Inspection Report on
Priory Residential and Nursing Home
THE PRIORY NURSING & CONVALESCENT HOME LLANDOGO MONMOUTH NP25 4TP
Date of Publication
Friday, 6 March 2019 Welsh Government © Crown copyright 2019. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] You must reproduce our material accurately and not use it in a misleading context. Description of the service
The Priory Residential & Nursing Home is registered to provide nursing and personal care for up to 57 people aged 18 and over. The service is owned by Adriana Limited. The company has nominated an individual to represent the company. The appointed manager is registered with Social Care Wales.
Summary of our findings
1. Overall assessment
On the whole people told us they were happy with the care and support they received at The Priory. Opportunities to participate in activities are available to people however levels of social interaction and stimulation are variable. Improvements are required in the accuracy of personal plans and daily recording to evidence care and support being provided. Medication practises require strengthening. Infection control measures, hygienic practises and storage of equipment require improvement. Arrangements are in place to monitor and assess the quality of services. However recruitment practises require strengthening and improvements in the frequency of staff supervision, access to training, learning and development to support staff is required. A review of the services statement of purpose, service user guide, policies and procedures is recommended.
2. Improvements
This is the first inspection following re-registration with Care Inspectorate Wales under the Regulation and Inspection of Social Care (Wales) Act 2016.
3. Requirements and recommendations
Section five of this report sets out our recommendations to improve the service and the areas where the care home is not meeting legal requirements. This includes the following
Statement of Purpose and service user guide. Policies and procedures. Recording, handling, safe keeping, safe administration of medications. Staff recruitment, training and supervision. Personal plans and daily recording. Management of the risk of infection. Storage of unused equipment. Staff engagement and interaction. Policies and procedures.
1. Well-being
Summary
Generally, people we spoke with told us they are happy with the care and support provided by staff. However, improvements are required in the levels and consistency of staff interactions with people. There are opportunities to participate in activities however levels of social interaction and stimulation are variable for people.
Our findings
People we spoke with and their relatives during our visit were generally happy with the care and support provided by staff. Comments made included; “I like most staff and I like living here, generally it’s good” and “staff are great”. We received five completed questionnaires from people receiving a service and all but one stated staff were caring and they were treated with respect and courtesy. Questionnaires completed by relatives were also on the whole positive with comments such as; “very caring and professional” when asked about the attitude of staff, however other comments made included; “accept the level of work care staff are under but it would be good if they had more time just to sit and talk to residents” and “staff are very friendly and helpful even when they have been understaffed”.
During our visit we saw staff interactions with people were predominantly task orientated. People appeared to be spending long periods of time with limited interaction from staff. Staff did not always have the time to respond to people promptly and people’s attempts at communication were not always acknowledged. We observed some positive interactions, such as staff addressing people by their preferred names and making appropriate use of touch to help reassure them. We also observed good interactions when people received assistance with moving and transferring, whereby staff explained what they were doing and provided reassurance. On the other hand, there were occasions where there was limited interaction, and significant periods of time with no staff presence. For example, we heard a person calling out for help from their room on the floor above and we had to locate a member of staff to alert them. Additionally, we spoke with one person in their room midmorning who stated “I would just like to have a cup of tea and some breakfast, staff came in and said she would be back but she hasn’t”. Throughout our visit we saw that the main lounge was regularly left unattended and people appeared bored with several people sleeping.
Additionally, during the lunchtime period, we observed limited staff interaction with abler people as staff were busy delivering meals to people who remained in their rooms and assisting people who needed more support. One person was clearly agitated and anxious to leave the dining room and requested to leave several times, some staff were seen reassuring and persuading the person to remain in the dining area. However, other staff ignored the person and walked passed with no interaction, as the person’s agitation increased we observed negative impact on other people seated at the dining table. We were told by staff this was “normal behaviour” and staff wanted to actively encourage the person to engage in the dining experience in part due to concerns that the individual was at risk of malnutrition.
Feedback we obtained from staff suggested that whilst they generally considered there were enough staff, there were often challenges in arranging cover when people called in to report sickness absences at short notice. On the day of our visit we were told “I feel we could do with more care staff, today we are running one short” and another member of staff stated “some days we are short and can be two staff down”. We therefore find that whilst some people may be uplifted with staff interactions, we conclude that this may not be the case for everyone all of the time. Improvements are required to ensure people receive the right care at the right time in the way they want it.
Generally, people are provided with opportunities to participate in social and recreational activities. A programme of activities was in place, an enthusiastic activity co-ordinator was employed who demonstrated comprehensive knowledge of people receiving a service, their likes and dislikes and how to get people to actively engage. Activities included games, singing, quizzes, movie matinee’s, a recent visit from children attending the local nursery and we noted themed events had been scheduled for example a forthcoming ‘Robbie Burn’s night’. Relatives and visitors we spoke with were very complimentary about the activity co-ordinator “activities are varied and interesting and delivered with real enthusiasm”. However, in the co-ordinators absence people cannot rely on staff recognising when they were bored or lonely. We found there are opportunities for engagement in social and recreational activities, however the level of stimulation people receive is variable. 2. Care and Support
Summary
An electronic care documentation system is in use, however improvements are required in the development of personal plans and the accuracy of documentation to evidence person centred care and support being provided. On the whole people’s rights are understood and promoted however, improvements are required in the oversight. Medication practises require strengthening in order to safeguard people and prevent poor health and wellbeing outcomes. Staff encourage people to be as healthy and active as possible, and to eat healthy nutritional food however improvements are required in the recording and oversight of this to prevent poor health outcomes.
Our findings
People cannot be confident they will consistently receive appropriate person centred care. We viewed six people’s care documentation. We found inconsistent and contradictory information on the electronic care system. For example, information contained in people’s assessment of needs did not correspond with information contained in personal plans. We noted one person on respite care did not have any personal information recorded, an assessment had been completed but no corresponding personal plan was in place. Another person was assessed as “unable to move independently” and we found no associated pressure care or moving and transferring risk assessment for this person. Overall we noted a lack of comprehensive risk management information for care staff to follow. For example, people requiring assistance with mobilising did not have comprehensive guidance for staff to follow ensuring safe moving and transferring of people, as required in the services ‘Managing of the Environment, Moving and Handling’ policy and procedure.
Also daily recording kept within individual rooms we examined were inconsistent and contained regular gaps in the recording of care provided. We saw monthly reviews of assessed needs for each person were undertaken, however as mentioned above these were not transferred into personal plans. Care staff did not have access to comprehensive documentation providing clear guidance ensuring people receive appropriate care and support based on the persons’ wishes and preferences. Following our visit, we were provided with evidence of email communication with technical support to address issues with the updating of electronic care documentation. However, improvements are required in the care documentation system and the accuracy of documentation to evidence person centred care and support being provided to fully meet legal requirements.
There are some systems in place to ensure that people’s best interests are promoted. We saw where people lacked the mental capacity to make important decisions relating to their life, safeguards in accordance with the Mental Capacity Act 2005 had been actioned, as Deprivation of Liberty Safeguard (DoLS) authorisations had been requested and put in place. The home maintained a record of applications it had made, but did not have comprehensive oversight of expiration dates. We concluded that people’s rights are understood and promoted however, improvements are required to ensure expiry dates are noted and followed up.
People are not completely protected by systems in place for the handling of medicines. We spoke with one staff member who administered medication to people as part of their role and observed administration of medication during our visit. We examined a sample of Medication Administration Records (MAR). We also examined medication storage arrangements and noted the controlled drugs cabinet contained controlled drugs currently in use and medication to be destroyed. We also noted gaps in staff witness signatures in the controlled drugs book. We saw opened tubes of medication with no evidence of the date medication was opened potentially allowing medication to be used beyond recommended use by date. We were informed a new lead nurse had been appointed, additional storage equipment had been purchased and management had taken the decision to change pharmacy. We found that current medication practises require strengthening in order to safeguard residents and prevent poor health and wellbeing outcomes.
Staff encourage people to be as healthy and active as possible, and to eat healthy nutritional food. The home had been inspected by the Food Standards Agency and had been given a rating of 5 demonstrating the service was rated as very good. We observed lunch being served on the day of our visit. We noted people’s likes and dislikes, allergies and specialist diets were known by kitchen staff. We saw balanced and appetising meals being provided for lunch. However, improvements in the recording for fluid and food intake for those at risk of dehydration and malnutrition are required. For example, we saw daily recording of fluid intake was haphazard, did not have optimum amounts or consistent daily totalling of fluid intake to identify potential risks of dehydration or actions taken to encourage additional intake. Based on the above we concluded that improvements are required in the recording and oversight of people’s nutritional needs preventing poor health outcomes and to meet legal requirements. 3. Environment
Summary
People have access to pleasant and interesting outdoor space, sufficient internal space for people to socialise with others or spend time privately. To enhance people’s wellbeing improvements are required in relation to infection control, hygienic practises and storage of equipment.
Our findings
People’s well-being is not always enhanced by the environment they live in. We found the home was secure from any unwanted visitors, with systems in place to secure entry and exit. People told us friends and family could visit when they wished to, supporting people to have a sense of wellbeing. People had access to pleasant and interesting outdoor space, which is easily accessible. We toured the environment and, overall, considered there was sufficient space for people to socialise with others or spend time privately. However, we saw a number of items, for example the storage of unused equipment in corridors and general clutter which could pose a risk to people mobilising independently.
Additionally, we noted malodours in various sections of the home and on further investigation we saw used continence aids left in people’s rooms and continence aids had not been disposed of safely in communal bathrooms. We also saw one care staff supporting a resident along a corridor whilst also holding an open bag of dirty laundry. At the time of our visit we were told of maintenance being carried out in the laundry area however suitable precautions against cross contamination had not been taken ensuring clean and dirty routes in and out of laundry facilities were maintained. The above demonstrates improvements are required to prevent poor hygiene standards and infection control measures.
During our visit we examined fire safety documentation and found them to be comprehensive. Following our visit, we were provided with a selection of health and safety certificates which were not available during our visit and we found them to be up-to-date. However, on the day of our visit we saw a fire door being propped open, when brought to staff’s attention it was closed. We considered equipment maintenance, including both passenger lifts and saw that servicing certificates were in place. Overall, the home ensures equipment is relevant and safe; however further consideration could be given to storage arrangements for equipment not being used. 4. Leadership and Management
Summary
Arrangements are in place to monitor and assess the quality of services. However current recruitment practises require strengthening and improvements in the frequency of staff supervision, access to training, learning and development to support staff is required. A review of the services statement of purpose, service user guide, policies and procedures is recommended.
Our findings
People do not receive care from staff that are consistently recruited in accordance with legal requirements. The records of six members of staff were examined, we saw that some pre-employment checks were in place. However, we noted not all files contained copies of birth certificates to verify identity, unexplained gaps in employment and references were not consistently verified. Based on the above evidence people cannot be fully assured they are cared for by safely recruited staff, therefore current recruitment practises require strengthening in order to safeguard people and meet legal requirements.
Additionally, people cannot be assured that staff are appropriately supported and trained to deliver care and support. We saw evidence of some staff supervision however these were not always held at regular intervals as required. Staff should be provided with a one-to-one supervision every three months with their line manager, which is formally recorded. We saw staff completed ‘suggestion sheets’ which were left for their line manager who then responded via the electronic ‘Care Docs’ system for staff to review. One member of staff who started in March 2018 only had evidence of two supervision sessions, one in April 2018 and the other in January 2019. Another member of staff who started in August 2018 only had one recorded supervision in January 2019, we could find no evidence of previous supervision or induction records on file. A third member of staff who started in November 2017 had supervision in January 2018, April 2018 and January 2019. Gaps of six months and longer between formal supervision were regular amongst the staff team. Staff we spoke with during our visit said “supervision is every six months” and another staff member said “I didn’t have an induction when I started but I’m starting one now” but also stated “I feel supported in my role”. We also noted staff team meetings were not being held on a regular basis, we were told by the manager the last recorded meeting was held in July 2018. A member of staff spoken with during our visit confirmed “we don’t tend to have team meetings now, they used to be good to help with communication, if they started again I feel they would be helpful”.
Following our visit, we were also provided with a staff training matrix. We saw gaps in mandatory training including fire safety, safeguarding, Deprivation of Liberty Safeguard andMental Capacity Act training. We saw additional training was provided to meet specific needs of people however we saw significant numbers of staff had not attended several of these. For example, oral health care only 13% of staff had completed, dementia training only 53% of staff and person centred care only 53%. The manager discussed issues regarding gaps in staff training during our visit and outlined future plans to address this including the introduction of e-learning within the service, which he felt would address the current deficits. Based on the above evidence people cannot be assured they will always benefit from care delivered by people who are appropriately supported with training and supervision to conduct their role. Improvements in the frequency of staff supervision, access to training, learning and development to support staff is required to meet legal requirements.
The service has a quality of care review process which incorporates regular quality assurance procedures and takes account of the views of staff and people receiving a service. We were provided with evidence of monthly visits by the responsible individual and corresponding reports. We were also provided with copies of internal monthly monitoring reports for example, evidence and outcomes following accidents, infection control audits and staff sickness absence information. Arrangements are in place to monitor and assess the quality of services.
The service has a range of policies and procedures in place. We sampled three of the services policies and procedures including safeguarding, medication and moving and handling. We noted that the safeguarding policy and procedure was not aligned with current legislation and national guidance, for example no reference was made to Social Services and Wellbeing (Wales) Act 2014 and local safeguarding procedures. Guidance for staff was not specific to local referral pathways and contact details or the relevant Welsh regulatory bodies. Policies, procedures and practices should be reviewed and updated on a regular basis ensuring they are relevant and appropriate to the service. A review of policies and procedures is recommended with specific attention to safeguarding to meet legal requirements.
People using, working within or linked to the home can be mostly clear about the service provided. We examined the statement of purpose and service user guide provided at the time of our visit, which were also available in Welsh. We saw improvements are required to the information included, for example reference to appropriate Welsh regulatory bodies and legislation, clarity of roles and accountability in relation to the responsible individual and the services ability to provide “An Active Offer” in relation to the Welsh language. We identified that the service did not fully meet the legal requirements in relation to their statement of purpose and service user guide. 5. Improvements required and recommended following this inspection
5.1 Areas of non-compliance from previous inspections This is the first inspection following re-registration with Care Inspectorate Wales under the Regulation and Inspection of Social Care (Wales) Act 2016.
5.2 Recommendations for improvement
We found that the provider is not meeting its legal requirements in relation to:
Standards of care and support - The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Part 7 Regulation 21(1) We found that the service provider did not ensure that care and support is provided in a way which protects, promotes and maintains the safety and wellbeing of individuals. Improvements are required in risk assessments and corresponding management plans, and individual personal care plans. A non-compliance notice has not been issued on this occasion as we did not identify any major impact to residents and we were assured measures will be taken to address the issues identified and manage any potential risks.
Other requirements - The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Part 15 Regulation 59(1) We found that the service provider did not keep and maintain the records specified in Schedule 2 Part1(f) care provided, including daily records or records of specific care interventions. A non-compliance notice has not been issued on this occasion as we did not identify any major impact to residents and we were assured measures will be taken to address the issues identified and manage any potential risks.
Supplies, hygiene, health and safety and medication - The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Part 14 Regulation 58(1) We found that the service provider did not have arrangements in place to ensure that medicines are stored and administered safely. A non-compliance notice has not been issued on this occasion as we did not identify any major impact to residents and we were assured measures will be taken to address the issues identified and manage any potential risks.
Supplies, hygiene, health and safety and medication - The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Part 14 Regulation 56(2) We found that the service provider did not have arrangements in place for the control of infection and to minimise the spread of infection. A non-compliance notice has not been issued on this occasion as we did not identify any major impact to residents and we were assured measures will be taken to address the issues identified and manage any potential risks. Staffing - The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Part 10 Regulation 34(4) We found that the service provider did not have arrangements in place for the support and development of staff. A non- compliance notice has not been issued on this occasion as we did not identify any major impact to residents and we were assured measures will be taken to address the issues identified and manage any potential risks.
Staffing - The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Part 10 Regulation 35(2) (d) We found that the service provider did not have a rigorous selection and vetting system, full and satisfactory information as set out in Schedule 1 Part 1 was not available for all staff. A non-compliance notice has not been issued on this occasion as we did not identify any major impact to residents and we were assured measures will be taken to address the issues identified and manage any potential risks. Safeguarding - The Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017 – Part 8 Regulation 27(1) We found that the service provider did not have a policy and procedure aligned to current legislation, national guidance and local safeguarding procedures. A non-compliance notice has not been issued on this occasion as we did not identify any major impact to residents and we were assured measures will be taken to address the issues identified and manage any potential risks.
General requirements on service providers - The Regulated Services (Registration) (Wales) Regulations 2017 – Part 3 Regulation 7 We found that the statement of purpose requires updating to ensure accuracy of information and all legally required information is contained as detailed in Schedule 2. A non-compliance notice has not been issued on this occasion as we did not identify any major impact to residents.
We expect the service provider to take immediate action to rectify the above matters and these will be followed up at the next inspection.
We also recommended that: Consistent levels of staff engagement and interaction promoting positive wellbeing outcomes for all people receiving a service. Policies and procedures are reviewed and aligned with relevant current legislation, national guidance and regulatory bodies within Wales. 6. How we undertook this inspection
This was a full inspection which involved an unannounced visit to the home on 24 January 2019 between 8:00 am and 6:40 pm.
The following methods were used: Information gathered through conversation and discussions with residents, visiting relatives, manager and staff on duty. Observations of daily life, staff interactions and care practices at the home. Observations relating to the care home environment. Examination of six care and support files for people. Examination of six staff personnel records. Examination of staff training and supervision records. Examination of internal quality assurance information. Examination of external quality assurance feedback review form completed by a commissioning body. Examination of the home’s Statement of Purpose and Service User Guide. Examination of health and safety records. Short Observational Framework for Inspection (SOFI2). The SOFI 2 tool enables inspectors to observe and record care to help us understand the experience of people who cannot communicate. Examination of 17 questionnaires returned to CIW. Information held by CIW.
Further information about what we do can be found on our website: www.careinspectorate.wales About the service
Type of care provided Care Home Service
Service Provider Adriana Ltd
Manager The appointed manager is registered with Social Care Wales.
Registered maximum number of 57 places
Date of previous Care Inspectorate This is the first inspection following re- Wales inspection registration under the Regulation and Inspection of Social Care (Wales) Act 2016.
Dates of this Inspection visit(s) 24/01/2019
Operating Language of the service English
Does this service provide the Welsh This is a service working towards providing an Language active offer? ‘Active Offer’ of the Welsh language. We recommend that the service provider considers Welsh Government’s “More Than Just Words…. Follow-on Strategic Framework for Welsh Language Services in Health, Social services and Social care 2016-19”.
Additional Information:
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