Inspection on 24/02/10 for Castle Keep Nursing Home

This inspection was carried out on 24th February 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Castle Keep Nursing Home 03/05/07

Castle Keep Nursing Home 07/02/06

Castle Keep Nursing Home 22/09/05

Castle Keep Nursing Home 08/03/05

Castle Keep Nursing Home 31/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/04/2010.

Key inspection report Care homes for older people Name: Address: Castle Keep Nursing Home Noddle Hill Way Sutton On Hull East Yorkshire HU7 4FG     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Beverly Hill     Date: 2 4 0 2 2 0 1 0 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 40 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. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 40 Information about the care home Name of care home: Address: Castle Keep Nursing Home Noddle Hill Way Sutton On Hull East Yorkshire HU7 4FG 01482372402 01482835651 castlecare@barchester.com www.barchester.com Barchester Healthcare Plc Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Carol Sarel Type of registration: Number of places registered: care home 58 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: None Date of last inspection Brief description of the care home Castle Keep is a purpose built, single storey building providing nursing and personal care for male and female residents over the age of 65years. The home is also registered to take up to eight people under the age of 65years. The home is divided into two parts; a Nursing unit called Nightingdale, and Willow for people with dementia care needs. Castle Keep is one of four homes on a site called Castle Care Village, which is owned by a large national company - Barchester Healthcare plc. The home is situated within a residential area and close to bus routes into Sutton and Hull. Care Homes for Older People Page 4 of 40 Over 65 58 58 58 0 0 8 Brief description of the care home The home has up to fifty-eight placements within single and shared room accommodation. Thirteen bedrooms on Willow and one on Nightingale have en-suite facilities. There is a lounge/dining room on each of the units in which people can relax and enjoy the company of others. The home provides an additional lounge for activities. Residents also have access to the spacious grounds at the home, which are designed to be accessible to those in wheelchairs and with mobility problems. There are three bathrooms and two shower rooms and sufficient toilets throughout. Information about the home and its service can be found in the statement of purpose and service user guide, both these documents are available from the manager of the home, and copies are given to every new resident. The latest inspection report for the home is on display in the entrance hall and copies are available from the manager on request. The homes weekly fees range between £465 and £922 and is dependent on the level of need. Residents will pay additional costs for optional extras such as hairdressing, private chiropody treatment, toiletries and newspapers/magazines. Information on the specific charges for these is available in the service user guide, contract or from the manager. Care Homes for Older People Page 5 of 40 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 0 star. This means that some people that use this service experience poor quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last Key Unannounced Inspection on 3rd May 2007 and two Annual Service Reviews on 16th June 2008 and 22nd April 2009. It also included a site visit to the home by two inspectors Bev Hill and Angela Tew, which lasted approximately ten hours. We had received a complaint regarding shortfalls in staff training and a lack of stimulation and attention to personal care in the dementia care side of the home. This was referred to the local authority to investigate but we also decided to bring forward the Key Unannounced Inspection. Care Homes for Older People Page 6 of 40 Throughout the day we spoke to people that lived in the home to gain a picture of what life was like at Castle Keep. We also had discussions with the Regional Operations Director, the Registered Manager, staff members and three relatives. Information was also obtained from surveys received from residents (some of which had been completed by their relatives), staff members and a health and social care professional. Comments from the surveys and discussions have been used in the report. During our discussion with the Regional Operations Director, it became apparent that he had recently been made aware of some of the shortfalls that we have highlighted in the report and had put an action plan in place, that included input from a support network within the company. He, and other senior managers we fed back to, were very clear that they wanted to address the shortfalls quickly. This is very positive and shows that the company want to work with the Care Quality Commission to improve the quality of life for residents in the dementia care side of the home. We looked at assessments of need made before people were admitted to the home, and the homes care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. We also checked with people to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. We observed the way staff spoke to people and supported them, and checked out with them their understanding of how to maintain privacy, dignity, independence and choice. Inspector Angela Tew carried out a Short Observation For Inspection (SOFI) for two hours in the dementia care side of the home. We wanted to check out the level of stimulation and interaction residents had with staff and also look for signs of wellbeing. The information from the SOFI has been used in sections of the report. The providers had returned their annual quality assurance assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We would like to thank the people that live in Castle Keep, the staff team and management for their hospitality during the visit, and also thank the people who completed surveys and had discussions with us. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Care Homes for Older People Page 7 of 40 What the care home does well: What has improved since the last inspection? What they could do better: The in-house assessments, carried out prior to admission, need to be completed fully. This will enable staff to have full information about the potential residents needs so a decision can be made as to whether the home can meet their needs. The way the home writes risk assessments, care plans and behaviour management plans could be improved so that they contain the most up to date and accurate information about people. This will ensure staff have all the information they need to care for people and will help to avoid important care being missed. The way staff record the care provided could be simplified. There were several recording systems in place and Willow and Nightingale used different methods. Monitoring charts also need to be recorded with full details of, for example, the food and fluid consumed, and any care provided such as reminders to use the toilet or pressure relief. Care Homes for Older People Page 8 of 40 Behaviour monitoring charts also need to include any restraint and holding techniques used when supporting people to remain clean, dry and safe. We also need to be informed when any restraint/holding techniques are used that have not been agreed in a best interest meeting and included in the care planning process. There are some improvements needed in the way the nursing staff manage medication to ensure it is recorded and administered as prescribed. The home must make sure that peoples social needs are assessed so staff can tailor activities to their needs. There is no activity coordinator and people in the dementia care unit had very little stimulation. They also had little opportunity to participate in meaningful activities or make decisions about aspects of their lives. Willow could be a much more homely environment for people and the lounge should be arranged in a more inclusive way rather than chairs all around the walls. Residents could also be supported to personalise their bedrooms to make them look more homely and stimulating. The home must make sure that residents are better protected. There have been lots of incidents between residents and some people have been harmed. In part this can be improved by staff training and awareness. Staff have had very little training in dementia care and how to manage behaviours that are challenging, despite this being available from the companys training department. Some residents have one to one support for periods of time throughout the day but this has not always been managed well. There have also been times when short-notice sickness has affected the staffing numbers on Willow. The staffing arrangements and back-up plans could be organised more efficiently. There has also been a lack of training in restraint/holding techniques, yet we found that some residents were regularly, held during personal care tasks. Whilst we acknowledge this was done in the best of intentions to keep the residents clean and dry, staff must have training in the least restrictive methods and care plans must give clear directions. The support and guidance the nurses and care staff have received could be improved, as some staff commented they felt stressed and not listened to. Care staff should also receive up to six, formal, one to one supervision sessions so they can discuss issues of concern. Senior managers have started to audit the quality of the service in a more robust way. This needs to continue to ensure improvements are made in the quality of life for people living in the home. 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. Care Homes for Older People Page 9 of 40 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 10 of 40 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 40 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home usually receives assessment information from external agencies to help decide if needs can be met in the home. However, the home did not gather full information regarding the needs of a particular resident. This means that they may not have sufficent information to plan their care. Evidence: We looked at five care files during the visit, one of which was for a person recently admitted to the home. We wanted to check out the admission process to ensure that the home had accurate and up to date information about peoples needs prior to admission. There had been a, best interest meeting for the new resident to arrange for a period of assessment in residential care to determine, the least restrictive way of delivering care to the person. There was evidence that the home had obtained a care and treatment plan produced by mental health services for them and a risk assessment Care Homes for Older People Page 12 of 40 Evidence: summary. However, the homes own assessment had no date of completion so it was difficult to establish if it had been completed prior to admission. It was also not completed fully. For example, the sections on past medical history, social interests, continence needs, pain, sleep and mental state were left blank. There was limited information about mobility, the section on tissue viability stated, bruises, nutrition stated, soft option and personal care/dressing stated, full assistance. This level of assessment does not provide sufficient information for the manager and staff team to determine if needs can be met in the home and how the needs are to be planned for and met. There was a, further admission assessment, which was a precis of information used to provide staff with initial information but this was not signed or dated. Two risk assessments were completed five days after admission and stated the person had a high risk of falls and a high risk of skin damage. These could have been completed prior to the person arriving at the home, as the admission was planned. Other care files evidenced that assessments completed by the local authority were usually received prior to admission. People admitted for nursing care have an assessment completed by a nurse employed by the primary care trust regarding the level of nursing care they require. This determines the health authoritys financial contribution to the persons care. The home does not provide intermediate care services so standard 6 does not apply. Care Homes for Older People Page 13 of 40 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. We could not be sure that all residents had their health and personal care needs planned for and met. The management of medication has areas to address to ensure that people receive their medicines as prescribed. Evidence: The home is divided into two sides: one for people requiring nursing care and one for people with dementia care needs. We looked at care plans for people in both sections of the home. Each resident had a plan of care to guide staff in how to meet their needs. The care files were organised and had risk assessment information next to the care plan area it related to. This made the care files easy to use. However, the care plans did not contain all the needs identified at the assessment stage. For example, three of the residents files examined indicated they had needs associated with their dementia or mental health condition. This led to behaviours that could be challenging to staff and Care Homes for Older People Page 14 of 40 Evidence: other residents but there was no clear management plan that stated what the behaviours were and what approaches staff were to use to manage their care in a consistent way. One person had specific needs identified in an assessment relating to the expression of their sexuality but there was no mention of this in the care plan and staff would have no guidance in how to manage this aspect of their care. Another resident had a catheter insitu, which had recently been removed. During the catheter use there were no clear instructions for its management. A further resident had an assessment in place that identified they were at risk of developing pressure sores but there was no plan to prevent them occurring and the skin inspection record was blank. Some of the care plans were personalised and contained information about preferences but this was not consistent throughout. The care plans were generally updated when needs changed significantly, although some staff were more vigilant than others in keeping them up to date. There was some evidence of monthly evaluations but these consisted of a signature and a date. There was no comment on the continued validity of the care plan and thorough evaluations should have picked up the lack of behaviour management plans. There were several areas where staff recorded the care provided. These included a daily living profile incorporating bathing, showering, shaving and whether the person had had their bowels opened, a progress and evaluation report, key worker notes and a care assistant communication sheet. Staff told us these were completed differently in each of the units. For example, the progress and evaluation record on the nursing side was completed intermittently and the care assistant communication sheet was completed daily and referred to care plan tasks. On the dementia care unit this was reversed for the care files examined. There were also gaps in key worker notes and the daily living profile so it was difficult to audit personal care tasks. The recording system could be simplified to ensure staff have clear directions in what and where to record information. There were monitoring charts in place for nutritional intake and reminders to use the toilet. Again these were not completed consistently so it was difficult to audit the care had taken place. For example, one persons nutritional intake chart for 20th February had recorded only 200mls of a food supplement at 10pm. Similarly on the 19th February another resident had nothing recorded from 1am to 3pm. Quantities of food and fluids were not recorded clearly, as staff stated, cup or mug of tea and, for example, cornflakes rather than the actual amounts. Another resident had a chart to Care Homes for Older People Page 15 of 40 Evidence: record when staff reminded them to use the toilet. There was nothing recorded from 18th February at 6.30pm to 10pm on the 19th. Similar gaps were found for other days. There was clear evidence from behaviour monitoring charts that some residents were very unsettled and had behaviours that were very challenging to other residents and staff. In discussions and surveys staff stated they did not have the skills to manage the behaviours and they used restraint methods to ensure personal care tasks were carried out. The method of holding residents whilst personal care was carried out had not been agreed in a best interest meeting. The staff had not received any training in how to use restraint techniques safely and the home did not have a restraint policy. This is very unsafe practice and must be addressed quickly with input from health and care management teams. There was evidence that people had access to health care service for advice and treatment. A health professional confirmed in a survey that they had received referrals for people that had experienced a high level of falls. They stated, they are receptive to recommendations from the service. There was also evidence that the tissue viability nurse had provided advice for wound care, dieticians for nutritional intake, speech and language therapists for swallowing issues and specialist nurses for end of life plans. People regularly saw GPs, emergency care practitioners, chiropodists and opticians for advice and treatment. Other specialists such as consultants, community psychiatric nurses and learning disability nurses were also involved with some residents. The homes annual quality assurance assessment advised that a consultant psychiatrist held clinics in the home every six weeks. The new Regional Operations Director, advised that they were aware of some of the issues we picked up during the day regarding care planning and risk management. He had requested an audit be carried out in the dementia care unit regarding nutritional needs using a specific dietetic tool and he had developed an action plan due to start on 8th March. This will now be brought forward. We spoke to residents and some relatives during the day and those able to, stated they were happy with their care. Comments were, its pretty good, my husband is getting looked after, it is excellent here and yes they look after us well. One resident did state in a survey, I would like assistance to go to the toilet when I want to go. There were cards from relatives displayed on the wall thanking staff for their care. It was clear that people in the home had different experiences of care. The nursing wing Care Homes for Older People Page 16 of 40 Evidence: was calm and people with complex nursing needs had their needs met. However, some people living in the dementia care unit were being targeted and hit by other residents, and staff were finding it hard to meet all the residents needs. Three residents received one to one funding from either the local authority or primary care trust. These were for specific amounts of time i.e. twelve hours for one person, eight hours for another and six hours for the third. We checked the staff rotas and asked staff specific questions about the one to one support. The rotas indicated the support was provided on the availability of staff rather than the needs of the residents. We looked at the management of medication in the nursing part of the home, Nightingale unit, and the dementia care unit, Willow. Medicines were provided in monitored dosage systems and managed and administered by trained nurses. There were some areas of practice to improve, to ensure a robust system. Not all medicines were signed into the home and amounts of medicines delivered midcycle were not carried forward to the current medication administration record (MAR). This makes it difficult to audit stock. Some residents were prescribed medicines at set times but staff had been administering them when required, for example Haloperidol for one person, Bisocodyl for another and Movicol for a third. Also some medicines were prescribed, as directed with no clear instructions for staff, for example eye drops and Forticreme. These issues need to be reviewed with the prescriber so the MAR is an accurate reflection of what they want their patients to receive. There were also no protocols or directions in care plans for some specific medicines prescribed when required. For example, night sedation and suppositories. Also one person was prescribed Diazepam 2mg 2-3 times a day but again no protocol for the rationale behind the decision making. Handwritten entries on the MAR did not consistently have a witness signature. This is advised for good practice to help avoid mistakes. One persons care plan had two different instructions as to how many food supplements they were to have each day. The MAR gave a third instruction. The deputy manager was to check out the correct amount. Two residents MAR charts stated they were to have topical products applied but there was no record that they had received them. Care Homes for Older People Page 17 of 40 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some residents did not experience a good quality of life due to a lack of social stimulation and limited opportunity to make choices. On the whole the meals provided met most of the residents nutritional needs. However, the dining experience for people with dementia could be improved. Evidence: It was clear from observation, discussions with staff members and examination of records that people had a different quality of life depending on which area of the home they lived in. We completed a short observation on Willow to try to get a snapshot of what life was like for people living there. We observed five residents from 9.55am to 11.45am. One resident was asleep for whole time and two further residents sat looking into space and had no, or very little, interaction with staff. One resident was sat looking at a newspaper and staff did attempt to discuss the contents but the resident did not communicate back. The fifth resident was more active and did get up out of their chair on several occasions and wandered around the lounge. On one occasion they were supported to an area where they could have a cigarette. The resident continually asked for cigarettes and staff gave differing accounts as to when they could have one. Care Homes for Older People Page 18 of 40 Evidence: The home does not currently employ an activity coordinator and there was a lack of occupation and stimulation noted on Willow. The only activity noted during the observation was the serving of tea and biscuits. The television was on for most of the time and music was played for a short period. However, people sitting in the lounge on Willow did not engage or take notice of this. The registered manager told us there was plans to recruit an activity organiser and the funding had been agreed by the organisation. The Regional Operations Director advised that funding for seventy staffing hours for activities has always been available but it has not been utilised by the home. When spoken with, a relative on Willow stated, some activities go on I think. The staff team were conscious of a lack of stimulation on Willow. Comments from discussions and surveys were, we need more facilities for clients, for example, TV, DVD and outings, we need more activities and parties and could do with more things to occupy clients time - games and visual things, as the things we have dont fit to our clients needs or abilities. When asked how the home could be improved staff members stated, enable clients to go out into the garden and make our home like a home, with a warm and cheery atmosphere where everyone, residents and staff alike, feel happy and welcome. Nightingale was more relaxed and some residents chatted with each other and staff members. Some residents had complex nursing needs and mainly remained in their bedrooms. Visitors were seen coming and going and told us that they were kept informed, if there is anything wrong then they tell us, we are informed about everything and I can visit or ring when I want to. There was evidence that some residents could make choices about aspects of their lives, for example the times of rising and retiring, what to have and where to sit for their meals, how much they would like to personalise their bedrooms and where to spend most of the day. However, people with dementia had little opportunity to make decisions and this area could be improved with staff training, clear care plans and exploring better ways of communicating with people. For example, ensuring people had a visual choice at mealtimes and when deciding on what clothes to wear and by the provision of occupational stimulation and activities. Catering was completed centrally and the food distributed in commercial hot trolleys to the four lodges in Castle Care Village. Staff served the food in each of the lodges so were able to provide people with the portion size they required on the day. The menus rotated on a four weekly basis and the home had won a heartbeat award for the last Care Homes for Older People Page 19 of 40 Evidence: fifteen years for providing a health option. Residents could have a cooked breakfast if they chose to and there were two choices for the main meals. There was also a list of alternatives available if residents preferred them. The menu was displayed in a written format in the entrance area of the home. To improve, a pictorial format would assist people with memory impairment with their choice of foods. People spoken with enjoyed their meals and said they had plenty to eat. The lunchtime meal on the day was observed on Nightingale. This was chicken or plaice, was nicely present and was served with fresh vegetables. Drinks were available at meal times and set times throughout the day. One person was observed struggling to cut their food and staff intervened and completed this for them. However, the resident soon lost interest and left the dining room. Staff later left a small plate of biscuits, cheese cubes, crisps and chocolate for them to return and eat when they wanted but this was largely left untouched. Staff spoken with were aware of the dietary difficulties for some residents with dementia, as they chose to wander around most of the day including mealtimes. They spoke of ensuring food was available so residents could, graze when required. This was good practice although the, grazing food could be of a more healthy variety. Two staff members commented in surveys that some of the meals could be improved. This related to the amounts available and that the meat and vegetables were sometimes, hard. This was mentioned to senior managers to check out. The dining room on Nightingale was set out with table cloths, napkins and wine glasses. The experience was a social occasion and staff were attentive. Special diets were catered for and food supplements arranged via the GP or dietician. Care Homes for Older People Page 20 of 40 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some people living in the home are not being protected sufficiently and they have been harmed during incidents with other residents. Staff do not have the skills to manage the behaviours that are challenging. Evidence: The home had a corporate complaints policy and procedure. This was displayed in the entrance. A complaints form was available for residents and visitors to complete and covered areas such as the nature of the complaint, the investigation process and how it was resolved. We saw evidence that in the last twelve months the home had received several minor complaints and all had been resolved appropriately. Since the last key inspection we were alerted to a complaint by a visiting professional regarding the homes inability to weigh a resident, as the scales were broken, and a lack of communication with the persons relative. The visiting professional was pleased that on the return visit, the tasks they had requested had been completed. All staff had received training in how to safeguard vulnerable adults from abuse. In discussions they were clear about what constituted abuse and what to do should they witness any abuse or poor practice. The registered manager had completed the local authority training specifically for the managers role in referral and investigation. She was clear about her referral and investigation role and had demonstrated this by sending appropriate alerts through to the local authority. Care Homes for Older People Page 21 of 40 Evidence: We have received a lot of notifications regarding incidents between residents, which include physical and verbal assaults. The local authority has also been made aware and care management teams have been monitoring the incidents. However, there has been an increase since several residents with complex needs moved from Castle Lodge into Castle Keep. Three residents receive specific one to one support for part of the day but this is managed more in line with staff availability rather that the needs of the residents. There are also other residents without one to one support that have behaviours that are challenging to others. The incidents leading to assaults on residents and on staff have continued and there is no clear guidance for staff in preventative measures. Staff do not have the skills to manage any escalated behaviour. There have been two safeguarding referrals regarding the care practices of two staff members. These were investigated by the local authority and they were satisfied with the actions taken by the company. One incident resulted in staff dismissal and another in re-training. As mentioned in the section on health and personal care, some residents are being restrained when staff support them. Whilst it is recognised that this is done with the best of intentions to ensure the person remains clean and dry, this has not been agreed in a multi-agency best interest forum and staff have not received any training in holding techniques. There is a risk of harm to the resident and staff member if techniques are incorrectly applied. People are not being protected sufficiently and we are to meet with the local authority and the providers to try to address this. Care Homes for Older People Page 22 of 40 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The communal and personal areas in the dementia care unit did not provide a stimulating living environment for people. The hot water outlets distributed luke-warm water. These issues mean that peoples wellbeing and quality of life could be compromised. Evidence: During the visit, a tour of the building was undertaken. Castle Keep is divided into two units; Nightingale and Willow. The standard of accommodation and cleanliness on Nightingale was of a good standard, it was homely, warm and the layout in the communal areas was welcoming. There were items such as a dolls pram, soft toys and other interesting things from the past for people to look at and touch. Individual bedrooms were personalised, with pictures, photographs and trinkets on show. People living in the home and two relatives told us that the home was a very nice and homely place to live, and they were happy there. One relative stated, yes its clean, that must take some doing. However, the environment on Willow was quite different and a stark contrast to Nightingale. A short observation (SOFI) was carried out on Willow for two hours and as well as observing the residents the inspector also observed the environment. The lounge was arranged in an institutional way having the chairs all around the outside of Care Homes for Older People Page 23 of 40 Evidence: the room, the decor was bland and the furnishings were poor in some parts. There was also a slight smell of urine. Two chairs in the lounge had their original cushions missing and had pressure cushions in their place. However, these did not fit correctly and would be uncomfortable to sit on for any period of time. Some of the bedrooms on Willow were sparse and had no personal items, and some rooms required redecoration. There was no formal refurbishment plan although the manager advised that there were plans to re-develop the lounge and foyer on Willow by purchasing new furniture and a carpet. There were also plans to refurbish Willow by putting in a bus stop and shop fronts to make it look more interesting and to enable people to partake in activities. She also advised there were plans to recruit two activity coordinators. The Regional Operations Director advised that a budget for environmental updates has always been available but again this had not been utilised by the home. There were malodours in some parts of the building, especially on Willow Unit due to a high incidence of continence issues. The home does employ cleaning staff and some rooms have had carpets replaced with nonslip flooring to help the problem. Some of the commodes are very old and unsightly and do not fit in with the furnishings. One relative commented, the environment is ok and it is usually clean. There were four communal toilets on Willow, one bathroom and one shower room. There were three communal toilets, two bathrooms and one shower room on Nightingale. These have picture signs on the doors which makes them easily recognisable. Two of the communal toilets have stable-type door and do not promote peoples dignity and privacy. There has been an extention to Willow called, Rainbow. This area has thirteen bedrooms, all with en-suite facilities of a toilet and a sink. There is also one bedroom on Nightingale that has en-suite facilities. The temperature of the hot water outlets in the bathrooms was recorded as 32 degrees centigrade. This is luke warm and requires urgent attention. The laundry was completed from a central building on the site. Care Homes for Older People Page 24 of 40 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs were not always met. This was as a result of shortfalls in staff training and the organisation of one to one support for specific residents. Evidence: Staff told us there were sufficient numbers of care staff and nurses on Nightingale to meet peoples needs. On the day of the visit there were four carers and one nurse in the morning and three carers and a nurse in the afternoon on Nightingale to care for seventeen residents. Willow had six carers and a nurse for twenty-five residents but three of the care staff were supporting people with one to one care. Staff told us they usually had five carers in addition to the three one to one carers but there had been staff sickness, which had left them short staffed. In discussions staff advised that, at times, the one to one support had to fit in with the staff rota and availability rather than the needs of the residents. Despite the one to one support there continues to be incidents between residents so there is a need for the management of these issues to be reviewed. There were four carers and two nurses at night for the unit as a whole. Two surveys were received from residents in Nightingale, one of which was completed with help from their relative. One stated that staff were available and listened to what Care Homes for Older People Page 25 of 40 Evidence: they said, always and the other stated this was, usually. Relatives comments about the staff team were very positive, the staff are friendly and always polite, its pretty good, my husband is getting looked after and the staff are welcoming and approachable. One relative of a person on Nightingale had written in a survey, I cannot believe I have been lucky enough to have mum in this home. I am highly satisfied - everything is perfect. Mum thinks staff are her children, she confides in them and knows them sometimes more than us. The company has a good training programme that covers mandatory training and service specific areas. There are designated training officers and a computerised system for keeping records up to date regarding what training staff have completed and when updates are due. In surveys from staff and in discussions with them it was clear that those working in the dementia care unit had received limited training in specific areas such as dementia care needs, restraint/holding techniques and how to manage behaviours that could be challenging. When asked in a survey if they received sufficient training to help them understand the needs of residents and keep them up to date with new ways of working, seven staff stated, no, six stated, yes and one person declined to answer. Eight staff also indicated that their induction could be improved. Managers told us that 52 of care staff had gained a national vocational qualification in care at level 2 and 3. This was a good achievement. The home needs to concentrate now on providing care staff, especially those working on Willow, with specific skills to care and support for people with a range of needs, for example, dementia, mental health problems and for one resident, a learning disability. Some comments from staff in surveys were, it provides all the training for the job, provides mandatory training, we have to deal with very aggressive, challenging clients and we dont get paid enough, I go home with bruises, scratches and at times feel very low and stressed because of this and we are always short staffed. There were other staff comments that have been shared with senior managers. During the observation on Willow it was noted that some staff communicated with people in a caring way, however, there was little or no response from residents. Staff appeared not to have the necessary skills to communicate effectively with people that had a memory impairment. One resident was observed trying to talk to staff and they had little or no understanding of what was being said to them. Staff made comments such as, are you ok and would you like a cuppa. There was little evidence to suggest they had developed a good understanding of the persons needs or wishes. Care Homes for Older People Page 26 of 40 Evidence: On three occasions people were woken up by staff. Each time this resulted in the resident becoming angry and on one occasion the resident became verbally and physically aggressive toward the staff member. This incident could have being handled better and probably avoided if the staff member had not woken the resident. This shows a lack of training, knowledge, skills and understanding when dealing with people who have dementia and mental health problems. Staff were observed giving a person tea and biscuits when there was clear instruction on the care plan that the person was to be given water as they had had diarrhoea and vomiting the previous day. There was a lack of communication between staff and some written records were not up to date. The company had a good recruitment system. All checks were carried out prior to the start of employment and there was a system in place to verify that nurses had a valid registration. On the rare occasions that staff started their employment prior to the return of the full criminal record bureau check (CRB), a check was made against the list barring people from working with vulnerable adults. By the time their induction had been completed the CRB had usually been returned or the staff member would pair up with another until they were completely cleared. In surveys all staff confirmed that they had a criminal record bureau check completed as part of their recruitment. Care Homes for Older People Page 27 of 40 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although there has been no management issues with Nightingale, there have been shortfalls in the management of the home in its entirety. This has meant that some residents have continued to be hurt following incidents, staff members have not felt supported and quality issues have only just been identified. Evidence: When one of the homes in Castle Care Village, Castle Lodge, closed last year, several residents, with specific mental health and dementia care needs moved into Willow in Castle Keep. Staff members and the registered manager of Castle Lodge moved with them for some continuity of care. The home in effect had two managers and the manager of Willow had experience in supporting people with a learning disability. However, the manager from Castle Lodge has since left. The remaining registered manager for the home is a qualified nurse and her skills lie in general nursing care. She has completed specific training in Leadership and in dementia care to keep herself up to date. However, there were shortfalls in the way this training has been applied in practice and the manager has found it difficult supporting and guiding the staff team Care Homes for Older People Page 28 of 40 Evidence: in the dementia care unit. Staff spoken with and surveys received from the staff team gave a mixed report of management support. Three people stated in surveys that they received management support either regularly or often, whilst five said this was, sometimes and six stated this was, never. Comments also confirmed that some staff members required more support and guidance than they had received, we need more support for nurses and carers, we dont get enough time out in the staff room, as the residents come in and out and we feel we have no back up. When asked how the home could improve, one staff member stated, listen to staff and provide solutions to staffs concerns. Staff told us that they did not receive regular one to one supervision. People indicated they last had formal supervision six months ago and another said, about nine months ago. They did not receive any de-briefing following any episode of challenging behaviour so lessons could be learned. Care staff should receive a minimum of six formal, supervision sessions a year to enable them to discuss issues of concern, their key worker role and training and development needs. It will also provide the supervisor with an opportunity to monitor care practices and offer support and guidance. There was clearly some staffing issues to address as some staff stated moral was low and they felt undervalued. The company had a quality assurance system that included monthly audits and a range of questionnaires to people. The Regional Operations Director advised that an in-house audit by a clinical development nurse had identified shortfalls in some parts of the service and they had produced an action plan to start to address them. These related to a lack of stimulation for residents in the dementia care unit, some recording shortfalls in care planning and risk management, a dining experience that fell short of expectations and required improvements in infection control. It is very positive that the issues we found during the visit had also been noted by senior managers and are to be addressed. The Regional Operations Director stated that an action plan will be initiated quickly. The action plan states that a clinical development nurse is to work at the home two days a week starting on 3rd March 2010 to assist the registered manager. There is additional support as another manager in the company, with extensive experience in risk management and personalised care planning, will also work for two days a week in Willow. Part of the action plan is to complete dietary screening on all residents in Willow to establish any changes from point of admission to the current date. New care files have been ordered and staff given guidance on completion of documentation. Care Homes for Older People Page 29 of 40 Evidence: The home had completed their annual quality assurance assessment. The content was rather sparse and to improve, the registered manager should look at how the home meets each standard and be clear about where the shortfalls are and what needs to be done to address them. The home had gained a, A in the local authority food safety assessment - scores on the doors and had been awarded a, healthy heartbeat award for the last fifteen years for ensuring a healthy option on the menu. Catering is produced centrally and food delivered in hot trolleys to each of the homes in Castle Care Village. The management of finances is the same in each of the homes. Families mainly manage the residents finances. An administrator maintains individual records on a computerised system and invoices are sent to relatives regarding any expenditure. Receipts are obtained for any purchases such as chiropody and hairdressing. Bedrooms have lockable facilities for people to store personal items. The home has not been a safe place for some residents and it may be after further assessment that some residents needs cannot be met in the home. The lack of specific staff training, shortfalls in care planning and risk management, and the dynamics of some of the residents has led to people, both residents and staff, being assaulted by others. The staff members have tried their best but they have not been equipped with the right skills to support people safely. This really should have been identified sooner during staff supervision and during visits completed by the Responsible Individual. However, it is acknowledged that there is a new Responsible Individual completing the visits required under regulation 26 and, as shown above, issues have been identified and can now be addressed. Care Homes for Older People Page 30 of 40 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 31 of 40 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The needs of potential residents must be assessed thoroughly prior to admission. This will help to establish if needs can be met in the home and assist when planning care to meet needs. 31/03/2010 2 7 15 Specific residents must have 30/04/2010 thorough behaviour management plans that detail the behaviours and guide staff in how to manage them safely and effectively. This will help to ensure a consistent approach to managing behaviours that are challenging to others and help reduce their frequency and injury to people. Care Homes for Older People Page 32 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 7 15 Care plans must contain all assessed needs identified at the assessment stage. This will ensure that staff have full and accurate information about how to support the person and prevent care from being missed. 31/05/2010 4 8 12 People must be supported to 30/04/2010 make decisions within their everyday life and if they are restricted in anyway, this must be subject to a mental capacity assessment and detailed risk management plan. This must be agreed in a multi-agency setting with the persons best interests in mind. This will help to ensure a person-centred approach and validate actions taken in the persons best interest. 5 8 13 Incidents involving people living in the home must be recorded in detail, giving information about what has happened, for how long it lasted and how this was managed and whether restraint was used. This will ensure that incidents of verbal and 31/03/2010 Care Homes for Older People Page 33 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action physical aggression are recorded appropriately and help to plan better care. 6 9 13 Extra guidance must be 31/03/2010 obtained and recorded about how to use medication prescribed, as required or as directed. This makes sure that the correct information is recorded so a person receives their medication as prescribed. There must be a clear record 31/03/2010 of all medicines signed into the home. This will help when auditing stock. 8 12 16 Activities must be provided on a regular basis, including occupation and stimulation for those people with more complex needs associated with dementia or mental health problems. This will help to promote wellbeing and prevent people from being bored. 9 12 14 People must have their social needs assessed. This will help to identify previous and current interests and help staff tailor 30/04/2010 30/04/2010 7 9 13 Care Homes for Older People Page 34 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action activities, occupation and stimulation to meet their needs. 10 18 13 The incidents that are occurring between residents must be managed more effectively. This is to ensure the residents are protected and are free from harm. 11 19 23 The home must have a redecoration and refurbishment plan with short and long term timescales for completion of the tasks. This will help to audit the completion of work and that timescales are met. 12 19 23 People must live in a home that is well maintained, homely and comfortable. This will help to ensure a good quality of life is promoted. 13 27 12 The organisation of one to 31/03/2010 one support for residents must be in relation to peoples assessed needs and not staff availability. This will help to ensure the one to one support is used effectively at the times 31/05/2010 31/03/2010 30/04/2010 Care Homes for Older People Page 35 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action assessed as the most appropriate for the person. 14 30 18 Staff must receive training in dementia care, mental health, learning disability and other diverse areas of need. This will help to ensure they have the skills required to care for and support people living in the home. 15 30 18 Staff must undertake appropriate training in the use of physical intervention before they use any form of holding or restraint. This will ensure that people receive support from staff that have been trained in physical intervention techniques that are safe to use. 16 31 9 The registered manager must have a plan to update their skills to ensure they are fully equipped to manage the home and support staff caring for residents with a wide range of needs. This will help to ensure the home runs smoothly, residents wellbeing and 30/04/2010 30/04/2010 31/05/2010 Care Homes for Older People Page 36 of 40 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action safety are promoted and staff are well supported. 17 38 13 The home must protect people from assaults from other residents by providing staff training, effective risk management and by ensuring specific residents needs can be met in the home. This will help to ensure the home is a safe place for people to live in and staff to work in. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 30/04/2010 1 7 Care plans should be more personalised and evaluations should be thorough and take into consideration information written in other parts of the care file. This will prevent information from being missed. The recording system could be simplified to ensure staff have clear directions in what and where to record information. Monitoring charts, obviously put there for a reason, should be completed fully and accurately. This will help to audit care and provide information to health professionals. Records of the use of prescribed skin care products should be more detailed. When medicines are prescribed mid-cycle or outside the monitored dosage system, the amounts should be carried forward to the new MAR. This will help to audit stock control. 2 7 3 8 4 5 9 9 Care Homes for Older People Page 37 of 40 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 6 7 9 14 Handwritten entries onto MAR should have a witness signature to avoid mistakes being made. Residents should be provided with more opportunities to make choices about their lives. This will help to improve wellbeing and self esteem. A pictorial format of menu would assist people with memory impairment with their choice of foods. The information in the behaviour monitoring records should feed into the care plan and risk management processes. This will enable lessons to be learned about effective ways of managing behaviours and help to protect people from harm. The communal lounge on Willow should be arranged in a more inclusive and less institutional way. The bedrooms lacking any personal touches on Willow should be reviewed and residents supported to personalise them. This will help to provide a stimulating environment for people. Hot water outlets should have a temperature of 43 degrees to ensure an ambient temperature for washing and bathing. The home should investigate and eliminate the malodours in some of the communal areas and bedrooms. There should be a back up system to address staff shortages when they occur on Willow. This will help to ensure there are sufficient numbers of staff to support people. Quality assurance questionnaires should be sent to staff members and visiting professionals to obtain a wider range of views on how the home is managed. Care staff should receive a minimum of six, formal supervision sessions per year. This will provide an opportunity for staff to discuss issues of concern and enable the supervisor to monitor care practices and training and development needs. There should be de-briefing sessions with staff following any episode of challenging behaviour. This will enable lessons to be learned and care approaches to be tailored 8 9 15 18 10 11 20 24 12 25 13 14 26 27 15 33 16 36 17 38 Care Homes for Older People Page 38 of 40 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations accordingly and risk management plans adjusted. Care Homes for Older People Page 39 of 40 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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