Random inspection report
Care homes for older people
Name: Address: Tower Bridge Care Centre 1 Tower Bridge Road Tower Bridge Care Centre Southwark London SE1 4TR one star adequate service The quality rating for this care home is: The rating was made on: 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: Vashti Maharaj Date: 2 4 0 6 2 0 1 0 Information about the care home
Name of care home: Address: Tower Bridge Care Centre 1 Tower Bridge Road Tower Bridge Care Centre Southwark London SE1 4TR 02073946840 02073947198 towerbridge@schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Virginia Cheytan Type of registration: Number of places registered: Conditions of registration: Category(ies) : Southern Cross Healthcare Services Limited care home 128 Number of places (if applicable): Under 65 Over 65 0 0 128 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Conditions of registration: 128 128 0 The maximum number of service users who can be accommodated is: 128 The registered person may provide the following category of service only: Care Home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Mental Disorder Code MD
Care Homes for Older People Page 2 of 14 Date of last inspection Brief description of the care home Tower Bridge Care Centre is owned by Southern Cross Healthcare Group PLC and the manager confirmed that the certificate gives the correct details of ownership. Tower BCC is a large purpose-built home, with four floors, providing care for up to 128 older people, the majority of whom have single rooms with en-suite toilet and basin. As its name indicates, this home is just to the South of Tower Bridge, London, and so it is close to a wide range of services and facilities. The home provides care, including care for people with dementia to varying degrees on each floor so that on two floors nursing care is provided and on others floors care is at residential, non-nursing level. The Commission has recently reviewed the registration conditions to ensure they are within the correct legal framework and the revised conditions are listed in the preceding section of this report. There is ample communal space, lounge and dining rooms, on each floor and there is a small courtyard garden to the front of the premises; there is also car parking space in front of the building. The fees for the home range from GBP 503 to GBP 866 a week as at July 2009 and additional charges will be made for personal items and further charges will negotiated with the purchasing authority if the need for extra arises. Care Homes for Older People Page 3 of 14 What we found:
At the last key inspection in October 2009, we had concerns with the way the service was managing medicines as a number of issues were found which provided evidence that medicines are not always given as prescribed, and which may have affected the health of people at the home. We made a requirement in the report with a compliance date of December 2009. In February 2010, we received notification from the service that a resident had not received a medicine, an injection for cancer, for over 9 months. It had been prescribed whilst the person was in hospital, however it did not appear on the list of discharge medicines.There was reference to it in the discharge letter from the hospital, and staff had initially made a note in the GPs communication log requesting that it was prescribed, however the homes GP did not prescribe this, and staff at the service did not follow it up again, resulting in the person not receiving this medicine for 9 months until a relative of the person asked when the next injection was due. Not being given this medicine would have affected their health. We visited the service in February 2010 to check on this issue and on the previous medicines requirement. Some improvement was noted however issues found at this inspection included a prescribed medicine being unavailable for 2 and a half days, another prescribed medicine being used four times a day instead of three times a day, the quantities of medicines received into the home not being recorded on one unit, and incomplete records of insulin given by the community nurse so the medicines requirement was unmet. Due to staffing issues at the home, we allowed more time to meet the requirement and advised the home manager we would return to check on compliance. In April 2010 we carried out a random inspection visit to check on compliance with the medicines requirement. The inspection team consisted of a Regulation Inspector from the Regional Enforcement Team, and a Pharmacist Inspector. We looked at a sample of medication records and care plans on all four floors, and carried out some random auditing. The home manager confirmed that there were now no staffing issues, 2 deputy managers were in post, and additionally, team leaders had been recruited on all units. We found some issues both with medicines management and care planning that could have affected the safety and wellbeing of people at the home. Following the inspection in April 2010, we issued two statutory requirement notices on medicines management and care planning. Details of the issues are contained within these notices. On the 24th June 2010 we returned to the service to assess whether the statutory requirement notices had been met. This inspection was carried out over 1 day by two Regulation Inspectors and one Pharmacist Inspector and involved speaking with the homes management, one GP supporting the home, some staff and residents, a brief inspection of the premises, inspection of medication supplies and records, care plans and other records such as the GPs communication log.
Care Homes for Older People Page 4 of 14 We found evidence to show that the home has now met the notice with regards to medicines management. Although one person had run out of a prescribed medicine, there was evidence staff had requested the GP to review this person but it had not been done. We have therefore left a new requirement on the home to ensure that appropriate arrangements are made to ensure people receive treatment from health professionals in a timely manner. There was evidence that the notice on care plans may not been complied with, therefore we issued a Code B notice and seized copies of some care plans and certain pages of the GPs communication log, however on further discussion at a management review of the service after the inspection, we made the decision that there was evidence of sufficient improvement in this area, as well as other areas, so we will not be taking any further enforcement action, Instead we left a new requirement on ensuring care plans relating to medication are kept up to date, as all other care plans were satisfactory. At the start of the inspection we met with the home manager, who explained that he is currently working through action plans for improvement that have been given to the Commission and the local authority who are monitoring the home on a regular basis. The manager said that a monitoring officer attends the home two or three times each week and sends a brief report of the outcome of the visits. The home manager said that recent issues relating to the border agency visits, when ten staff were removed from working at the home, had been a difficult period and had affected staff morale. The manager said that the border agency are being provided with details of all current recruitment. The home manager said that the local authority had placed an embargo on placing any new residents in the home and that there are currently thirty three vacant placements as a result of this. The home manager told us about current quality assurance systems and showed us files of recent audits conducted on medication. One file contained weekly audits and another contained monthly audits. He advised that the supplying pharmacy had also visited to inspect arrangements and that a report of their findings is available. The provider has a quality assurance team and a member of the team had visited the home the day before to conduct an inspection. The report of the outcome of that visit is pending at the time of this inspection. The tabled results of a customer satisfaction survey conducted in the autumn of 2009 are displayed in the reception area, along with local newspapers clippings of recent celebrations in the home. We also looked at minutes from a recent friends and relatives meeting held at the home. The home manager updated us about changes in the management structure at the home. There are now two deputy managers and each unit, nursing and residential, also now has a head of unit. Both posts are supernumerary. One of the deputy managers is new in post and was promoted from within the team. There was evidence that recruitment procedures are more robust and that records presented confirm that relevant statutory authorities are consulted to clarify work status for all new employees.
Care Homes for Older People Page 5 of 14 The training matrix was supplied, it confirmed that staff training is ongoing and that opportunities are given to develop staff skills. We found that the environment was calm with fewer episodes of challenging behaviour than on previous visits. We began our inspection on the second floor of the home. The second floor provides nursing care. We found evidence that communication in relation to medical care is not as effective as it should be. Staff on duty said they use a hard backed book to communicate the names of residents who need to see the GP and a brief note as to why. A GP visits from a local surgery three times each week. When we visited we heard that the GP had not visited the day before, and several names had been written in the GPs communication book for the GP to review. No concerns were raised by staff about the GP not coming. We heard that the GP visits at various times and there is an inconsistency in the consultations. Examples were seen of how this has the potential to lead to lack of essential medical care to service users.Some entries in the GPs communication book were made four days earlier. Yet there were no signs such as names crossed off or ticked to confirm that consultation took place when the GP last visited the home. For one service user, an entry was made in the book some two weeks earlier to say that she had bruising on her legs and was referred to the GP to be seen on his visit.We found no evidence in the GPs communication book that the GP had examined her. We also examined her care file to check if she had been seen by the doctor. No information was recorded to confirm this. We later checked with the visiting GP to clarify if she had been seen. She confirmed that the service user had not been seen when requested, but that she would review her condition that day. There was no evidence that staff had carried out an investigation into the cause of the bruising or whether a safeguarding referral was needed. For a second resident, the GP communication book shows that staff also requested that the GP see people when they had observed unexplained bruises and skin tears. This method of communication does not appear to be effective as there is no evidence that these concerns had been followed up by the GP in a timely manner or the causes of the bruises investigated. For example, there is an entry that a resident had a bruise on her left hip and a swollen left leg on the 13th of June. This entry has not been crossed through to indicate that the GP has seen the resident. The GP visiting the home during our inspection confirmed that the resident was not seen on the GP round of the 13th of June but had been seen on the 17th of June. This is an unnecessary delay that could have health and safeguarding implications. We have left a requirement to ensure that consultations with health professionals are carried out in a timely manner. These examples show that not all staff are clear on when they must refer safeguarding issues such as when bruising is observed. We are not confident that staff despite training are fully competent at following up as appropriate so we have left a requirement in this area.
Care Homes for Older People Page 6 of 14 One resident had recently been reviewed by the local authority and the report says that they are satisfied with his care arrangements. He has a range of appropriate care plans and risk assessments in place and they had been reviewed each month. We saw that on the 26th May 2010 staff had made an entry in the GP communication book that this resident was confused, aggresive, very resisted. UTi BP 148/88, nose dripping clear fluid. We saw that on the 20th June 2010 staff had made an entry as the resident was running out of one of his medications and they were concerned that his blood pressure was 143 and he had a very low pulse rate. Staff had made another entry on the 23rd June 2010 that indicated that he had now run out of the medication again . We saw a risk assessment and care plan that said the resident is at high risk of a stroke if his blood pressure increases above 140 and that a GP should be contacted and that his blood pressure should be monitored and recorded regularly at weekly intervals. The risk assessment advises staff to look out for signs of raised blood pressure for example, headaches, dizziness, confusion and agitation. We asked staff on duty about this and they said that the GP puts a line through each entry in the book as it is dealt with and as there is no line through any of these entries that this indicated that the issues raised had not been addressed by the GP yet. Staff on duty also said that there are no fixed times for the routine GP visits and night staff sometimes facilitate the surgery. Staff said that the GP had visited the home on the 21st June 2010 but an expected visit on the 23rd June 2010 had not taken place. We also looked at a record called a professional visitors record where staff record the outcome of visits by health and social care professionals for each resident . This record shows that the the resident has not seen his GP since the 19th May 2010. Medication administration records confirmed that the resident had not received the medication for 3 days because there was no supply available. We asked to see the records of how the residents blood pressure is being monitored. There was a blood pressure record on his file but there were no entries on it. Staff on duty provided us with a hard backed book that they use to record blood pressure, weight and pulse rates. There were significant gaps in recording. We have left a requirement to ensure that actions required by risk assessment are followed through by regular monitoring of key areas of identified risk, such as raised blood pressure. We raised this with the home manager who looked at the records and requested that the staff on duty take immediate action to request the appropriate prescription and the medication was ordered. The home manager said he was not aware that the GP had missed a visit to the home on the 23rd June 2010 as he had not been on duty. He contacted the surgery and a GP attended the home that afternoon. The resident has a care plan around occasional challenging behaviour and staff said that at times some of the residents can be physically challenging. We asked what training they are given to enable them to breakaway from potentially aggressive situations. Staff said that they had not received any training about this and we therefore recommend that staff be given basic training in breakaway techniques as this will make it safer for the residents and the staff themselves.
Care Homes for Older People Page 7 of 14 On the first floor we met with one service user who has a feeding tube called a PEG to promote his nutrition. His care plan details the feeding and flushing regime that now takes place during waking hours. At the last inspection in May 2010, we found evidence that staff were interrupting his sleep by flushing the tube at 4 hourly intervals throughout the night instead of just during waking hours according to his care plan. The new arrangements support the service user to have a restful night. The service user told us that staff are good at supporting him to lead a meaningful life. He also said that all the activities related to this feeding regime take place during the waking hours and that he enjoys a good night rest. For two other service users on the first floor we case tracked the care arrangements. We found the care plans for both service users were up to date, and records concluded that regular reviews took place in house for both of these service users. The floor has GPs communication log where entries are made for service users who require a visit from the GP. Some of the entries were not ticked to confirm that consultation had taken place with the visiting GP in recent weeks. We checked with staff how communication with the visiting GP is facilitated. We asked the senior nurse how they communicate with the GP , in the event of the doctors book not used by the GP. She said that when there is a team leader this person speaks with the GP, but that the times of the doctors visit varies. It was noted on the file for one service user that there were concerns regarding her weight loss. This is closely monitored by staff with accurate records held. When changes took place and concerns raised this was responded to promptly recently and referred to the GP. Her name was placed in the book held for GP appointment. Food supplements were prescribed. This information is recorded clearly on the file for staff to view and to inform care planning. The records held were viewed, these record that regular observations take place of weight, blood pressure and pulse rate. RS had a recent statutory review. It was found that the home was making good provision in meeting this persons needs. We also case tracked care arrangements for another service user on the first floor. She has a care plan that reflects her current needs. The care plan demonstrated that it was reviewed regularly. On the book used to record the service users that the GP must see was a record for this service user to be examined by the doctor. There was no evidence on the book that the service user was seen by the GP recently when she sustained bruising to her legs. However records were maintained on the care file that confirmed the examination by the GP and the treatment prescribed. We discussed this with the nurse in charge the inconsistencies in the use of the GPs communication log, and the fact that it was unable to always confirm if consultation takes place. On this floor there is evidence to confirm that there is more effective communication between the GP and staff but the reliance on the book has the potential to mislead on essential GP consultations. We found that medicines were being stored safely, medicines records were up to date, and accurately reflected whether medicines have been taken, refused or destroyed, allergy information was up to date, the ordering system had improved, and only one
Care Homes for Older People Page 8 of 14 medicine was out of stock, so there was sufficient evidence the notice on medicines had been complied with. Some minor improvements are needed, for example on one unit, staff are not always recording the dose of medicines given when the GP has prescribed a range, 10 to 20mls or half to one tablet. Staff are also using a code for giving medicines M which means make available, this usually means that the medicine is unavailable however staff are using this code to indicate that creams have been given to carers to apply, which could cause confusion. One prescribed painkiller had also run out, staff have requested the GP to prescribe but this was done late so staff were going to give homely remedies if the person was in pain, however it would be safer to ensure all prescribed painkillers are reordered on time. One person is having essential medicines added to their food, which has been agreed with their GP and next of kin as being in their best interests. There is a care plan in place, more detail is needed for example what the medicine can be added to, who will supervise the administration and what to do if the food is refused. What the care home does well:
The home manager told us about the progress being made towards improving end of life care at the home and input from a hospice. They have registered to complete the Gold Standards Framework for end of life care, the accreditation programme starts in September 2010, with staff training scheduled for four members of staff. Along side these plans there is also input from a charity who are working with the residents to discuss their expectations of living their lives in care. Members of the charity are involved in drama and had presented a show for the residents to help raise discussion points. There is regular contact and input from other local resources. One resident attends a local day centre for people with a learning disability. An art therapist also visits the home and we saw a resident painting with the therapist in a dining room. We observed that a group of residents were being escorted to the front garden area as the weather was sunny. They were listening to music sitting in chairs under the shade of the trees. As we moved around the building we observed that there were no unpleasant odours and the building was well ventilated and clean. The temperature on the day of our visit was very high outside, but we found the environment was well ventilated and pleasant. Service users were provided and supported with an abundance of drinks. Dining rooms areas were prepared in advance and looked very enticing for service users. We met with four relatives on our visit. Three of the relatives were visiting the first floor service users. We received positive comments on the direction of the services delivered at the home, I feel more confident in the service, staff are kinder and gentle now, the home has changed for the better in the last six months, I visit regularly, I feel the home has moved forward and the place is a pleasant place to visit. We found that the activities programme in Tower Bridge Care Centre is varied and stimulating. We found that numerous external sources in addition to in house programme compliment the quality of life for people living in the home. The service has implemented daily checking of medication records. A Team Leader confirmed that this included stock audits to ensure medicines have been given as well as checking records have been completed accurately.
Care Homes for Older People Page 9 of 14 What they could do better: 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. Care Homes for Older People Page 10 of 14 Are there any outstanding requirements from the last inspection? Yes £ No R 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 Care Homes for Older People Page 11 of 14 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.
No. Standard Regulation Requirement Timescale for 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.
No. Standard Regulation Requirement Timescale for action 1 8 13 The registered person must 13/08/2010 ensure that unnecessary risks to the health and safety of service users are identified and where possible eliminated. In that actions required by risk assessment are followed through by regular monitoring of key areas of identified risk, such as raised blood pressure. To ensure the health needs of people are met and to ensure their safety. 2 8 12 The registered persons must 13/08/2010 ensure that the care home is conducted so as to make proper provision for the health and welfare, and where appropriate, treatment, of service users. In that there must be an effective system for arranging GP consultations in a timely manner. To ensure the health needs of people are met and to ensure their safety. Care Homes for Older People Page 12 of 14 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.
No. Standard Regulation Requirement Timescale for action 3 8 15 The registered person must ensure that service users care plans are kept under review, in that care plans related to health issues and medicines must be kept up to date. To ensure the health needs of people are met and to ensure their safety. 13/08/2010 4 30 18 The registered person must ensure that staff are aware of when issues need to be referred to safeguarding. To ensure the safety of people at the home. 13/08/2010 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 30 The registered person should arrange staff training in basic breakaway techniques so that they are better trained to safely manage incidents of aggressive challenging behaviour. The registered person should arrange refresher training for all staff on dealing with bruising and discolouration. 2 30 Care Homes for Older People Page 13 of 14 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 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 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 14 of 14 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
