Random inspection report

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Random inspection report

Care homes for older people

Name: Alexandra House Address: 143 High Street

Pensnett Brierley Hill West Midlands DY5 4EA

The quality rating for this care home is: zero star poor service The rating was made on: 21/01/2009

A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection.

This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report.

Lead inspector: Date:

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Information about the care home

Name of care home: Alexandra House

Address: 143 High Street

Pensnett Brierley Hill West Midlands DY5 4EA Telephone number: 01214343996 Fax number:

Email address: [email protected] Provider web address:

Name of registered provider(s): Mr Jayantilal James Bhikhabhai Patel

Name of registered manager (if applicable)

Type of registration: care home Number of places registered: 50

Conditions of registration:

Category(ies) : Number of places (if applicable): Under 65 Over 65

dementia 0 20

old age, not falling within any other

category 0 30

physical disability 10 0

Conditions of registration:

The maximum number of service users to be accommodated is 50.

The registered person may provide personal care with nursing, and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: - Old age not falling within any other category (OP 30) - Dementia over the age of 65 (DE (E) 20) - Physical Disability over the age of 50 (PD 10)

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Brief description of the care home

Alexandra House is an extended and converted house, which is registered to provide nursing care for 30 older people of which up to 10 beds may accommodate people requiring terminal illness care and 20 older people with dementia. The home is divided into two units: "Rose" accommodates persons requiring nursing care, including

palliative care and "Briony" which provides dementia care. The home also provides Accident and Emergency Diversion beds, Intermediate care and GP Respite beds when required. The home is situated on an easily accessible public transport route, is close to Merry Hill and Dudley shopping centres and other local shops and amenities. There is a car-parking facility to the side of the building and a garden, which is mainly laid with grass and secluded areas. The home also has a memory garden.

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What we found:

We, the Care Quality Commission, undertook this random inspection visit to monitor compliance with Statutory Regulation Notices issued to the registered persons, following the key inspection on 21 and 22 January 2009. The Statutory Regulation Notices related to failures to put in place care plans and risk assessments and failures to put in place safe systems for the use of bedrails, which meant that people living at the home could not be assured that their needs would be understood or met or that risks to their health safety and well being would be minimised. We also monitored compliance with requirements issued at the last inspection relating to the management and administration of

medication, where we had identified serious concerns.

The registered provider had informed the CSCI that the registered manager had resigned from her post and left the home the home on 19 February without working the period of notice. The new acting manager Mandy Coyne, the registered manager from another home within the organisation was transferred to Alexandra House Nursing Home on a permanent basis and had been in post for four weeks when we undertook this random inspection. The new acting manager was a Registered General Nurse with 27 years experience, she had been a registered manager for two years and five years experience as deputy manager. She holds RGN, RMA, City and Guilds Teaching Certificate in Further Education and Edexcel IT qualifications. An Operations Manager from the organisation was also present at this inspection.

We immediately noted that there was a much calmer and more relaxed environment at the home. We were told that there were 20 people accommodated, 12 people with

dementia on Briony Unit and 8 people on Rose Unit, including 3 people admitted into GP respite beds for short rehabilitation stays at the home. The acting manager had made commendable improvements in the short time she had been in post at the home. We noted that she had reorganised the staff teams so that they were allocated to work on specified units, which had created improved continuity and consistency for people living at the home. She had also introduced a named nurse and key worker system, which included the people admitted for short stays and appeared to be working well. There was a planned staff meeting held during the inspection visit and we spoke to a number of staff who told us that they liked the new way of working and felt less pressurised and spoke of the benefits to people living at the home. The acting manager acknowledged that it was 'early days, with lots more improvements to introduce'. She also told us that there were currently no admissions to the home's palliative care or accident/emergency diversion beds, which meant that there were few people with complex needs at the present time and felt the real test would be when new admissions resumed.

We monitored compliance with Statutory Regulation Notice Regulation 15(1), which stated, "the registered person, shall after consultation with the service users, or

representative, prepare a written plan how the person's needs in respect of their health and welfare are to be met". The registered persons were given until 31 March 2009 to "ensure that all people using the service have a written plan as to how their individual needs in respect of their health and welfare are to be met." The plans had also to be kept under review, with the person and amended to reflect any changes to their health and welfare.

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We looked at the care records of 3 people permanently accommodated at the home and care records of 2 people admitted for short respite stays, since the last inspection. We also looked at how people were supported and given assistance to meet their daily needs. The acting manager had introduced new comprehensive formats for pre-admission

assessments, healthcare screening tools, risk assessments and care plans and the

monthly evaluations. We noted that a considerable amount of work had been completed in just a few weeks and each person on Rose Unit had all of the new documentation in place, with good progress made on Briony unit to transfer the existing information into the new formats.

One of the people living on Rose Unit had comprehensive risk assessments and health screening tools all completed on 26/2/09, for example the moving and handling risk assessment indicated needed the assistance of 1 member of staff for supervision and referred to previous falls recorded, which was positive, it was also recorded this person preferred a shower. However some of the records such as the weight records, nutritional assessment and Waterlow score, were initially not accurate because the assessments had not included all areas of risk such as the skin condition, level of incontinence, poor

appetite, which meant that the risks would not be properly assessed or appropriate

control measures put in place to minimise the risks. It was positive to see that the acting manager had reviewed the care records, completing the care plan review sheet,

identifying areas which were not accurate and needed to be improved, and had allocated another RGN and on 31/3/09 the records had been accurately updated. We spoke to the nurse during the inspection and commended her thorough approach. We also noted the acting manager's proactive approach to monitoring the nurses competence and dealing with areas of weak practice.

We noted that new risk assessments relating to risks of choking at night, had been put in place following incident with sweet found in a person's mouth, after relatives brought sweets into the home. There was evidence that family had been involved and were in agreement with monitoring arrangements, which demonstrated good practice. This person had a new risk assessment and care plan following incidents of spilled drinks due to deterioration in physical health, with monitoring arrangements well documented which demonstrated good practice. There was also a risk assessment and care plan put in place on 3/4/09 related to the administration of prescribed Aspirin, following observations relating to bruising, which may have been attributable to aspirin. There were instructions for further observations and control measures to minimise bruising, which demonstrated good practice.

We noted on another person's weight records fluctuating weights for example 30/1/09 77.9 kg, 23/2/09 74 kg, 1/3/09 76.1 kg and 1/4/09 74.6 kg. We recommended that weight records should show that fluctuations in weight have been investigated, for

example whether the person was weighed at same time of day, on the same scales, and accuracy of the calibration of scales.

We looked at the care records for a person admitted to the home for rehabilitation

following surgery and noted that all required risk assessments, healthcare screening and care plans were in place and diligently completed. For example it was recorded that this person was unable to bathe or shower for two weeks postoperatively, and included instructions that 'Ted' socks in place were to be removed daily, that the person was mobile with crutches, and would like a walking frame in the bedroom. The exercise

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programme prescribed by the orthopaedic nurse specialist and occupation therapist was recorded and was being followed. This person also had care plans, additional medication and monitoring for postoperative nausea and oral thrush. This person had chosen to administer their own subcutaneous injections for 25 days post operatively and was being supported to do so by the nursing staff. This demonstrated that people were encouraged and supported to remain as independent as possible, which was very good practice.

Another person admitted for a respite stay had a pre-admission assessment recorded using the new format, which was very comprehensive and well completed. This included important details about the involvement of the community network of family, friends, and carers. The care records also included a, new sheet, identifying the type of admission and information about other agencies involved, such as social worker, district nurse. This meant that the person was clearly identified as "GP respite, short stay", which was a positive development and provided all staff with information about the reasons for this person's stay at the home. This person also had a comprehensive and clearly documented plan for discharge, including information to be passed to other agencies.

We concluded that there was satisfactory evidence of compliance with the Statutory Regulation Notice 15(1) relating to care planning.

The CQC Pharmacist Inspector undertook inspection of the control and management of medication within the service on 7th April 2009. We spoke with two members of staff. All feedback was given to the Acting Manager.

We were shown a new medication policy dated 6th April 2009, which had not been shown to staff at the time of the inspection. The manager informed us that all staff had signed a document to say they had seen a copy of the Royal Pharmaceutical Society of Great Britain guidance document on safe administration of medication in Care Homes. The service had also recently changed to a new pharmacy to obtain medication. A member of staff informed us that the new system appeared to be working well with no major

problems. This means that safe medication procedures were in the process of being implemented and agreed with staff to ensure that the residents were safeguarded. We saw that medication was stored neatly and tidily in locked medicine trolleys in each unit. The person in charge of the unit held the key. This means that it was easy to locate residents' medication and it was stored safely.

The treatment room downstairs felt very warm. Daily temperature records were available which documented that the temperature of the room varied between 24 -26 degrees C. Manufacturers recommend that medication should be stored below 25 degrees C and therefore medication was sometimes stored at higher temperatures which may cause deterioration. We saw that a window was open in order to allow some cool air into the room, however it was not secure and increased the risk of unauthorised access to the treatment room. Medication was also stored in Briony unit, however there were no

temperature records available for the room or for the refrigerator, which means that the service could not demonstrate that medication was stored within a safe temperature range.

The majority of the medicine records seen were documented with staff signatures to record that medication had been administered to a resident or a code was recorded to explain why medication had not been administered. We also saw records for the receipt

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and disposal of medication, which were double checked by two members of staff. We looked in detail at three residents medication records. We were able to follow an audit trail to ensure that medication was being administered safely and correctly. The records were clear and up to date which demonstrated that the service was recording and

documenting medication accurately.

Two residents care plans were looked at because they had been prescribed medication for behaviour control to be administered 'when required'. The medication records for both residents documented that the medication for behaviour control had been administered and a reason for giving it was recorded on the medication record charts. However, there was no protocol in place to inform staff under what circumstances the medication should be administered. We discussed this with the manager who agreed that a protocol should be available. This means that the residents' healthcare and medication care records were not always person specific and did not document a plan for staff to follow to ensure the well being of the residents.

We monitored compliance with Statutory Regulation Notice Regulation 13(4), which stated, the registered persons were required by 31 March 2009 to carry our risk

assessments for people living at the home, including risks associated with bedrails and bed bumpers, which are to be fitted to a person's bed, carry out comprehensive risk assessments for any activities, which may affect the person's health and safety, and put systems in place to ensure any unnecessary risks to people's health and safety are identified and so far as possible eliminated.

We toured the home to look at all the bedrails currently in place. There were two people on Briony Unit assessed as requiring bedrails fitted to their bed. We saw that both people had 'Third Party bedrails' in place, this meant they were not integral to the bed. We saw that they were extended to full length of bed, with a bar under the mattress, which was tight fitting and had limited movement. The acting manager had purchased new full length bedrail bumpers for all beds with bedrails in use. The first bed we observed had a high foam mattress in place and the measured height from uncompressed mattress to the top of the bedrails was 300mm, well within the 220 mm required and there were no

excessive gaps. The second bed we observed had a pressure relieving mattress in place and the measured height from the uncompressed mattress to the top of the bedrails was 280mm, well within the 220 mm required dimensions and there were no excessive gaps. There were integral bedrails on nursing profile beds on Rose Unit but they were only in use for one person. We observed this persons bed, which had full size bumpers in place and there were no excessive gaps of more than 60mm between the bed and mattress. The measured height from uncompressed mattress to top of bedrails was 300mm, well within the 220 mm dimension required.

We also looked at the revised and updated bedrails risk assessment on these persons care records, which accurately reflected the persons care needs and associated risks. We spoke to a care assistant, who accompanied us on the review of beds with bedrails. She confirmed that the acting manager, Mandy Coyne had delivered a training session relating to the use of bedrails for all staff two weeks prior to this random inspection visit. The member of staff was very knowledgeable about the use of bedrails, associated risks and control measures needed to minimise any risks of harm to the person requiring their use.

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The acting manager acknowledged that she had not recorded the training session. We recommended that all awareness and training sessions delivered 'in house' should be documented, together with staff signatures to demonstrate improved knowledge and skills have been provided for the benefit of the welfare and safety of people living at the home.

The acting manager held planned meeting with the handyman during this random inspection visit to discuss the responsibilities of the newly revised and updated job description. We witnessed her one to one session to raise awareness of this person's responsibilities, including a practical session to check that all bedrails that were currently in use at the home were fitted correctly, were within the permitted dimensions, were compatible with the mattresses, to ensure that there were no excessive gaps and that there were the correct size of bedrail bumpers in place.

We looked at the accident records and noted that there had been 29 recorded accidents between January 2009 and March 2009. We saw that the acting manager had introduced rigorous accident analysis, evaluation and control measures.

Prior to this random inspection we noted evidence that Regulation 37 Notifications had been made proactively to the Commission since February 2009. We assessed records at the home, which corresponded to the Accidents records and notifications. This

demonstrated good practice and compliance with the Requirement relation to Regulation 37 issued at the key inspection on 21 January 2009.

We concluded that there was satisfactory evidence of compliance with the Statutory Regulation Notice 13(4) relating to the assessment and management of risks, especially related to bedrails.

We looked at how complaints were being managed and noted the homes complaints procedure was in place and displayed, together with contact details of external agencies. We looked at the homes complaints log for any complaints received since the last

inspection. We noted that the acting manager had recorded details of complaint from a relative of a person living at the home and had conducted a thorough investigation and offered a resolution.

The acting manager had made appropriate safeguarding referrals as incidents have come to her notice and responded proactively, fully co operating with external agencies to allegations of abusive behaviour towards people living at the home, which were recently made at a training venue outside the home.

We also noted the acting manager's positive and prompt action to diligently monitor the performance of the Registered Nurses in relation to care planning, risk assessments and medication. In the short time, four weeks, since she was transferred to this home, she had commenced staff supervisions, performance appraisals and held staff meetings. We saw evidence that she was taking action to support staff and also deal with areas of weak practice. She had evaluated and reorganised the staff team, and care staff had been allocated to work on either Rose Unit or Briony Unit, improving the continuity and consistency of care for people living on those units.

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This random inspection was conducted with full co-operation of the recently appointed acting manager and operations manager. There was satisfactory evidence of compliance with two Statutory Regulation Notices issued following the last key inspection.

Considerable improvements had been made in a very short space of time, which was commendable.

The staff were friendly, caring and made efforts to communicate and offer assurances to people living at the home. For example staff were seen talking to people in a reassuring manner and at a level and pace that the person understood.

Considerable improvements had been made to the systems for administering medication to people living at the home, though a few additional improvements must be put in place to make the system as safe as possible.

The acting manager had made a proactive safeguarding referral to the Lead Agency, Dudley DACHS, and had co-operated fully with ongoing investigations, which means people feel assured they will be safeguarded from harm.

We spoke to two people staying temporarily at the home in GP respite beds, following surgery. They both told us they had enjoyed their stay at the home and had felt well care for and supported with their programmes for rehabilitation. One person told us her

mother had stayed at Alexandra House some years ago and so she felt she knew what she could expect, and she had not been disappointed. She told us that she had made a friend of the other person and they said they intended to keep in touch with each other when they returned to their own homes. This was a very positive outcome for them.

What they could do better:

The registered manager had resigned since the last inspection and though a new manager was recently appointed, an application for registration as the manager of the home must be submitted to the CQC Regional Registration Team as a priority.

The registered persons must make sure that the additional improvements required at this inspection visit for the administration of peoples medication are put in placed and that medication is stored at the correct temperature and everyone living at the home receives their medication as prescribed by their doctor, with safeguards in place to maintain their health and well being.

The registered persons must continue the improvements to ensure full compliance with requirements and recommendations issued at the key inspection in January 2009 and not assessed at this random inspection.

If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2.

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Are there any outstanding requirements from the last inspection?

Yes R _No £

Outstanding statutory requirements

These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.

No. _Standard _Regulation _Requirement _{Timescale for}

action

1 8 12 The registered persons must ensure that special care records such as food, fluid balance charts and turn charts are in place, with care provided appropriately

recorded and monitored. This is to ensure residents health and well being is maintained

02/03/2009

2 9 13 The registered persons must provide a written protocol for the administration of covert medication, which

incorporates NMC and Royal Pharmaceutical GB guidance and maintains records

reflecting the reasons why covert administration is

required, how the medicine is given, the persons

agreement, or evidence of an assessment in accordance with the Mental Capacity Act, with an Independent

Advocate as necessary to indicate decisions are made and reviewed in the persons best interests. Documented Pharmaceutical must also be obtained to demonstrate which medicines can be given covertly and in which food preparations. This is to

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Outstanding statutory requirements

These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards.

action

safeguard the health and well being of people living at the home.

This is to safeguard the health and well being of people living at the home. 3 33 24 The registered persons must

implement effective quality monitoring systems, which demonstrate that positive quality outcomes are

consistently achieved for all persons living at the home. This is to safeguard the health, well being and safety of people living at the home.

31/03/2009

4 36 12 The registered persons must implement a robust formal staff supervision system for staff support and

development to ensure that they have the knowledge, skills and training to met each persons individual needs.

This is to safeguard the health, well being and safety of people living at the home.

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Requirements and recommendations from this inspection:

Immediate requirements:

These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours.

action

Statutory requirements

These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.

action

1 8 13 The registered persons must make arrangements to

ensure that care plans include detailed information and instructions for staff in respect of the administration and management of

medicines, including the reasons to give medicines on an as and when basis and what constitutes 'needed' for the named person.

This is to safeguard the health and well being of people living at the home.

01/06/2009

2 9 13 The registered persons must make arrangements to

ensure that medication is stored securely and at the correct temperature

recommended by the manufacturer.

This is to safeguard the health and well being of people living at the home.

01/06/2009

3 31 9 An application must be

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Statutory requirements

These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set.

action

Registration of the manager within 3 months.

This to ensure the home is managed and run to assure the health well being and safety of the people living there.

Recommendations

These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.

No Refer to Standard Good Practice Recommendations

1 1 It is strongly recommended that the homes statement of purpose and service user guide include specific information about the diverse range of services offered and how the needs of people living permanently at the home will be met.

This was a previous good practice recommendation. Not assessed at this Random Inspection.

2 2 That each person living at the home is given an up to date, accurate contract of residence with details of their

individual fees and RNCC reimbursement where applicable, signed date and witnessed.

3 8 It was recommended that weight records should show that fluctuations in weight have been investigated, for example whether the person was weighed at same time of day, on the same scales, and accuracy of the calibration of scales. 4 15 That there should be daily menus produced in appropriate

formats, such as large print or pictorial, suitable for people with dementia or sensory impairments to assist their

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Recommendations

These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service.

No Refer to Standard Good Practice Recommendations

understanding and help them make realistic choices. This was a previous good practice recommendation. Not assessed at this Random Inspection.

5 15 There should always be an equitable choice of meal available. This was a previous good practice

recommendation. Not assessed at this Random Inspection. 6 20 That serious consideration be given to providing separate

facilities for people admitted for short stays or intermediate care, so that they do not intrude on people who live

permanently at the home, unless this is with their clear documented agreement and consent and is regularly reviewed.

7 20 That serious consideration be given to the internal

environments of each unit to provide more orientation and stimulation, especially for people with dementia and

sensory disabilities.

8 21 That the action is taken to undertake minor repairs to bathrooms and WCs , and bedrooms including securing wardrobes, which could pose health and safety risks to people living in the home.

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Reader Information

Document Purpose: Inspection Report

Author: Care Quality Commission Audience: General Public

Further copies from: 0870 240 7535 (telephone order line)

Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop

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