased by the company in 2009, improvements had been made to the fabric of the building. Further plans were in place to improve the environment. This included replacing the lift. The provider is also considering how best to re-decorate the large hallway which would require scaffolding to enable this to take place. 12

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14 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. 14