Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Mae r adroddiad hwn hefyd ar gael yn Gymraeg / This report is also available in Welsh The Pines Mona Terrace Criccieth LL52 0DE Type of Inspection Focused Date(s) of inspection 29 September 2016 Date of publication 30 January 2017
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Summary About the service The Pines is situated in Criccieth town centre. The service provides nursing and personal care for up to 38 people over the age of 65 who have a diagnosis of dementia. The registered provider is Madog Nursing Home Limited, and the person nominated by the company as responsible individual is Andrew Mark Paynter. The registered manager is Gwen Maurice. What type of inspection was carried out? This was a baseline inspection in response to concerns raised with The Care and Social Services Inspectorate Wales, (CSSIW), the concerns were regarding the quality of care provided in the home, from the evidence obtained during the inspection, the concerns raised were found to have substance and have been upheld. Two inspectors conducted the first inspection and one conducted the second inspection. The inspections took place on 29 September 2016, between the hours of 10:30 a.m. and 5 p.m.; and on 5 October 2016, between the hours of 12:30 and 3p.m. Information was gathered from the following: Discussions with staff and managers. A tour of the home including people s rooms. We viewed a selection of people s care files including some records which are kept on a computer data base. We looked at a selection of staff files, rotas, supervision, and training records. The practice of staff was observed throughout the inspection visit. We looked at the menus and types of food offered in the home, and viewed fluid and food charts. We looked at pressure area care management and people s rounding sheets which detail the frequency and type of care received by people using the service. We observed a lunch time period in the home using the Short Observational Framework for Inspection (SOFI 2) tool. The SOFI 2 tool enables inspectors to observe and record life from the perspective of people who use the service; how they spend their time, activities, interactions with others and the type of support received. What does the service do well? As the inspection was in response to a concern, we did not focus on this area. Page 3
What has improved since the last inspection? As the inspection was in response to a concern, we did not focus on this area. What needs to be done to improve the service? The service is non compliant with Regulation 10 (1) of The Care Homes (Wales) Regulations 2002. This is because there is a lack of evidence to show that the provider and registered manager have carried on and managed the home with sufficient care and skill. This is a serious matter and we have issued a non compliance notice to the provider. The service is non compliant with Regulation 12(1) (a) due to a lack of timely referrals to specialists such as tissue viability, dietician, and speech and language therapists. This is in conjunction with inadequate monitoring of people s hydration and nutrition needs, pressure area care, and people s consistent weight loss. This is a serious matter and we have issued a non compliance notice to the provider. We informed the provider that the service is non compliant with Regulation 13 (4) (c). This is because call bells were seen to be out of reach in all rooms, no risk assessments were in place to ensure people s safety and to address people s needs as they are without a means to call for aid. The service is non compliant with Regulation 15(1). This is because care plans contain insufficient detail to guide care workers to give safe, holistic, and robust care. Care plans are not centred on individual people s needs. This is a serious matter and we have issued a non compliance notice to the provider. The service is non compliant with Regulation 16 (2) (c&g). This is because bedding was found to be old and worn in some people s rooms. People were seen to be struggling with the crockery provided, resulting in spilt food, which affected their nutrition, and dignity. This is a serious matter and we have issued a non compliance notice to the provider. The service is non compliant with Regulation 16 (2) (i). This is due to difficulties in providing, suitable, wholesome, and nutritious food which is varied and properly prepared and available at such time as may be reasonably required by service users. This is a serious matter and we have issued a non compliance notice to the provider. The service is non compliant with Regulation 18 (1) (a). This is because the providers did not ensure that at all times suitably qualified, competent, skilled, and experienced persons are working in the care home in such numbers as are appropriate for the health and welfare of service users. This is a serious matter and we have issued a non compliance notice to the provider. Page 4
We informed the provider that the service is non compliant with Regulation 19 (2) (b). This is because the provider did not ensure that staff in lead roles have the skills, competence, and experience necessary for the work he or she is to perform. Page 5
Quality Of Life We saw that people living in The Pines were well groomed and well presented. However, we found that some aspects of people s care within the home require improvement to ensure their well-being. The people living in the home cannot be assured that their nutrition and hydration needs are well monitored and provided for. We saw that, although the stocks of food and snacks are fresh and plentiful, the snacks were out of reach of people, and there was a lack of staff to aid people at meal times. We saw that many of the people living in the home required assistance with eating and drinking. Staff were either trying to assist more than one person at once or, where staff assisted people one at a time, others had to wait for assistance with their food resulting in a cold, unpalatable meal. We observed that people who could eat independently were struggling to eat off the side plates - which had no plate guards- resulting in some of the food sliding off the plate, the crockery used are therefore not fit for purpose. People who did not like the meal offered were given an alternative, but had to wait some time for the food to arrive due to the staff being busy. The lunch time meal was tinned tomatoes on a piece of white, toasted bread, served on a side plate. This is of low nutritional value for people who require high calorie supplements to maintain body weight and to promote healing and well-being. The alternative was a fresh vegetable soup which would be of higher nutritional value. We saw that most people were having lunch in their easy chairs in the lounges, and eating from hospital style tables. Tall people had difficulty eating from the tables due to the low setting compared to their chairs. The tinned tomatoes had soaked through the toast making it sloppy, and people were, therefore, spilling their food. The home has a pleasant dining room, but very few people were using the dining tables provided for their meals. The registered manager told us that people were encouraged to eat in the dining room but preferred not to. We did not hear any active offers from the staff for people to eat in the dining room during our inspection, resulting in a lack of occasion, and no feeling of community around meal times. We saw that many people did not eat all of their meal. Food monitoring charts noted that people had eaten ½ or ¼ of their meal - but no mention was made of what supplements were then offered and some food and fluid charts also contained gaps. We observed that some people s drinks were out of reach, full cups of tea were cold and untouched. We saw that some fluid charts recorded people drinking a litre or less in a 24 hour period. Government health guide lines recommend two litres or eight glasses of fluid per day should be drank by adults for a healthy level of hydration. People s nutrition and hydration needs are, therefore, inadequately planned, monitored, and provided for. People s property is respected in the home. We saw that people were tidily dressed in their own clothes and accessories. We saw that people had their own clothes hanging in the wardrobes which were clean and pressed. People had personalised their rooms with Page 6
furniture, pictures and ornaments to make them homely. People, therefore, have the comfort of having familiar things around them. People s needs are not adequately anticipated and they are not enabled to have access to specialist support in a timely manner. We saw that the weight charts in the home showed that a large number of people had been losing weight over several consecutive months. However, this evidence did not always trigger a referral to a dietician, speech and language therapist (SALT), or Doctor. We saw that people with pressure area problems were not always referred to a tissue viability specialist. The description of people s pressure sores were incorrect, resulting in incorrect grading of the pressure sore, this is unacceptable as it can lead to incorrect treatment of the pressure sore. Adverse changes to people s health were not adequately detailed in the care notes and people s care plans were not updated to reflect any extra care needs. People s care requirements are, therefore, inadequately identified and staff are not sufficiently proactive in sourcing specialist advice. The door to the home is locked, we saw that there was a lack of a signing in book; therefore staff cannot always know who is in the building and who has left. This practice is also a fire safety risk as the staff have no means of knowing if everyone inside the building had been evacuated. People are generally treated with familiarity and warmth. We saw that people living in the home and staff spoke together in a natural manner in both Welsh and English. Staff spoke to people of their interests and families, demonstrating that they were familiar with the people in their care. We did witness a staff member speaking about a person in the third person in their presence, answering she always does this in response to a query from another member of staff about a routine habit. The staff member was also abrupt, in their answers to CSSIW s questions regarding lunch time practices. Other members of staff were observed to treat people with dignity and respect, having patience, understanding, and kindness towards people in their care. People can be assured of being treated with dignity and respect by most staff, but all staff members should practice this to an acceptable level. People were seen to be bored in the home. There was an afternoon tea event for the people living in the home and their families to raise funds for the Macmillan charity in progress on the afternoon of the first inspection. We were told by the registered manager that a part time activities co-ordinator had been employed for the home. However, we saw that as staff were so busy with activities of daily living, there was little time spent on activities or entertainments, and people spent a lot of their time sitting around doing nothing. Further work is therefore needed to help people maintain their interests, hobbies, and activities. The planning of people s care in the home lacks personalisation. A description of the person receiving care, their needs, preferences, and personal history was not evident in their notes. Staff are working to convert paper based care records to the computer at present, but neither record is currently person centred. Further work is required to Page 7
provide people who are living in the home with a personalised plan of care designed to meet their individual needs. People living in the home have no means to call for aid. We found in all of the people s rooms that call bells were out of reach, leaving them at risk of harm. The manager told us that people lacked capacity to use the bells. No risk assessments or extra monitoring could be evidenced to ensure that people received help in a timely fashion. Page 8
Quality Of Staffing The staffing at The Pines is insufficient to meet the needs of the people living in the home. The care giving in the home is rushed. We saw that staff were very busy. The nurses in particular, were trying to compete with several demands at once, for instance, trying to keep a person safe, whilst answering the phone and trying to answer a care worker s query. As noted previously, care workers were busy giving aid with eating, drinking and helping people to the toilet, and so had little time for other tasks, or activities. We saw from the rotas that the staffing on the day of inspection was average for week-days, and that there were less on duty on week ends, with only one trained nurse on duty, even though people s care needs are no less at weekends. Staffing numbers should reflect the high level and complexity of care needs of the people living in The Pines. Staff members spoken to told us that they loved working with the people living in The Pines that they were busy, but felt well supported. The staff meetings minutes show that issues of concern are discussed amongst the staff and management, but that staff do raise concerns regarding lack of support at times, concerns are acknowledged, but outcomes are not always documented. People with complex needs do not experience adequate monitoring from staff. We saw that rounding sheets, which show the care given by care workers, are not always signed by nurses. We found that care plans were brief, and lacked detail with which to enable care workers to receive adequate direction to give appropriate care according to people s needs. Care plans were not person centred, and did not address people s individual care requirements, people can, therefore, expect routine orientated care that does not necessarily address their care needs. We saw from the care records that some things which are reported to the nurses by care workers, such as a person with a sore on their skin over an area of high pressure, was not sufficiently followed up or assessed, no written record was seen of the nurses looking at the sore area themselves. People cannot be confident of thorough assessment and monitoring of their needs to maintain their health and well-being. Page 9
Quality Of Leadership and Management Managerial and clinical over-sight regarding people s health and well-being is lacking in some areas, and requires addressing, insufficient care and skill are evident as regards people s care and management. The responsible individual and registered manager at The Pines are active in working with CSSIW regarding the identified areas of noncompliance with the Regulations. Daily meetings are held between managers and clinical lead staff. However deficits in robust health needs assessments and timely referrals to specialist health care professionals, inadequate monitoring of people s nutrition and hydration and poor weight and pressure area management were evident. Nurses were unable to inform CSSIW on the number of people in the home who were suffering with pressure sores. We were told that one person required treatment in the home; however, we noted from care documentation that two people were receiving pressure sore care. Care plans had not been updated, regardless of people s changing care needs. We saw that timely interventions and referrals to specialists did not occur in response to people s sustained weight loss. We saw from people s care notes that, although nurses were informed of people s changing care needs by care workers, people were inadequately assessed by the nurses. People living in the home cannot be confident of robust, active treatment to their health care needs. We saw that the employment practices in the home to ensure that staff are suitable to be working with vulnerable adults are robust. However, a practice regarding employing people with insufficient experience and knowledge to meet the demanding clinical needs of people receiving a service in the home requires consideration. We saw that staff placed in positions of authority lacked pertinent experience to be placed in such roles. People cannot be assured of receiving care from sufficiently experienced staff. We informed the provider about this and appropriate action was taken. We saw from the training records that although training opportunities are offered to staff, very small numbers of staff actually attend training events. We saw from the staff meeting minutes that this issue has been brought to the attention of staff by managers. Some gaps were noted in the staff s yearly mandatory training. The records we saw showed that specialist training such as tissue viability, where staff learn how to care for people s skin, guard against pressure sores, and where they do occur, how to grade and treat them, had not been attended since 2013, and not at all by some staff members. The Manager has informed us that staff were trained in tissue viability in 2015. People cannot be confident of being cared for by staff that are sufficiently updated in their knowledge to give safe, appropriate care. Page 10
Quality Of The Environment The Pines has bright, modern décor, and is a clean and comfortable home. Family and friends are free to visit people in the home, and many communal events are held for people and families. The lounges in the home are rather full, but people can receive visitors in their rooms if they require privacy. The home has a good standard of maintenance. We saw that the wood flooring on the third floor is a little worn and shiny and requires covering or replacing to minimise the risk of falls. The bedding in some people s rooms was found to be thin and worn, and needs to be replaced to ensure people s comfort, warmth, and to enhance their environment. The paint work is well maintained, and people s rooms are airy and clean. Page 11
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
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 www.cssiw.org.uk The Pines Mona Terrace Criccieth LL52 0DE Date of publication: 30 January 2017 Page 13
Quality of leadership and management Non-compliance identified at this inspection and action to be taken Description of Non Compliance / Action to be taken The registered provider and the registered manager have provided a service to people with insufficient numbers of staff to safely care for them. Clinical over-sight is lacking in the home leading to a failure in health and nutritional monitoring, and late referrals to health care specialists. The registered manager and registered provider must show that they are carrying on and managing the service to a satisfactory standard with due regard for people s welfare and the numbers of staff required to safely care for them. There is a lack of adequate monitoring regarding people s nutrition, hydration, and pressure area care needs. The home is not proactive in dealing with proven weight loss for a number of people, leading to late referrals to specialists who can advise with people s care. Health and nutritional monitoring needs to improve in the home, and specialist referrals need to be made in a timely manner. Care plans are not person centred, and contain insufficient detail with which to guide care workers towards safe, holistic care. Care plans need to be person centred, and contain sufficient detail to enable care workers to meet people s individual care needs. Timescale for Regulation number completion 6 February 2017 10 (1) 6 February 2017 12(1)(a) 6 February 2017 15 (1) Page 14
Bedding is old and worn in some rooms. Crockery is not fit for purpose. Bedding is required to be of sufficient standard to provide warmth and comfort for people. Crockery must be suitable for people s use to maintain nutritional needs. Food provided was of poor nutritional value, snacks were out of reach. Nutritional and fluid monitoring was in need of improvement. People must be provided with sufficient, wholesome food and fluids with which to maintain their well being and a healthy body weight. Hydration levels should be within government health guidelines. Staff numbers were found to be insufficient compared to the complex needs of the people living in the home. Staff numbers must be improved to ensure safe, holistic care in the home. 6 February 2017 16 (2) (c&g) 6 February 2017 16 (2) (i) 6 February 2017 18 (1) (a) The registered persons are not compliant with Regulation 10 (1) of The Care Homes (Wales) Regulations 2002. This is because the home was found to be carried on and managed with insufficient care and skill by the responsible individual and registered manager. The evidence for this is as follows: There was a lack of quality control regarding the planning, provision, and monitoring of people s nutritional and hydration needs in the home. We saw from observations, and by use of the SOFI2 tool, that people received a meal of poor nutritional value. As staffing levels were low, we saw that people had to wait for long periods for assistance with their food, leading to cold, unpalatable meals and drinks. We saw from reading a broad selection of people s food charts that some gaps were evident in recording people s food and fluid intake. People frequently only completed ½ or ¼ of their meals but no record of the supplements then offered were seen. Snacks were seen to be plentiful in the home, but were out of people s reach on tables in the far corner of the room in two main lounges. Health monitoring, and subsequent referrals to specialists such as tissue viability and dietetics were found to be poor in the home. All but two of the people living in the home had consistently lost weight over the summer months, but referrals to the dietician had not been triggered by this evidence. Referrals to tissue viability for people with pressure sores were not done in a timely fashion as evidenced from reading the related care plans. On both inspection visits, care giving was seen to be rushed. We saw that there were insufficient staff to aid people with their meals within a reasonable time frame. We Page 15
saw that staff were busy with basic activities of daily living and did not have the time or scope to support people psychologically, emotionally, or to provide daily activities to spark people s interests and to help pass the day in a pleasant way. We saw three staffing rotas showing that staffing was poor on several shifts, especially at night and on week ends. We saw that people s basic needs were not provided for; some bedding seen was old and worn. We saw that people struggled to eat from the types of crockery provided in the home leading to spillage and lack of dignity for people. Call bells were out of reach in all of the rooms viewed, and no extra measures or risk assessments were seen to be in place to ensure people s safety. We saw from the staff records that inexperienced staff had been recruited in to lead roles. Staff require knowledge and experience in order to fulfil a senior role in a safe and satisfactory manner. The evidence indicated to us that the home has not been carried on or managed in a sufficiently skilful manner with which to ensure people s comfort and well being. The impact of this is that the welfare of people using the service is not assured due to the lack of careful quality monitoring and management oversight. The registered persons are not compliant with Regulation 12 (1) (a) of The Care Homes (Wales) Regulations 2002.. This is because health monitoring, and subsequent referrals to specialists are inadequate in the home. The evidence for this is as follows: We saw from the records that all but two of the people in the home lost weight consistently over the summer months, this was not reflected in dietician referrals or in care plan updates. We saw from the care plans that people with pressure sores were not referred to the tissue viability specialists in a timely manner. Grading and descriptions of the pressure sores were also incorrect, and could lead to the wrong treatment. This evidence indicated to us that that health monitoring is unsatisfactory in the home and people cannot be assured of receiving specialist advice in a timely manner. The impact of this is that people cannot be assured of their health and welfare in the home. Page 16
The registered providers are non compliant with Regulation 15 (1) of The Care Homes (Wales) Regulations 2002. This is because people s care plans were found to lack sufficient details regarding their care needs and were not person centred. The evidence for this is as follows: We viewed a selection of care plans and saw that information contained in them was brief. We saw that care plans were repetitive, and not focused on individual people s needs. The evidence indicated to us that the care plans in the home are not robust enough to instruct care workers as to individual people s needs. Care plans are not person centred, are impersonal and clinical. The impact of this is that people are not robustly assessed as to their individual needs; there is no written evidence that the home is familiar with people as individuals, and know their needs and wishes. The registered providers are non compliant with Regulation 16 (2) (c&g) of The Care Homes (Wales) Regulations 2002. This is because resources to meet people s basic needs are not always in place in the home. The evidence for this is as follows: We saw that some of the bedding in the rooms viewed were old and worn. We observed that the crockery in the home was not fit for purpose, we saw that unguarded side-plates were used with difficulty by people causing food spillage. This indicates to us that some basic provisions are not available to people in the home. The impact of this is that people s comfort and dignity cannot be assured in the home. The registered persons are non compliant with Regulation 16 (2) (i) of The Care Homes (Wales) Regulations 2002. This is because wholesome foods are not provided within a reasonable timeframe in the home. The evidence for this is as follows: We observed that small portions of nutritionally poor food was provided for people. We saw that people had to wait for some time for assistance leading to cold food and drinks. We saw from viewing a broad selection of people s charts that food and fluid monitoring was in need of improvement. We saw that fluid balances were not always Page 17
totalled and that people drank under the recommended government guidelines amount for health and hydration during the day. This indicates to us that food and fluid provision and monitoring in the home is insufficient. The impact of this is that people are at risk of dehydration and malnutrition. The registered persons are non compliant with Regulation 18 (1) (a) of The Care Homes (Wales) Regulations 2002. This is because staffing levels are insufficient in the home. The evidence for this is as follows: We observed from both inspection visits that care giving was rushed and that staff only had scope to attend to routine orientated basic care. We saw from the three months rotas viewed, that staffing levels on shifts were low compare to the range of complex needs, and number of people living in the home. This was especially so of night duties, and on week ends where only one member of staff is on duty. This indicates to us that the numbers of staff provided by the home to care for people using the service is insufficient. The impact of this is that people cannot be confident of being cared for in a safe, robust manner and of having their needs attended to. Page 18