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Archived: Pitchill House Nursing Home

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All reports

Inspection report

Date of Inspection: 15 August 2011
Date of Publication: 19 October 2011
Inspection Report published 19 October 2011 PDF

There should be enough members of staff to keep people safe and meet their health and welfare needs (outcome 13)

Not met this standard

We checked that people who use this service

  • Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff.

How this check was done

Our judgement

The absence of a manager or deputy manager in the home means staff do not always have access to suitable guidance and support to carry out their duties.

User experience

In July 2011 a relative of a person living at Pitchill Nursing Home contacted us to share concerns about the absence of the manager and the inconsistent arrangements for relief managers. They said, ‘The staff seem to be doing their best but with nobody in charge or taking responsibility I feel that the residents are at risk. Already standards are dropping and I believe that it is only a matter of time before something serious happens.’

We observed that nursing staff spent time in discussion with visiting health professionals such as doctors and social workers as well as delivering nursing care, maintaining records and administering medicines.

We spent time talking to six people who used the service and one of their relatives. People were complimentary about the staff. They told us they were friendly and helpful. One person said they were ‘thankful for the companionship’ given by staff. The people we spoke with during our visit told us they did not have any concerns, they were satisfied with the service.

Other evidence

The local authority (Warwickshire County Council) told us they were concerned about the absence of an effective management structure. People were complaining that there was no one in charge they could bring their concerns to.

In July 2011 we contacted the area manager to check the management arrangements in the home. She told us the manager was absent pending an investigation onto concerns about the way the home was managed. We were told managers from other Southern Cross care homes in the area were providing a system of ‘relief’ cover in the absence of the manager.

However, the actual arrangements for relief managers only provided cover for two days a week.

We made an unannounced visit to Pitchill House on 15 August 2011 and we found there was no manager on duty.

Staff told us the relief managers were only in the home two days every week. For the rest of the week, management support consisted of telephone advice.

This meant that registered nurses had to undertake some management duties. Nursing staff were not allocated supernumerary time ‘off the floor’ to undertake these duties. Nursing staff told us they were always ‘rushed and busy’. One nurse commented, ‘It is very stressful dealing with the other things that go on while trying to look after my patients, although the relief managers are available by phone and respond quickly.’

When an adverse event occurred in the home, there was not often a manager present to deal with it. For example, a ‘whistleblower’ contacted us to tell us the home was without gas so hot water was limited. This was due to a faulty meter which should have alerted the (LPG) gas supplier to renew the tanks. This was resolved within 24 hours without any adverse impact on people using the service.

On another occasion the cooker broke down which affected the provision of cooked meals to people using the service.

At the time of our visit the cooker was operational and there was sufficient gas.

The local authority made us aware of several safeguarding referrals concerning medicine errors. On two occasions, these errors were made by a bank or agency nurse, not a regular, permanent staff member. The absence of a manger meant that clinical supervision was not taking place and agency staff were not routinely assessed for competence or given a brief induction.

Nursing staff told us the usual staff complement for the home was:-

- two nurses and eight care assistants on duty between 8am and 8pm

- two nurses and three care assistants OR one nurse and four care assistants on duty between 8pm and 8am

The nurses we spoke to told us the staff complement has been consistently maintained at these levels for the past few weeks. One nurse said, ‘It has improved since the relief managers have been supporting the home. We often worked short of staff previously. ’

We looked at staff duty rotas which showed the service was relying on the use of agency staff to make sure there are enough suitably qualified staff on duty. This means people using the service are not always cared for by staff who are familiar with their needs.

During this visit, we had a telephone discussion with Southern Cross’s service quality advisor who was providing cover for the annual leave of the area manager. She made a commitment to immediately arrange and sustain effective management cover Monday to Friday with on call provision at weekends. These arrangements were put in place before we completed our visit and confirmed in writing by email later the same day.