Inspection on 14/07/09 for Camelot Care Homes Ltd

This inspection was carried out on 14th July 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

Camelot Care Homes Ltd 28/01/10

Camelot Care Homes Ltd 21/12/09

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Camelot Care Homes Ltd 1 Countess Road Amesbury Wiltshire SP4 7DW Lead Inspector Susie Stratton Unannounced Inspection 08:55 14 July & 20 August 2009 th th DS0000073153.V376062.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. Camelot Care Homes Ltd DS0000073153.V376062.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 Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Camelot Care Homes Ltd Address 1 Countess Road Amesbury Wiltshire SP4 7DW 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) 01980 625498/549 01980 624698 Xcel Care Homes Ltd To be appointed Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57), Physical disability (5) of places Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) 2. Physical disability (Code PD) - maximum of 5 places The maximum number of service users who can be accommodated is 57. New Service Date of last inspection Brief Description of the Service: Camelot is a 57 bedded care home with nursing. The home consists of two wings, Comilla Wing parts of which are listed, and Countess Wing a new-build home. The oldest part of Comilla Wing is on the main road into Amesbury, with a wing off this older building, leading to a linked area into the unit called the Lodge. Countess Wing is a purpose-built care home. Accommodation is provided over two floors with passenger lifts in-between. The two wings are separated by a court-yard garden, which they share. The home is owned by Xcel Care Limited, a company which owns a range of care homes, mainly in the south of England. Xcel Care Homes purchased the home in February 2009. The manager’s post is currently vacant. A person is acting into the role. This person leads a team of nursing, care and ancillary staff. The home is situated near the centre of the small market town of Amesbury, in the middle of Salisbury Plain. Amesbury is on the A303, which links to the M3. There is a bus station in Amesbury. The closest railway station is in Salisbury, about 20 minutes drive away. There is parking on site. A copy of the service users’ guide is given to all new admissions. Fees range from £600 to £750 per week. Additional charges are made for chiropody, hairdressing, newspapers, optical requirements and toiletries. Camelot Care Homes Ltd DS0000073153.V376062.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. As part of the inspection, questionnaires were sent out to residents and staff. Eight were returned. Comments made by people in the questionnaires and to us during the inspection process have been included when drawing up the report. The homes file was also reviewed and information provided since the homes registration considered. We also received an Annual Quality Assurance Assessment (AQAA) from the home. This was their own assessment of how they are performing. It also gave us information about what has happened since the new owners purchased the home in February 2009. We looked at the AQAA, the surveys and reviewed all the other information that we have received about the home. This enabled us to decide what to focus on during the inspection. As the Camelot is a larger registration which has recently been purchased by a new owner, two site visits were made. One inspector performed the first site visits and two the second site visit. These people are referred to as we throughout the report, as the report is made on behalf of the Care Quality Commission (CQC). The first site visit took place on Tuesday 14th July 2009, between 8:55am and 5:30pm. The second site visit took place on Thursday 20th August 2009 between 9:00am and 6:15pm. Both visits were unannounced. The prospective manager was on duty for both the site visits. The prospective manager and the responsible individual were available for feedback at the end of the site visits. During the site visits, we met with thirteen residents and six relatives. We observed care for sixteen residents for whom communication was difficult. We performed a short observation of care for five residents, in accordance with our procedures. We toured all of the home and observed care provided at different times of day and in different areas of the home. We reviewed care provision and documentation in detail for six residents, and specific matters relating to a further five residents, across all parts of the home. As well as meeting with residents, we met with five registered nurses, ten carers, the laundress, the activities coordinator, a kitchen assistant, a two cleaners and the maintenance man. We observed lunchtime meals on both inspection days in all parts of the home and two activities sessions. We reviewed systems for storage of medicines and observed medicines administration rounds. A range of records were reviewed, including staff training records, staff employment records, accident records, complaints records and records of residents financial transactions. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 6 What the service does well: Camelot is close to the centre of the small town of Amesbury and so some relatives find it easy to “pop in” to it when passing. This meant that there were a higher number of visitors during the inspection than can happen in care homes which are in remoter locations. This also facilitates ease of access for external health care professionals. The home has effective working relationships with such professionals, some of whom were seen visiting the home to support them during both days of inspection. The home benefits from attractive well-kept gardens, which are fully wheelchair accessible. Staff who have worked in the home showed a high commitment to their residents. People commented on the home. One person reported “staff very good, they actually care”, another “the staff are fabulous”, another “most staff helpful” and another that the home was good at “care for the clients”. People also commented on the home. One person reported “the home’s very good actually” another that it was “not too bad at all here” another “the home gives a good standard of care” and another described Camelot as “friendly, homely”. One person reported that “I feel the home does well in all aspects”. What has improved since the last inspection? What they could do better: At this inspection, we identified a wide range of areas which needed improvement. People commented to us on such matters in questionnaires and during the inspection. One person stated “when visiting, the atmosphere is very unfriendly”, another person reported that the residents have “no say”, another that management needs to “get the negativity out of the home” and another that “staff moral needs to be higher”. The home needs to ensure that full assessments of residents’ needs take place either before or immediately after admission and be able to demonstrate that they are able to meet prospective new residents’ needs. They need to ensure confidentiality when informing staff about prospective residents’ nursing and care needs. All residents need to have full assessments of need or risk put in place. Where a need or a risk is identified, a care plan must always be drawn up to direct staff on how the need or risk is to be met. These must be evaluated regularly and also when a person’s condition changes. There must be full documentary evidence that staff are meeting directives in care plans. Staff at all levels must be informed of how to meet residents’ needs and be able to demonstrate that they are meeting residents’ individual needs. The home must follow guidelines Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 7 from us and research-based evidence when providing nursing and care. They must ensure that residents’ privacy and dignity is up-held at all times wherever they are being cared for in the home, including taking into account any more complex needs that they may have. The home needs to ensure that guidelines on the administration and recording of medication are followed, particularly in relation to care planning for certain drugs. They need to ensure that residents’ prescribed items are not used for other residents. Records and storage of Controlled Drugs need improvement. The home must ensure that residents are provided with full support for activities when the activities coordinator is in different parts of the building. Supervision of residents by staff is needed at mealtimes, to ensure that residents are enabled to eat their meals in the way that they wish and have full support from staff if needed. The home needs to ensure that all staff understand the importance of residents exercising choice in their daily lives and that systems for communicating with relatives are effective. Practice needs to be improved in relation to complaints. All complaints must be documented, with evidence that they have been investigated in full and relevant actions taken. The home must ensure that all residents are safeguarded from issues relating to staff practice, the home environment and from other residents who have complex behaviours. The home needs to provide all necessary equipment and furniture needed to meet individual residents’ needs. Major improvements are needed in ensuring that the principals of infection control are up-held at all times. This includes practice in cleanliness, provision of relevant equipment and disposables, stopping communal use of items used in care and management of infected and potentially infected materials by staff. A full review of the home’s staffing levels is needed, to ensure that they are able to meet residents’ nursing and care needs. They need to ensure safe practice in relation to the recruitment of staff so that residents are protected by their recruitment processes. There needs to be full evidence that all new staff have been inducted into their role. Effective systems for staff training need to be introduced, to ensure that staff are able to meet residents’ needs, both by statutory training and specific training in residents’ needs. The home needs to understand its management responsibilities and fully review quality of current care provision, particularly in relation to clinical care. Records need to be improved, including records relating to residents’ moneys. There are a wide range of areas relating to health and safety, which have been in the public domain for a period of time, which the home are not meeting. We are concerned about a wide range of matters relating to the health safety and welfare of residents in the home. Therefore we have reported our concerns to other relevant agencies, including the Health and Safety Executive, Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 8 the Environmental Health Officers and the Fire Brigade. We will be asking our pharmacist inspector to perform an inspection of medicines procedure. We will also be requiring that the home send us an improvement plan to set out how they will address deficits in service provision. We will perform a random inspection prior to the next inspection, to ensure that improvements in service provision have taken place. 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. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 9 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 Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 10 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): 3 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Residents’ needs will not be fully assessed at admission, so the home cannot ensure they are in a position to meet the person’s needs. EVIDENCE: In their AQAA, the home reported on their up-to-date statement of purpose. We are also aware that our registration team reviewed their statement of purpose and service users’ guide during the registration process to ensure that it met our Standards and Requirements. We therefore did not review either document during this inspection, apart from looking at them to review the fee range in the service users’ guide. We noted that the service users’ guide had not had the fee range added to it after registration. This is required so that people are fully aware of what costs they may incur when moving into a care home. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 11 In their AQAA the home reported that “A pre admission assessment is carried out which includes needs related to personal care, physical well being, dietary and nutritional requirements, risks, communication abilities, medication, activities of daily living plus social interests and hobbies”. They reported that this pre-admission assessment is always carried out by the manager or care manager. They also reported that “on admission a care plan is produced by the home and reviewed monthly or when circumstances change”. The inspection shows that the home are not complying with these statements in their AQAA. We met with one person who had recently been admitted to the home, reviewed their records and discussed their nursing and care needs with staff. The person was quite frail and unable to converse for any period of time but they were aware of where they were and that the home was to become their permanent residence. They reported to us that they found the home “quite good”. They also reported that they felt they were settling in and that they preferred sitting on their own in their room to going to the sitting room. We looked at the persons’ pre-admission documentation. We observed that the home had a copy of the person’s discharge summary from the local hospital. This discharge summary indicated that the person had a complex medical condition, which might deteriorate, it also listed a range of prescribed medication, including Controlled Drugs. We looked at the home’s assessment of the person’s needs. We observed that the assessment had not been dated or signed, so it was not possible to assess who had performed it or when it had been performed. This is contrary to Nursing and Midwifery Council (NMC) guidelines on the completion of documentation by registered nurses. The home’s assessment did not include an assessment relating to the person’s need for pain control, this was despite clear documentation that the person was prescribed a range of painkillers. It also did not assess if there was a likelihood that pain relief would need to be reviewed regularly and if new interventions would be indicated in the near future, including the use of more complex equipment relating to pain relief. Discussions with staff and a review of staff training records (see Staffing below) indicated that there was limited evidence that there were sufficient registered nurses who had been trained in more complex areas relating to assisted pain relief. Admission information indicated that the person had a catheter in place but was not specific as to the type of catheter. The assessment did not include an assessment of whether the home could meet this person’s needs in caring for this catheter, including if the home had sufficient registered nurses over the 24 hour period to meet the needs of a male with a urinary catheter or a person with a suprapubic catheter. Discussions with staff and a review of training records (see Staffing below) did not indicate that the home would have had sufficient registered nurses employed over the 24 hour period who Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 12 had qualifications to meet the needs of this person in changing this person’s catheter when needed. When we visited the person, we observed that they used a walking aid, which the person confirmed. Their pre-admission assessment did not show that the person’s mobility needs had been assessed, including whether they would be able to mobilise in their room, along a corridor and how they would be able to access any other area of the home, either by choice or in an emergency. The resident had only been admitted recently. It is appreciated that on occasion it is complex to perform all needed assessments prior to admission. Therefore it accepted that on occasion, fuller assessments have to be performed immediately after a person’s admission. However when we reviewed this person’s records, this had not taken place a week after the person’s admission. Key assessments such as an assessment for risk of pressure ulceration had not been made. The National Institute for health and Clinical Excellence (NICE) and local guidelines state that assessments for risk of pressure ulceration need to take place promptly in clinical settings. Failure to promptly complete this assessment could have put such a frail person at risk of pressure ulceration. During the inspection, we went into the staff room and observed that the manager advises staff of people planned to be admitted in a short report, which is pinned up on the staff room notice board. The reports states matters such as the person’s diagnosis, care needs, including continence care needs and any additional needs relating to confusion or dementia. The staff room is used by all staff, including domestic staff, kitchen staff and the maintenance man. This is a breach of a person’s confidentiality in a semi-public area. We asked staff about how they found out about newly admitted residents’ needs, other than by these notices. Registered nurses reported that they read pre-admission assessments. Carers reported that they did not routinely read assessments or care plans, as these were kept in the nurses’ stations, so they relied on verbal reports. Some carers reported that they were verbally informed about peoples’ needs by more senior staff, others reported that they were not. Some carers said to us that they would ask residents how they wanted their needs to be met or if the resident had difficulties with communication, they would have to work it out for themselves. This is clearly an unsatisfactory and unsafe situation for people newly admitted to the home. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 13 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, 10 & 11 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including visits to this service. Residents in this home will be at risk of not having their personal and healthcare needs met. EVIDENCE: In their AQAA, the home reported that “care is provided by a regular and stable staff base who are able to get to know individual residents’ needs and personalities in order to deliver good quality care”. They also reported that they “assess and complete care plans on admission, review after one month and continually thereafter” and that “assessment and care plan includes information to ensure residents care needs are understood and delivered as required”. Evidence from this inspection indicates that these statements in the AQAA are not correct. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 14 As part of our inspection process, we sent out questionnaires to receive peoples’ views on service provision. One person commented that “the carers care but there are not enough of them”. Another person commented that staff needed to “listen to residents instead of saying “yes” and “no” and hoping it’s the right answer”. Another person commented that when the home had “enough staff” it “gives a good standard of care”. One member of staff commented that the home was “very friendly with service users and staff” and another “service users are at the front and always come first.” During the inspection, we discussed provision of nursing and care with residents, visitors and staff. One resident commented “staff very good, they actually care”, another “the staff are fabulous”, however another person reported “I feel I’m not properly looked after” and another “nobody will help you”. We looked at assessment records and care plans which were drawn up by the registered nurses. Some assessments were clear, for example for manual handling needs. Others had not been completed accurately. One person had an assessment for risk of pressure ulceration which had not considered all the person’s risk factors and so they were assessed as being at lower risk than they should have been. Another person had a care plan relating to their nutritional state which did not reflect the appearance of the person or what their relative informed us. Care plans also need improvement in precision avoiding the use of working such as “regular pressure area care”, “continence aids” or “appropriate position”. Care plans need to include measurable terms in order to fully direct care. During the inspection, we became increasingly concerned about a range of areas where staff were not following care plans. Several people we met with were noted to have difficulties in swallowing and to be stated to need thickening agent to enable them to swallow safely; they also needed to be fed with teaspoons to prevent risk of choking. When we visited one such person, their fluids did not show evidence that they had been thickened. Another person’s fluids were thickened to a jelly consistency, not a syrup consistency as stated in their care plan. We asked care staff about thickening residents’ drinks and some reported that they thought this was the catering assistants’ role. Catering assistants all reported that this was the carers’ role. Some of the carers who knew it was their role were not able to inform us of actions to take to ensure that individuals had their drinks thickened correctly. Two residents who were documented as needing to be fed with teaspoons to ensure their safety in swallowing were observed to be fed using a dessert spoon and on one of these occasions, the care assistant was standing above the resident, not sitting and so could not watch if the person was swallowing safely. Such observations mean that residents are not being protected from risks of choking. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 15 Several of the people we met with were assessed as being at high risk of pressure ulceration. While some had turn charts in place others did not. One person’s care plan stated that they needed to have their position changed two hourly. They did not have a turn chart in their room, to assess if this was taking place. Another person who had a care plan which stated that they needed their position changing two hourly did have a turn chart, but this showed that their position was being changed three to five hourly. One person’s care plan stated that as they were at high risk of pressure ulceration, they needed an air mattress on their bed. They were observed not to have an air mattress on their bed. This evidence is of concern. There is a wide range of research-based information relating to prevention of pressure ulceration, which state that where a person is at risk of pressure ulceration, the emphasis must always be on prevention, as once pressure ulcers have occurred, they take an extended period to heal, are painful and present risk of infection. Therefore a care home with nursing must always ensure that they follow local and NICE guidelines on the area. Many of the frail people were unable to feed themselves or give themselves drinks. One person had a care plan which stated that fluids were to be encouraged, however they did not have a fluid chart so that staff could monitor the person’s fluid intake. Another person’s care plan stated that they were to be given a choice at meals, to encourage them in taking in a good diet. The person had a liquidised meal. The kitchen staff confirmed that where a person eats a liquidised meal that there was no choice of meal. We met with a resident in their room at 10:15am. This person was unable to give themselves fluids, food or change their position independently. Their chart showed that between midnight and 8:00am the person had had sips of fluid, 20mls of juice and 100mls of non-specified fluid, with no other records after 8:00am. They were recorded as having their position changed at 3:00am and 6:00am, with no other records of changes of position. Their urine bag was documented as “clear” at 8:00am when it was over half-full. The resident was observed to be on their side with their knees touching their bed-rail and described discomfort to us. We observed that a registered nurse, who came to the resident at 10:25am, did not look at their fluid or turn chart. When we returned to this resident after lunch, their records showed that they were “moved” at 12:00noon. A visitor was giving the resident sips of drinks and they reported that the person had not eaten their lunch. No records of any meal or drink at lunch-time had been made. This and other observations above indicates that people may not have had their basic care needs met. Two inspectors performed parts of this inspection and we both observed a person who had a wound visible. We separately asked different members of staff what was the cause of this lesion for this person. One person reported that it related to an injury sustained during a fall and another that it was an on-going condition, exacerbated by the person’s restless behaviours. A resident had a care plan which stated that they needed a dietary supplement Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 16 but there was no evidence that they had been given this. One carer informed us that two particular residents did not get on well, so they tried to ensure that they did not sit side-by-side. However they were observed to be sat side-byside in the temporary sitting/dining room, resulting in an altercation between them (see Complaints and Protection below). As noted in Environment below, a carer was observed to place linen from a person who was known to have MRSA in general linen skip, not a red bag for infected laundry. As we were concerned that the home may not have effective communication systems, we asked carers how they found out about people’s needs. All carers spoken with reported that they did not use the care plans. They reported that care plans were kept in the nurses’ stations and they did not access them, mainly because they did not have the time. Carers reported that they were not usually given a report when they came on shift. Senior carers would be given a report but this was time-limited. Sometimes, carers reported, they were given information by senior carers about how to meet needs, but there was not generally enough time for this. Carers reported that they asked the resident what their needs were and when a resident could not communicate, they would just look at how the resident responded. Several carers reported that there was a rota so they knew who they would be caring for each shift, one member of staff reporting that they would then just “start whenever”. This inspection showed that information systems need to be put in place for carers to ensure that they know how to meet peoples’ needs. This situation is clearly not satisfactory and could put residents at risk. Management is not ensuring that in a nursing home they are complying with NMC guidelines to “communicate fully and effectively with your colleagues, ensuring that they have all the information they need about the people in your care”. Registered nurses need to comply with NMC guidelines or they may be at risk of being referred to the NMC’s misconduct committee. When we looked at staff training (see Staffing below) we noted that there was limited evidence that staff had been trained in areas such as how to meet the needs of frail people, including people with swallowing difficulties or people at risk of pressure ulceration. We also were aware that several new members of staff had taken up roles as carers recently, including at least two people who had not undertaken such a role before, apart from assisting in looking after relatives. There was no evidence that they had been trained in providing care to people with complex needs. We discussed this area with registered nurses who reported that they had used to train care staff in such areas but had no had time to do so more recently. Where a person had more complex nursing needs, evidence of meeting needs was variable. Where people had wounds, these were regularly assessed. While some people with catheters had clear records about them, others did not. One person did not have the clinical reason for use of a catheter and their records showed that they were prone to urine infections. Catheters are a risk Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 17 factor in urinary infections, so consideration should have been made as to whether a catheter was in the best interests of the person. A person who was a diabetic had clear records of actions to take in the event of a low blood sugar level but limited documentation as to actions to take if their blood sugar levels were raised. Additionally it appeared that registered nurses were not following current guidelines on the most appropriate choice of injection sites. Reviews of training records (see Staffing below) indicated that not all registered nurses had recently received training in diabetes management and one registered nurse spoken with was not aware of these guidelines. We met with and reviewed a resident who was under the care of the local hospice. This person had not had their assessments or care plans reviewed when their condition changed. The plans which were in place had not been dated or signed and did not include all relevant areas such as pain relief and the observed administration of oxygen. Their covers were not over them and their continence aid was visible. There was no evidence of a turn chart or a fluid chart in their room. The person did not have an end of life care plan. This was of particular concern as the person’s records indicated the importance of their faith to them, but there was no evidence of action to consider this in their records, to ensure that their spiritual needs were met at the end of their life. On both days of the inspection, we observed that some residents had been left in bed with sheets and blankets not covering them or pushed away by the resident, with continence aids or under-clothes showing. On one occasion a resident was observed without coverings, as they had pushed them off. They were shredding their continence aid and dropping the shredded material on the floor of their room. Some work-men were repairing the lift close by, including using loud speech and swear-words. No action was taken to ensure the person’s privacy and dignity, until we found the prospective manager and advised them of the situation. We are aware that where residents have complex behaviours relating to mental health care needs that they may throw off their covers and/or shred continence aids, particularly if they do not have sufficient stimulation. Where this is the case, as part of care provision, the home needs to ensure that people with such complex needs have them met. The individual who was described above did have a care plan which stated that their privacy and dignity was to be provided for “at all times.” Such observations indicate that this was not taking place. As part of this inspection, we performed a short observation of how the home met residents’ needs in accordance with our procedures. This was because the first day of the inspection indicated that the home appeared to be caring for people who had additional complex needs relating to dementia. The observation showed that residents, as noted above, were not having their privacy and dignity respected. Three of the people observed showed particular needs in relation to the management of behaviours, including noisy behaviours and interfering with objects and other people. During the short observation, Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 18 two residents showed behaviours including rolling up the hems of their skirts and raising their skirt revealing underclothes. Staff were not available to prevent people from doing this. For periods of time, different registered nurses and the activities person were in the room. We observed that the registered nurses and activities persons did try to support people with complex behaviours but as they had other roles to perform, they could not do this consistently. Most of the time, the people were not supported. The registered nurses, activities person and a senior carer all consistently called residents by their own name, however more junior carers were observed on most occasions to call people by generic terms of affection such as “my love” and “my dear”. This is not appropriate as people who experience dementia will become more confused when not called by their own or preferred name. When we inspected the home, we observed that more than one person had clothes in their room which were un-ironed and were creased. Many older people appreciate being well turned out and un-cared for clothing does not support this. On both days, several of the residents were observed to have unclean and or torn fingernails. One resident in particular had visible brown stains and debris under long fingernails. Several residents who were cared for in bed had an appearance of un-brushed hair. One person who had had a stroke did not always have their waste bin placed within reach, so they had to drop their rubbish, such as tissues on the floor. One person who spent all their time in bed and was visibly wearing a continence pad had a high odour of urine about them. We observed that a resident had a pillow supplied which had obvious brown staining on it and when we stripped back the made up beds for several residents, we found that they had been made with stained sheets. We observed three medicines administration rounds and observed that registered nurses performed them in accordance with NMC guidelines. Registered nurses were careful to take time to ensure that they read the medicines administration record correctly and administered the correct medicine to the correct person. During our short observation, we observed a registered nurse supporting a very frail person in taking a range of medication, giving the person time and helping them throughout. We observed another registered nurse supporting a frail resident who was initially refusing their medication, supporting them, accepting what they were saying and respecting their wish not to take the medication. The registered nurse returned on two more occasions to try to persuade the person to take their medication and was successful on the third occasion. During the inspection, when we toured the home, we observed some occasions where prescribed items for people, such as creams and dietary supplements, had been given to and used for people for other than the person they had been prescribed for. One of these was over its use-by-date. This is contrary to NMC guidelines. Prescribed items belong to the individual and must not be used for other people. Where items are out of date, there is a risk that they will not have intended effect on the resident. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 19 We observed systems for storage of medication. The home has three medicines trolleys and two rooms for storage of medication. We observed one occasion where a medicines trolley was not secured to a wall in a public area of the home, as is required. All medicines requiring cold storage were correctly stored. We looked at records relating to medication. We observed that all hand-written instructions were signed and counter signed. Where residents had been prescribed a variable dose, this was documented. We observed that several residents had been prescribed items such as aperients or painkillers regularly, however the home were giving these items on an “as required” basis. This is not good practice and needs to be referred back to the prescriber for clarification. This was of particular concern as the home did not have clear care plans or protocols in relation to giving people medications on an “as required” basis. This included people who experienced pain from a terminal condition. Several people were prescribed drugs which could affect their activities of dally life, such as mood altering drugs. These people did not have care plans so that the benefits or not of such drugs to them could be assessed. The home does have a procedure to provide people with homely medicines if needed. The prospective manager reported that they had begun to review this process. This is needed as most homely medicines protocols had not been agreed by the residents’ GPs for over two years and many included items such as suppositories and enemas which are no longer generally accepted as advisable as homely medicines. We reviewed the Controlled Drugs Cupboard and identified that in Comilla Wing, the Controlled Drugs register had been used for an extended number of years and so the index had been written over in a range of places, which made audit complex. The home has recently reported to us on the loss of two schedule two drugs and one of the factors in this may be that the record is confusing to use and audit. When we looked at Controlled Drugs, we identified that there was a major discrepancy in the Controlled Drugs, in that the register stated that certain Controlled Drugs had been destroyed on the death of a resident, but an inspection of the Controlled Drugs cupboard showed that they were still stored there several days later. This is an unsafe situation. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 20 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 & 15 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. Residents will be at risk of not being supported in their daily lives and social activities, particularly at mealtimes. EVIDENCE: In their AQAA, the home commented on activities provision, reporting “there is an in-house Activities Coordinator who organises a varied schedule of daily activities, monthly entertainment and also themed activities relating to special days in the month. Activities include EXTEND – keep fit programme, music and movement provided externally”. People also responded in questionnaires about this area. One person responded that “entertainment” was an area that the home “does well”, another on the “good activities programme” and another “activities for the residents are good and involved a lot of residents taking part”. During the inspection, we observed the activities coordinator running an armchair dancing group, encouraging the residents and all of the people in the Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 21 room gave an appearance of enjoying the activity. The activities coordinator also does one-to-one activities, for example during the second day of the inspection, they took a resident out in a wheelchair down to the river Avon which is close by, which the resident clearly enjoyed. One resident and their relatives reported on how much they enjoyed the BINGO session once a week. The activities coordinator reported that they had a weekly outline of activities with groups being put on in the afternoon and individual activities for residents in the morning. They reported that they tended to be flexible about groups, so as to respond to residents’ varying needs and requests. Camelot has a range of different sitting rooms, with two larger rooms in the different wings and a smaller quite room in Comilla Wing, as well as a conservatory entrance area. We observed that when the activities coordinator was in one of the main sitting rooms, that there was no-one with the residents in the other room. On the second day of the inspection, when we performed a short observation, we observed that for two hours, the television was tuned to morning television the whole time, which included a confrontational panel programme, which none of the residents appeared to be watching or enjoying. Only one resident appeared to take any notice of the television and this was mainly when an advertisement including a fox was on the television. During the whole of the two hours of the observation, for only 2 of the time frames did residents show a positive state of being. For 25 of the time residents showed a negative state of being, with one resident showing a negative state of being for 81 of the time frames. Two of the residents spent most of their time in a passive condition or withdrawn. Staff did come into the room from time to time but as they were performing other roles, such as giving out tablets or drinks, they were not there to support residents. Our short observation indicated that many of the residents needed support during this time due to their complex behaviours relating to dementia. For example, at one time there were four residents exhibiting noisy and confused behaviours, including shouting, which did not support the other residents. While the home cares for so many residents with dementia care needs, such residents need to be fully supported in their daily lives. During the inspection, we met with the activities coordinator. They were very enthusiastic in their role and were prepared to consider ideas from different people to develop their service. The activities coordinator has not been trained in their role and it is much to the person’s credit that they have been able to develop their role without training, however they would be able to provide an improved service to residents if they were trained. The activities coordinator reported that they provided a tea party every month, which was popular. They have also had singers and a theatre group in. They reported that they take round a trolley shop to residents so that they can buy small items for themselves. They reported on the good links with the local churches, with Holy Communion being provided every Friday. They reported that only one group outing from the home had been planned for the summer. Group outings can benefit some residents and we are aware that some homes perform several Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 22 outings during the summer months. This is an area for management to develop. We looked at the activities coordinator’s records. The activities coordinator maintains individual records of activities participated in by residents, including benefits to residents, so that they could use such records to further plan and develop the service. Some residents had profiles of their past lives but not all. This is an area which needs development, so that the activities coordinator can target their programmes more effectively. The home does not develop individual care plans relating to activities for residents. As part of the care planning system, in order to meet residents’ individual needs, their needs for recreational activities needs to be assessed and care plans developed to meet these assessed needs. These can then be evaluated to asses if individual peoples’ needs are being met. Such processes will support the activities coordinator and ensure that carers are able to meet individual people’s needs when the activities coordinator is not available. In their AQAA, the home reported that “residents are encouraged to make their own choices with regard to rising and retiring, where they would like to spend their time” and that “families are welcome to visit at any time”. During the inspection, we met with at least six visitors. They said that they could visit when they wanted. Several visitors came into the home to support their relatives at mealtimes. One relative reported to us that communication was an area which needed further development. For example, they reported that they were not informed that their relative had been provided with new spectacles, they were pleased that this had taken place but could not understand why noone had discussed this with them, as they visited nearly every day. Another resident reported that communication with relatives by staff tended to be by notes left on the resident’s table. The home has recently introduced relatives’ communication books in residents’ rooms to improve communication. We observed in one book that the relative had documented details of specific foods that the resident did not like. When we met with the cook, we found that the cook had no information on this. When we reviewed these communication books, we observed that staff did not write in them to respond to relatives. This was also confirmed by a relative who was not sure if their messages had been read. On both days of the inspection, we observed that several residents spent all of their time in bed. We asked a range of people why this was and for some residents, it was reported that this was due to their choice, but for others that they were cared for in bed as they had been at risk of coming out of the armchairs provided by the home. None of these residents had had an assessment by an occupational therapist relating to seating needs and the home does not have any Q-Foam chairs for people which conditions such as advanced Parkinsons Disease which can put them at risk of falling out of an easy chair. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 23 We asked staff how they ensured that residents were able to exercise choice. Staff reported that where they could, they asked residents what they would like to wear each day. One resident with complex communication difficulties had a care plan which stated how important their appearance was to them and we observed that they were dressed in stylish clothes and that the activities coordinator promptly changed their cardigan when they reported late morning, that they did not like it. Staff reported that due to the constraints of working in a home and necessary routines, that choice in when people got up and went to bed was difficult to manage. On the first day of the inspection, we observed a resident who had not had their breakfast by 10:25am. On the second day of the inspection, we observed one resident eating their breakfast in the dining room after 10:30am. One carer was observed to be told to do another task when a resident was half way through their personal care. We observed a resident who was not given a wash or assisted to get up during the morning. We also observed one resident being put back to bed in the late afternoon, who was informing the care assistants that they did not wish to do this at that time in the afternoon and would prefer to go later. During the short observation, we observed a carer asking a resident if they wanted a blanket, the resident replied that they did not, however the carer still put a blanket on the resident, which the resident shortly after the carer left the room, took off and rolled into a ball, placing it on the table in front of them. Several care assistants reported that such observations were not isolated occurrences and that due to the dependency of residents, there were occasions when residents were got up and put to bed in accordance with the home’s routines, not the individual’s preferred routine. In their AQAA, the home reported “A varied menu is provided and special diets catered for. Sufficient staff available to assist those residents who are unable to feed themselves. There is a weekly menu and residents have an alternative choice if required”. We asked residents how they liked their meals. Comments varied from “absolutely wonderful”, “I like the meals”, to “food sometimes nice, sometimes horrid” and “food on & off”. People also commented on choice and again comments varied from “you can have anything you like for your breakfast”, “pretty good food, you get a choice if you ask for it” to “food not bad, sometimes get a choice” and “set menu – there’s not much choice apart from what they have available”. Several residents commented on the temperature of the meals. One person reported “the other day the food was cold and I had to get them to heat it up again”. We observed on the second day of the inspection that a care assistant showed residents their meal before giving it to them and when one resident looked at what they had chosen and said they did not want it, that they gave the person the other choice of meal. During the second day of the inspection, we met with the catering assistant who was doing the cooking, as the cook was not on duty. There was a folder in the kitchen with recipes. The kitchen assistant described how they knew what people liked to eat. The recipe folder had information of likes and dislikes of Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 24 some people, but not others. It also contained details of Gluten free diet for a person who was no longer resident at the home and included papers headed with the previous owner’s name. There was information labelled “Dieting tips for Diabetics”. It was very generic and did not include no specific diets for people with diabetes. When asked, the catering assistant reported that the carers are aware of who was a diabetic. There was also a swallowing advice sheet on folder. This was also very generic, for example it stated re distraction – “Turn off TV”, “Avoid lumpy food – use very soft or mashed” with no specifics relating to the people living in the care home. The catering assistant reported that menus were in the process of being changed. We observed mealtimes on both days of the inspection. On the second day of the inspection, at 10:10 am we observed a resident still had their breakfast with them, they were not able to assist themselves to eat. The breakfast tray was observed to be taken away at 10:25am, with the breakfast cold and not eaten. Residents had their meals either in their own rooms or in one of the two dining rooms. On the first day, due to the lift being broken, meals in Comilla Wing were given in a room which had been temporarily made into a sitting/dining room, by the second day of the inspection, the lift had been repaired and meals were given in the dining room of Comilla Wing. Residents were observed to be placed in blue plastic aprons to protect their clothing when eating meals. We asked why residents were not given more appropriate clothes’ protectors. It was reported both that clothes protectors were available but that there were not enough of them to meet requirements and also that they had not been washed overnight. The effect the use of plastic aprons was that they did not always provide full protection to residents’ clothing. Particularly where a resident was confused and pulling at it. We observed on more than one occasion that residents pulled plastic aprons off and therefore food was dropped down the person’s clothing. We observed that when residents ate their meals in the dining rooms, meals were not given sequentially table by table. This meant that some residents sitting at a table finished their meal before other residents had been given their meal. We observed that where residents ate from a tray in their own room or one of the sitting rooms, and this included all of the residents in the temporary dining room on the first floor, that they were given all of their meal, on the tray, including their dessert. This meant that where residents were given a hot or a cold dessert that it became cold or warm respectively whilst they ate their main course. Other residents tended to eat their dessert before their main course, with the main course becoming cold and so they were less likely to eat the more nutritious part of their meal. There was a lack of supervision of residents in the dining rooms. On both inspection days, we observed that no members of staff were available to assist residents in the dining and sitting room of Countess Wing. We observed on the Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 25 second day that a resident had become tilted in their chair and was at risk of spilling their drink on themselves and would have done so if we had not supported them. They were also not able to reach all of their meal on their tray in front of them. On the first day of the inspection, there was no-one with residents in the temporary sitting room throughout the meal. One resident had a full plate in front of them, they appeared to have lost concentration, as there was no-one in the room to support them, their meal gradually became colder and less appetising. We observed a resident feeding themselves custard with a fork and therefore loosing most of it in the process. Another frail resident was pushing their food round their plate trying to cut it with a fork but gave the appearance of not being strong enough to do so. When we rang the bell to summon assistance, a carer did respond promptly and apologised, reporting that they were assisting a resident to eat their meal in their own room. There did not appear to have been any other staff allocated to this dining room. On the second day of the inspection a care assistant reported that they had been allocated to the dining room at Comilla Wing but they also had the role of going to collect the residents’ meals from the kitchen, so during this period, they had to leave the dining room unsupervised. There were eleven residents in this room, many of whom needed support. Observations included a resident who was given one of the first meals, who sat with their arms folded, looking elsewhere. This resident was able to feed themselves but by the time the care assistant was able to support them and remind them to eat, their meal was cold. Another resident was eating their food and at times spitting it onto the floor. We observed that another resident was not eating. When we asked them why this was, they said “I can’t get near it for the obstacles”. Their wheelchair was not pushed under the table and the resident was unable to move it themselves. Observations of lack of supervision in the dining room are of particular concern as many of the residents were assessed as having swallowing difficulties or being at dietary risk. If staff were not available to support a resident, they could have experienced chocking, with no-one there to take action to ensure their safety and they would not receive the meal that they needed, to reduce dietary risk. We observed variable practice when staff were supporting residents in eating meals when not in the dining room. At lunch-time, a resident was observed sleeping in the lounge. When they woke up, they were put in a blue plastic apron, which they immediately tore off. They were brought their lunch, which they spilled down their front. The resident was then observed to leave their food and suck on the buttons of their cardigan. This was not noted by staff until we approached them. A care assistant was observed feeding a resident, sitting down using the opportunity to chat and support the resident, as well as observing that they were swallowing safely. A care assistant was observed to offer a relative a cup of tea and ask if they wanted help with feeding their relative or not. However we also observed a registered nurse standing up to feed a resident, using a Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 26 large spoon, when the resident was assessed as having swallowing difficulties. The registered nurses was also not using the opportunity to chat with the resident. We also observed a care assistant standing up to feed a resident, blowing on the food on the spoon to make it cool. The care assistant was using dessert spoon, however the resident could not open their mouth enough for such a large spoon. In another observation, a resident was being fed by a carer, who used a large table/desert spoon, filled with food. This was pushed into the resident’s mouth, filling it entirely. One relative who visited regularly at mealtimes reported that they preferred to do this as they were not always sure that their relative was always given their meals otherwise. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 27 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 & 18 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. Residents will not be protected from harm and complaints will not be fully investigated. Where matters are identified inadequate action has been taken to ensure residents’ best interests. EVIDENCE: In their AQAA, the home reported on the “in house complaint system made available to all residents and their families. All complaints are investigated and acted upon promptly to ensure satisfactory resolution. Full complaints record kept in office”. During the inspection, we discussed with residents and their visitors about how they would raise issues of concern to themselves. A resident reported “I’d talk to one of the girls”. A relative reported that they had complained in the past but that nothing had happened. We looked at the complaints records. Complaints were kept in folder, they were not in date order. An audit of complaints, to identify any themes had not taken place. A range of issues relating to complaints were identified at this inspection. These included, among other areas, one complaint which did not document a resolution which had related to a relative reported to be asked to give their relative their medication and that wrong medications were given. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 28 The manager reported that they had tried to resolve the issue but that the relative had not responded to requests for a meeting. Due to the seriousness of the complaint, there needed to be evidence of full investigation, so that management could ensure themselves that registered nurses were undertaking safe practice in administration of medicines. We were aware that a particular visitor had made a complaint, as they had told us of this during the first day of the inspection. Their complaint was not included in the complaints records, although the prospective manager and the responsible individual were aware of the complaint and reported that they had taken action to investigate and take action on the complaint. In the manager’s daily notice for 5th August 2009, they reported on complaints from relatives about newly purchased residents’ clothing going missing. However none of these complaints were logged in the complaints records. In the minutes of the staff meeting, there was a record made that a resident’s family had complained about a hoist being left in the resident’s room all day as it gave it a cluttered atmosphere. We observed on the second day of the inspection that a hoist had been left in this room. This complaint and actions taken by management had not been documented in the complaints records. The home has a copy of the local safeguarding procedure and a copy of the “no secrets” booklet. The home’s files did not include a whistle blowing policy. This is despite a report of a manager’s visit of April 2009, where it was stated that the home needed a whistle-blowing policy. During the inspection, we observed a range of areas where residents were not being safeguarded from harm. Some of these related ensuring that residents were protected from risk of choking and pressure ulceration (see Health and Personal Care above), residents being properly supervised in sitting rooms and at mealtimes (see Daily Life and Social Activities above), that staff are properly recruited and trained (see Staffing below) and principals for health and safety up-held (see Management below). We observed that residents were not being safeguarded from other residents. Observations included at lunchtime in the first floor temporary sitting/dining room where we observed that a resident dropped the spoon they were eating with, both the resident and another resident bent between their chairs to pick it up. An altercation followed, one resident hit the other with the spoon, then the other grabbed it from the first resident and hit them back with it. We rang the bell for assistance and took the spoon away from the residents. A care assistant came quickly, however they had been in the middle of feeding another resident close by and not available to support residents in the dining/sitting room. On the second day of the inspection when member of staff was not in the dining room, a resident was observed swearing at another resident and aiming their fist at them. During our short observation we observed a confused resident repeatedly shouting at the resident next to them during the two hours of the observation, including pulling at the person’s Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 29 sleeve and on one occasion intentionally spilling juice over the arm of their chair. On another occasion, the resident removed a drink from a third resident. No staff were available to support residents or to protect residents from interference from other residents. During our observations in sitting and dining rooms we observed that residents were not left with access to a call bell and that none of the residents had devices such as pendants to summon assistance when they needed it. Several of the residents who spent all or much of their time in bed were not left with access to call bells. It is appreciated that some residents with dementia care needs may not be able to use a call bell and may need other supports. We looked at a care plan relating to safety for one such resident. The plan did state that the person was not aware of personal safety but did not indicate any actions to be taken to ensure that the person was safe. During our short observation, we assessed staff interaction with residents and noted that 68 of interactions were positive, however 21 were neutral, for example handing a cup of tea to a resident but not using the opportunity to engage with them and 11 were negative, for example putting a person who was asleep’s slippers on without conversing with them at all. We observed that many residents showed evidence of bruising on their limbs or body. This was supported by written evidence, where the manager’s daily notice for 3rd August 2009 stated that in July 2009, there had been 21records relating to skin damage. We are also aware that not all such incidents had been documented (see Management below). During our inspection, we observed some very poor manual handling practice (see Management below). Much of the bruising observed was consistent with poor manual handling procedure. The manager’s daily notice for 3rd August 2009 also documented 12 falls during July 2009. It is appreciated that older people do experience falls, however our short observation showed at least three occasions during two hours when residents had placed themselves at additional risk of falling but there were no staff with them to support them and prevent such an occurrence. We are also aware that at least one of the documented incidents related to use of safety rails and there was no evidence that the use of such rails had been properly reviewed over time to ensure the safety of the person. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 30 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, 22 & 26. 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. Residents will be supported by an environment which is maintained. However there are some deficits in equipment to meet the needs of people with disability. Systems for prevention of spread of infection are not safe and could present a range of risks to residents, visitors and staff. EVIDENCE: In their AQAA the home stated they “have a safe, well maintained home which meets both individual and collective needs”. They report that “new carpets laid for dining room in Comilla Wing and all corridors and stairs where carpets were worn out”. Camelot is divided into two wings. Comilla Wing is the larger building, parts of which are listed. The building has been used as a care home Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 31 for an extended period of time. Parts of the older building have been extended at different times. The passenger lift in the old part of the building was being mended on the first day of the inspection. There is also a lift in the newer extension to Comilla Wing as the first floors of Comilla Wing and this newer extension are not linked. Countess Wing is a new purpose-built building, across a garden area from Comilla Wing. Countess Wing is also over two floors with a passenger lift in-between. The garden area is very attractive, with raised flower beds and a fountain, and paved areas suitable for wheelchairs. Comilla Wing has a large sitting room, a dining room a quiet lounge and a conservatory sitting room. Countess Wing has an “L” shaped sitting room and a small dining room. The kitchen for the home is provided in Comilla Wing, with a support kitchen in Countess Wing. The main laundry is in Countess Wing, with a small support laundry in Comilla Wing. We toured all of the building during the inspection days, met with the maintenance man, the laundress, a cleaner and a bank cleaner. The bank cleaner reported that they had all the chemicals that they needed to perform their role. The laundry was clean throughout, including the areas behind the washing machines and dryers. No issues relating to general maintenance were observed, apart from on the first floor sluice room in Comilla Wing. The prospective manager reported that this had been identified and a new bed-pan rack was on order and repairs to the grouting round the hand wash basin were planned. All the bath hoists were clean at the back and on their undersides. As noted in Health and Personal care above, the home was not observed to have any Q-foam chairs for people with complex seating needs and very few recliner chairs and this may account for why so many residents spent all their time in bed. Additionally, whilst they had a few profiling beds, most of the beds were hospital-style variable height beds with non-integral bed rails. In order to prevent risks associated with the use of bed rails, where a person is at risk of falling out of bed, it is preferable for a person to be cared for in a profiling bed, which can go down to the floor, to reduce the risks associated with the use of bed-rails. The home has a range of hoists available to support residents with manual handling needs. Several of these hoists were not clean, particularly in their bases, showing deposits and debris. As hoists may go to any area of the home, they can present a risk to cross infection, therefore they must be clean at all times. We discussed this with a registered nurse who reported that care staff have been instructed to clean hoists after use. We did not observe care staff cleaning hoists after use. We discussed lifting slings with several staff. They reported that slings were allocated to residents if they have infections but otherwise they were used communally. Frail elderly people may have infections, but have them sub-clinically, so that the home are not aware of the inspection. Communal use of slings therefore presents a risk to cross infection and all hoist slings need to be allocated to one resident, named for them and Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 32 regularly laundered. We looked at equipment used in care such as commode chairs, pressure relieving equipment, safety rail bumpers and residents wash bowls. We noticed a variability in standards of cleanliness. Whilst some were clean, others were not, including dried-on brown matter on pressure relieving cushions, a commode bucket with yellow staining in it and an armchair in a communal room with a round brown stain on its chair cover. This may present a risk to cross infection and also does not support residents’ dignity. Clear systems need to be put in place to ensure that all items used in care are free of debris and clean. Several of the carpets in residents’ rooms and the sitting room in Countess Wing were not clean, showing obvious signs of staining. There was no odour. These stains detracted from the appearance of the rooms and did not support a homely appearance. The home needs to further develop its systems to ensure that equipment needed to prevent risk of spread of infection is available across all of the home. During the inspection, we found several soap dispensers at wash basins across all of the home which did not have any soap in them. In some places, small non-wall mounted soap dispensers had been provided but this was not the case in all areas. This is a risk to cross infection as people will not be able to properly cleanse their hands when needed, particularly after providing care. In Countess Wing, we observed that the paper hand towels provided did not fit the hand towel dispensers, so paper towels had been placed in a pile on a surface. This is a risk to cross infection as any water dripped from washed hands has the potential permeate through several layers of towels and may contaminate all of them. As noted in Health and Personal Care above, some prescribed items for one resident were being used for other residents. This included jars of topical creams. In other cases jars of un-named creams were placed in resident’s rooms. Communal use of jars of cream is a well documented risk to cross infection and the home needs to develop systems to ensure that this risk is reduced. We observed practice in relation to potentially infected items. On the second day of the inspection, there were two open yellow bags (bags for infected items) placed on top of the external clinical waste bin. Yellow bags must always be secured and placed in the clinical waste bin to present risks presented by infected materials. We discussed this matter with the maintenance man who informed that that this was not an isolated occurrence. Such practice has also been identified by the prospective manager in their daily notice of 7th August 2009. Management should therefore have taken steps to ensure safe practice in handing of clinical waste before the inspection. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 33 We were also concerned about practice in relation to potentially infected laundry. During our inspection, we observed that used laundry from a person with MRSA had been placed in an ordinary laundry bin and so would not be washed separately under sluice wash conditions. At lunchtime on the first day of our inspection, we observed red alginate bags for potentially infected laundry bulging out of the red bag skip onto the floor in Comilla Wing. At the end of our first day of inspection, we observed laundry in Countess Wing, “boiling out” over the edge of a laundry bag on to the floor. Such practice presents risks to cross infection and presents a hazard to staff as well as residents. We observed practice and discussed infection control with staff. One care assistant reported that when applying topical applications from jars, they always changed their gloves after washing the person and before putting their fingers in the jar to apply the cream. A care assistant was also able to describe in detail how they ensured that wash bowls and toiletries were not used communally in shared rooms. However this was not reflected across all staff. We were informed by a cleaner that they had been instructed to change mop heads weekly, using red mops for the clinical room, sluice and bathrooms, blue for residents’ rooms. This does not conform to current guidelines where mop heads need to be laundered or changed at the end of the day and stored dry. Mops for clean areas such as clinical rooms must not be used in dirty areas such as sluice rooms. We observed a care assistant come out of a resident’s room carrying a red alginate bag for infected laundry, the bag had split in it and the care assistant was not wearing gloves. The care assistant proceeded to push the bag firmly into the red bag skip and thus widen the split. After this, they did not wash and dry their hands. We also observed in Countess Wing that a pile of different hoist slings had been left on a surface jumbled together. Such practice does not support prevention of spread of infection. We asked about cleaning schedules. The prospective manager reported that their housekeeper managed this area and that they were not on duty on either of the inspection days. We advised that any cleaning schedules needed to be in writing and regularly reviewed as part of the home’s quality audit. We looked at induction and training records for all staff in relation to infection control (see Staffing below) and they did not provide evidence of recent training in the area in principals of prevention of spread of infection. Practice in this area will be improved if such training is progressed. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 34 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, 28 & 30 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. Residents will not be supported by the number and skill mix of staff. Staff have not been safely recruited or trained in their role. EVIDENCE: In their AQAA, the home reported “staffing level and skill mix are appropriate and we have a stable staff base that support each other and provide good quality care”, “mandatory training for all care staff”, “recruitment procedures follow requirements to protect residents” and “new staff complete induction training”. They reported that 75 of care staff are trained in or are training for National Vocational Qualification Level II. A number of people responded to us in questionnaires. One person reported that the home needed to “employ more staff!!”, another “shortages of staff happens quite often” and another “provide more staff to meet individuals care needs”. We discussed staffing levels with residents and visitors. One relative reported “they’ve been short-staffed” and another “lack of staff”. We discussed response times when residents used the call bell. One resident reported “ring bell, not too bad at coming but I wouldn’t say they were quick”, another Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 35 “sometimes quick and sometimes a long time”, another “hope staff will come when I ring my bell” and another “going downstairs is worse – left alone and can’t communicate – no pendants or anything”. On the second day of the inspection, we rang a resident’s bell at 10:15 am on their behalf and no member of staff attended for seven minutes. As Camelot is a care home with nursing, where people may have complex medical needs which may require prompt attention, seven minutes before a resident is checked on is a longer than anticipated period to ensure that a resident is not experiencing a medical emergency. During our short observation, we observed that staff were only interacting with residents for 19 of the possible time frames. When this was broken down 50 of the interactions related to one resident. During this time, we also observed a resident who was not part of the short observation, asking for the toilet but they had no means of summoning assistance and no members of staff appeared to be available to hear them, although their voice was audible. They were eventually responded to and supported by the activities coordinator, who had other roles to perform. As documented in outcome areas above, we made a range of observations which indicated that residents were left unsupported for extended periods of time, which could have compromised their safety. There was no evidence that additional staff had been rostered on duty to ensure resident safety during the period when the lift was out of order in Comilla Wing and a temporary sitting room had to be provided on the first floor for the residents living there. In their AQAA, the home reported that reviews of staffing levels have relied on residential forum guidelines. They appeared to have used this tool without taking into account the additional needs presented by frail people, particularly people with dementia and those who are dying. They also reported on a dependency tool which they had introduced. We reviewed a range of these dependency tools and identified that many had not been completed correctly. For example, one person’s dependency stated that they were uncomplicated and at low risk of complications, when the resident had very limited communication abilities and therefore would be highly complex to care for. They had been assessed as having a very high risk of pressure ulceration and therefore would have a high risk of complications. Another resident’s dependency stated that mechanical/technical assistance was intermittently needed, however the person needed a hoist/slide sheet for all movements. It also stated that their condition was relatively uncomplicated, when the person had complex dementia care needs, highly limited communication abilities and was cared for the whole time in bed. We discussed the dependency ratings with several registered nurses, who reported that they had had no training in how to complete them. This evidence indicated that the provider needs to revisit their reviews of staffing levels, to ensure that staffing levels relate to actual resident dependency, the home environment and the number of resident with complex dementia care needs. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 36 Discussions with staff also indicated that there had been a reduction in laundry hours, as a previously employed weekend person had not been replaced. This meant that either weekend and night staff had to perform laundry, as well as caring duties or there was additional workload for the laundress when they next came on duty. The activities coordinator works 30 hours a week. For a 57 bedded unit, this works out to an average of only 32 minutes per person per week to support them in activities. Considering so many of the residents have additional dementia care needs, 37 minutes per person per week is unlikely to support them. During the inspection, we tried to review past rosters to review staffing levels and sickness rates. Unfortunately it was reported that rosters were currently at the provider’s main office, so we were unable to review it to assess staffing levels prior to August 2009. The home are advised that off-duty rosters need to always be available in the home for inspection. We looked at records relating to four newly employed staff. All people had a proof of identity on file, including a photograph. One person had only one reference on file, their other reference was a “to whom it may concern” reference. This is not acceptable. References must be directly sourced. Another person had two references on file but due to the nature of the reference format used, it was not possible to assess who the referee was and if they were a relevant person to comment on the prospective member of staff’s suitability. Also one of these two references had not been completed in full. A third person’s references were also not fully completed. A fourth person had a letter from a person stating who the person was. This is not a reference. The person’s other reference had been only signed and dated with none of the sections completed. The prospective manager was able to advise us of why this was, however this was not documented in the person’s interview assessment and no action plan was developed in relation to this. This is not satisfactory. All people must have two clear satisfactory references on file, which have been directly sourced. There must be evidence that any discrepancies in this must be probed and relevant actions taken. Two people had full employment histories on file, however one did not. Another person’s application form was not fully completed, included no previous employment. These matters were not probed at interview. One person’s interview assessment indicated that their communication was limited but there was no action plan on their file as to how their communication skills were to be improved and supported once in post. Two peoples’ past experience indicated that they had not worked in a caring role previously but there was no action plan as to how they were to be supported into a role new to them. One person’s reference showed that they were to continue to work elsewhere in a “sleeping in” role. This was noted at interview but no further details documented, such as how many hours they worked and arrangements for ensuring that they would be safe in their current role. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 37 One member of staff’s reference stated that they had left their role as they were “unable to lift heavy items”. There was no evidence that this was probed at interview as such a difficulty in a care home with nursing m ay have implications for a person’s suitability for their role. The home has a medical questionnaire but it only asks about the person’s back, not their neck, this is despite directives from the home’s insurers of 24/2/09. Three of the people had commenced work after their protection of vulnerable adults clearing had been received and before their Criminal Records Bureau (CRB) was received. Our Regulations state that homes may do this, but if they do, the person must work fully supervised until CRB clearance is received. There was no evidence that this was taking place in practice and on the second day of the inspection, we observed one of these new members of staff working without any supervision. One of the newly employed members of staff was a registered nurse. Whilst the home had a record of this person’s pin number, there was no evidence on file that they had met with NMC guidelines on verifying that the person was currently registered with the NMC to practice as a nurse. We looked at inductions. In their AQAA, the home documented that they provide “induction for all staff”. Only one of the four staff files looked at included a record of induction. This person’s induction indicated that they had performed the whole of their induction on one day. It had not been signed by the inductee. Considering the range of areas covered in the home’s induction, it is unlikely that the induction could have been performed in any depth to support practice if all areas had been covered on one day. In the minutes of a staff meeting dated 26/5/09 a staff member was documented as stating that they had not yet done their induction, despite working in the home for six months. The home is using agency staff. We asked about inductions for agency staff. It was reported that agency staff were inducted into the home but there was no written evidence that this was the case. Several staff commented about training in questionnaires. One person reported that “staff training programme is well thought out”, another “although the people may have up-to-date training and practice it is not followed through”, another “staff training is important but would be better if this could be done in working hours” and another “variation of training days to ensure available to all”. We looked at training records. These showed that during the past year, 13 nursing and care staff had not received manual handling training and 21 had not received safeguarding training. None of the domestic staff had received infection control training during the past year. The prospective manager reported that some of the records may not be up-to-date. It is appreciated that the provider had only recently purchased the home, that the prospective manager had only recently come in post and the previous provider’s training Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 38 manager may not have passed on all their training records when the home was purchased. We advised them that an effective system would have been to have considered staff training, commencing with a review of needs and deficits and then develop an action plan to address these deficits. For example, they had not identified if registered nurses had been trained in extended roles such as syringe drivers and male catheterisation, although they cared for people with such nursing needs. They needed to consider areas of training to meet needs such as care of people who have had a stroke, management of care for people at risk of choking and aggressive behaviours. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 39 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, 35, 37 & 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. Residents’ health, safety and welfare will not be fully protected by the home’s management and administration systems. EVIDENCE: The previous registered manager for the home left soon after the new provider took over the service. The provider has appointed a person to the home manager’s post, they have not yet been assessed by us in accordance with our procedures as the Registered Manager of the home. In their AQAA, the home reported “residents’ safety and welfare are promoted”. Some people Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 40 commented to us in questionnaires about the management. One person commented “I am very happy here at Camelot. More so now that a new management team is in place who are truly dedicated to the care of the elderly and the staff” and another “[first name], new manager started about 7 weeks ago, I feel [the person] will be a great asset to Camelot for residents and staff”. Other people were not so confident. One person reported that the new management team ran the home “as an institution”, another that the new management had introduced “no choice all set times” and another that the residents “feel it is no longer their home”. We discussed systems for audit of quality of service with the provider. A manager from the provider performs monthly written reports into the conduct of the service, as we require. Reports seen notes activities provision and that carpets had been replaced in Comillla Wing living room and most corridors. It is understood that the providers are planning to introduce standard systems for assessing feedback on quality of service provision, including questionnaires. They reported that they had already commenced this process by introducing residents, relatives and staff meetings. We discussed clinical audit with the manager and advised that this needs to be progressed. For example we asked her on the first day of the inspection about how many residents had pressure ulceration - a key clinical area. They were not aware and did not have a documentary system to inform them of the numbers of residents with pressure ulceration on a regular basis. We also asked them how many people had a dual diagnosis and they replied that they were aware of one person who had a dual diagnosis of both physical and dementia care needs. This inspection showed that there were far higher numbers of residents with a dual diagnosis and we would have anticipated in a care home that this would be a key area for the manager to have a detailed awareness, as such clinical issues have implications for resident safety, staffing levels and staff training. The manager has introduced a daily notice for staff, which they put up in the staff room, to inform staff of positive points and points for action. We reviewed several of these notices. The notice for Thursday 9th July 2009 noted a fire door held open, the notice for 3rd August 2009 noted the number of accidents and skin damage to residents, the notice for 5th August 2009 noted issues relating to infected laundry and for 7th August 2009 that clinical waste bags were not being tied and that a resident was got up later in the morning than they or their family wished. On the first day of our inspection, we observed a fire door held open by a chair for the whole of the inspection. On the second day of the inspection, we observed that a resident did not have their wash or get up until late in the morning, contrary to their wishes. Issues relating to falls, observed skin damage and inappropriate handling of clinical waste are dealt with in other sections of this report. The inspection indicates that such issues as reported by the manager in their daily notices continue to Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 41 be on-going and that therefore management needs to consider how they will ensure matters are progressed. As noted elsewhere in the report, not all records such as staff duty rotas were available for inspection. Other records which were in place had not been dated or signed or completed in a prompt manner. Maintenance of records is a key area as they provide evidence to us that the home is complying with our guidelines and Regulations. We looked at systems for management of residents’ own moneys. The new provider reported that they were planning to move to a full invoicing system for residents’ moneys, as they did in their other homes. We observed that with the current system, all residents had their own record of moneys paid into individual accounts and of their moneys paid out. Some of the moneys paid out were supported by receipts, others were not. The home also does not routinely give receipts when moneys are paid into a person’s account. There was no system for receipts when residents’ valuables are handed in or given back, although there were sealed envelopes in the home’s safes indicating that residents’ valuables were being stored in them. One of the two safes was not secured. The provider reported that security of this safe had been identified as an issue and there was a plan in place for it to be addressed. The home therefore needs to establish a full audit trail for all matters relating to residents’ moneys and valuables. We observed a letter from the home’s insurance company effective of 17/3/09. This included five directives and a recommendation. There was no written evidence that all the required actions had been carried out. This inspection shows that some requirements, for example relating to staff training may not have been addressed within the insurer’s compliance dates. The kitchen was clean. Different coloured chopping boards were all present but there was no signage to detail usage. The panel covering the boiler was falling off the wall and being held up by the chopping boards. The store cupboards were well organised, as well as dry goods store. We did observe a care assistant enter the kitchen without apron, but they were noted by a senior carer and told to go and put an apron on. The panelling on one wall of the wash-up area was loose. Issues relating to signage and loose panelling will be referred to the Environmental Health Department, as they take the lead in this area. During the inspection we observed staff performing manual handling and were concerned about what we observed. On one occasion two members of staff were assisting a resident to move from a wheelchair to an easy chair using a lifting belt. They did not use the belt correctly to assist the person. On another occasion one carer assisted a person to move using a hoist. Where people need to be moved using a hoist, two people must always perform this task to ensure the safety of the resident and themselves. The carer was aware that Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 42 there needed to be two people to use a hoist but reported that they could not wait for a second carer. As a result the resident was not safe and their dignity was not respected. We observed two carers support a resident who was sliding out of their chair. They each put an arm under the person’s arms and legs and bodily lifted them. This is unsafe practice for both the resident and staff. As well as observing such matters, we also observed staff lifting and tilting the rear ends of wheelchairs with residents in them, to manoeuvre them. This is also unsafe practice. As noted in Staffing above, the home could not evidence that all staff had been trained in manual handling during the past year and this may explain why poor manual handling was observed. We were also particularly concerned about poor manual handling practice, as we observed high rates of bruising on residents and some of these bruising could have been caused by poor manual handling practice. The home needs to ensure safety in the storing of oxygen cylinders. Oxygen cylinders, by their shape, can topple easily if they are not securely stored. If they do topple, as they are heavy they can cause injury and additionally can present a risk of explosion. Therefore they must either be placed in an Oxygen carrier or be secured to a solid wall. We observed that the home uses bed rails. The home does have a few profiling beds, but these were not being used in their lowest position so as to avoid the use of bed rails. All other residents who were cared for in bed had non-integral safety rails. None of the rails we inspected were safe. All were mobile in their sockets and many had a significant gap between the bed rail and the head of the bed. This is a risk as a person’s head and or limbs can become entrapped. Some people who had an air mattress in place also had bed rails and this had raised the height of the mattress, so that there was a risk that the person could come over the top of the bed rail. Most residents who had bed rails had bumpers on them to provide protection to the person from contact with the rail, however several of the bumpers did not fit the rail and so could provide a risk to people. People did have care plans relating to the use of safety rails, however they were not being used to review their safety. For example one residents’ care plan evaluation stated that their bed rails were in “good order” when a visual inspection showed that they were not. The care plan also did not consider the risks to the person presented by the use of bed rails or of any other systems which could be used to improve the person’s safety. The maintenance man has the responsibility of checking bed rails but they have not been trained in this role. We observed that while some people had been left with access to the call bell in their rooms, many of the call bell cords were trailed across the room, as the cord was not long enough. On more than one occasion these cords were at calf-height and so could present a serious tripping risk. On the first day of the inspection, the home had had a delivery of continence aids and the conservatory was taken up with these boxes, which were observed to be moved manually by the kitchen assistant towards the end of the day. We also Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 43 observed a registered nurse moving a delivery of disposable gloves using a wheelchair. The conservatory room was hot when the sun came out. These observations and others indicated that we needed to look at the home’s environmental risk assessments in such areas as these. The home has not yet drawn up environmental risk assessments for the areas described above, and other areas, to ensure the safety of residents, visitors and staff. They were advised that under Health and Safety legislation, they had a duty to assess risks and if risks were identified by the home environment that they needed to draw up action plans to ensure that risk was reduced. We looked at the home’s accident records and observed that some serious incidents involving residents experiencing falls which had been reported to us, were fully documented in accident records. However we are also aware that some other accidents to residents, which were not of such a serious nature but still needed reporting, had not been. For example one relative reported to us on an injury sustained by their relative during manual handling but no record of this had been made in the home’s accident book, although they reported they were receiving regular dressings to the area by registered nurses. We are concerned about the range of deficits relating to health and Safety identified during this inspection. We will report these matters to the Health and Safety Executive, who are the lead agency in care homes with nursing. The fire log book did not show any evidence that staff had been trained in fire safety, this included newly employed staff and agency staff. There is a fire risk assessment on file. There is also a fire safety audit, dated 25/09/08 with a list of faults and/or actions needed. There were no actions recorded and no signatures. Fire checks were performed regularly, but there was no evidence of recent drill at Countess Wing since 25/02/09. Two folders are used, and new and old information is in both, which makes audit complex. There is a fire risk assessment form on file. The form uses a severity vs likelihood scale to assess risks. Some risks had been identified as severity = fatal, but were still classed overall as “Low” risk. No actions were recorded as to how risks were to be minimised. Matters relating to fire safety need to be revised, to ensure that they conform to fire brigade directives. This matter has been reported to the Wiltshire Fire brigade. Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 44 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 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 2 3 x 2 x x x 1 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x 2 x 2 1 Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 45 Are there any outstanding requirements from the last inspection? N/A 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 OP1 OP3 Regulation 5(1) 14(1) Requirement The service users’ guide must include the home’s fee range. A full assessment of all of a person’s needs must always take place prior to or on admission. A person must not be admitted unless the home can demonstrate that they have suitably qualified staff to meet the person’s needs. Personal details relating to a prospective resident must be kept confidential. All residents’ assessments must be accurate. Assessments must be reviewed when a resident’s condition changes. Where a person is assessed as having a risk or a need, a care plan must always be put in place. The care plan must include all relevant matters for the individual, including recreational activities, as well as personal and health care needs. Care plans must be reviewed and up-dated when a person’s condition changes. DS0000073153.V376062.R01.S.doc Timescale for action 30/09/09 30/09/09 3. 4. OP3 12(4) 14(1) 30/09/09 30/09/09 OP7 5. OP7 15 30/09/09 Camelot Care Homes Ltd Version 5.2 Page 46 6. OP7 12(1) 7. OP7 12(1) 8. 9. 10. 11. OP8 17(1) 13(2) 13(2) 13(2) OP9 OP9 OP9 12. OP9 13(2) 13. OP9 13(2) 14. OP10 12(4) Where a resident is not able to perform activities of daily living such as changing their position or giving themselves a drink or a meal, monitoring charts must always be put in place to ensure that the home can demonstrate that peoples’ needs are being met. Monitoring records must be accurate and provide evidence that care plans are being followed. The home must ensure that nursing and care staff are fully aware of residents’ individual and health care needs as set out in their plans of care and that they comply with the directions in plans of care. Registered nurses must ensure that all required records relating to clinical issues are maintained. Prescribed items must be in date and only used for the person they are prescribed for. Medicines trolleys must always be fully secured. Registered nurses must administer prescribed medication as directed on the resident’s medicines administration record. If they do not do this for a reason, the reason must always be documented. Where a resident is prescribed a medication on an “as required” basis, an individual care plan or protocol must always be drawn up. All Controlled Drugs must be managed correctly. Records relating to Controlled Drugs must be accurate. The home must ensure that residents’ privacy and dignity is respected at all times. Where a resident has complex behaviours which may not make them aware DS0000073153.V376062.R01.S.doc 30/09/09 30/09/09 30/09/09 30/09/09 30/09/09 30/09/09 30/09/09 30/09/09 30/09/09 Camelot Care Homes Ltd Version 5.2 Page 47 15. OP14 12(2) 16. OP16 22 17. OP18 13(4) 18. OP18 13(6) 19. OP22 23(2) 20. 21. OP26 OP26 13(3) 13(3) of such needs, they must ensure that staff meet such needs on the resident’s behalf. Residents must have effective personal care provided, to ensure that they are in a clean condition. All clothing and bed linen must be clean and free of debris and staining. The home must ensure that there is evidence that residents are able to exercise choice and supported in doing so. The home must always comply with its own complaints procedure and ensure that all complaints are documented, that there is evidence of investigations and of actions taken, where indicated. Care plans relating to personal safety must include an assessment of how a person can be enabled to summon assistance. Where a person needs assistance to do this, the plan must state how the person is to be supported, including any relevant aids. There must be evidence that all staff who have contact with residents have been regularly trained in their responsibilities for safeguarding residents and protecting them from abuse. Where the home does not provide equipment for residents who may not be safe in chairs provided by the home, an assessment of seating need must be performed by an appropriately qualified person and where recommendations are made, appropriate seating be provided All equipment used in nursing and care must be clean. All equipment, chemicals and DS0000073153.V376062.R01.S.doc 30/09/09 30/09/09 31/10/09 31/10/09 30/11/09 30/09/09 30/09/09 Page 48 Camelot Care Homes Ltd Version 5.2 22. 23. OP26 13(3) 13(3) OP26 24. OP27 18(1) 25. OP29 19(1) 26. OP29 19(1) 27. OP29 19(11) 28. OP30 18(1) 29. OP30 18(1) disposables needed to prevent risk of spread of infection must be provided in all areas of the home where personal care is provided. Systems must be put in place to prevent the communal use of items used in personal care. The home must ensure that all clinical waste, potentially infected laundry and general laundry is correctly managed. The home must ensure that there are enough staff on duty at all times to meet residents’ nursing and care needs and that residents are supervised when in communal rooms, so that they are fully supported and not put at risk. The home must ensure that it follows standards and regulations on the employment of staff in full at all times, including the employment of registered nurses. Where issues are identified in relation to employing staff, the home must document these and set out actions plan(s) as to how any risks identified by the employment of certain members of staff are to be fully reduced. All newly employed staff must always work fully supervised during the period between when a pova clearance has been returned and receipt of a clear CRB record. The home must ensure that it can provide evidence that all newly employed staff, including agency staff, have been fully inducted into their role. The home must ensure that it can demonstrate that all staff have been trained in all relevant areas relating to meeting the DS0000073153.V376062.R01.S.doc 30/09/09 30/09/09 31/10/09 30/09/09 30/09/09 30/09/09 30/09/09 30/11/09 Camelot Care Homes Ltd Version 5.2 Page 49 30. OP31 24(1) 31. OP31 8(1) 32. OP33 24(1) 33. OP35 17(2) 34. OP37 17(1) 35. OP38 13(4) 36. 37. 38. OP38 13(4) 13(4) 13(4) OP38 OP38 39. OP38 13(4) range of different residents’ nursing and care needs. Managers of the home must ensure that they have effective systems in place to ensure that when they identify deficits in service provision that they are acted upon. The provider must ensure that they apply to us for a “fit person” to be the registered home manager. As Camelot is a care home with nursing, systems for audit of quality of clinical outcomes for residents must be developed. The home must have a full audit trail of moneys and valuables handed in to the home for safekeeping. Records must be backed by receipts. The home must ensure that records required by us are always available in the home. And records relating to nursing and care must be dated and signed by the person completing the record. There must be written evidence that all relevant staff have been trained in areas relating to ensuring the health and safety of people, including manual handling and infection control. All staff must perform safe manual handling practice at all times. All Oxygen cylinders must be fully secured. Where bed rails are used, there must be a full written assessment of the need for their use, which is regularly reviewed. All bed rails must be safe and not present a risk to the resident. The home must develop full environmental risk assessments DS0000073153.V376062.R01.S.doc 30/11/09 31/10/09 30/11/09 30/09/09 30/09/09 30/11/09 30/09/09 30/09/09 30/09/09 30/11/09 Page 50 Camelot Care Homes Ltd Version 5.2 40. 41. OP38 17(1) 23(4) OP38 for practice and management of the home. Where risks are identified, a plan must be put in place to demonstrate how risks presented by the environment have been reduced to a minimum. The home must ensure that all accidents are fully documented in accident records. The home must be able to evidence that it is complying with regulations from the fire brigade. 30/09/09 31/10/09 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. 4. 5. Refer to Standard OP7 OP8 OP9 OP9 OP9 Good Practice Recommendations Care plans should use clear and measurable language. The clinical reason for use of a urinary catheter should always be documented. Registered nurses should follow current clinical guidelines on sites for injection. Where residents not longer need their medication on a regular basis, the prescriber should be approached and asked to change the prescription. Where residents are prescribed a medication which can affect their daily lives, such as a mood-altering drug, a care plan should be drawn up, so that the affect of such regular prescriptions can be assessed. The home should fully review and up-date its homely medicines policy and ensure that there is evidence that residents’ GPs have agreed to it. The home should provide a new Controlled Drugs register. Staff should always call residents by their proper or preferred name, generic terms of endearment when addressing residents should be avoided. Residents’ clothes should be cared for in such a way that residents are not dressed in creased clothing. DS0000073153.V376062.R01.S.doc Version 5.2 Page 51 6. 7. 8. 9. OP9 OP9 OP10 OP10 Camelot Care Homes Ltd 10. 11. 12. 13. 14. OP11 OP12 OP12 OP12 OP13 15. 16. OP15 OP15 17. OP15 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. OP15 OP15 OP16 OP19 OP26 OP30 OP30 OP38 OP38 OP38 End of life care plans should be put in place when people are dying. Staff should take into account residents likes and preferences when putting the television on in sitting and other rooms. The home should further develop systems so that more trips out of the home are arranged for residents. Full records of profiles of residents’ past lives should be maintained. The home should further develop its communication systems with relatives and visitors and ensure that all notes in communications books in residents rooms are responded to and information passed on to relevant people in the organisation. Residents who need to be given a liquidised meal should be offered a choice of meal. Staff who feed residents should always sit down to assist them to eat, to ensure that they can observe that residents are swallowing safely and to support the normality of mealtimes. The home should assess why residents are not provided with appropriate clothes protectors when eating their meals and ensure that appropriate action is taken to meet residents’ needs. When serving meals in the dining room(s), meals should be served table by table by table. When residents are served meals on a tray, their desserts should not be served with their main meal. Complaints should be maintained in date order and should be regularly audited as part of the home’s quality audit systems. All staining should be removed from carpets in residents’ rooms and communal areas. Jars of topical cream should be labelled with the person’s name. Registered nurses should be trained in how to assess dependency needs and correctly complete the home’s dependency tool. The activities coordinator should be provided with relevant training in their role’ to support their practice. The home should provide more profiling beds which can go down to the ground and use them effectively, to reduce risks associated with bed rails. All people who use, fit and check safety rails should be fully trained in their use. The fire safety records should be reviewed, to ensure that they are less complex to audit. DS0000073153.V376062.R01.S.doc Version 5.2 Page 52 Camelot Care Homes Ltd Camelot Care Homes Ltd DS0000073153.V376062.R01.S.doc Version 5.2 Page 53 Care Quality Commission South West Region 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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