Inspection on 21/08/08 for Charlton Court

This inspection was carried out on 21st August 2008.

CSCI 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

Charlton Court 19/02/09

Charlton Court 22/05/07

Charlton Court 19/06/06

Charlton Court 17/01/06

Charlton Court 27/09/05

Charlton Court 10/05/05

Charlton Court 07/12/04

Charlton Court 13/05/04

Charlton Court 12/09/02

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Charlton Court 477-479 Bradford Road Pudsey Leeds West Yorkshire LS28 8ED Lead Inspector Paul Newman Key Unannounced Inspection 21st August 2008 07:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charlton Court Address 477-479 Bradford Road Pudsey Leeds West Yorkshire LS28 8ED 01274 661242 01274 656799 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) Charlton Care Homes Limited Mrs Karen Anne Pickard Care Home 71 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (71), Physical of places disability (2) Charlton Court DS0000001330.V370552.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 the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP; Learning disability - Code LD; Physical disability - Code PD The maximum number of service users who can be accommodated is: 71 The place for Learning disability under 65 is for the service user specified in the NCSC Notice dated 2 October 2003 The places for Physical Disability under 65 are for the named service users only One specific service user under the age of 65, named on variation dated 20th December 2006, may reside at the home. 22nd May 2007 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Charlton Court is a large, purpose built care home, which provides care, with nursing, for up to 71 service users. It is located in a residential area of the Leeds suburbs and is very close to the boundary with Bradford. It provides accommodation on two floors, mainly in single rooms, some with en-suite facilities and has three communal sitting rooms and a dining room. There are wide corridors in the home and a passenger lift. There are facilities for laundering all communal linen and personal clothing and a central kitchen that provides all meals (there is, in addition, a kitchenette on the upper floor where drinks and snacks can be prepared). There is a large car park for staff and visitors. There are grounds to the rear and an outside area where residents can sit comfortably and safely. There are local facilities nearby - shops, pubs etc.- and it is well placed for access to public transport. Information about services provided by the home is available in the home’s combined Statement of Purpose and Service User Guide. Copies are kept in the reception area and can be taken by relatives or visitors. At the time of the inspection, 21 August 2008, the weekly fees were from £538 to £575 per week. These charges do not include hairdressing or chiropody and a separate list of charges for these and other services is available from the provider. Charlton Court DS0000001330.V370552.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 star. This means the people who use this service experience poor quality outcomes. The accumulated evidence in this report has included: • • The previous key inspection. The annual quality assurance assessment (AQAA) that was sent to us by the service in preperation for an annual service review in May 2008. 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. What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. Relevant information from other organisations. What other people have told us about the service. Information obtained from residents, relatives, staff and other health care professionals both in conversations during the visit and surveys that were completed and returned to us at the time of the annual service review. • • • • This inspection visit was prompted by an annual service review carried out in May 2008. The information we had at that time, and in particular, the poor information provided in the AQAA was insufficient for us to be confident that the service was continuing to provide good quality outcomes for people living at the home. Two inspectors made an unannounced visit to the home on 21 August 2008. One inspector started at 7.30 am the other arriving at 10.30 am and both concluded that day at about 5.00 pm. A further visit was made to the home the following morning by one inspector that lasted four hours. Up-to-date documents were requested and collected from the home on 28 August 2008. During the visit, a number of documents were looked at and some areas of the home used by the people living there were checked. A proportion of time was spent speaking to the manager, the area manager who was based at the home at that time, other staff, people who live at the home and visitors. Three healthcare professionals – the community matron, a consultant geriatrician and a doctor were also spoken with. Time was also spent in communal areas and the dining room, watching what was going on with people and whether they seemed comfortable and cared for. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 6 The AQAA that was returned was poorly completed and gave us little information about how the service is meeting National Minimum Standards, what it has improved during the last year and any improvements it plans to make. Evidence seen during the inspection across a range of issues gave rise for serious concern that these placed at risk. Some verbal feedback was given on the first day of the inspection but was cut short when the manager became unwell. In view of the seriousness of the concerns, and in the awareness that the Company Operations Director was visiting the home on August bank holiday, 25 August 2008, the lead inspector arranged for a verbal feedback session at the home to outline the most major concerns. What the service does well: What has improved since the last inspection? What they could do better: The scoring outcomes at the end of this report reflect where National Minimum Standards (NMS) are exceeded, met, have minor shortfalls or are not met and have major shortfalls. These do not necessarily reflect the legal framework Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 7 that applies when the Commission notes that a service must meet the requirements of the law. People should be reassured that the requirements noted at the end of the report embrace all the major shortfalls in NMS and are therefore enforceable by law. This report should be read in its entirety to fully understand the extent of the problems we found. There are significant improvements that need to be made without delay, many of which are tied into the day-to-day management and clinical management of the home. Outcomes for people living at the home are rated as poor in five of the seven outcome groups. These are: • • • • • Health and Personal Care. Complaints and Protection. Environment. Staffing. Management Sixteen requirements are made and the company will be required to send us an improvement plan to say how it intends to address shortfalls. We will assess and continue to monitor the situation closely. Areas where shortfalls were identified were: Assessment and care planning – people must have their needs reassessed and more detailed and specific care plans written so that staff have clear advice and guidance about how to meet their needs. The record keeping in the care plans must reflect that all the nursing interventions and treatment needed is being given. Early referrals must be made to healthcare professionals for advice where needed. This will give people confidence that their care needs are fully known and are being addressed. Food and nutrition – the quality of the food must improve and where people lose weight, their care plan must be reviewed and referrals made to healthcare professionals at an early stage for advice. The combination of these two will make sure that people are living as healthily as they can. Safety and protection – Where there are concerns expressed about the competency of staff, managers must take appropriate action to safeguard people. The home must provide the right specialist equipment for people so that they can be nursed appropriately and safely. Protective clothing must be provided at all times to reduce the risk of cross infection. Staffing, numbers competency and training – Staffing levels must be reviewed and improved and this should take account of the dependency levels of people and the nursing input they need. People must also have the support of sufficient numbers of care staff so that their personal care needs can be met and life preferences and choices can be made. All staff must receive training in Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 8 infection control so that they are aware of the steps to take to avoid cross infection. Management and quality assurance - The company must investigate why services have not been clinically managed and also managed on a day to day basis that makes sure that the home consistently meets National Minimum Standards and Regulations. The company must then take steps to make sure the home is managed consistently well. Measures must be taken to make sure that the internal auditing systems identify shortfalls and an action plan to put things right is made. They should also ask the opinions of the community matron, representatives of the PCT including Doctors who are associated with the home. This will make sure that the home is run safely, efficiently and effectively for people living there. The company must notify the Commission of significant events so that we can monitor the home the way we need to. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Charlton Court DS0000001330.V370552.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 Charlton Court DS0000001330.V370552.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. People who use the service experience good quality outcomes in this area. People are assessed before admission so that a plan of care can be written showing the home can meet a person’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Where possible the person who intends to use the service visits the home but where this is not the case, their family or representative always visits to gain information. All of the relatives spoken with said that they had visited the home, and most said that they had seen others before making a decision to choose Charlton Court. One said he had looked at a number of homes and also looked at the inspection reports on the CSCI website. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 11 From the discussions and case tracking that was carried out that included checking four case files, it showed that the registered manager carries out most pre-admission assessments of people before they are admitted to the home. The pre-admission process includes a summary of the main issues, family circumstances and any specialist equipment that might be required. There was sufficient information gathered to form the basis of a plan of care for individuals when they were admitted to the home. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience poor quality outcomes in this area. People are put at risk because of major shortfalls in the detail of the care plans which leave staff with insufficient information about how to treat and monitor conditions like pressure sores. Lack of communication, observation and nursing action, is leading to a deterioration in peoples’ health and wellbeing. People value and appreciate their relationships with the care staff but do not always get the attention they need in a timely way. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Four care plans checked showed similarities in their shortfalls. At the verbal feedback session with the company Operations Director detailed notes prepared about two people case tracked were read and the Operations Director Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 13 acknowledged the shortfalls. This report focuses on the evidence of one of these people identified as A. The evidence is necessarily detailed to demonstrate the extent of the problems we found. The nurse on duty stated that he believed that A had come into the home with a pressure sore. The pre admission assessment, undertaken on 26/09/07 provided basic information. A had previously been living in a residential home and had been cared for on an air mattress and a profiling bed. She was noted as ‘good appetite, weight 75.5kg. Pressure areas intact. Double incontinent, low risk of falls’. A was admitted to Charlton Court on 28/09/07. The first daily entry on that day stated in the text ‘she was assisted to bed pressure areas checked and skin is intact including heels’. The nurse was asked if A had been brought into the home and been nursed on an air mattress and a profiling bed. The nurse was not sure but had not been working at the home at that time. The notes were inspected for clarification. Care plans were in place and a care plan titled “At high risk of developing pressure sores” dated 29/09/07 was inspected in detail. This clarified under nursing action: “A is chair bound and needs pressure relief during the day and night. Staff should ensure she is sat on a pressure cushion and in bed. Staff should ensure the airflow mattress is working well. Incontinence care should be given by ensuring that after each bowel motion she’s washed with soap and water staff should report any redness noted on the pressure areas to the nurse. Ensure intake of a high nutritious diet. Review Waterlow score monthly or as necessary. Encourage two hourly position change with the assistance of staff and the usage of a slide sheet. Staff should check daily the pressure pump and ensure it is set between 4-6 in relation to her body weight’. We concluded that an air mattress was in place however there was no evidence to say this lady was nursed on a profiling bed. There was no evidence of turn charts to prove two hourly position changes occurred. There was no evidence of what chair was suitable to meet her needs, neither was there evidence recorded in the daily entries to say the pressure pump was at the right setting and was checked. One entry on 30/09/07 stated in the text “ pressure relief provided”. This did not describe how, and lacked the detail needed to demonstrate that essential care had been given. Three care staff spoken with all said they thought A’s profiling bed was not in place when she arrived at the home. The second care plan was titled ‘Wound care plan’ and was dated 27/10/07 It stated: ‘A has a grade 2 sore on the left buttock area of redness more on the right buttock. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 14 Nursing actions: Staff should ensure the pressure mattress is working well and regulated according to her body weight. Normally A sleeps on her back but if she is informed of the effects of lying on the same side she will comply and lie on her side. An allevyn dressing is in situ ensure it stays intact. Inform the community nurse if no healing after 7 days. Apply barrier cream on surrounding area inform the next of kin about the sore bottom’. We concluded that the care plan did not specify what type of mattress is on A’s bed and if she is on a profiling bed it is not specific enough. It did not state what staff should look for, for signs of infection, what those signs may be and what staff should do if this happens. It did not specify how staff are going to ensure that this person’s position is monitored to ensure more tissue damage does not occur and she has to be reminded to change position, staff should have monitored and ensure her position was changed or that the equipment in use was of a standard which would achieve adequate pressure relief for her. The care plan did not state if the GP had been contacted and how often the dressing should be changed. Inspecting the daily entries for this period. The first mention of the pressure sore was 26/10/07 and said, ‘sacral area very red with darkish’. The sentence was not complete. The entry at night said, ‘Bottom noted to be sore with a grade 2 sore on the left buttock dressed with Allevyn sacral dressing to request for more dressings and A advised’. Daily entries did not specify how staff looking after A were ensuring position changes occur. There was no evidence of a turn chart, no evidence of phone calls to the GP. Daily entries before this do not indicate any redness, bruising or deterioration of this area - just suddenly on this one day, a grade 2 pressure sore had occurred. There was no evidence for us to determine if this was poor observation by staff or if care staff had been asking nurses to look at this and no action had been taken. On 12/11/07 a Tissue Viability referral was made stating a pressure ulcer, approximate duration of wound 2 weeks, slough no grade noted, current treatment granuflex (not effective). Past medical history Toxic epidermal necrolysis with erythema multi form MRSA bacterium. On this referral form A was reported to be eating well. However her weight at pre admission on 26/09/07 was 75.5kg and on 4/10/07 her weight was 66.2kg. This was a significant weight loss and we wanted to find out what action had been taken. When the nurse on duty was asked what was done about this, he stated the scales must be wrong. When asked if he had flagged this up to management he said no. The nurse said that A had been ill and the doctor took blood tests. No supplementary drinks were prescribed. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 15 Evidence of dressings used for this sore was sought. Medication administration charts (MAR) were not at hand and had to be found in archived records. On 27/10/07 twenty allevyn sacral dressings were recorded, but there was only one signature on the (MAR) to say a dressing had been applied during that four-week period. The dressings were changed on the next MAR to granuflex. There was no record to say why the change had occurred and how often the granuflex was to be applied. The manager was asked to be involved to clarify things and the dressings were discussed with her. She was not aware of what dressing A was having applied. On the current MAR chart granuflex was recorded but for the whole of August there were none signed for. We could not establish if the dressing was being changed or how often. Other documents seen in A’s care plan were - Waterlow, moving and handling assessment, falls risk assessment, nutritional assessment and continence assessment. All were in place and reviewed monthly but changes in A’s condition were not always picked up on and acted upon appropriately, as should be expected by a qualified nurse. In our discussions with care staff, some said that nursing staff did not always act upon concerns that they raised about individuals. One member of staff gave a specific example where she had brought concerns to a nurse who had shrugged her shoulders and walked off. This was referred to in the verbal feedback. On 28 August 2008 when documents were collected from the home we were informed that the nurse named by the member of care staff had been suspended having been reported for similar behaviour on that day. Three members of care staff said they are asked to do dressings, bandaging and flush peg feeds. They have had no training in these areas and should not be doing this. They said they have taken concerns to the management and they said a staff meeting is called, the meeting is held but nothing happens. The other three care plans checked had similar patterns in lack of detail, of pressure sores suddenly appearing (in one case a grade 3 sore) but there being no apparent observations to the lead up to this. There was insufficient advice on what to do, what to monitor and lack of evidence that people’s dressings were being applied but, in one case where there was a record, it clearly showed that the pattern of changing the dressing every three days was not always being followed. In one case there was evidence of weight loss for an individual recorded as weighing 62.4 kg on 26/06/08 down to 44.8 kg on 5/8/08. There was no review or action plan done on the day this was noted. We were told that the manager and area manager undertake care plan audits, but on the evidence we found, these are clearly not good enough. We asked for the names of people with pressure sores but two of the people we looked at Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 16 were not included on the list suggesting the extent of people with pressures sores is greater than we were led to believe. We spoke with a consultant geriatrician, the community matron and a doctor. All expressed the view that a year ago when the input from the community matron was greater things were improving. As her input has decreased concerns have been about the lack of clinical leadership in the home and there was evidence in the notes in four plans checked that there was a heavy reliance on the community matron. We are aware that the community matron wrote a paper/action plan for Charlton court that identified, as far as she was concerned, the issues that needed to be addressed. Our evidence is that those issues have not been addressed. The healthcare professionals spoken with are concerned that until they are, people are at risk. The doctor visiting the home said that when she had gone to a nurse to discuss a person who had been referred to her, the nurse was not aware of the reason for the referral. Medication policies, procedures and practices were not inspected in detail, but there was sufficient evidence from the case tracking to show that dressings for pressure sore care were not being signed for on the MAR charts and not always being applied and changed when they should be. This is despite the auditing of medication that has apparently been taking place by the manager and area manager (outlined in monthly reports on the conduct of the home). This does not give confidence that things are safe and the next inspection will include a specialist pharmacy inspector to check this. With the exception of one, the relatives we spoke to were happy with the care although there were comments made about there not being enough staff. One said that he was concerned that that staff were not picking up on things and had to ask a nurse to get a doctor as his mother had not been well for a few days. The son suspected a urinary infection based on his own experiences with his mother. This turned out to be the case. Whilst we are critical of the clinical oversight and nursing skills at the home, we acknowledge from what we were told by people living at the home, their relatives, the healthcare professionals and own conversations and observations of care staff, that they are committed, caring and good at their job. ‘They do their best’ was an expression frequently used, but what is apparent is that there just are not enough of them to deal with things effectively and in a ‘person centred’ way. Their work is task orientated and they will admit that sometimes people have to wait longer than they should to be helped. This is something the care staff are not at all happy about. (See sections on daily life and staffing). Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. People’s social expectations and personal preferences are generally met but more could be done to stimulate them. Peoples’ choices and personal preferences for lifestyle are restricted. The food provided at the home is variable in the way it is cooked and peoples’ opinions vary about its quality. Accumulative evidence suggests that people may not be eating in a healthy and nutritious way. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The home has employed an activity organiser since November 2007. It was clear to us from what we were told and saw that care staff are unable to spend the time with residents they want to, to get involved with activities and that their work is task and routine orientated. The activity organiser works for 27.5 Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 18 hours a week. There is a new activity programme being introduced at the request of people that includes popular choices on specific days of the week. People prefer this approach rather than spontaneous activities arranged on the day. There have been some trips out and in-house functions and entertainers. The new programme includes an hour at the start of each day to spend one to one time with people who may be unable to leave their rooms. All the people have been seen individually to make a profile of the activities they like and this is recorded. Her time is limited and consideration should be given to extending the number of hours available for activities. In our conversations with people living at the home, we were saddened by the general acceptance that their lifestyles were limited to taking their turn to wait to get up or have a bath or shower when they wanted. People said that staff did their best. One lady had one bath a week and when asked would she like more she said yes but there weren’t enough staff to do it. ‘They have other people to attend to’. She said that she felt lonely in her room but did not think there was a lot of activity for her to join in so stayed in her room. Another said she thought that the home was being run down to sell or close. She said that she got her breakfast that day at 9-45am but would have liked it earlier but had to wait for staff to get her up and then get her breakfast. She said another resident brings her a cup of tea each morning at 6.00am. One man called to an inspector from his room asking for help in getting assistance to get him up out of bed and go down for his breakfast. Indeed this was a feature of the first day of the inspection, of people hearing footsteps down the corridor and calling for help. Staff were doing their best to deal with people, wash, dress and get them up, as well as answer emergency call alerts and serve breakfast and assist those who needed it. Visitors spoken with were generally happy with the care and also praised the staff, one saying they are marvellous. There was a steady flow of visitors throughout the day. They said they felt welcome at the home, and that staff communicated well with them about changes in the condition of people. They did however, talk about there not being enough staff. Dining arrangements are threefold. Some people go down to the dining room on the ground floor, some in the lounges on the first and second floors and some in their rooms (some of these by choice and some because they are unable to leave their rooms). The cook and a kitchen assistant help serve in the dining room. During the inspection there were twenty-six people on the first floor and nineteen on the ground. There were no people up when the inspection started at 7.30am and the shift handovers were taking place. By 8.10am the heated breakfast trolley arrived on the first floor. At this time, the nurse was involved in giving out medication while the four care staff on duty were getting people up, taking them to either the first floor lounge or dining room and also assisted people staying in their rooms to get up and prepare for breakfast. So that people did not have to wait any longer, they were given their breakfast when they reached the dining room or lounge. These were the Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 19 less dependant people. This meant that more dependant people had to wait and clearly were not necessarily getting up when they wanted and were waiting longer for their breakfast. A similar pattern was happening on the ground floor where there was one nurse dealing with medication and three carers seeing to the nineteen people. The emergency call system was sounding regularly on the first floor and sometimes going to emergency mode because staff were delayed in dealing with other people. The same staff who were dealing with personal care – washing changing pads etc. were then serving breakfast on the first floor. At lunchtime, there was a similar pattern. Lunch was later than normal and some people had been in the dining room for about twenty minutes before lunch started to be served. The area manager was assisting in the dining room and was able to feed one gentleman who needed assistance. This would not normally be the case. Care staff were busy taking meals to people in their rooms and feeding people who needed that support. An emergency call to one bedroom was not answered during lunch until it went into emergency mode because staff were just too busy dealing with people. There was a choice of meals offered at lunchtime – stew and dumplings or fish in parsley sauce. Care staff told us that they go around the day before and give people the alternatives to choose from but people living at the home said there was not always a choice. One comment made by a person working at the home about peoples’ ability to choose said ‘People with a voice get the choice, the rest get what is left’. We felt the vegetables accompanying the lunchtime meal looked overcooked especially the cauliflower. When asked later, the area manager agreed. The other vegetables were brussell sprouts - clearly not fresh for this time of year. The mashed potato was lumpy. In a conversation with one lady eating in her room upstairs she said ‘sprouts are for Christmas, not this time of year’. She had chosen the stew and it was evident that she did not like it, had tried chewing it and found it too tough, so the meal was effectively untouched and left. There were varied opinions offered about how good the meal was but the staff spoken with said there had been a lot of wastage. Both staff and people living in the home said that the standard of the food was variable and had ‘gone down’ since the last cook left. When the standard of the food seen and comments made by staff are taken into consideration with issues of weight loss and lack of monitoring noted earlier in this report, we are concerned that people are not getting the right nutrition to help them maintain their weight. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience poor quality outcomes in this area. The people who live at the home and their relatives know how to complain but more able people appear to have accepted that raising things will not make things any better because there are not enough staff to improve their quality of life. The voice of less able people is not heard. People have not received the correct nursing interventions, they have been neglected and this is abuse. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The complaints record was seen and showed seven complaints. Two safeguarding referrals made this year were not recorded in the file but should have been. The relatives spoken with said that they were comfortable in raising concerns and felt they would be listened to and acted upon. This was not the case with more able people living at the home who, as seen in previous sections of this report, are experiencing problems that affect their quality of life. One said she had ‘given up and what’s the point, they are running the home down to close it or sell it’. People have accepted that things are the way Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 21 they are, they must fit in with the system, with staff availability and take their turn. As outlined in the section, health and personal care, there is evidence that at least one individual nurse was not acting upon concerns raised by staff and care staff told us they have raised concerns with management and nothing gets done. That lack of action to address things is poor management and allows what is essentially an abusive situation to continue. On the basis of what has been said to us, care staff are ‘whistleblowing’ and we have found no evidence that poor nursing practices have been challenged. Staff are trained in adult protection and safeguarding and we encourage them to bring forward their concerns to management at the home and where their concerns are not acted upon, then report them on to the Commission. This is their duty under their codes of practice. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26. People who use the service experience poor quality outcomes in this area. Whilst people living at the home live in a comfortable environment, they may not be provided with the proper and safe specialist equipment that puts them at risk. Infection control practices are questionable and increase the risk of cross infection. We have made this judgement using available evidence including a visit to this service. EVIDENCE: First impressions of the environment are good and there has been some investment in redecoration and replacement of furnishings over the last year. The home appears clean and on both days was free from unpleasant odours. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 23 One small kitchen area has been converted to provide a comfortable visitors’ lounge that affords a private place on the ground floor. The gardens to the rear of the building have been improved and there are now safe pathways to a summerhouse. In our case tracking there was evidence to show that one lady who was identified as having the need to be nursed on a profile bed was admitted to the home without the bed being in place. As a matter of health and safety we noted that overlay mattresses on profiling beds were on top of standard mattresses and because of this, when the bed rail was raised, there would not be sufficient railing to prevent a person falling out of bed. For another person case tracked the notes highlighted the need for hoisting and a specific sling to be used. When checked in the person’s room the sling was found to have a plastic securing buckle broken and this was compromising the safety of the person when being hoisted. The carer who assisted said that the matter had been reported to the manager about three months ago and was told a new one would be ordered. She also said that a specific bath sling was needed and this has also been mentioned to the manager. When this matter was referred to the area manager it was quickly resolved. We were made aware during the inspection visit that the main lift had been out of operation for a period of time and that on the Sunday before the inspection visit a man had been trapped in the lift. It was now repaired but we were also told that the smaller lift was unreliable. On the first day of the inspection the fire detector system was going off intermittently. On the second day the emergency call system was not operating properly and was going straight into emergency mode. We were told that the previous week the call system had been out of operation for four days. This does not ensure that peoples’ safety is protected. In our discussions with care staff we were told by five of them who were specifically asked about infection control, that protective gloves and aprons that are used to reduce the risk of infection control are not always available. This arose when one inspector saw three staff putting aprons and gloves on to serve lunch. Staff were all looking at each other and making comments. They were asked if they always wore aprons and gloves to serve food. They did not want to reply initially, but one said they always washed their hands but then said they had been told to wear aprons and gloves today because inspectors we were on site. They said “gloves at lunchtime sometimes happens”, they said they only get one box of gloves a day and “when these are gone they are gone”. They added that they had been told gloves are not needed for everyone. Independently two other care staff working in different areas and at different times said that they are sometimes left with no gloves because the home is awaiting a delivery of new stock. This does provide adequate infection control. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience poor quality outcomes in this area. Whilst there is a qualified nurse manager and qualified nurses working at the home, their collective competency is lacking and people are at risk. People living in the home appreciate being cared for by care staff they consider to be committed, friendly and caring but their quality of life is affected through there not being enough staff on duty. We have made this judgment using available evidence including a visit to this service. EVIDENCE: There is sufficient evidence identified in earlier sections of this report to support the judgements made. Where professional qualified nurses are not identifying, recording and treating the nursing needs of people, and managers are not carrying out the type of audit that identifies this; where one qualified nurse follows another and fails to pick things up and this is not addressed this is of great concern. It is not for the Commission to investigate the degree of incompetence of individuals. The company, as the employer, has powers and responsibility to deal with staff who individually demonstrate they are not Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 25 competent and this must be done. Collectively the nursing staff have failed to treat and care for the people in the way they should. Other evidence gathered was that on arrival at 7.30 am, the night nurse handing over to the day staff on the ground floor was spoken to briefly. She said that during the night there was one qualified nurse and one carer on the ground floor. She considered that this was not enough for the dependency levels of the people they were caring for. She felt it was not possible to effectively get people to bed (dependant people needing two staff to move and handle) at times of their choice, also to do medication leaving just one carer who would be unable to move and handle people, treat and assess people who were not well, address pressure area care with turning requirements, deal with incontinence and emergency calls and keep detailed records of events during the night. The day nurse on the ground floor said that whilst things were mainly manageable with three care staff during the morning, during the afternoon numbers of care staff fell to two. This was also insufficient to cover things effectively. Our own observations during the first day supported this. Similar circumstances and reasons for additional staff were quoted on the first floor. They work during the day with one nurse and four carers. On the first day, the four carers included an agency member of staff. On the second day the ground floor was working with just two carers at the start of the shift. This was because a carer from the first floor had telephoned to say they would be late and one member of staff had been loaned for a period of time. This decision to loan a member of staff seemed essentially because there were two agency staff working on the first floor and their lack of knowledge about peoples’ needs and routines demanded at least two permanent carers on the floor – each one pairing with an agency staff. On the second day, on arrival for the visit, when the door was answered by the home’s administrator she apologised and rushed down the corridor because the emergency call system was immediately going into emergency mode and several calls were being made around the same time. It seemed chaotic to be greeted like this, but also necessary that the administrator was involved because there were insufficient care staff to deal with all that was going on. Our own observations of things are a mirror image of the situation a year ago: • • • • There were insufficient staff on duty. Staff could not afford people the time and consideration that was fully needed to make individuals feel valued. Staff were dealing with personal care immediately followed by handing food and assisting people with their meal. The volume of people with medication requirements means that the time to do the medication administration is extended. Throughout this phone calls or visitors, can distract the nurse dealing with medication, therefore increasing the possibility of errors being made. DS0000001330.V370552.R01.S.doc Version 5.2 Page 26 Charlton Court • • • People who like to spend their time in the lounge were observed to be in a passive state with little interaction from staff who were busy elsewhere. There were not enough staff to support and assist people in the dining room or lounge areas. The lack of numbers of staff limits some aspects of choice that an individual should be able to make like getting up when they wish, eating when they want. At the start of the inspection we asked for a number of documents. This included the training matrix (spreadsheet of training that staff have done) amongst other information and documents. Later in the day it became clear through speaking with staff that the matrix was inaccurate. Some staff we talked to were not included on the matrix and the training programme that was also provided appeared more extensive than the matrix showed. A new spreadsheet was provided on 28 August 2008 and showed that staff are, in the main, up to date with safe working practice training. We are still unclear about the numbers who have achieved National Vocational Qualifications but are satisfied that the home is committed to making sure that care staff have those qualifications. The staff spoken with appeared committed to personal development. From the information provided and, supported by staff spoken with, there is an exception and training in infection control where about two thirds of the total staff team have not received up dates or been trained at all. One nurse who has worked for the company in another home and transferred to Charlton Court in the last few months said she had not received training in infection control during her period of employment of over four years. With other evidence outlined earlier in this report that highlights our concerns about infection control, this is an area that once again reinforces that people are at risk. The recruitment files for three staff most recently appointed were checked. These had the documentation to show that the necessary procedures and vetting takes place to make sure people are suitable to work in the care industry. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. People who use the service experience poor quality outcomes in this area. The home is not managed in a way that makes sure that people are protected and are safe. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The accumulative evidence of this inspection demonstrates serious shortfalls in the way the home is managed. These are highlighted in poor outcomes under Health and Personal care, Complaints and Protection, Environment and Staffing in the preceding sections of this report. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 28 In the management section of the AQAA that was sent earlier this year, it stated: ‘What we do well – The home is well managed. Regular audits. Service users financial interests are safeguarded. Our evidence to show what we do well – Very low level of complaints. Record of internal audits. What we could better – blank. How have we improved in the last 12 months – Internal audits and action plans. Our plans to improve over the next 12 months – blank’. Apart from the lack of detail, the registered manager who completed the AQAA has not got a clear picture of the major problems at the home. The quality of checking and auditing is poor and should have picked up the serious shortfalls in care planning. It may be that the inspection visit was at a time when there were unfortunate problems with the emergency call system and fire system and that staff were just having a rushed and busy day. But once again there was evidence from the people we spoke with to support our judgements and indicate these are longer term problems. Reports written by senior management about the conduct of the home, that are required by law, reflect a positive picture about the home and it is our belief these have not accurately reflected some of the problems – again this is routed in the quality of the auditing and checking that has been done. The company needs to take urgent action and carry out investigations into the management of the home and make sure that clinical management and day-to -day management are effective. The company must satisfy itself about the competency of the nurses and address issues that arise and make sure that the audits that are done are thorough. The company must make sure that the day-to-day management of the home makes sure that staff are equipped with the right protective clothing and gloves to reduce the risk of cross infection and must make sure that equipment and facilities are reliable, safe and particularly for pressure care, the right equipment is provided. The company must make sure that the Commission is notified of all incidents, accidents and events that it is required to do and advice was given about this in the verbal feedback. There was sufficient evidence in the documents we saw to indicate they are not notifying us and particular reference is made to informing us of people with pressure sores. Whilst it is acknowledged that there were positive views expressed by people and their relatives, particularly about the care staff, much of what has been found at this inspection particularly in relation to care planning will be unknown to them and they will not realise the vulnerable and unsafe position people are living in. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 29 The home keeps some small amounts of people’s money for safekeeping. The systems and methods of record keeping were checked with a focus on two people’s accounts. These were inorder and ensures people are protected from financial abuse. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 30 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 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X 1 X X X 1 STAFFING Standard No Score 27 1 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X 1 1 Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14(2)(a&b) Timescale for action The company must make 17/10/08 arrangements to conduct a review of the care needs of each person living at the home by a suitably qualified and trained person or persons. The purpose of the review is to satisfy the company, the people living in the home and their relatives that each person’s care needs are clearly identified and recorded and that the home can currently meet those care needs. This will place a firm foundation for a plan of care to be written. Following review (referred to in 1 17/10/08 above) that must involve the individual or their representative, each person’s plan of care must be written in such a way that it gives clear and specific guidance to staff about how to manage, treat and monitor the specific care needs of the individual. This will make sure that staff have the information they need to properly care for people. Requirement 2 OP7 15(1)(2) (a,b,c,d) Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 32 3 OP7 17(1)(a) Schedule 3(1)(b&k& m&n) The plan of care referred to (in 2 17/10/08 above) for each person, must record the persons condition and any changes together with all nursing treatment, details of any plan relating to medication (including dressings), nursing (including records to show nursing to prevent pressure sores like turning regimes and diet/fluid intake), specialist healthcare or nutrition. 4 OP8 This will fully evidence that people are getting the care they need and are prescribed. 12(1)(a&b) The individual plans of care must 17/10/08 fully evidence that proper 13(1)(b) provision has been made for the health and welfare of people. People must receive the care, oversight and treatment when they need it. Timely referrals must be made to healthcare professionals. This will make sure that people receive the treatment they need and staff receive the advice they need to continue caring in the safest and most effective way. As part of the review of plans of 17/10/08 care the records must evidence that that people have expressed their decisions with respect to their care, and their personal wishes and feelings must be taken into account. As examples, this includes their personal preferences about lifestyle, getting up, going to bed, when they want to bath or wash and when they want to eat and what they want to eat. Staff will then know how people want then lead their lives and quality of life will be improved. 5 OP14 12 (2)(3) 17(1)(a) Schedule 3(3)(q) Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 33 6 OP15 12(1)(a&b) People must be provided with 17/10/08 13(1)(b) food that is properly prepared 16(2)(i) and cooked, is available at times when a person could reasonably expect it, and in quantities and suitable to their personal preferences and food that is wholesome and nutritious. This will make sure that people live as healthily as possible and according to their personal preference or need. Where staff have raised concerns 17/10/08 about the lack of skills of another staff member or raise issues about apparent neglect or lack of care, the management of the home must act promptly and follow safeguarding policies and procedures. 7 OP18 12(1)(a) 13(6) 21(1) 8 OP22 This will make the home a safer place to live. 16 Equipment identified as being 17/10/08 (1)(2)(c) needed for the continuing care 23(2)(c&n) and treatment of people living at the home must be provided and the necessary environmental adaptations made to meet the needs of people living at the home. This will make sure people are being nursed with the equipment they need, when they need it and will live a safer and more risk free life. Staff must be provided with 30/09/08 protective clothing and equipment at all times. Soap must be provided in the dispensers of all peoples’ bedrooms. This will help make sure that there are no unnecessary risks of cross infection to people living at 9 OP26 12 (1)(a) 13 (3)(4c) 16 (2)(j) Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 34 10 OP27 18(1)(a) 18(2)(3a) the home, their visitors or staff working at the home. The company must take steps to 17/10/08 satisfy itself that all nursing staff are competent to effectively provide people with the nursing, oversight and treatment they need. Nurses must be provided with relevant clinical knowledge and be supervised by someone suitably experienced, qualified and able to give them the support and guidance they need. 11 OP27 This will make sure that the nursing staff are monitored and supervised to a level that makes sure mistakes do not happen and people get the nursing care they need. 18(1)(a&b) Staffing levels must reflect the 30/09/08 dependency of the residents and skills of the staff and also into account the use of agency staff who may not know the specific needs of people they care for. People must get the care they need when they need it. Residents come first and it is for the home to ensure there are sufficient staff on duty to meet the needs of the residents in a timely, caring way. Care staff must not carry out 30/09/08 nursing procedures unless trained to carry out the task and that they are given periodic supervision and monitoring by a qualified and competent nurse. This will make sure people doing clinical tasks are up to the job and monitored to make sure they are doing it right. All members of staff must 17/10/08 receive training in infection control. DS0000001330.V370552.R01.S.doc Version 5.2 Page 35 12 OP27 18 (1)(a)(ci) 13 OP30 18(1)(c1) Charlton Court 14 OP31 9(1)(2a), (2b)(i&ii) This will help make sure the home is a safer and more hygienic place to live and work. The company must investigate 17/10/08 why services have not been clinically managed and also managed on a day to day basis that makes sure that the home consistently meets National Minimum Standards and Regulations. The company must then take steps to make sure the home is managed consistently well. 15 OP33 This will make sure that the home is run safely, efficiently and effectively for people living there. 24(1)(a&b) Measures must be taken to make 17/10/08 (2)(3) sure that the internal auditing systems identify shortfalls and an action plan to put things right is made. This will make sure the home consistently meets National Minimum Standards and Regulations and is run safely, efficiently and effectively for people living there. Managers must notify the CSCI 30/09/08 orally and then confirm in writing, of any events required by this regulation that affect the health, safety and welfare of people living at the home. Advice was given. Then the CSCI can be fully informed and monitor events in the home as part of its ongoing inspection process. 16 OP37 37(1)(2) Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 36 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. Refer to Standard OP33 Good Practice Recommendations The company is strongly advised to enter into discussions with the community matron, representatives of the PCT including Doctors who are associated with the home to further identify their views and concerns and take steps either independently or together with the PCT to make sure the home is managed and operated to the benefit of people who live and work there. Charlton Court DS0000001330.V370552.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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