Inspection on 25/04/06 for Apple Court Care Home

This inspection was carried out on 25th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Apple Court Care Home 03/10/06

Apple Court Care Home 22/12/05

Apple Court Care Home 29/07/05

Apple Court Care Home 16/12/04

Apple Court Care Home 21/05/04

Apple Court Care Home 13/02/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Apple Court Care Home Apple Court Mental Nursing Home 76 Church Street Warrington Cheshire WA1 2TH Lead Inspector Anthony Cliffe Key Unannounced Inspection 09:00 25 and 26th April 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Apple Court Care Home Address Apple Court Mental Nursing Home 76 Church Street Warrington Cheshire WA1 2TH 01925 240245 01925 240123 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hallmark Healthcare (Warrington) Limited Mr Ian Smallwood Care Home 67 Category(ies) of Dementia - over 65 years of age (67), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1) Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 67 service users to include: * Up to 67 service users in the category of DE (E) (dementia over the age of 65). * Up to 1 named service user may be MD (E) (mental disorder over the age of 65). Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection. The registered provider, must at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 2. 3. Date of last inspection 22nd December 2005 Brief Description of the Service: Apple Court is a 67-bedded care home providing nursing and personal care to older people diagnosed with dementia and is operated by Hallmark Healthcare. The home is located in Warrington town centre and is on a main bus route and close to all local amenities and facilities. The home is a purpose built twostorey building. Each floor has two living areas that have been combined to provide one larger living group and facilitate the support of a larger group of staff, with a minimum of two registered nurses on duty at any one time. Each floor has two lounges, two dining rooms and recreational areas. Each resident has their own single bedroom with en-suite facilities. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two regulatory inspectors undertook this unannounced site visit. The Key inspection was triggered by two complaints and two adult protection referrals, which were referred under the local authority adult protection procedures. The Commission for Social Care Inspection (CSCI) met with representatives of Hallmark Healthcare In February 2006 where the company made a commitment to work on an improvement agenda at Apple Court. Despite this serious concerns have been raised with the CSCI. The site visit took place over 17 hours. Feedback was given to the manager, peripatetic support nurse manager and Operational Director for Hallmark Healthcare. Records were inspected and staff practice was observed. Discussion took place with residents, visitors, visiting healthcare professional and staff. A tour of the premises was undertaken. Information was collected form the local authority, Hallmark Healthcare and people who wrote to the CSCI. Two requirements remained outstanding from the last site visit on 22nd December 2005. What the service does well: What has improved since the last inspection? A new fulltime manager was appointed in January 2006. Management and administration of medication has improved. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 6 Moving and handling procedures have improved to ensure that residents’ health is promoted. The quality assurance system has improved incorporate the auditing of care plans and medicines to provide feedback to staff on the relevant standards. The presentation of meals and choices available has improved so that residents are now served a meal in an appropriate manner. The maintenance of portable electric appliances has improved to ensure that residents and staff are protected from injury. What they could do better: The manager needs to ensure that Apple Court is managed in a manner that promotes the health and welfare of residents. The manager needs to ensure the management team work as a cohesive unit and communicate effectively with one another. This includes conducting supervision with the two clinical managers who in turn need to supervise the staff team. The management of Crossfields/Rylands units needs to improve so residents’ mental health is not at risk from poor management decisions and poor liaison with professionals. The use of physical intervention should be understood. Staff need training in communicating with residents to support them in making choices in their lifestyle and in meeting their personal, health and social needs. This will ensure they have control over their lives and are treated with dignity and respect. Care plans need further development to ensure that they identify all residents assessed needs including personal, health and social care needs. The management and use of physical intervention needs to be made clear, and in line with the statement of purpose and philosophy of care in the home so residents are protected from harm. Complaints need to be appropriately acted on so residents and relatives will be confident that their concerns are treated seriously. The activities coordinator needs more training on providing suitable activities for residents, and assessing residents’ suitability for activities. An activities programme should be based on residents’ preferences and expectations. The choice of meals should be available to residents so that they or their relatives can make choices. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 7 The quality assurance system in Apple Court needs to improve to identify the priorities to improve the management of the four units, care practice, standards of recording and management of residents’ monies so Apple Court is managed in the best interests of residents. The maintenance and safety of residents and staff needs to improve with fixed hoists verified as serviced. The ground floor sluice room should be kept locked and staff trained in fire safety so residents’ safety is maintained. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available for residents and their representatives but the statement of purpose should include Hallmark’s commitment to equality and diversity and reflect the change in management. Residents’ needs are assessed prior to moving in. EVIDENCE: In discussion with the manager and peripatetic home support manager about equality and diversity, it was agreed that the statement of purpose should reflect Hallmark’s commitment to equality and diversity and to reflect the change in management. Apple Court accommodates residents from Warrington and does not currently accommodate residents from a different ethnic or religious background. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 10 In November 2006 the local authority suspended placements. This suspension was lifted in April 2006. A resident had moved into Apple Court at the time of the visit and had a needs assessment completed. A copy of the local authority assessment of need was obtained prior to the resident moving in. Several care plans had been completed to meet the resident’s needs. The clinical manager who completed the assessment discussed the resident’s needs and identified she was independent needing prompting and support. For two other residents needs assessments were in place at the point of moving in. See recommendation 1. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to the service. Residents’ plans do not ensure that health and social care needs are identified and met. Residents’ mental health is at risk from poor management decisions and not liaising with professionals. The management of physical intervention is unclear and staff are unsure what constitutes restraint therefore both residents and staff are at risk of being harmed. Medicine administration is safe and residents receive their prescribed medicines. Residents are not treated with dignity and respect. EVIDENCE: Several care plans showed that a wide range of assessment documents were completed; with a care plan to address residents’ identified needs. From looking at care plans, observing staff working practices and talking with residents, staff and visitors the health needs of residents were generally met. There were several examples of poor practice regarding the care of residents and recording of personal, social and health care. Several care plans had been completed to meet the needs of a resident who had recently moved in. The clinical manager who completed the assessment discussed her needs and identified she was independent with prompting and support. The care plans were written to reflect the interpersonal skills staff needed to use in promoting independence and stated positive values on offering the resident choices and Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 12 recorded choices about personal care and meals. A care plan for moving and handling highlighted the use of bed rails, as the resident was unsteady and walked with an aid. However the pre admission assessment did not highlight that the resident had a history of falling out of bed. In discussion with the nurse in charge she clarified that bed rails were not being used, as these were not required. The clinical manager who completed the pre admission assessment and care plans for the resident said ‘ she will require a pressure mat at night to alert staff when she gets out of bed to look for the toilet. She will remain continent and safe with this’. A pressure mat was not in place on the night the resident moved in. The pre admission assessment identified the resident wore dentures and had chiropody every six weeks. In discussion with the resident she said she liked her hair done weekly. These aspects of personal care were not addressed within the care plan. A resident who attempted to urinate in a lounge when no other residents were present, dribbled urine on his clothes. Help was summoned and staff informed. The resident’s care plan for continence stated that he wore an incontinence pad but non was apparent. The resident was unshaven and not wearing shoes. In the afternoon the resident remained unshaven, wore the same clothes and was wearing shoes. The resident’s care plan for personal care stated the resident was ‘to be offered a bath once a week’. The ‘carer’ diaries used to record personal care noted the resident had not had a bath or shave for nine days. A senior carer said ‘ he can be aggressive and difficult to manage. He has definitely had a shave, the records have not been filled in’. Daily records for a month did not record if the resident had had a bath or a daily wash. The nurse in charge said ‘he settles after 6pm and you can bath him and shave him’. This information was not recorded in the resident’s care plan. A care plan to manage his aggressive behaviour was written with an emphasis on the necessary interpersonal skills needed by staff when engaging the resident. No details were recorded on how staff should manage the behaviour or the triggers to aggressive behaviour. In discussion with the nurse in charge about who decides routines for personal care he alleged that staff did not use their initiative and said ‘I decide the routines for residents if they cannot. I decide if they need a bath or a shower if I dont have this information then the carers should decide this as they see if someone is dirty or needs a shave. Some staff you dont need to tell them what needs doing, others you have to ask as they dont like work’. All the residents on the ground floor are well presented appearing clean, well dressed and there are no malodours. A nurse assessor from NHS funded care team was visiting. She advised that she had two roles, one for free nursing care assessment and the other as a liaison nurse with direct access to the psychiatric team. She spoke well of Apple Court saying care plans and assessments were generally satisfactory and there were good working relationships with the staff. When recommendations were made there is evidence that they were put into practice. An example of this being advice was given regarding one resident on the disguising of Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 13 medicines and this was put into practice. The arrangements needed to be confirmed in the care plan. Staff were observed in the moving and handling of residents. Whilst they used the correct techniques and equipment they did not always explain to residents what they were doing. This was brought to the attention of a clinical manager and in the afternoon staff were observed explaining procedures to residents. One staff member took the lead and asked a resident if he wanted assistance and then explained exactly what was happening. He evidently enjoyed the interaction and was able to assist them with the manoeuvre, which appeared smoother and safer. The resident’s care plan for moving and handling was positively written and described the arrangements for mobilising him. However it did not refer to communicating with him. The nurse assessor confirmed she had visited in response to a letter from a resident’s General Practitioner about the increase of unmanageable aggressive behaviour where staff were having difficulty in managing him. The clinical manager on the ground floor said ‘his behaviours are unpredictable and unmanageable. Residents are at risk because he is indiscriminate in his attacks. He is a strong man and he will lash out, he has hit residents in the past and they are at risk of harm. The nurse assessor asked the clinical manager to clarify why the resident was unmanageable and the difficulties staff were experiencing in managing his aggressive behaviour. She replied ‘we don’t know what to do, we have tried everything, medication reviews, different strategies we cannot manage him and assure the safety of other residents’. Because staff have not had training in the management of violence and aggression or breakaway techniques and they are also at risk of harm. In discussion about the resident’s deteriorating mental health the unit manager confirmed she had not requested professional support for a month during which he resident’s mental health had deteriorated and she had not contacted the resident’s social worker to request a review but relied on the nurse assessor to do this. She confirmed she had not correctly recorded a serious incident when the resident attempted to attack a visitor and other residents and had to use restraint. The use of restraint was not recorded and the clinical manager denied restraint was used and later clarified restraint was used but not recorded as such. She said “it is done but not recorded, nurses can’t win, one nurse was suspended for restraint. Terms such as ‘moved’ or ‘escorted’ were recorded and clarified as meaning restraint was used. Staff members interviewed clarified they saw the resident being ‘held by his arms’ with a staff member standing at either side’. Another staff member said ‘we don’t use restraint’. The incident was not reported to the Commission for Social Care Inspection. Another resident did not have a pressure mat in place as identified in a risk assessment written in November 2005. The resident had fallen in February 2006 and received a head injury. The pressure mat was used as a control measure as the resident was identified as at risk of falling when she gets up in the nighttime. The clinical manager was present when the resident’s bedroom was looked at and concern was raised about the lack of a pressure mat on 25th Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 14 April 2006. The bedroom was again checked on 26th April and no pressure mat was in place. Medicine receipt, storage and administration were examined on both floors of Apple Court. Only one minor error was found. See requirements 1 to 6 and recommendation 2. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is assessed as adequate. This judgement has been made using available evidence including a visit to this service. Residents are not supported in making choices in their lifestyle and in meeting their social needs so do not have control over their lives. Residents do not have a range of meaningful activities to promote choice. Residents have a choice of meals in pleasing surroundings but choice and provision of meals needs to improve so residents can make decisions about their preferences. EVIDENCE: The atmosphere in Apple Court was quiet and relaxed. Music playing was designed to relax and sooth residents. There is little evidence of any stimulating activity other than the normal rhythms of the day even when the activities co-ordinator is engaged with residents. Staff could not say what activities were available because the activities programme is not followed as residents are said to respond better to ad-hoc activities. The activities programme was only displayed on the first floor. The activities co-ordinator was seen speaking to individual residents and a visiting relative said ‘there was always something to do and the activities co-ordinator is very nice’. The activities coordinator said that she used to be assisted by a second activities co-ordinator but she has now left. She said she understood that the vacant post is to be filled. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 16 Although there is an activities schedule the activities coordinator said she did not follow this. She said residents respond better to being asked what they would like to do, e.g. board games, dominoes, soft ball, parachute exercise or just a chat. She said that she has not had any training to fulfil her current job and has been in post since November 2004. Activities records are kept but do not make sense or provide any useful information for analysis and review. For example one resident’s activity record last recorded her participation on 28th March 2006. There was no indication what this activity was. The activities coordinator could not clarify the information as she does not follow the set programme or complete the activities sheets. The tick list used indicated the resident refused to join in the activity but could recall without prompting, responded spontaneously, actively participated when prompted and enjoyed the majority of the session. The activities coordinator could not explain the purpose of the recording. Activity records for four other residents were just as obscure. A nurse in charge said the problem with activities is that she is only here four hours a day between 12 and 4. We need more staff to stimulate residents to do things, as the care staff don’t always have time to do so. They are keen, but no time. Visitors and family carers were spoken with. One visitor said ‘ I visit every day and spends 4-5 hours in the home, staff make me feel welcome. Mum is well cared for they meet her every need. Mum is very picky with food but staff encourage her to eat her meals. There are always activities on including dominoes and board games. The activities co-ordinator is very nice. Mum’s an early bird she has lived here for a number of years and gets up early each day. She enjoys the garden. My sister works upstairs. Staff are fantastic and very well trained they know residents very well. I don’t know if there is a contract or terms and conditions my other sister deals with that. Mum’s care is reviewed on a regular basis. We had a meeting with the social worker. Mum is doing well she has lived at the home for seven years and is well. Mum is happy in the home and staff are familiar with her needs and routines’. Another relative said mum has been at Apple court for eighteen months. We moved here from Surrey. In the previous home she was pushed over and had a fall, fractured both her hips and her wrist. The care she receives here is excellent. We dont have any concerns or worries. The staff team are very caring and lovely. K and the staff do a very good job. The standard of care on this floor is very good. At the recent relatives meeting those who raised complaints were relatives of residents on the ground floor. I am always welcomed. I feel very comforatable here. Staff always keep me informed of how mum is. Mum is not mobile but spends time in the lounge with other residents. A care plan to record a resident’s social preferences was positively written to ascertain the resident’s wishes and offer choice in recreational and social activities. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 17 Not all residents spoken to with could respond coherently but were relaxed and at ease. The atmosphere was very relaxed with music is playing. The clinical manager said that this would not be the residents’ choice because it is relatively modern but they like it and it has a relaxing affect on them. Later in the day older style music was playing and residents appeared more stimulated by this as some were moving in rhythm to it. Choices about personal care were recorded in care plans and the ‘offer of a weekly bath or shower’ was the standard of choice recorded. A qualified nurse said if a resident was obviously in need of a bath on a daily basis they could have one but staff made decisions about personal care. On Daresbury and Grosvenor unit residents wore bibs at lunchtime including a resident identified as being able to eat independently. When asked about this practice the nurse in charge said ‘ staff decide this, it is not a choice of the resident’. A new resident said she liked to be involved in decision making and said ‘I moved here yesterday. I arrived last evening and had a good tea and a nights sleep. I have a large bedroom with my own toilet. My son visited last night. he decided I had to move here as at the other place I was supposed to be shouting too much. I liked living there and I will have to get used to living here. It seems very nice and I have met all the staff. That girl is P. Staff have showed me where the toilet is when I asked. I can find my way around with their help. I will tell them how I like to be cared for and they will have to learn very quickly. I like to be involved in my care. I like to be called by my first name and if they dont I will tell them. I used to bake and would be interested in doing some even at 95. I dont go out much but still have an active mind and like to keep it that way. Staff record the choice of meals on white boards. Lunch was roast chicken or sausages with mashed potatoes and vegetables. No one had chosen sausages. The chef was serving meals and said there is no routine for informing her if residents wished an alternative other than when the resident moves to Apple Court, when she is told about their likes and dislikes. She said unless staff come and tell me a resident wanted sausages then I will cook them. Today I have cooked only chicken. They dont tell me daily what people want. Out of 57 residents none had chosen sausages. A senior care assistant said we know what residents like or dont. Most prefer chicken. If liver is on they like that. We dont routinely ask every day as not everyone will remember. On 26th April the choice of meal was recorded as beef stew and dumplings or chicken nuggets, carrots, peas and creamed potatoes. The choice recorded on the ground floor units was only beef stew. The chef said she was still catering for full occupancy despite having ten vacancies, as some of the men prefer extra portions. Plates were used not bowls. Pureed meals were served as individual portions. A trained nurse had to instruct a care assistant to sit next to a resident who she was assisting to eat. Staff asked residents what choice of dessert they would like. On Crossfields unit the activity coordinator stood over a resident while assisting her to eat a bowl of trifle and no one commented on this practice. The satellite kitchen on Daresbury unit contained details of Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 18 residents diets such as diabetic or pureed and not details of residents food preferences as stated by the clinical manager. At tea time sandwiches were served followed by chocolate éclairs. When asked if this was a snack the clinical manager said yes a snack, no its tea. We have sandwiches for tea and for supper. Night staff can make toast as well and we have biscuits. The kitchen closes at 4pm and staff do not have access to this, a hot meal is not provided after 4pm so residents have sandwiches for tea. A resident said about the choice of meals I dont remember you from the last visit but you are right I dont like cheese, youghurt and other things. My memory about food is poor and I dont know what the choices are. I know I had chicken today. Yes I would liked to have known that sausages were avalable. I would not have chosen them but it would have been nice to know. See requirements 6 and 7 and recommendation 3. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to this service. Complaints are not acted on appropriately so residents and relatives will not be confident in the complaints procedure. The management of physical intervention on Rylands and Cossfeilds units is unclear and staff are unsure what constitutes restraint and residents and staff are at risk of being harmed. EVIDENCE: The Commission for Social Care Inspection (CSCI) investigated two complaints about the standard of residents’ personal care. Requirements were identified under the Care Homes Regulations 2001 and an action plan to address the requirements was received on 19th April 2006. Concerns remain about the standard of personal care provided to residents. On 22nd March 2006 a Regulation Manager and lead Inspector from CSCI attended a relatives meeting. The new manager chaired the meeting and both positive and negative comments about the management of Apple Court were received. No complaints were received by the CSCI at this meeting. During the site visit on 25th April the daughter of a resident said I was concerned how the nures in charge spoke to me when I came to visit mum. I asked him how she is and he was very rude and said ask your sister. He was unhappy I visited mum during my break. I told the clinical manager about this and she said put it in writing. No one has bothered to come and say it was dealt with. The manager at the time wouldnt do anything about it . Things have changed and if I complained now it would be dealt with differently. The nurse had stand up arguments with my sister because she challenged him. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 20 This was seen by other staff but it wasnt dealt with. I have to be careful as I am fearful I will loose my job. Since he has left staff have been very happy. Since Helen became manager we are recruiting more staff and can have monies for toiletries. The old administrator would never part with any monies. We are recruiting an activities coordinator to help J. Moore activities will be good. Moral has improved and I can talk to the unit managers. Helen Sellars is approachable. We had a staff meeting a few weeks ago and she talked about how we can be more positive with more staff and more activites. The use of restraint was discussed with the clinical manager for Rylands and Crossfeilds units regarding various entries in a resident’s care plan that indicated restraint was used. She said that restraint was used but only insofar as holding the resident’s hands and moving him one staff member on either side and on one occasion bodily moving him off the floor to dress him. This information was not recorded. Since the last visit there have been two adult protection procedures referred to the local authority for investigation. Hallmark Healthcare has cooperated fully in the investigation of the allegations made. See requirements 8 and 9. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is assessed as good. This judgement has been made using available evidence including a visit to this service. Residents live in a well-maintained home, which is clean and hygienic but the environment could be improved to aid residents recognise their bedrooms and facilities. EVIDENCE: All communal areas and some bedrooms were seen. The interior and exterior of the building was well maintained. The home was free from odours. Signage is poor for residents who have significant levels of cognitive impairment. There are no large signs or visual cues to aid residents recognise toilets or bathrooms or inform residents of the day, date or time. See recommendation 4. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is assessed as adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are adequate to meet residents’ needs. The training programme has provided a more informed and skilled staff group but training in NVQ level 2, care planning and communication skills is needed to promote quality care. Staff recruitment needs to improve to ensure that residents are protected. EVIDENCE: Staff were observed to use appropriate moving and handling techniques. A senior care assistant and care assistant moved a resident using a hoist and sling from the lounge into the dining room. They explained to the resident the procedure they were using. Another care assistant transferred a resident from a chair to standing and into a chair in the dining room using a transfer belt. She used the correct technique but did not explain the procedure to the resident. A training matrix provided by the manager recorded only two staff of thirty-six staff employed had an NVQ level 3 qualification. No staff held an NVQ level 2 qualification. Information from the previous manager in December 2005 recorded 17 staff had an NVQ level 2 qualification. Staff recruitment records for three new staff examined of a qualified nurse, care assistant and domestic assistant. The qualified nurse was recruited from outside the United Kingdom. Records confirmed that all appropriate documentation is in place other than Criminal Records Bureau Check (CRB) and POVA First check. The manager stated these would be pursued when the nurse had a permanent address. Copies of a police check from the country of Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 23 origin were on file with references of employment. The nurse was registered with the Nursing and Midwifery Council. The manager was advised about the requirements of regulation 19 of the Care Homes Regulations 2001, which says ‘The registered person must not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2.’ The care assistant’s employment records confirmed that all appropriate documentation was in place other than that the CRB indicates, “Checks completed on information provided, no other name disclosed although title indicates marital history” It was not clear as to what this meant and Hallmark Healthcare agreed to look into this. The Domestic assistant’s records did not confirm the date of commencement of employment. A CRB and POVA First check were in place but there was a gap in the employment history from 1999 to 2005. Both the references were typed in same format and same style on plain paper and were, unsigned and not addressed to Hallmark or to Apple Court. There was no evidence as to whether the employment gap had been explored. A training matrix provided by the manager recorded the last fire training for staff as took place on 9th, 11th and 15th November 2005. Since 1st January 2006 ten staff have commenced employment and no fire training is indicated on the training matrix for them. Staff completed training on moving and handling in November and December 2005. In discussion about training a staff member said about the care of a resident ‘ training opportunities are good’. When asked about training on the management of challenging behaviour she said ‘staff need training in management of violence and aggression’. See requirements10 and 11 and recommendation 5. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is assessed as poor. This judgement has been made using available evidence including a visit to this service. The management of Apple Court has improved since the appointment of a full time suitably competent and experienced manager but she is not registered with the Commission for Social Care Inspection. Communication between the manager and clinical managers needs to improve ensure residents on Rylands and Crossfields units are protected from poor management decisions, which compromises their safety. Quality assurance needs to improve to identify the priorities to be addressed about improving the management of the four units, care practice, standards of recording and management of residents’ monies. The maintenance of the building and equipment does not ensure the safety of residents’ as records confirming maintenance need to be kept up to date. EVIDENCE: The manager confirmed that she would submit an application to register as manager. Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 25 The peripatetic support nurse manager from Hallmark Healthcare said she would support the manager for four weeks. She said ‘my primary role is to familiarise her with Hallmark’s policies and procedures and use of administration documentation. As no administrator is in post we are doing the staff wages. My role also cover clinical governance, staff development and team building with a particular emphasis on looking at the standard of recording in documentation’. Serious concerns were raised with the manager and the peripatetic support nurse manager from Hallmark Healthcare about the concerns about the management of the care of residents on Rylands and Crossfields units, who’s safety is at risk from poor management decisions and comprehension about the use of restraint. The conduct of the manager of these units was questioned due to her denial about the use of restraint and not acting to ensure the mental health needs of a resident were reassessed when the resident deteriorated and placed himself and other residents at risk. Care staff spoke positively about the appointment of the new manager and one said ‘ the new manager is approachable, and I feel comfortable with her, as with all the managers support is available’. She said she had one-one supervision in January 2006. The training matrix provided recorded staff had last received one to one supervision in November 2005. The manager and the peripatetic support nurse manager were able to provide basic documentation relating to each individual’s income that enabled the process of how their monies were handled to be verified. One resident’s monies were being held in two places. When the records and balances were put together they tallied. No receipts were available for various items of expenditure. The peripatetic support nurse manager said she was aware of this and has instructed that receipts must be acquired and kept. Information faxed from Hallmark’s head office provided details of monies paid over to residents’ accounts in cash. There was no information available that would indicate the source of the money. This information was not checked against all accounts. It is noted that a resident was sent £200 in cash on the 14th October 2005 but only £175 was paid into his account showing a discrepancy of £25.00. The maintenance man kept comprehensive records and details of maintenance contracts were in place. Weekly fire alarm tests were evidenced. The last alarm service was recorded as 25th November 2005 Emergency lighting is tested monthly and a monthly maintenance plan completed. No records were available to confirm if fixed bath hoists located on the ground and first floor had been serviced. Water service records were completed. Portable appliance testing had been completed in February 2006 as required. The sluice room on the ground floor had a deep Belfast sink and high tap with unregulated hot water at scalding temperature. This room was found open on a previous visit presenting a serious and unnecessary hazard to the health and safety of residents. The sluice room was found door open and unattended on the Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 26 morning of the 25th April 2006. The matter was reported to the manager who took immediate action to ensure the door is shut after use and the hook and eye at the top of the door used to prevent residents gaining access. Later the same morning the room was found to be unattended and the door wide open. The matter was again reported to the manager. Arrangements were made to fit an appropriate self-closing device and lock. See requirements 12 to 16 and recommendation 6 Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 2 X 1 Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 28 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP8 Regulation 14 23(2)(n) Requirement Timescale for action 01/07/06 3 OP8 12(1)(b) 4 5 6 OP8 OP8 OP10 17(1)(a) Schedule 3 (p) 37 18(1)(i) The registered person must ensure that records identify all residents’ needs. The registered person must 01/06/06 provide the necessary equipment to ensure residents’ independence and safety is promoted. The registered person must 01/07/06 ensure that residents are referred to the appropriate professionals when their needs change. All incidents of restraint must be 01/06/06 recorded. All incidents which affect the well being of residents must be reported to the CSCI The registered person must ensure that residents are treated with dignity and respect at all times and staff must be provided with suitable training on how to provide personal care, communicate with residents and support residents in making decisions about their lives and explain to them any assistance DS0000046209.V289823.R01.S.doc 02/06/06 01/07/06 Apple Court Care Home Version 5.1 Page 29 7 OP12 8 OP16 9 OP18 10 OP29 11 OP30 12 OP31 13 OP31 offered. The activities coordinators must be provided with training on assessing the suitability of residents for activities and the suitability of activities provided for residents based on their interests and wishes. 17(2) The registered person must Schedule ensure any complaints are acted (4)(11) upon, investigated and the and complainant informed of the Regualtion outcome of the investigation. 22 18(1)(i) The registered person must ensure that staff receive appropriate training on the use pf physical intervention and management of challenging behaviour. 19(1)(a)( The registered person must not b)(c) employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. (Timescale 1.2.06 not met). 18(1)(i) The registered person must provide staff with mandatory fire training at the intervals specified by the fire authority. 8(1)(a) The registered person must ensure that an application for a suitably qualified and experienced manager is submitted to the Commission for Social Care Inspection. (Timescale 1.3.06 not met). 12, The registered person must 13(6)(7) ensure that the care home is conducted to make proper provision for the health and welfare of residents including timely referal to health anfd social care professionals and inappropriate use of restraint. 18(1)(i) DS0000046209.V289823.R01.S.doc 01/08/06 01/08/06 01/08/06 01/06/06 01/07/06 01/07/06 01/06/06 Apple Court Care Home Version 5.1 Page 30 14 OP35 16(2)(l) and 24(3) 15 OP19 13(4) 16 OP38 23(2)(c) The registered person must ensure that monies received on behalf of residents are held in safe keeping and suitable accounted for. The registered person must ensure residents do not have unsupervised access to unsafe areas of the premises. The registered person must ensure that static equiment for moving residents is tested as required. 01/07/06 01/06/06 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP7 OP15 Good Practice Recommendations The statement of purpose should be amended to reflect the change in manager and affirm Hallmark Healthcare’s commitment to the promotion of equality and diversity. All staff should receive training on the writing of care plans. A greater variety of meal choices should be made available to residents and the system for promoting choices of meals revised to ensure residents are supported to choose their meals. The times the kitchen is open should be extended so residents have the choice of a hot meal in the evening. The signage of toilets, bathrooms and residents bedrooms should be improved to aid residents who are cognitively impaired recognise their environment. Further opportunities should be provided to ensure staff have access to NVQ training. All grades of staff should have regular supervision to ensure their performance is assessed and they can meet their job description. 4 5 6 OP19 OP28 OP36 Apple Court Care Home DS0000046209.V289823.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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