Inspection Report October 2018

ANNOUNCED VISIT

This is a report of an inspection to assess whether services are meeting the needs of the people who use them. There is provision within The Nursing Homes and Residential Homes (Guernsey) Law, 1976 and the Nursing Homes Ordinance, 1977 and the Residential Homes Ordinance 1977 that such inspections take place.

This was an announced inspection conducted as part of the annual inspection process to examine the care provided and to monitor the progress in relation to the requirements and recommendations, which were made on the previous announced inspection in March 2018.

NAME OF ESTABLISHMENT:

The Connaught

REGISTERED OWNER:

The Royal Connaught Residential Home Limited

REGISTERED CARE MANAGER:

Ms Elizabeth Bowskill (RGN)

CATEGORIES/NUMBER OF REGISTERED BEDS

CATEGORY

Residential 

NUMBER REGISTERED

25

Date of most recent inspection:

20/03/18 - Announced

Date upon which this report is based:

03/10/18

Type of Inspection

Announced

Registration and Inspection Officer

Vanessa Penney

This was an announced inspection to review the progress that has been made from recommendations on inspection in March 2018. The following areas were also examined as part of the announced inspection process;

• Is the service safe?
  
• Is the service effective?
  
• Is the service caring?
  
• Is the service responsive?
  
• Is the service well-led?
  

Progress from recommendations made in March 2018

• Replacement of some of the carpets due to staining - Replacement of downstairs hall and lounge carpets are commencing this month
• Laundry room requiring maintenance work and refurbishing - currently in progress
• Larger passenger lift to be installed when funds allow - in the business plan for extension to the home 2020/2021
• Ensure regular refresher training for all staff - see within main report

Method of inspection

1. Discussion with 5 residents + observation of residents who had difficulty with communication
   
2. 2. Walk through the home and garden area
   
3. 3. Observation of staff working and interacting with residents
   
4. 4. Examination of 4 care plans
   
5. 5. Discussion with Care Manager, Staff Trainer, Administrator, Senior Carer, Carer
   

Is The Service Safe?

The Connaught care home provides residential care for up to 25 people who require support/assistance with personal care and who have limited mobility. Although the home does not specialise in dementia care specifically, places are offered to people who require residential care and who have dementia care needs, which the care team are able to manage. This enables the person to remain in Alderney as this is the only residential care home on the island. The care home has a locked gate (keypad protected) so that it is secure for a person who likes to wander; however, the Care Manager said a person is supervised, or is discreetly observed by a member of staff, when they are out in the garden.

A walk through the home and out into the garden demonstrated that these areas are kept clean and tidy and are kept maintained. An Infection Control Specialist Nurse from within HSC undertook an infection control audit in April 2018. A score of 100% was achieved, which demonstrates that the team have a good understanding of infection control within a care home environment. The refurbishment of the laundry area and the replacement of some of the carpets should also help to maintain the score on the next inspection. An Environmental Health Officer undertook a food hygiene inspection in June 2018 and the home retained their 5 star rating, which is excellent. The catering staff have a food hygiene certificate at a minimum of level 2, which is current.

A solid level pathway around the outside of the home enables people to walk around the garden without coming to a dead end; no trip hazards were noted. Residents who were spoken to said that they felt safe living in the home and described the staff as kind and caring. Other residents who were not able to verbally communicate in this way due to dementia, appeared happy through the conversations that were had with them. When being approached or attended to by staff, they were observed to be relaxed and smiling and happy for carers to assist them.

Service checks and inspections for various pieces of equipment e.g. hoists, slings, lifts and electrically operated profile beds are carried out as recommended by the accredited supplier/contractor and staff have all of the equipment that they need to provide care for their residents and it is kept in good working order. There is a fire evacuation procedure in place and there is a copy of the fire evacuation procedure displayed on the back of each resident's door and in the entrance area of the home. Staff undertake training for fire safety and the fire alarm is tested each week and a log is maintained for this.

There is under floor heating throughout the home and the temperature of the water in residents' rooms has been restricted to 43 ̊C to prevent a resident from scalding him/herself with excessively hot water. The windows on the ground floor are the tilt and turn doors and above the ground floor the window opening has been restricted to prevent a person from being able to climb out. Both of these are regularly checked and a record is maintained for this.

Accidents/incidents are recorded in an accident/incident book; the Care Manager and the Senior Carers are aware of the need to report accidents/incidents to the department if a resident goes missing from the home, transfer to hospital for treatment (as the result of an accident/incident - also to the Health & Safety Executive under RIDDOR if necessary), or any other serious or untoward incident that should occur in the home. The Care Manager also undertakes an internal investigation so that this can be reflected on by the team and additional measures can be put in place as necessary to minimise a recurrence.

Safe recruitment practices are in place. Written references are sought for all new employees; one from the person's most recent employer. An enhanced police check (DBS) is also undertaken for care staff (basic police check for all other staff not involved with assisting a resident with personal care). A new employee undertakes induction and is supervised until the Staff Trainer and the Care Manager are satisfied that the person has developed the required level of knowledge and skill that is necessary to work with the residents without constant direct supervision. The period of supervision provided is flexible and depends on the person's current knowledge and prior experience.

Following induction, a new employee has a programme of training in place, which continues throughout their employment at the home and there is a Staff Trainer in the team who works at the Connaught 3 days per week. Almost all of the Carers are up-to-date with fire safety (updates due 2019/2020), first aid at work (update due 2020), moving & handling (refresher session organised for this month with an accredited trainer), infection control (update due 2019) and safeguarding vulnerable adults (update due 2019). It is recommended that staff who are not able to attend training on the day organised, due to lack of their availability at that time e.g. annual leave, sickness or night duty, should undertake the training via an alternative session so that everyone completes the necessary training for their role within the team. This could be either through a 1-1 with the Staff Trainer, or through e-learning from an accredited site. All staff undertook a 2-day training session for dementia care in 2017. The Care Manager and Staff Trainer are further supporting staff to undertake additional training for dementia care through Stirling University. The Staff Trainer has undertaken training to become a facilitator for the course and 4 Carers are currently undertaking this course. It is envisaged that as soon as these Carers have completed this course early on in the New Year, there will be a rolling programme for others to undertake the course, which is a good initiative.

The Care Manager is a VQ assessor and the Staff Trainer is a VQ candidate assessor. One Carer has a VQ award at level 3 with another 3 Carers currently undertaking this award. Four Carers are undertaking the B-tech level 3 diploma through the Institute of Health and Social Care Studies (IHSCS) from within HSC.

There is a policy and procedure in place for adult protection and for whistle-blowing. All new staff undertake training for safeguarding during their induction to enable them to understand abuse and to be able to identify potential or actual abuse and the reporting system to raise an alert. Carers who undertake the VQ or B-tech award undertake a unit for safeguarding within their course. The Care Manager and the Senior Carers are aware of the process for reporting an allegation of abuse to the Safeguard Lead and also to the Registration & Inspection Officer from within HSC and the Care Manager has done so previously where necessary. There is a complaints policy and procedure in place, which discusses how to make a complaint, who will manage the complaint and there is a timescale for a response to the complaint. The Care Manager said complaints are generally little 'niggles' that can be actioned immediately and ones that she would expect to receive within a group living environment.

Policies and procedures are in place for the safe administration of medication. Only the Carers who have completed the VQ unit at level 3 for the administration of medication, or who have completed training by the island Pharmacist administer medication to residents. The Care Manager undertakes an annual documented competency assessment for these Carers.

Each resident has a medication administration record (MAR), which displays the necessary information e.g. name, date of birth, GP and known allergies etc. All medication, which also includes controlled drugs, are stored, administered, recorded and disposed of following current regulations. Medication, which is no longer in use/required is returned to pharmacy. There is also a policy and procedure in place if a medication error is made. The Care Manager is aware of the need to report a medication error to the Registration and Inspection Officer should this occur and has done so previously.

The Deputy Chief Pharmacist from within HSC undertook a medication inspection in September 2018; recommendations made were actioned promptly. The Care Manager undertakes regular checks of the MARs (on monthly cycle changeover) to identify where further training may be required within the team and this training is provided by the Care Manager.

The staffing levels are satisfactory for the number of residents and their level of dependency. The Care Manager is supernumerary and works from 9-5 from Monday - Friday (flexible for the needs of the home and is on-call when not on duty). During the morning, afternoon and evening shifts there is 1 Senior Carer and 4 Carers on duty and overnight there is 1 Senior Carer and 1 Carer on duty. The Care Manager said these staffing levels are increased if dependency levels rise, or for outings where this may be necessary. A Senior Carer who was spoken to said she felt well supported by the Care Manager and was happy to discuss with her, any issues where she had concerns or where she thought improvements could be made for the benefit of the residents and staff.

On the day of inspection call bells that were heard to ring were answered promptly; an indication that there is sufficient staff on duty at this current time. Feedback from residents and from other healthcare professionals who visit the home periodically suggests that the staffing levels are about right for the needs of the current residents.

Is The Service Effective?

Prior to a person moving in to the home the Care Manager undertakes an assessment of the person's care needs. The information is collected either by visiting a person in hospital or a person may already be known to the team through respite care, sheltered accommodation at the adjoining facility Jubilee House, or through the island's home care service. The prospective resident and their NOK are encouraged to visit the home to have a look around and to speak to some of the people who live in the home and also to the staff, prior to making their final decision. A resident is admitted to the home for respite care if there is a vacant bed at the time of need. However, this has become increasingly difficult now that the Connaught is at full capacity with long term care residents and there is also a waiting list for long term care.

Each resident has a care plan, which has been developed from the information following the assessment and risks identified have been recorded. Both documents include reviews and monitoring for environmental risks, nutritional status (MUST tool), skin integrity (Braden score), cognition and physical ability and for the risk of falls (FRAT). There is also an element of the care plan completed, which is titled 'Things I can do for myself' and this gives a clear indication of what each person can manage to do independently. The team continue with the development of life stories for each resident, which are particularly beneficial for the people who have dementia and stimulate much discussion around things people remember and enjoyed. It was noted that there were some gaps within the care records where the review date had not been recorded. The Senior Carer said this was due to some resident's care plans currently being re-written. This was also brought to the Care Manager's attention for her to continue to monitor. All of the residents' care plans are stored in the staff office, which is kept locked when staff are not there.

During the inspection a Carer who was spoken to was undertaking an activity with a resident. The Carer appeared knowledgeable in relation to the person's communication needs and with knowing the person's preferences. Other residents around the home were observed to interact well with the care staff who were undertaking various activities with them; some in the garden as the weather was fine.

Healthcare professionals from within HSC also visit individual residents as needed, or the care team contact them via a telephone call to give support e.g. Dietician, Diabetic Nurse, Physiotherapist, Occupational Therapist, Social Worker, Speech and Language Therapist, Community Nurses and Palliative Care Nurses etc. Residents see their own GP, Dentist and Optician, so the Care Manager generally arranges appointments for individual residents in consultation with the resident's next of kin (NOK). Residents' and/or their NOK are kept informed of changes that are required with the resident's care and treatment and changes are made in agreement with the person or with their NOK (as needed). This was also confirmed in conversation with a resident. A Social Worker visits the Connaught regularly to undertake care reviews and to discuss referrals with the Care Manager.

Residents are supported to make the decisions that they are able to such as, what time a person would like to get up or go to bed, or whether the person likes to have a rest on their bed after lunch. Residents reported that they had a choice of foods at each meal time and were offered regular drinks and snacks throughout the day in between meals. Residents were able to choose how they spent their time during the day; some residents liked to undertake the activities offered at the home, which also includes outings within the wider community. Other residents were observed to be in their room either watching the television, reading or listening to the radio. Many activities are also provided to invite people from outside of the home to join in with activities with the residents, which is enjoyed by everyone.

Where people are not able to make decisions about their daily life and care, this is done by the staff in the person's best interest through the information collected from a person's NOK, GP or Social Worker.

Is The Service Caring?

Residents who were spoken to were very positive about the attitudes of staff and described staff as kind and helpful and said that they are treated with respect. Staff were observed to provide privacy when assisting a resident by closing the door to their room. When providing assistance to residents staff were heard to explain what they were going to do and waited for the resident to agree before continuing. Staff had time to sit and chat with residents at various times during the day and residents appeared to enjoy their company. One resident was observed to be undertaking an activity with a Carer. It was observed that the person had a very limited attention span and the Carer was observed to provide opportunity for the resident to sit quietly and then to continue when the resident wanted to do so. The resident remained relaxed and happy throughout the interaction.

A walk through the home demonstrated that residents are able to personalise their room to reflect their personalities and the rooms observed were bright and clean. Each resident's room had a number and their name outside, so that residents can identify their room more easily. There are no restrictions for visiting; however, the Care Manager would organise a restriction if requested by a resident or their NOK. This would then be communicated to all staff and would also be included in the person's care plan (has done so previously as necessary).

Residents were observed to be addressed by their chosen name and staff were observed to always knock on a resident's door and call 'hello' and wait for a reply before entering their room. Residents always appeared happy to see them.

Residents are encouraged to maintain as much independence as possible and there are various pieces of equipment around the home to support a person to do this, for example; height adjustable beds, passenger lift, appropriate height chairs and wet room/showers in en-suites etc. Additional equipment is also in place where necessary to help to minimise the risk of a fall e.g. pressure sensor mats.

There is an Activity Co-ordinator in the team and a minimum of 35 hours of activity provision is provided each week with support from the volunteer helpers. Activities offered are a combination of in-house activities such as arts and crafts, flower arranging, armchair yoga, singing and musical sessions and faith services. Social activities within the wider community include shopping trips, walks and attendance at community events. There are 2 small buses to take residents out for a drive and there is also access to the Age Concern minibus for residents who like to go to church on a Sunday and for transportation to meetings and for general excursions. An island drive is offered twice per week (subject to weather). Carers also undertake activities with individual residents as part of their daily routine e.g. pet therapy. Interestingly, the Connaught is twinned with a care home in Romania through the Milly's Foundation. Each home provides the other home with a newsletter with the activities and developments going on in the homes, which both the residents and staff enjoy reading and learning about the different cultures. A more recent addition to the activities for a person with dementia is a 'Tovertafel'. This provides interactive light projections for people with a cognitive challenge, but where they can have fun together with other residents, staff, family and friends.

Relatives have a good relationship with the Care Manager and her team. Relatives are able to speak to her or to the Senior Carer on duty in relation to their relative's care when they are visiting; they do not need to make an appointment unless they prefer to do so. Several relatives were observed to speak to the senior staff on the day of inspection and there appeared to be a very good relationship between the two.

Feedback in relation to the care in the home from within the wider community and from other healthcare professionals prior to the day of inspection was also complimentary. The team have also received letters and cards of thanks from relatives of former residents and residents who have stayed in the home for a period of respite, which are also very encouraging.

Is The Home Responsive?

People are assessed through the Needs Assessment Panel process prior to moving in to the home, unless the person is funding their placement privately. The Care Manager and the Senior Carer appeared knowledgeable in relation to peoples' care needs and the care plans were person-centred. If a concern arises in relation to a resident's care; for example an increase in the number of falls a person is having, a person is offered a transfer to a downstairs room to enable a higher level of supervision (when an appropriate room becomes available). The room is also set out as it was in their previous room to minimise confusion and upheaval for the resident.

Residents who require a higher level of care e.g. nutritional support were noted to have a food diary and fluid chart in place where needed and a resident is weighed frequently to monitor weight loss/gain, which is recorded. A turning chart is in place where a person requires regular repositioning when on bed rest to minimise tissue damage. Where a person can at times present with frustrating behaviour, a specific care plan is in place and where necessary a behavioural chart may be introduced. For a person who has diabetes, a recording of their blood sugar level is recorded (as directed by their GP or the Diabetes Specialist Nurse). This provides other healthcare professionals with the necessary information when they are requested to review the person's care needs.

Daily notes recorded enabled the staff to get a quick overview of any changes with a person's care or well-being, visits by other healthcare professionals and personal visitors and outings attended when having a handover on the changeover of each shift.

The team aim to provide care for a person until end of life with support from the Community Nurses from the Mignot Memorial Hospital (MMH) whenever possible. The Care Manager said the person is then able to remain in the place that has become their home where they know the people who are looking after them and have built up a relationship of trust with them and their relatives over the time that they have lived there. Specialist equipment can be brought in as necessary e.g. pressure relieving equipment to minimise the risk of skin pressure damage. Unfortunately this is not possible in all cases and where a person requires more frequent intervention by a registered nurse, the person may need to transfer to the MMH for this level of care. Prior to making a decision to transfer a person, a case meeting is held with the family, Care Manager, Social Worker, person's GP (where relevant) and the nurse from the MMH.

On admission in to the Connaught a resident and their NOK are provided with information for how to raise a concern. Details of the complaints procedure is documented within the policy. Residents who were spoken to had no issues to raise on this visit but knew who to speak to if wanting to raise a concern. Residents felt confident that the concern raised would be taken seriously and would be acted upon and they would be given feedback of the action taken and of the final outcome.

As previously discussed in this report some residents chose not to take part in activities, preferring to remain in their room. Some residents are also confined to their room due to the care they require or are on bed rest. So that these people do not become socially isolated, time is organised for the Activity Co-ordinator or the Carers to undertake a 1-1 with the person (as relevant). Carers were also noted to undertake frequent checks on the residents who liked to/needed to remain in their room and call bells were noted to be answered promptly.

Is The Home Well-led?

The Care Manager is a RGN (degree level) and has a diploma at level 7 in Strategic Management and Leadership. She is also a VQ assessor. Previously she has held positions as a Practice Nurse, Community Nurse, Safeguarding Adults Lead, Clinical Governance Nurse Manager and as a Nurse Manager for a drugs and alcohol service (UK local Trust). She has good experience of working with older people and undertakes regular refresher training with her team to maintain her knowledge and skills for caring for her client group. The Care Manager is supported by a Staff Trainer, Carers, Administrative Assistants, Housekeeping staff, Maintenance person, Catering staff and by the Board of Trustees. The Care Manager is visible around the home whenever she is on duty and meets residents, relatives, visitors and staff both formally and informally to discuss any issues. There is an organisational structure with clear lines of accountability and responsibility both at operational and provider level.

There are systems in place to support staff. All staff undertake induction (includes a staff hand book and contract) when they commence employment at the home. A person has a named supervisor who they work with in order to develop the necessary knowledge and skills that are required to work with the residents. Following successful completion of their induction this is signed off by their supervisor and the Care Manager. A person is then supported to undertake additional training throughout their employment at the home and an annual appraisal system and regular supervision is in place to monitor training and development.

The Care Manager has a meeting with the heads of departments (care, catering, housekeeping) every 6 weeks and the minutes of these meetings are documented. Approximately 1-2 weeks later a general staff meeting is held; minutes also recorded. The Care Manager also has a monthly meeting with the Board of Trustees to discuss developments in the home, finances and operational issues etc. The minutes of these meetings are also recorded.

Policies and procedures are in place for best practice guidance and all staff have access to these, which are updated 3-yearly; sooner if best practice/legislation directs this to be done.

Feedback as a result of inspections and audits by outside services/organisations (e.g. care standards, infection control, medication management, fire safety, food hygiene) is accepted constructively and prompt action is taken where a recommendation is made for best practice guidance (where able), or for further development. An annual survey is also undertaken with residents, relatives and carers. The survey looks at areas such as care, catering, laundry service and activities etc. The results provide guidance for the future of care and delivery of services in the home and also for budgeting purposes.

Registration & Inspection Officer's Comments

Royal Connaught is a residential home that provides care and support for up to 25 residents.

Residents who were spoken to were very complimentary in relation to the care and services offered at the Connaught and residents were observed to be treated with kindness and respect by staff who knew them well. There is a good programme of activities both within the home and within the wider community and residents said that they felt safe living in the home.

As discussed in the main report all staff must undertake regular training and updates for their role in the team, which may require a 1-1 or e-learning for a person who is unable to attend the training on the organised day, or at a specific time. The introduction of the dementia care training through Stirling University will further support staff in their approach to dementia care, which is excellent.

A regular care plan audit would help to identify gaps in the recordkeeping process and provide guidance where further action is required. It is acknowledged that the care plan documentation (including risk assessments) was undergoing a review at the time of inspection, however, during this period all areas of the care plan documentation should contain an up-to-date review date so that the staff know that the person's care needs are current.

There is a robust recruitment process in place, which is followed by a programme of induction and an annual appraisal is in place. Ongoing supervision throughout the person's employment at the home is monitored by the Care Manager and the Staff Trainer.

New website live October 2018 - www.connaughtcare.org

Vanessa Penney

Registration & Inspection Officer