May 2015 - Warrendale Cottage

Care and Social Services Inspectorate Wales
Care Standards Act 2000
Inspection Report
Warrendale Cottage
Old Warren
Broughton
CH4 0EG
Type of Inspection – Focused
Date(s) of inspection – 2nd and 20th March 2015
Date of publication – 21st May 2015
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Summary
About the service
Warrendale Cottage is currently registered to the provider/manager, Mrs Marjorie Kirby to
provide accommodation for twenty nine older people requiring personal care. It is a
condition of the registration that the home may accommodate up to six people with a
diagnosis of dementia/mental illness.
During the previous inspection we found that a limited company was carrying on the
service without being registered to do so. An application to register has been submitted by
the company and was being processed by CSSIW at the time of this inspection. This is a
significant regulatory breach and the service has been determined by CSSIW as a service
of concern because they are operating without being registered.
What type of inspection was carried out?
This was an unannounced focused inspection to measure progress with the areas of non
compliance identified at the previous inspection. This inspection was carried out over two
days by two inspectors. The first visit was carried out on 2 March 2015 between the hours
of 9.50am and 15.45pm. The second visit was carried out on 20 March 2015 between the
hours of 9.45am and 12.40pm. At the time of the inspection there were 29 people living at
Warrendale.
What does the service do well?
The home offers a good range of home-cooked food that people speak highly of. People
like the well cared for garden and going outside.
What has improved since the last inspection?
There was some improvement in the care planning and the introduction of audits into the
home. However, they are not yet of sufficient standard to meet the non-compliance
requirements.
What needs to be done to improve the service?
Three non-compliances notices were issued following the previous inspection conducted
on 12 November 2014:
Regulation 10 (1) - The registered provider/manager shall, having regard to the size of the
home, the statement of purpose and the number and needs of the service users, carry on
the care home with sufficient care competence and skill.
During this inspection we found that there is no evidence to support that complaints and
safeguarding matters are properly recorded and acted upon appropriately there was no
evidence of a robust quality assurance system in use at the home and the policy and
procedures regarding Deprivation of Liberty Safeguards were not sufficiently detailed to
enable staff to follow the correct process. Therefore compliance has not been achieved
with this regulatory breach.
Regulation 15 (1) The registered person shall ensure that all people residing in the home
have care plans in place which reflects the person’s needs in respect of their health and
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welfare.
During this inspection we found that there had been some improvement in care planning.
However, we viewed six care plans and found in all of those seen that not all identified
risks had a corresponding care plan advising staff of the action required to minimise the
risk. We also found that information from visits by other health care professionals was not
recorded in individual care plans. Not all records were dated and signed when completed.
Therefore compliance has not been achieved with this regulatory breach.
Regulation 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 ensure that at
all times suitably qualified, competent, skilled and experienced persons are working at the
home care home in such numbers as are appropriate for the health and welfare of service
users.
During this inspection we viewed three staff files. We found that the induction programme
for new staff did not meet the criteria specified in the induction framework by the Care
Council for Wales. We found that audits of staff training had been undertaken as required
following the previous inspection. However, the audits were not sufficiently robust to
determine the effectiveness of training provided and competence of staff. There was also
no evidence of staff being supervised during delivery of care to enable senior staff to
determine carers’ competence. Therefore compliance has not been achieved with this
regulatory breach.
During this inspection we identified the following areas which need improvements and
have made the following practice recommendations:
Consideration should be given to consulting people if they would like curtains in
their bedrooms in addition to the blinds currently in use.
National Minimum Standard 8.
Consideration should be given to removing the notice on the front door that tells
people they are not allowed outside because of ‘health and safety’ issues.
National Minimum Standard 8.
Consideration should be given to the activities programme available for people in
the home. Consideration should be given to using noticeboards to publish the
activities programme, when there will be visitors to assist with meeting people’s
religious needs, dates the hairdresser was visiting and the daily menu. People
should also be given the choice of what to watch on television.
Consideration should be given to displaying the activities programme in other areas
of the home additional to the front foyer. National Minimum Standard 9.5.
Consideration should be given to displaying the menu, including on tables so that
people are aware of what they will be served at each meal. Consideration should be
given to make sure people receive their meals at the same time as others at the
table and in a timely way. National Minimum Standard 16.
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Improvements should be made in relation to infection control, specifically in relation
to towels and toilet rolls being left on the cistern and toiletries in bathrooms.
National Minimum Standard 18.2.
Improvements should be made to the tool used to audit the way that medicines are
managed. National Minimum Standard 28.1.
Consideration should be given to providing pictorial signage to promote peoples’
independence on communal rooms in line with current research into providing
appropriate environments for older people. National Minimum Standard 33.1.
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Quality Of Life
People can be confident that they will receive a nutritious diet. However, people cannot
be confident that they will be made aware of the choice of menu. Only one person we
spoke with could remember what they were going to have for lunch on the day of the
visit. There was a menu displayed in the entrance hall but not all service users access
this area during the day. We have made a practice recommendation about displaying the
menu in other areas of the home
We saw that the main meal of the day was served at lunchtime. There were two choices
of meal and pudding. People spoken with told us they enjoyed the food. Comments
included, “It’s always lovely”, “they know what I like” and “I’m looking forward to my
dinner”. We saw that meals were home cooked and well presented. Staff told us that
people are asked the day before what they want to eat the following day.
We saw that the dining experience could be enhanced for people at the home. We saw
that meals were plated one at a time in the kitchen and then taken by staff individually to
people waiting at the dining room tables. This process was slow and meant that not
everyone at a table was served at the same time. It also meant that people were sat at
the dining room table for up to an hour before they received their meal. People were
heard to say, “when’s it coming, I’m hungry”. We have made a practice
recommendation that consideration should be given to how food is served to make sure
that people receive their food in a timely way.
We saw that tables at lunchtime were laid with cloths and cloth napkins. However, we
saw that some cloth napkins were in poor condition and needed to be replaced.
Condiments were freely available.
People cannot be confident that they will be treated with dignity and respect at all times.
Whilst we saw that staff provided the care that people needed, we did not see any staff
spending time with people just talking or doing activities. All contact seen on the day of
the inspection was when people needed care, so was task, and not person, centred. We
saw a sign on the front door informing people that they were not allowed to go outside for
health and safety reasons. We also found in the case of one person, that their wishes
regarding preferred bath times had not been followed. All of these issues impact on
peoples’ dignity. We discussed with the manager the practice of putting ‘kylie pads’’
(incontinence fabric) on every chair. This is institutional practice and should be
reconsidered and looked at on an individual basis to preserve people’s dignity.
People spoken with were very positive about staff. Comments included, “they are very
kind”, “staff are lovely” and “they always look after me very well” but staff must ensure
that peoples’ dignity is maintained in all areas of care.
We saw that there had been some improvements in the care records. We saw that care
plans had been rewritten to make them more person centred. They recorded the name
people wanted to be known by and if they preferred male or female staff. Records seen
contained good details of a life history, in some cases written by the person themselves.
This is good practice and should be used to inform care plans. All records seen
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contained details about how people preferred to spend their time and their individual care
needs. People spoken with confirmed that they were able to get up and go to bed at
times to suit themselves. It was positive to see that people who were able to had been
asked to sign the care plan. This meant that they had agreed with the way that their care
was to be delivered.
People cannot be confident that robust risk assessments are in place to reduce risk and
keep people safe. This is because in the six care plans we viewed, we found that some
significant risks had been identified for people such as serious allergies, nutritional risks,
challenging behaviour, risk of falls, use of bed rails, visual problems, but there were no
care plans in place detailing the action required to be taken by staff to minimise risks for
people.
We viewed food and fluid records that were being maintained for some people but there
was no evidence that these records were being overseen by senior staff. This would
enable the person in charge to be aware when food or fluid intake was inadequate and
instruct staff accordingly. In the case of one individual, a record was being maintained of
food intake but there was no nutritional risk assessment or record of weight monitoring.
This meant that there was no obvious reason for staff to monitor the person’s intake.
We saw in the daily record for one person that they sometimes displayed challenging
behaviour towards staff. The care plan did not make any reference to this. Risk
assessments dated 30 August 2014, November 14, December 14, January and February
2015 had not been updated to reflect the risks of challenging behaviours. The care
record was not dated or signed so we were unable to determine when it had been
written. It did not contain any reference to the risk of challenging aggressive behaviour.
This meant that staff were not provided with advice and guidance on how to minimise
risks. We later saw a care plan evaluation form that stated the care plan had been
implemented on 30 August 2014.
We saw that one person had a diagnosed medical condition. This was referred to in the
care plan but there was no information about the condition on file. This meant that there
was no advice or guidance for staff on the symptoms of the person becoming unwell or
what to do if this occurred. There was no specific risk assessment relating to the medical
condition. This meant that staff may not be aware of the specific risks related to the
health condition and measures that could be taken to reduce risk where possible.
It was positive to see that the home’s pressure area policy was kept in each person’s
care records. This gave advice and guidance for staff on how to reduce the risk of
pressure/areas. However, we found that policy was not always being followed by staff.
We saw in the records we checked that a pressure sore risk assessment had been
undertaken, but this was an in-house document and did not include a professionally
recognised assessment tool for determining peoples’ risk of developing pressure
damage. Advice should be sought from the commissioning authority and/or the
community nursing service on the correct assessment tools to use.
The risk assessments we saw were not dated or signed so we were unable to determine
if they were up to date. We also saw that the document entitled ‘pressure area care’ did
not always correspond with the risk assessment. For example, in one care record
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checked, information that the person should always use a pressure relieving cushioned
when seated was not included in the care record. It also stated that the person should be
offered a change of position every two hours but there were no records to evidence this
took place during the day.
We saw on one person’s record that they had fallen on the 8 February 2015 and
sustained an injury. There was no evidence that the risk assessment relating to falls had
been reviewed and updated after this had happened. This meant that there was no
evidence that measures to reduce risk were considered or put into place.
The moving and handling risk assessment was inadequate and did not identify the
specific circumstances of each individual which might increase their risk of falls. In
addition, in the section for recording action taken to mitigate risks, it was recorded that all
staff had completed appropriate training. This is not sufficient to reduce people’s risk of
falls. The assessments need to be updated to reflect specific individual risks and what
action staff need to take to reduce the risks. The failure to identify and minimise risk is
further evidence of non compliance with Regulation 15(1) identified in the previous
inspection.
People cannot be confident that they will have sufficient stimulation and activities. This is
because, other than three people playing dominos in the afternoon of the second visit,
we did not see any other activities taking place. The majority of people in the main
lounge were seen to be asleep through the morning. The temperature in the lounges was
very hot which may have contributed to people sleeping. Consideration should be given
to providing appropriate activities to people in residential care, including those with
dementia.
We saw that books and magazines were freely available for people. Some people chose
to have a daily newspaper and told us they enjoyed this. We saw that televisions were
not on during the visit one lounge. One person told us that the TV is not put on until the
evening when staff choose what programme is on. They commented that sometimes
there was, “something good on in the afternoons”. There was no music playing in the
lounges so people were sat in silence. People told us that sometimes entertainers go into
the home and they enjoyed this. People also enjoyed going outside and using the garden
when the weather allowed. Some people spoken with told us that there weren’t any trips
organised to give them the opportunity to go out. People told us that ‘there’s not a lot
going on’ and one person said, “It’s a very long day with nothing to do”. People said they
would like more to occupy them in the day. We did not see people supported in daily
activities such as laying tables, folding napkins or clean clothes.
The home’s website tells people that it employs an activities coordinator and offers a
wide range of activities including the opportunity to go out on trips to ‘garden centres and
the seaside’. A senior member of staff told us that the home had not had an activities
coordinator since December 2014 and there were no immediate plans to employ one.
They said that activities were undertaken by care staff.
On the upstairs landing we saw a notice board. This contained information about care
home fees, newspaper cuttings and other information aimed at staff. Information
intended for staff should be kept separately from that for people who live at the home to
reflect that it is not a work place but the home of the people accommodated there.
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Quality Of Staffing
People cannot always be confident that they will receive care from staff who are well
trained and supervised. This was identified as an area of non compliance in the previous
inspection. During this inspection we looked at three staff files. We identified that the
induction programme for staff was not in line with the induction framework produced by
the Care Council for Wales. Staff files showed that the training undertaken by staff was
largely e-learning. Some staff told us they had completed this at home. During the
previous inspection, the registered person was required to develop an audit system to
enable them to determine the effectiveness of the e-learning and whether staff were
competent to carry out their roles. In the files we saw, an audit-style document had been
introduced since the previous inspection. However, this was very basic and would not
enable the registered person to determine that staff were competent or whether they
needed additional training. This is further evidence of non compliance with Regulation
18(1)(a) identified in the previous inspection.
The records showed that supervision of staff had not been conducted on an eight week
basis as required by regulations. There was no evidence that staff were supervised in the
day-to-day delivery of care. This would enable poor or inappropriate practices to be
identified and rectified and would also highlight training needs of staff.
We looked at the staff rotas for a three-week period during this inspection. Whilst the
manager’s name was on the staff on rota for two out of three weeks, there was no
evidence that the manager was actually working at the home as their shifts were not
recorded.
The manager was not in the home when we arrived, or when we telephoned the home
the day after the second inspection visit. The rotas did not record who was managing the
home in the manager’s absence. The manager should ensure that their shifts are
recorded on the rota.
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Quality Of Leadership and Management
People cannot be confident that there is a robust system in place for managing
complaints and concerns, or reviewing and improving the service. This is because
complaints or safeguarding records were not appropriately maintained. This means that it
is not possible to audit any issues raised to determine if there were any trends, or to
check if all complaints and safeguarding issues had been dealt with appropriately or for
the registered persons to know what action to take to improve the service. Issues looked
into under safeguarding procedures following the last inspection were not upheld.
However, improvements to the referral process will ensure that any future issues are
reported appropriately in a timely manner.
We asked the person in charge to provide us with written evidence of the measures in
place to look at and review the quality of the service. At the start of the visit we asked to
see management audits in relation to infection control, the environment, care records and
staff records. These were not provided.
We saw that an audit had taken place of medication practice. The audit tool used did not
record the names of Medication Administration Records (MAR) looked at. It did not cover
a check of returned medicines, controlled drugs, staff competency or a random check of
fridge temperature. The audit should be more detailed and record specific findings rather
than a generalised view. We have made a practice recommendation about this.
We asked to see the management audits of falls and the accident book. The home uses
an in-house document for recording falls. The information in the audit document was
incomplete. We saw that one person had fallen on the 8 February 2015 but this had not
been included in the monthly incident record. We also saw that one person had fallen on
11 January 2015 but this had been recorded as an incident instead of a fall. The record
included some falls but not all those that had occurred so we were unable to track the
true number of falls. In addition there was no evidence of any management over view,
evaluation or information about the number, nature or patterns to the falls and any
measures that had been considered to reduce risk. This meant that incidents were not
evaluated by the manager to see if measures could be put in place to reduce risk and
keep people safe.
We saw that records were kept of when wheelchairs were cleaned. However, there was
no evidence that there were regular mechanical checks on all wheelchairs to make sure
they were safe.
This is further evidence of non compliance with Regulation 10(1) identified in the
previous inspection.
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Quality Of The Environment
The home was generally clean, tidy and free from unpleasant odours on the day of the
visit. We looked around the home and viewed all communal areas and some bedrooms.
In people’s bedrooms we saw that blinds were fitted at the windows instead of curtains.
We discussed this with the manager who told us that curtains had been removed in case
people pulled them down. We saw no evidence in care records checked that this had
been discussed with people who live in the home. People living in the home should be
offered the opportunity to have curtains if there is no evidence of a risk to themselves or
the premises. We have made a practice recommendation about this.
We saw that bedroom doors did not have people’s names on and all looked the same.
People’s names were written on in very small type on the key box outside the room. One
person told us that, “it took ages for me to find my room, they all look the same”. The
home’s registration conditions allow up to six people who have dementia. Other people
living in the home may also have some problems with their memory. The lack of signage
means that people may be reliant on staff to find their way around. This does not enable
people to remain independent for as long as possible. We saw that there were small
signs on bathroom and toilet doors. Whilst this may be sufficient for more able people
this would not provide a visual prompt for people with dementia or memory problems.
Consideration should be given to current research on environments that promote
people’s independence for as long as possible. We have made a practice
recommendation about this.
People can be confident that there is a choice of communal areas in which they can
spend their time. It was positive to see that a range of furniture was provided that was
suitable for peoples’ needs. However, we saw that the conservatory off the main lounge
was not accessible as a chair had been placed in front of the doorway. We also saw that
a kitchen used as a dining room had a notice on ‘staff only’. This could be confusing for
people with dementia and should be reconsidered.
We saw that some areas of the home were cluttered and used to store items such as
pressure relief cushions and tablecloths. Consideration should be given to reducing the
clutter so the rooms look ‘cared for’. In one lounge we saw that photographs were
displayed of the manager’s family. Consideration should be given to whether this is
appropriate and in line with people’s wishes as it is their home.
We saw that there were wooden boards in between doorways. These were raised and
could be a potential trip hazard. We saw that a number of carpets were in poor condition
in doorways with carpets worn and frayed which also presented a trip hazard. This a not
compliant with Regulation 13(4)(a) which requires the registered person to ensure that all
parts of the home to which service users have access are so far as reasonably
practicable free from hazards to their safety. This was discussed with the owner during
the inspection and they gave assurances that the wooden boards and worn carpets were
going to be replaced in the weeks following the inspection. We have not issued a non
compliance notice in light of these assurances but we will continue to monitor this in
future visits to the home.
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People cannot be always be confident that measures are in place to prevent the risk of
healthcare acquired infections. Whilst the majority of toilets and bathrooms seen were
clean and tidy, we also saw that cloth towels were stored in communal bathrooms and
some bathrooms contained communal toiletries. Toiletries should be kept in people’s
own rooms and taken to the bathroom when needed for individual use only. We looked in
the upstairs bathroom /shower room. We saw that the bath and bath seat were dirty and
items of clothing were in the bathroom and a hairbrush. We saw that in en suites, cloth
towels were stored on top of the toilet cistern and on hand rails near the toilet. We also
saw that in some rooms toiletries were stored behind the toilet. This is inappropriate due
to the risk of ‘splash back’ of urine, faeces and cleaning products. We also saw that toilet
rolls were sometimes stored on the toilet cistern instead of being in a holder. No infection
control audits are carried out, so we were not able to check if these issues had been
identified by the manager. We have made a practice recommendation that infection
control practice needs to improve to keep people healthy and well.
People can be confident that they will have the opportunity to use the home’s garden
which was very well maintained and accessible for people using a wheelchair. People
spoken with told us they ‘loved the garden’ and enjoyed spending time outside when the
weather allowed. The manager told us that they were planning to extend the patio area
so more people could use it at the same time. This was very positive and showed that
thought had been given to making the most out of the garden so people could benefit
from being outdoors. When planning this work consideration should be given to how the
garden can be used safely and with minimum supervision by people who have dementia.
We saw that the front door had a notice on saying ’no resident is allowed out to get the
newspapers – for your own safety’. The door was locked but the key was in the door.
This approach is institutional and does not recognise the rights of people who are able to
go out alone safely to do so. We discussed this with the manager and advised this sign
should be removed. We also held discussions regarding the Deprivation of Liberty
Safeguards and advised that the manager should identify if applications for authorisation
were required for any of the people living in the home. We will continue to monitor this in
future visits to the home.
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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.
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. Focussed
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.
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