Care and Social Services Inspectorate Wales Care Standards Act 2000 Inspection Report Red Rose Care Home Park Road Garden City Ebbw Vale NP23 8UP Type of Inspection Focussed Date of inspection 26 September 2013 Date of publication 26 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: 0300 062 8800 Email: cssiw@wales.gsi.gov.uk www.cssiw.org.uk
Summary About the service Red Rose Care Home is situated on the outskirts of Ebbw Vale and has close links to the local amenities. The homes ownership changed in September 2013, Four Seasons (Bamford) Limited are registered as the owners of the home and Rowena Martin is the registered manager. The home is registered with CSSIW (Care and Social Services Inspectorate Wales) to accommodate a maximum of 33 people aged 18 years and above with nursing and personal care needs. The home has been working with commissioners, local authority and the local health board to address a number of deficits. In response, a voluntary embargo which prevents any service user admissions had been placed on the home by Four Seasons (Bamford) Limited. On the day of our visit 18 residents were living at the home. What type of inspection was carried out? An unannounced focussed inspection visit was conducted at the home on 26 September 2013. The focus of our visit was the quality of leadership and management as the home has been without a registered manager since November 2011. In addition, the home experienced a high turnover of staff predominately qualified nurses which required agency staff to provide staff cover. Also, there had been allegations that residents had received inconsistent care which resulted in a number of safeguarding referrals to the local authority. During the visit we spoke to residents and staff, examined two residents care documentation looked at the homes quality assurance documentation examined the homes staff training matrix looked at the homes accident/ incident and complaints logs. What does the service do well? We (CSSIW) did not identify any specific areas of excellence during the inspection. What has improved since the last inspection? We saw some investment had been made in the form of a number of environmental improvements to the home. Discussions with a senior manager indicated other areas of the home were earmarked for repair and renovation. We saw that people s care documentation had been transferred into the standard Four Seasons document which supports a more person centred approach to care delivery. What needs to be done to improve the service? No non compliance notices have been issued following this inspection. However a number of good practice recommendations have been identified (specific details are outlined in this report): Peoples care documentation which includes service plan and risk assessments 3
should include up-to date information about the individual to ensure reliable care delivery. A record of the food people consume is to be maintained at the home. This will establish if people are receiving a balanced diet, one which considers individual dietary needs and any personal preferences. Staff members continued not to receive regular supervision. Following consultation with qualified nurses a number of care monitoring systems were being considered for implementation at the home. Whilst we recognise the registered managers need to be able to make individual nurses accountable for their actions we suggest recording a number of resident s details in lists does not support a person centred care approach and could lead to ineffective monitoring and replication of information. It is expected that the registered persons will take responsibility for addressing the above areas by undertaking whatever necessary actions are required to achieve improvements and compliance; this will be followed up at the next inspection 4
Quality of life From our observations throughout the visit, we saw that people were treated with dignity and respect. Communication between staff and people was noted to be respectful and appropriate. During our visit, people were not positively occupied or stimulated. We saw a number of residents dozing in their chairs. The only stimulus was from the two TV s in the main lounge. We were told that no activity staff were working on the day of our visit and that alternative arrangements had not been made for activity provision in their absence. We did not see any activity timetable on display to indicate any planned activities for the next few days. Examination of people s delivery plans contained personal histories which recorded people s likes and former hobbies. However, the information we viewed regarding one individual s participation in activity sessions was left blank. We spoke with residents who told us that they did take part in a number of activities at the home and enjoyed them. One resident told us they were escorted out to the local community for meals and shopping trips by the activities staff. Photographs of residents participating in a recent musical event were on display. One female resident showed off her painted fingers nails which she reported had been done by staff. People cannot be assured they will receive consistent care. This is because residents receive care from staff who are directed to deliver assistance for their individual needs via people s documentation. We viewed two people s service plans and found that they provided inconsistent guidance for staff. To ensure reliable care is provided the registered persons need to maintain information contained within people s assessments, service plans and risk assessments is complete and up-to-date. We found: One of the two residents care documents examined had not been reviewed since July 2013. This does not comply with good practice standards which supports reviews are conducted on a monthly basis as any changes in this persons need would not have been identified. Also, as the home is staffed according to resident s dependencies it is essential reviews are consistent as staffing levels would not provide an adequate reflection of the accumulative needs. One residents care documents indicated a need to maintain their daily fluid intake following a recent hospital admission. Information established a required daily fluid amount which was not transferred into their records. This meant that monitoring was ineffective as the care staff delivering care were unaware of the required daily allowance for the individual. The result of which is since the persons discharge from hospital they had not received their required daily intake of fluids. We examined two residents care documents and found that both individuals were taking antibiotics prescribed by their GP. Neither persons risk assessment viewed contained full and complete information in the form of the medication regimes dosage or duration to direct staff to achieve the identified outcome which was to provide medication safely. We also saw the need for regular review of information as, for one of the people whose documents we examined; this was their second course of recent antibiotics. We saw that two risk assessments were in place within the persons care documents for the medication. This could create confusion in the individuals 5
care delivery as the one risk assessment should have indicated the initial course of antibiotics had finished. This was not the case and could hinder the identified outcome to provide medication safely. We examined care documents for two individuals who were both assessed with the same score on a nutritional assessment scoring tool. The care staff was directed via each individual s service plan of the frequency the individuals weight was to be monitored. Examination of the information supplied contained no rationale as to why one person was to be weighed weekly and the other on a monthly basis. Again this indicated a lack of full and complete information. We discussed our findings with a senior manager who provided evidence that six monthly care audits had been introduced for each person. The intention is to eliminate such inconsistencies in peoples care delivery. We were assured the examples provided above would be considered as a priority. Residents gave us mixed responses about the food offered at the home. One person pointed to their stomach suggesting good food was responsible for its size when asked if they liked the food at the home. Another told us it was too much for them. A four weekly menu was on display at the home. We saw people being offered food choices for their lunchtime meal the same morning. On the day of our visit the meal was not as stated in the menu, we were told this was because the necessary food stocks were not available. We were unable to establish how many days the menu had not been followed as the home failed to maintain a record of people s food consumption. We were told a record was only maintained if there were individual issues with people s nutrition. This is required, in accordance with the Care Homes (Wales) Regulations 2002 to ensure people living at the home get a varied and nutritious diet. People experience good interactions with staff who support them to feel valued and provide them with a sense of attachment and belonging. This is because we observed interactions and spoke to residents about the staff who assist them. During our observations people appeared calm, relaxed and were smiling. One resident told us about the relationship they had with a staff member as they were both keen football supporters. He said they enjoyed light hearted banter as they supported opposing teams. The resident told us he was able to watch sport on his TV in his bedroom. He couldn t wait to see the particular staff member as his team beat the staff member s team the night before and felt the staff member was avoiding him. 6
Quality of staffing People living at the home continued to be assisted by a number of unfamiliar staff. Agency staff continued to be used to supplement the staff team despite the current reduced resident numbers. We were told that the organisation had made attempts to achieve consistency in practice by accessing the same staff. The organisation was in the process of recruiting two nurses to vacant positions. CSSIW had been informed of two instances where agency nurses had failed to turn up for work which meant that the staff team had worked below the homes identified staffing levels. A lack of sufficient staff would impact on people receiving timely support in a relaxed manner. In view of this, the use of agency staff was being monitored by commissioners. People cannot be satisfied that the home is staffed in accordance with people s current needs. We were told that the staff rotas were dictated by monthly evaluations of residents need. From our examination of care documentation one of the two persons information viewed had not been reviewed since July 2013. This meant that robust reviews needed to be taking place to ensure any change in an individual needs which indicated they required additional assistance or supervision was reflected in the staff skill mix. Staff told us they felt more involved with the running of the home. Qualified nurses were being consulted regarding the implementation of a number of care systems. We saw documents e.g. handover sheets which demonstrated nurses involvement in making changes to reach an agreed format. Whilst we acknowledge the importance of improved communication for staff and their roles. We suggest the registered persons are mindful that systems should support a person centred care approach and prevent replication of documentation which can be time consuming and remove staff from providing direct care to residents. 7
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Quality of leadership and management. Overall, we found from our observations and general discussions there had been improvements at the home. However, we feel there is a need for this to be sustained to have any positive impact on the lives of people who live at the home. Rowena Martin became the registered manager of the home in September 2013. Following her registration non-compliance has been met. Rowena is currently working in a part-time capacity. As an interim measure a senior manager is based at the home to oversee the homes day to day management in the registered manager s absence. Neither manager was present on the day of our visit; however a senior manager visited the home and assisted us throughout. Both residents and staff told us they found the present managers very approachable. We spoke to staff, who told us that they felt the situation at the home had improved. People benefit from consistent leadership and management. Prior to the appointment of the registered manager in September 2013 a number of managers had been appointed to work at the home which created inconsistency. In addition the home experienced an increase in staff turnover which resulted in a number of deficits in care practices being identified. This led to increased monitoring from commissioners, local health board and social services and resulted in the providers placing a voluntary embargo on the home which restricted admissions. People using the service can be fully confident that the registered persons will respond positively to feedback and critical incidents. We viewed the homes complaints logs and found that the registered manager had responded to each complaint received. There was evidence the complaints were satisfactorily resolved. We also found that the managers had informed CSSIW of events affecting the wellbeing of residents. However, we would remind the registered persons that notifications should include incidences of staff shortages. Following a number of safeguarding investigations, to reduce medication errors the home has revised its safe working practices which involved refresher training for the qualified nurses employed by the organisation. We were told that routine medication competency testing is to be introduced. An independent medication audit had also been conducted by the supplying pharmacy. People need to be satisfied they will receive reliable care. We saw a number of systems which had been introduced to monitor and measure the quality of the service. We viewed the last report compiled following the three monthly providers visit completed in May 2013. It identified staff training was required in mental health, infection control and wound care. We further saw evidence that training in these topics had been arranged and conducted. We also had general discussions with a senior manager which outlined future improvements and investment at the home. This indicated that the managers were planning for the future needs of the service. The theme of quality assurance with regards to quality monitoring systems based on seeking the views of residents to measure the homes success in meeting its aims and objectives will be looked at future inspections. 9
Quality of environment Although we did not visit the home to consider the quality of the environment we observed that the lounge had been extended by the removal of the nurses observation area. One resident told us disruption at the home was minimal as the dining room was made available for residents to use to ensure their comfort safety. This provided a fresh look to the home. Discussions with the senior manager indicated other areas were earmarked for repair and renovation. We were told that this could require further discussion surrounding the homes registration. We asked kept informed of any future plans for the home. 10
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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. 12