Inspection on 23/06/09 for Ashcroft House

This inspection was carried out on 23rd June 2009.

CQC found this care home to be providing an Poor service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ashcroft House 01/02/10

Ashcroft House 17/11/09

Ashcroft House 25/06/08

Ashcroft House 27/06/07

Ashcroft House 12/06/06

Ashcroft House 23/01/06

Ashcroft House 11/10/05

Ashcroft House 02/08/04

Ashcroft House 14/04/04

Ashcroft House 11/02/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Ashcroft House Fairview Close Wilderness Hill Cliftonville CT9 2QE Lead Inspector Anne Butts Key Unannounced Inspection 23rd June 2009 10:15 DS0000040622.V376448.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought 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. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ashcroft House Address Fairview Close Wilderness Hill Cliftonville CT9 2QE 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) 01843 296626 01843 571551 jacquibutler2000@yahoo.co.uk Regal Care Homes (Margate) Ltd Care Home 88 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP) The maximum number of service users to be accommodated is 88. 2. Date of last inspection 25th June 2008 Brief Description of the Service: Ashcroft House is an exceptionally large detached property, that was previously a hospital, with three floors, which have additional wings, currently the top floor is closed whilst the company considers refurbishment requirements. The Home offers a mixture of care provisions; residential, nursing and dementia. The home is situated within walking distance of local amenities. There is a shaft lift to access the upper levels. The home has it’s own secure garden area. There is limited parking for cars available. There are additional costs for items such as hairdressing, chiropody, newspapers and taxis. Fees at this home range from £312.81 - £660 per week. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 stars. This means the people who use this service experience poor quality outcomes. This was a Key Unannounced inspection that took place in accordance with the Inspecting for Better Lives (IBL) process. Key inspections are aimed at making sure that the individual services are meeting the standards and regulations and that the outcomes are promoting the best interests of the people living in the home. The actual site visit was carried out by two inspectors over the course of one day from 10.15 in the morning until 20.40 hours. We (the Commission) spent time touring the building, talking to people living in the home and relatives. We also spoke to the manager and staff and reviewed a selection of assessments, care plans, medication records, staff files and other relevant documents. Prior to our visit an Annual Quality Assurance Assessment (AQAA) had been sent to us. The AQAA is a self-assessment, required by law. This assessment focuses on how the service considers they are meeting the outcomes of the people using the service and where it feels it can make improvements. It also provides statistical information about the service. Information from the AQAA has been used in this report where appropriate. The AQAA was well completed and contained all the information we asked for. Judgements have been made with regards to each outcome area in this report, based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Care Quality Commission (CQC) to be able to make an informed decision about each outcome area. The owner has appointed a person to run the home on a day to day basis in the position of manager. They are not registered with the Commission, but will be referred to as ‘the manager’ within this report. At a previous inspection we had made six requirements and at this visit we found that progress in meeting these requirements had been disappointing with action taken not fully supporting people in meeting their needs. We have advised the registered provider of our concerns using our enforcement pathways. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 6 What the service does well: We observed that staff were kind and caring to people living in the home. Activities continue to be promoted and people have the opportunity to participate in a variety of pastimes and leisure interests, both therapeutic and recreational that suits their individual needs. People living in the home and relatives told us that the food was nice and that there were no complaints. Relatives told us that they were able to visit at anytime and were always made welcome. What has improved since the last inspection? What they could do better: The initial needs assessments for people moving into the home need to contain more detail so that the home can be confident that the home will be able to meet the needs of the prospective service user. Care plans were not always individualised and lacked clear guidance. There was limited evidence to show that care plans are reviewed on a regular basis and reflected individual changing needs. The risk management procedures do not fully identify and minimise the potential risks to people living in the home. Daily records are not fully reflecting when people are being supported with their bathing and care needs, this does not enable effective monitoring of the care and support provided to people. Records maintained for monitoring people’s weight and intake of food and fluid were not maintained to a standard that evidenced that people were being fully supported and monitored in these areas. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 7 People who live on the first floor (which is the part of the Care Home that supports people with a diagnosis of dementia) are not always treated with dignity and respect. In that we saw that people were not offered a choice of drinks and staff told us that they were not offered a choice of meals, because they would forget what they had ordered. Dignity is also not always respected on the first floor as everyone was given a protective apron to wear, whilst they were eating their meal, regardless of the need. People’s privacy was seen to be compromised with bedroom doors being left open whilst carers were carrying out personal care and improper use of screening in communal areas. The environment on the first floor places restrictions on people’s choices in relation to accessing or leaving some of the bedroom areas as there are electronically locked doors that can only be opened by staff. This means that people whose bedrooms are in these areas do not have unrestricted access to their bedrooms or communal areas. The staff training programme and content of some of the courses did not evidence that it was sufficient to always meet the needs of the people living in the home. Inspection of the homes rotas and staffing levels on the day of inspection showed that staffing ratios are not always at their own assessed levels. The management structure does not reflect the size and layout of the home which has led to shortfalls in the providing consistent quality care. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 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 Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users are provided with the information they need to make an informed choice about moving into the home. The pre-assessment process covers areas of individual need, but people would benefit from a more in depth process so as to ensure that their needs can be fully met. EVIDENCE: The home has produced a Statement of Purpose and Service Users Guide which is available. The Annual Quality Assurance Assessment (AQAA) told us that the Service Users Guide is available is two formats including a pictorial version. We saw that the Statement of Purpose contained all the information as required by regulation. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 10 We viewed the records for five people to see how the home assesses their needs prior to moving in. We saw that four of these people had an assessment carried out prior to them moving into the home and records also showed that they had obtained information from the referring authority. The AQAA states that during the pre-admission assessment process the home aims to identify all areas of need. The documentation we viewed did cover the different areas of need, but we saw that this process was mainly in the form of a tick list. This meant the information was not detailed and lacked clarity (including movement and handling risk assessments) and did not fully explore individual needs. The documentation for one person, however, did not contain any up to date information. This person had previously visited on respite (which is a short stay visit) and there were no records to show that an updated needs assessment had been carried out when they returned to stay in the home. We asked if this had happened and was told that it had not. This meant that the home did not have an up to date needs assessment for this person. The first floor accommodates people with a diagnosis of dementia and we saw at our visit that one person who had been assessed with nursing needs as well as dementia was accommodated on this floor. At a subsequent conversation with the responsible individual we were told this should not be the case and it was clear that staff did not have the skills and competences to meet this service user’s nursing needs. The Statement of Purpose states ‘If on assessment, we feel that we are unable to adequately meet the needs of an individual, then we will refuse admission’. In order to support this, the pre-assessment process needs to be completed in more detail. This home does not offer the facility of intermediate care. Intermediate care is a specialised service with dedicated accommodation, facilities, equipment and staff, aimed at maximising residents independence to allow them to return to their own homes. It does, however, offer respite care for people on a short term basis. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans and the associated risk management culture do not fully support people with their individual needs. People cannot be confident that their healthcare needs within the home will be fully supported. Lack of robust medication training is putting service users at risk with medication. EVIDENCE: We looked at the care plans for five people in detail. At our last visit in July 2008 a new care planning system was in the process of being implemented and care plans (particularly on the ground floor) had improved although care plans on the first floor were still in need of improvement. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 12 We saw at this visit that this care planning system had been introduced. Care plans are designed to cover the different areas of support required in relation to a persons daily living needs. We saw, however, that the information in the care plans was not always clear and reflective of individual needs. For example a care plan stated ‘needs help with all aspects of personal care’ and that care staff were to assist ‘with washing and dressing’, it did not expand on how to assist or reflect this person’s individual choices and preferences. We also saw that some sections of the care plans were pre-printed and of a generic nature and did not cover an individual need in relation to the person whose care plan it was. For example part of a care plan for a gentleman identified that this person needed assistance with a strip wash and then went onto give the name of a female service user and identified that personal hygiene should be carried out in own room. Another care plan (again for a gentleman) stated ‘can choose toiletries herself’. In some instances the information was also contradictory within different parts of the care plan. For example part of a care plan for one person said that they needed a Zimmer frame to support whilst walking but chose not to use this and then in another part of this care plan specifically for using a Zimmer frame there was generic guidance which stated that the person walked with a Zimmer frame. Information in the care plans in relation to people’s choices, preferences, likes and dislikes varied in the different care plans, with some containing more information and identifying preferred times of getting up and going to bed for example. Others, however, did not reflect individual preferences. A requirement has been made in relation to care planning. A personal hygiene chart is used as a tick box system alongside the daily notes. This is used to identify when a person had been supported with a bath, shave, mouth care etc. We saw that these were not being completed and did not indicate when a person had last received support in these areas. A care plan we viewed stated that the person should have a weekly bath with two carers, the daily records for this person did not show that they had received a bath and only showed evidence of the person being supported with a body wash. There was no indication in the care plan if this was the person’s choice. There is also a section for additional handwritten notes and these only gave a brief overview of any support e.g. up, washed and dressed and made comfortable in lounge. There was a system within the care plans to record when they have been reviewed and updated. We saw that this was not being used and this record in five of the files we viewed was blank. Some individual parts of care plans did indicate that a review had taken place. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 13 Records we viewed contained evidence that risk assessments were in place. Risk assessments covered areas of need such as movement and handling, falls risk and use of bed rails for example. Again some of these are generic risk assessments and not always fully relating to the individual need. For example the movement and handling assessments stated if a person needed the use of a hoist, but did not state which hoist and which size of sling. We asked a member of staff how they knew which sling to use for an individual person and we were told that they would look at the person and make a visual judgement. This has the potential to put service users at risk from injury due to incomplete guidance and lack of staff knowledge. In some cases the risk assessments contradicted each other. For example in one file there were two assessments relating to falls, with one identifying that the person was a low falls risk and the other stating that this person was prone to falls. Another service user who used a wheel chair and needed support with moving and handling did not have an up to date risk assessment in place. Staff informed us that the wheel chair was also too small and the service user needed to be assessed for a sling. They stated that this had been identified several months ago but no records could be found that a referral had been made or followed up. The two senior staff spoken to did not know who was responsible for doing this. This information was passed to the manager to follow up. People have access to local healthcare facilities including GP, district nurses, chiropodist etc. In house assessments relating to health care needs and the procedures in the home were not robust and did not evidence that people were fully supported with an identified need. For example assessments and care plans on how to support people with their diabetic needs was not clear. A care plan for one person said that they were at risk of hypoglycaemic attacks (which is when a person has a low blood sugar level) and the action to support the person was to recognise when this happens. There was no guidance, however, as to what the signs were. Another part of this care plan also stated ‘to liaise with GP or nurse if the need arises’, but did not state who was responsible for this. One part of the care plan relating to the persons diabetic need stated ‘to give a milky drink at night with two biscuits’, but this was not referred to in the care plan which supported the individuals eating and drinking needs. We looked at a random selection of the food charts which are maintained for this person and only one occasion out of four evidenced that this person had been given a drink and two biscuits at night. It was also clear that some service users with diabetes were paying for chiropody privately when they should be able to access this service free of charge via the NHS. Records did not indicate that service users had chosen to have their chiropody care privately and staff spoken to were not aware that they should be able to access this through the NHS. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 14 We looked at charts maintained for monitoring food and fluid intake. We saw that the food and fluid charts for people were not completed accurately or in detail. We viewed a sample selection of dates for twelve people and these all showed differing levels of information. For example the food charts for people allowed for staff to record what was eaten and exactly how much. We saw that sometimes actual meals were recorded, but not how much was eaten or in other instances the meals were not recorded and a box was ticked to indicate how much was eaten. On the day of our visit we also saw that one person only ate approximately half of their lunchtime meal, and although this person is not on a food chart, the daily notes stated ‘Eating and drinking well - lunch eaten’. Fluid charts also did not fully evidence the support people. Records did not always showing that people consumed drinks during the middle of the day for example. Staff were also unclear about the expectations of what the average fluid consumption for people would be and a senior member of staff was unable to give a clear answer. The poor level of record keeping and care planning in relation to nutritional and fluid intake led us to conclude that they have been completed by staff who were not trained or experienced in completing these records and had little understanding of the significance of this in relation to peoples’ health and welfare. We also saw that weight charts were still not maintained to a standard that showed that people’s weights were monitored regularly or changes in weight were always acted upon. For example on the ground floor we saw that not all people had been weighed every month, with different people missing different months and no explanation offered within these records. A selection of weight records had also not been signed by a member of staff. On the first floor the records were confusing as there were two systems in place, with records initially being entered into a book and then transferred over into an individual file for more detailed monitoring. We spoke to a senior on duty who was unsure of how to follow the system. We also saw that the records for one person had only been entered into the book and had not been transferred over into the individual file. This person had lived in the home for approximately four months and the records in the book showed that this person had undergone a steady weight loss since moving into the home. Staff were aware of this. The senior member of staff was not able to explain why this person did not have an individual weight chart in place. Lack of appropriate records for this person in the file did not show any evidence that this weight loss had been acted upon. Another person, who had been unable to weight bear, had no records for weight and we were told by a member of staff that they were waiting to be shown how to use alternative methods for measuring weight. There was evidence that there was some monitoring occurring. For example one person who had lost weight had been referred appropriately. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 15 Evidence at this visit showed that staff are not recognising the significance of these records and in particular on the first floor there were no clear lines of responsibility and consequently appropriate action was not always being taken to monitor and support peoples weights. Care plans also have a section for making a risk assessment on a person’s vulnerability to bruising and / or pressure areas. Body maps are used to monitor this. We spoke to a gentleman on the first floor with a diagnosis of dementia. We saw that he had a large bruise on his arm, but when we looked at his records there was no evidence of this being recorded, despite the fact he had a bruise risk assessment which stated that a body map needed to be completed for any bruising. We spoke to the senior in charge and asked how he got this bruise. The senior was unaware of this and could not explain how it had occurred. The inspector observed medication being administered and looked at a sample of medication administration records. These showed that medication administration and record keeping has improved since the last inspection and was now being administered appropriately and in a timely way. Records also showed that several staff had undergone further training with a pharmacist. However it was noted that some medication administration was being undertaken in house with the use of a training video. This training was being facilitated by the manager who told us that he does not hold a qualification to train. In addition the home does not have a system in place to monitor staff competency at periodic intervals. A requirement has been made that the home should review its policy regarding staff training in medication administration. We spent time observing how people were treated by staff during the course of our visit. We saw that staff were kind and courteous to the people living in the home. We spoke to three relatives and they told us that staff were caring. One relative told us ‘the staff are always very kind’. We also observed, however, that there were occasions when people were not treated with dignity and respect. For example when staff were carrying out personal care for people in their rooms they did not always close the doors. We also observed staff hoisting a service user in the lounge area in an undignified manner, and although they did put up a screen which partially shielded the person this did not fully protect their dignity. A requirement is being made to ensure that the home upholds peoples’ rights to privacy and dignity. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activities are organised so that they provide stimulation and interest for people living in the home. Not all people who live in the home are always offered their meals in a manner that promotes their dignity and respects their choices. EVIDENCE: There is a leisure therapist employed for each floor and their role is to arrange activities and support people with their social needs. Different pastimes include group activities such as bingo, sing-a-longs, playing games, ball activities, film shows and arts and crafts sessions. Support is also given to people on an individual basis and time is spent colouring, doing jigsaws, reading and talking to people. We spoke to the leisure therapists on both the ground and middle floors and they were able to demonstrate the Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 17 activities and pastimes that were arranged for people. For example: if people are interested in gardening – time had been arranged for this to happen. On the first floor (which is where people who have a diagnosis of dementia are supported) additional therapeutic pastimes had been introduced and this included the use of ‘doll therapy’, and this has given some of the people with a diagnosis of dementia an added interest in life. We spoke to people living in the home and relatives who were present at the time of our visit. Overall everyone we spoke to said that they thought activities were good within the home. We were also told by relatives that they were able to visit when they wanted to and were always made to feel welcome. One service user explained that they were not able to have a bath when they wanted. Normally their relative supports them with a bath but on one occasion when this was not possible the service user asked staff if they could support them to have a bath in the morning. The service user was told that they could not because staff would be too busy in the morning. This person’s care plan stated that they need support to have a bath although it had not explored with them their wishes in terms of time and frequency. Also an inspection of this persons care plan showed that the bath record was not filled in at all. We observed the lunchtime meal both on the ground floor and first floor areas. The ground floor supports people who need residential or nursing care and the first floor supports those people with a diagnosis of dementia. We observed different care practices in these areas. On the middle floor we observed that people were not offered a choice of drink and were given lemon squash only. We also observed that people were not offered a choice of meal, when we asked a member of staff about how people were given a choice we were told that people would forget what they had ordered. One member of staff said “people of this age tend to prefer meat and two veg”. When the meal was placed in front of people they were not told what it was. A gentleman asked a member of staff what the lunch was and she said “I don’t know – I think it might be beef stew”. The menu stated that it was lamb stew. The gentleman also asked for salt and pepper, the salt and pepper was brought to the table and the member of staff put salt on the meal but did not offer the pepper. We also observed that the ten people eating in the dining area were given a protective apron to wear whilst they were having their meal and this included one lady who placed a serviette on her lap. We observed that only two people spilled a small amount of food whilst they were eating. The observations and comments from staff do not promote the dignity and choice of people living in the first floor. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 18 On the ground floor we saw that people were offered a choice of blackcurrant, orange or lemon squash with their lunchtime meal. We asked members of staff if people were given a choice for their lunchtime meal and we were told that staff would go round in the morning with the menu and ask people. On the ground floor we also observed people being assisted with eating their meals and saw that staff did not ask what part of the meal they would like to eat. People who were eating in the lounge area had their meals brought to them on a tray and both the main course and the desert were served up together. We observed, however, that meals were well presented and people told us that they enjoyed the food. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are investigated, but not all people feel confident that their concerns are acted upon and listened to. Service users are potentially put at risk due to not all staff being trained in Adult Protection and procedures that reflect current good practice. EVIDENCE: The Statement of Purpose and Service Users Guide contains information about how to make a complaint. The Annual Quality Assurance Assessment (AQAA) stated that there had been seventeen complaints made in the last twelve months. It stated that all of these had been resolved within twenty eight days and that sixteen of the complaints had been upheld. We spoke to relatives at the time of our visit. One person told us that they had no complaints about the home. Another relative, however, voiced several concerns which included a lack of clean clothing being returned to the room and items of clothing that had been brought in going missing, we were told that this had been raised with members of staff but items of clothing were still going missing. We saw that there was a large quantity of clothing stored in a downstairs room Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 20 The staff training records showed that some staff had received training in the recognition and prevention of abuse. We spoke to members of staff about their understanding of abuse and what action they would take. Some staff indicated that they would take their concerns to the manager; other members of staff did not have a clear understanding of safe guarding protocols. It was also noted that this training was facilitated by the manager with the use of a video, who could not evidence that he had appropriate training to do this. Some members of staff have received training in the Mental Capacity Act, which provides a proper framework for supporting people with their best interests. The Mental Capacity Act also identifies different forms of restraint including environmental restrictions whereby electronic keypads are used to limit access to certain parts of the building. We identified on the first floor (which is where people with a diagnosis of dementia live) that there were two corridors which led to some of the bedrooms. These corridors were accessed through doors which had a keypad system and were kept closed at all times. At the time of our visit we saw that there was a service user who wanted to come out into the communal area, but was unable to do so until a member of staff saw them and opened the door. A review needs to be made in order to ensure that the environment is not placing restrictions on people which are not in their best interests. This issue has been discussed with the responsible individual of the organisation. The (AQAA) identified that there has been three safeguarding referrals made by the home and that these had been assessed by Kent County Council Safeguarding team. There is currently an ongoing safeguarding investigation in operation and this was shared with the Commission under information sharing protocols. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23 and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from a clean and pleasant environment. More needs to be done to ensure specialist equipment is in place to maximise independence and ensure their safety. Overall people have access to safe and comfortable indoor and outdoor facilities, some restrictions on the first floor do not support all people with this. EVIDENCE: As part of our visit we toured the environment and viewed a selection of bedrooms. We also spoke to relatives and people living in the home and referred to information provided in the Annual Quality Assurance Assessment (AQAA) and the home’s Statement of Purpose. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 22 The Statement of Purpose told us that the home has an ongoing refurbishment programme and the AQAA indicates that this is happening. We saw that areas of the home had been redecorated and flooring had been replaced. The home is currently laid out over two floors with the ground floor accommodating people with residential and nursing needs and the first floor accommodating those people with a diagnosis of dementia. There is a second floor which is currently not in use. On the ground floor access is available to all main communal areas. However on the first floor access to and from bedrooms situated at the sides of the building is restricted due to partition doors which are only accessible through the use of a keypad. As identified under the complaints and protection section of this report this has the potential to restrict peoples choices as to where they spend their time as they have to wait for a member of staff to let them on or out of these areas. The ground floor is mainly for people with nursing needs and although people’s bedrooms had appropriate call bell systems the communal areas do not. Some residents and relatives stated that they could not always find staff when they needed them particularly in the evenings and did not have any way of calling for assistance if they were in the lounge. The home is required to review the call bell system and ensure that safe systems are in place for seeking the support of staff when needed. The home is set in its own grounds and staff told us that people are supported to use the garden areas if they wish. The AQAA identifies that there are plans to develop the gardens to accommodate a sensory area. We viewed a selection of bedrooms and saw that they contained peoples own possessions and many have en-suite facilities. People we spoke to said they were happy with their rooms. There was suitable equipment in place including hoists, airflow mattresses, wheelchairs and stair lifts. The AQAA confirmed that regular checks are carried out on equipment. Where people have cot sides, there are agreements in place. The AQAA states that there is a cleaning schedule in place and we observed domestic staff carrying out their duties during the course of our visit. A member of staff told us that there is a rota and that this included weekend cover. A relative told that the home ‘always smelt fresh and clean’. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users benefit from being cared for by staff who are kind and caring. Service users cannot be confident that staff have the competency and skills to meet their needs due to the level of training. More needs to be done to ensure that service users are protected by the homes recruitment policies and procedures. EVIDENCE: Eight staff files were inspected including the most recently employed staff members. Files showed that appropriate police checks and references had been obtained for the most recently employed staff although one person’s criminal records check showed that they had received a caution. The reason for this was not explored and no records showed that employing this person had been risk assessed. This issue was discussed with the manager who explained that the recruitment process for this person had been undertaken by the previous manager. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 24 We looked at how many staff were on duty at any one time and viewed four weeks rotas for the June period. We also spoke to members of staff. We were told by a senior on the first floor there were five members of care staff allocated on in the morning, four in the afternoon and that there were two members of staff during the night. The leisure therapist also works five days a week from 10.00 am until 6.00pm. On the day of our visit there were only four care staff on duty in the morning and rotas showed that this had happened on other occasions during the month. Members of staff told us that when there were only four members of staff this did have an impact on the work. At the time of our visit the first floor was being managed on a daily basis by ‘acting seniors’, who were also working within the allocation of care staff to provide care for people living in the home. There is no robust management structure on the first floor to enable to smooth running of this area. A relative told us that ‘sometimes the staffing levels are low, but if we look hard enough we can find someone’. Rotas showed that there is always a nurse on duty on the ground floor with six care staff allocated in the morning, four in the afternoon and a nurse and two members of care staff during the night. There is also a leisure therapist who works three days a week. Rotas also indicated that the amount of morning care staff was reduced to five at the weekends. The ground floor is managed on a daily basis by the senior nurse on duty. A service user also told us that she had not been allowed a bath one morning as there was not enough staff available at the time. There are ancillary staff allocated for laundry, cleaning and kitchen duties. Although the Annual Quality Assurance Assessment (AQAA) stated that staffing levels have improved and are adjusted according to the needs of the home. The layout of the home and concerns about effective call bell systems and locked doors are making it difficult for people to seek the support of staff at all times. In addition inspection of the homes rotas and staffing levels on the day of inspection showed that staffing ratios are not always at their own assessed levels. At this visit we identified shortfalls in training. We looked at staff training records and spoke to members of staff and the operations manager. The Statement of Purpose identifies that staff will undergo specific training in areas such as movement and handling, adult protection and dementia for example. It also states that refresher courses will take place as required. The Annual Quality Assurance Assessment (AQAA) states that ‘All staff receives statutory training’. Evidence taken from the staff training matrix, staff records and discussions with staff showed that not all staff had completed the appropriate statutory training. For example we saw that not all members of staff on the training Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 25 matrix had completed adult protection training and only twenty two members of staff had been identified as completing one part of movement and handling training and only nine completing a second part. A member of staff told us that the movement and handling training had consisted of watching a video. The actual training did not cover the practical use of hoists. We spoke to the manager about the level of training for movement and handling and he confirmed that he trained staff through the use of video training programmes in movement and handling and also in other areas. We asked how staff were trained in the practical use of supporting people with their movement and handling needs and he told us that a senior member of staff would observe them using the equipment and then would ‘sign them of as being competent’. We asked about the qualifications of staff who trained people in movement and handling and he told us that staff had not completed a trainer’s course in this. He also told us that he was not a qualified trainer, but as a manager could use the videos. There were also shortfalls in other areas of training including infection control and health and safety for example. The training matrix showed us that staff have been supported with dementia training and a member of staff told us that she was currently completing this with an external provider and was finding it very useful. We did not identify on the training matrix any other training relating to the specialist needs of the people living in the home. New members of staff should undergo induction training in line with the common induction standards developed by ‘Skills for Care’. The Statement of Purpose states that will receive a basic induction which shows them the procedures and their responsibilities in relation to the running of the home and that they will spend time in a supernumerary role prior to being allocated on shift. Following this care staff will then complete an induction over a period of six weeks in line with the Skills for Care induction standards. We spoke to a new member of staff who told us that they had been shown the fire procedures and had worked alongside other staff, but could not recall any other induction. Another member of staff who had no previous experience of caring had been working for three months with no safe guarding or fire training and was undertaking personal care by themselves and working nights. Discussion with this staff member showed that they did not understand the procedure for safeguarding vulnerable adults. Although they had received some training in moving and handling and infection control, this training was again in house using a training video. We looked at staff files and these records also showed that staff induction did not always ensure that staff had appropriate training before working unsupervised. Although it was noted that the home had made an effort to implement a training programme, the quality of this training was not robust enough to evidence or ensure that staff were competent in the duties they are to perform. A requirement has been made. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users can not be confident that the home is managed by a person who is fit to be in charge and able to discharge his responsibilities fully. The poor management arrangements do not reflect the size and structure of the home and this had led to inconsistent care practices which have put service users at risk. EVIDENCE: Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 27 The organisational structure for the home shows that they are part of Regal Care homes Ltd. The home is overseen by a care director and within the home there is an operations manager who oversees the care and ancillary staff. There is a lack of management structure within the home and although the registered provider has appointed a person to run the home on a day to day basis, evidence has shown at this inspection that they are not managing the service effectively. They did not have a clear understanding regarding appropriate levels of training and was found to be facilitating training that he was not qualified to undertake. The responsible individual told the commission that he had told them that he had a moving and handling training qualification, which he does not. This and other poor management practices call into question this persons fitness to undertake the role of manager. On the ground floor there are nurses who have a senior role but we were told that there was currently no deputy manager and that they were advertising. This means that there is no clinical supervision of the nurses, within the home, as the operations manager says he is not responsible for clinical supervision. On the first floor the lines of seniority were also unclear and two members of staff are currently managing this in the role of ‘acting seniors’, whilst continuing to be allocated on shift. The home does not have a manager registered with us (the Commission). The Care Homes Regulations state that the registered provider shall appoint a person to manage the home where there is no registered manager. We saw evidence that care staff have received supervision from the manager and that nursing staff have received some supervision from the responsible individual for the larger organisation. The Annual Quality Assurance Assessment (AQAA) states that there are regular quality assurance audits carried out and feedback is sought from people who use the service. However it was clear that many examples of poor practice identified at this inspection was not being identified by the home through their monitoring systems. The AQAA contains requests for information about the health and safety systems within the home. This identified to us that the majority of equipment used in the home was serviced or tested as required by the appropriate regulations. It acknowledged where these safety tests were due. The AQAA also states that regular safety checks are carried out in relation to maintaining water temperatures and checking for Legionella. Quarterly audits for the environment and there is maintenance support available to address issues around the home. Staff have been trained in fire procedures and the AQAA tells us that the manager is trained for carrying out fire risk assessments. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 28 There is a system in place for staff to complete hourly checks during the night from 11.00pm until 6.00am. We looked at these records and saw that they were not always being completed. For example for the nights of 20 June and 15 June 2009, staff had only signed to say they had carried out checks between 1.00 and 4.00 am, on the night of 21 May 2009, staff had signed to say that they had checked half the service users at 1.00am and all the service users at 2.00 and 3.00 am. These records do not evidence that people are checked on a regular basis throughout the night and care plans we viewed stated that there was a need for hourly checks. Not all the procedures within the home fully promote the health, safety and welfare of people including ensuring safe working practices in relation to movement and handling and thorough risk assessments which identify and minimise potential risks to service users and staff. Evidence of this has been reflected throughout this report. In April 2009 the Mental Capacity Act alongside with deprivation of liberty safeguards was fully implemented. This means that people are legally protected in relation to being supported with making their own decisions wherever possible and that they are not deprived of their liberty. We were not told at this visit of any service users who were subject to a deprivation of liberty order. We did, however, identify that some people’s choices and liberty within their environment was restricted, as identified in the complaints and protection section of this report and as such a requirement has been made. Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 29 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 2 3 1 3 X X 2 STAFFING Standard No Score 27 2 28 1 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X 2 X 1 Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? No 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 Standard OP3 Regulation 14 Requirement The registered person shall not provide accommodation to a service user at the home unless the needs of the person have been fully assessed. This is so that people can be confident that their needs will be met. The registered person shall prepare a written plan in respect as to how service users’ needs in respect of their health, safety and welfare are to be met. These must be kept under review. This is so that care plans are individualised, specific to the person and give clear guidance to staff and are kept up to date. The registered person shall ensure that unnecessary risks to health or safety of service users are identified and as far as possible eliminated. These must be kept under review. This is so risk assessments identify all individual risks, give clear guidance to staff and are kept up to date. DS0000040622.V376448.R01.S.doc Timescale for action 31/08/09 2 OP7 15 30/09/09 3 OP7 13 (4) (c) 31/08/09 Ashcroft House Version 5.2 Page 31 4 OP7 17 5 OP8 13 (1) (b) 6 OP8 17 – schedule 4 7 OP8 12 (1) (a) 8 OP8 17 (1) (a) Schedule: 3 (j) (o) The registered person shall ensure that records are maintained in respect of each service user so that they reflect the care and support provided. This is so that daily records evidence that people’s needs are being met as detailed within the care plans. The registered person shall make arrangements for service users to receive treatment, advice and other services from healthcare professionals. When a person is identified as needing new equipment a referral must be made and followed up. This is so that people are supported with their individual needs. The registered person shall ensure that records of the food provided are maintained in sufficient detail so as determine whether the diet satisfactory. This is so that the service users can be confident that their nutritional, including special dietary needs, and fluid needs will be monitored and met. The registered person shall ensure that the care home is conducted so as to promote and make proper provision of the health and welfare of service users. This is so service users needs are monitored and action taken where appropriate in relation to monitoring peoples weight. The registered person shall maintain a record of any accident, injury or fall. Unexplained bruises should be recorded in accordance with the homes procedures. This is so that people’s DS0000040622.V376448.R01.S.doc 31/08/09 31/08/09 31/08/09 31/08/09 31/08/09 Ashcroft House Version 5.2 Page 32 9 OP10 12 (4) (a) 10 OP14 12 (2) 11 OP22 23 (2) (n) 12 OP27 18 (1) (a) 13 OP29 19 healthcare needs can be monitored. The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. This would ensure that people’s personal dignity and choices are respected with regards to day to day living. The registered person shall so far as is practicable enable service users to make decisions with respect to the care they are to receive and their health and welfare. Care plans must identify individual choices. This is to ensure that service users have a choice in respect of their routines especially in relation to bathing, food and care. The registered person shall ensure that suitable adaptations are made as may be required for service users. This is so that there is a safe system in place for service users seeking the assistance of staff in communal areas. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users to ensure that staffing levels are in such numbers are as appropriate to meet the health and welfare of the service users. This is so that staff are available to meet the needs of all service users in regard to the size of the home. The registered person shall only employ a person to work at the care home in line with regulation DS0000040622.V376448.R01.S.doc 31/08/09 31/08/09 31/08/09 31/08/09 31/08/09 Ashcroft House Version 5.2 Page 33 14 OP30 18 15 OP31 8 16 OP33 12 (3) 17 OP38 13 (5) 19 and Schedule 2 of the Care Home regulations. This is so that service users can be confident that staff are fit to carry out their duties. The registered person shall ensure that persons employed to work at the care home receive training (including structured induction training) appropriate to the work they are to perform. This is so that staff (including new staff) are trained and competent to meet the needs of the service users. Any person who carried on or manages an establishment or agency of any description without being registered under this part in respect of its (as an establishment or, as the case may be, agency of that description) shall be guilty of an offence. Care Standards Act 2000 (11 (1)). In that an application be made for a registered manager by date set. The registered person shall for the purpose of providing care to service users and making proper provision for their health and welfare so as far as practicable ascertain and take into account their wishes and feelings. This is so that people are supported to make their own decisions in accordance with the Mental Capacity Act and unnecessary restrictions are not placed on people’s liberty. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. This includes risk assessments and training of staff This is so service users will be in safe hands at all time. DS0000040622.V376448.R01.S.doc 30/09/09 31/10/09 31/08/09 31/08/09 Ashcroft House Version 5.2 Page 34 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ashcroft House DS0000040622.V376448.R01.S.doc Version 5.2 Page 35 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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. Copyright © (2009) Care Quality Commission (CQC). 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