Inspection on 04/11/08 for Coton House

This inspection was carried out on 4th November 2008.

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

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

Other inspections for this house

Coton House 13/01/09

Coton House 09/07/08

Coton House 18/10/07

Coton House 22/06/06

Coton House 26/09/05

Coton House 12/10/04

Coton House 08/06/04

Coton House 08/03/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 16/12/2008.

Inspecting for better lives Random inspection report Care homes for older people Name: Address: Coton House 55 Coton Road Penn Wolverhampton West Midlands WV4 5AT The quality rating for this care home is: The rating was made on: zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Deborah Sharman Date: 0 4 1 1 2 0 0 8 Information about the care home Name of care home: Address: Coton House 55 Coton Road Penn Wolverhampton West Midlands WV4 5AT 01902339391 F/P01902339391 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Coton Care Limited care home 27 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category 0 0 Over 65 12 27 Conditions of registration: The registered person may provide the following category of service only: Care Home Only (Code PC) 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 (OP) 27 Dementia - over 65 years of age (DE(E)) 12 The maximum number of service users who can be accommodated is: 27 Date of last inspection Brief description of the care home Coton House is situated in a very quiet area of Penn, some 400 yards from Goldthorn Hill. The property was built in the 1930s and has been a residential home for the elderly for many years. Coton House is registered for 27 service users aged over 65 years and can admit up to 12 residents with mild dementia. In 2001 the Home had major development and refurbishment with a new purpose built wing of 10 en-suite Care Homes for Older People Page 2 of 16 bedrooms being added. The home is well maintained and as a result of a low turn over of staff has an experienced staff team. Weekly fees range from £349.00 to £400.00 per week. Care Homes for Older People Page 3 of 16 What we found: I am writing following the random inspection on 4 November 2008 when Roz Dennis Regulation Inspector accompanied me. The inspection commenced at 9.45am and finished at 4.30pm. We were able to talk briefly to Mrs Kular the Proprietor the Registered Manager and staff on duty. We had access to all records and looked in detail at how the health and safety of five people living at Coton House is being managed. The reason for this inspection was to primarily assess compliance with regulations 12, 13 and 19. These relate to health management and recruitment practice. We also planned to look at progress made towards meeting other requirements that affect the health and welfare of people who live at the home such as the provision of first aid training. We did not on this occasion, assess how people are admitted to the home. We will inspect this at the next key inspection. Therefore a requirement made at the last inspection to ensure this improves has been carried forward in this report. We did not look at how people are receiving their medication because our Pharmacy Inspector assessed this in an earlier random inspection on 16 October 2008 when documentation was taken from the premises to evidence ongoing concerns about medication practice. We are considering what action we will be taking to ensure practice improves. However the Manager told us that since the pharmacy inspection she has worked hard to address the issues raised and she is now satisfied medication is safe. Our Pharmacy Inspector will continue to monitor this. We have included the Pharmacy Inspectors findings in this report. The reason for the medication inspection on 16 October 2008 was to establish what progress the home had made in meeting the requirements set after the key inspection on the 9th July 2008. In summary we found the medicines management systems within the home were still poor and as a result evidence was photocopied and removed from the home under code B practices set out in the Police and Criminal Evidence Act 1984. Although there had been some improvements, the medication records were still poor and could not be used to evidence that all medicines were being administered as prescribed. The receipt of the monthly medication order was on the whole being recorded but medicines being received during the monthly cycle were still not being recorded. Medication carried over from the previous month was still not being taken into account and added to the new quantities at the start of the next month. We found evidence of where members of staff had signed the MAR charts but had not administered the medication. We found on one MAR chart that 28 antibiotic capsules had been administed on 30 occasions. On another MAR chart we found that the audit accounted for 139 antipsychotic tablets when only 128 tablets had been received into the home. We found gaps in the administration record and therefore it could not be confirmed whether the person concerned had received their medication.We found that where variable doses had been prescribed the records did not show what quantity had Care Homes for Older People Page 4 of 16 been given. We also found that the disposal of medicines were not being recorded accurately. We found overall that the care plans were poor for containing information about the administration of medicines. In particular we found little or no information about the administration of when required medication, the administration of as directed medication, the changes made to the doctors original directions and the reason for the administration of the medication and where appropriate the length of treatment, in particular the administration of antibiotic eye drops. We found that a number of people who were using the service were holding and administering part of their own medication. We found that there was no documented assessment of the risks, to either the people themselves or other people in the home, associated with this activity. We also found that there was no monitoring programme in place to ensure that the people were administering the medication as prescribed by the doctor. We found that none of the staff had undergone any assessments to establish whether they were able to administer medication safely and in accordance with good administration practices. In light of some of the issues identified during the inspection the assessment of the care staffs competency to administer medication safely must be carried out as a matter of urgency. We found that the home was failing to maintain the temperature of the fridge within the correct range, two to eight degrees centigrade. We found that the home had a maximum and minimum thermometer to record the maximum and minimum temperatures on a daily basis but were failing to do this. Instead the home was recording the ambient temperature shown on the thermometer three times a day. During the current month the majority of the readings were being recorded at one degree centigade. The maximum and minimum temperatures observed on the day of the inspection were twenty six degrees centigrade and minus seven degrees centigrade respectively. Further concerns were expressed when three bottles of antibiotic eye drops , which must be kept in the fridge at all times were found in the mobile drug trolley. We found differences of opinion as to whether these eye drops had been kept in the fridge. The pharmacist inspector pointed out that if they had been continuously stored in the fridge the poor storage conditions within the fridge would have still meant that the eye drops had not been stored at the temperature specified by the manufacturers. Medication apart, we are satisfied following this later inspection on November 4 2008 that peoples immediate health needs are being met. Nobody living at the home has a pressure sore and changes in peoples health have received medical attention promptly. One resident has been admitted to hospital twice since we last visited and we can see staff kept in daily contact with the hospital and in the absence of family, visited him there too. There have not been any service user restraints since the last inspection and in this time staff have received training in behaviour management. We observed staff to be interacting with residents positively. One of the proprietors was not available at the time of inspection because he was attending a four day physical intervention and crisis instructor course which will enable him to cascade training to staff. However staff tell us that nobody is now demonstrating severe challenging behaviour that they are concerned about or that they feel is unmanageable. The skills and knowledge will Care Homes for Older People Page 5 of 16 however better prepare staff in the event that these are needed and will ensure that residents can be supported without injury. A resident told us he has plenty to drink and we could see a jug of squash next to him in his room. He told us he always drinks a jug of squash every day and sometimes he has two, in addition to seven cups of tea throughout the day. Care records refer consistently to the provision of fluids and this represents an improvement. A District nurse had asked that fluid input be measured and we could see that staff had done this. The manager must ensure that more detailed records of fluid and dietary intake are kept where risk is identified. Staff are recording when they have noticed changes in peoples condition and in records are asking other staff to monitor this. We can see that medical advice is being sought when symptoms provide concern. Staff must now demonstrate that they are monitoring all specific changes highlighted by their colleagues. We found some occasions when colleagues were asked to please monitor and then there is no further reference to the matter in subsequent records. On these occasions we could not see that this had lead to poor outcomes, but there is the potential for this. The homes improvement plan submitted to us on 17 October 2008 addresses the need to ensure that medical conditions are adequately followed up. It states that steps have been taken to ensure the Registered Manager is now away from the floor and acting solely in a management role. This it says will enable her to read the care plans on a daily basis and therefore to act or liaise with the relevant district nurses and GPs. Perusal of rotas showed that this has not always been the case. We can see that in the time from the last inspection leading up to the submission of the improvement plan that the manager had been working in a care, rather than a management capacity for a combined total of two and half weeks. Further steps were then taken and the Manager is now supernumerary again. This is essential if care standards are to be effectively regularly monitored and improved. We will continue to monitor this. We could see that time has been spent changing the care planning format to the Standex system. This has given better structure to care plans as it provides a format to assess key areas of need and levels of risk for pressure sores, nutrition and moving and handling. We could see that these have been completed and that levels of risk are known and are being reviewed. This is positive progress. We found however that changes are not always being recorded and a plan of care is not in place for all key needs. For example one persons care records state that he is diabetic as he has been treated as such by District Nurses for many years. He has recently been diagnosed as not diabetic. We talked to a staff member who told us that he is diabetic. A plan of care was not in place to tell the staff member otherwise, or for his behaviour or continence management. The one care plan in place for his catheter care is too vague. Similarly dementia care is not included in care plans and does not explain to staff the effects of dementia for that person or steps staff should take to overcome the barriers it imposes. Staff are however, beginning to develop their understanding of dementia, its effects and how to manage it positively although they are very much in the early stages of this. Since the last inspection, staff have completed a distance learning training course about dementia. Staff have found this to be very interesting and beneficial. A staff member told us she has learned that it is important to talk to people with dementia as Care Homes for Older People Page 6 of 16 prior to undertaking the course, she had not understood the purpose of this. Some steps have been taken also to provide signage to try to help to orientate people in their surroundings. Its effectiveness should be kept under review. We found equipment or turn charts to be in place for those service users whose care we looked at and who are assessed as at risk or at very high risk of pressure sores. One service user assessed as being at very high risk has a pressure relieving mattress and cushion but is not on a formalised turn programme as we would expect. A chart is not in place and we received contradictory information from staff about whether this person is being turned. Another person is being woken hourly throughout the night to be turned. We queried the accuracy of the records and suggested that someone needing that level of intervention should be provided with pressure relieving equipment. District nurses have decided this is not required so we advise that the turn programme is reviewed with them to ensure it is personalised, meets the persons needs but also facilitates effective sleep. However we can see from scrutinising records that there have been no deterioration in peoples skin condition and a number of people told us that no one currently has a skin breakdown. It is positive that risk of pressure sores has been assessed and is being regularly reviewed. This represents an improvement. Where people are immobile and need support to move and transfer, care plans are helpful in that they state when the hoist must be used and how many staff are needed to effect safe care. The resident we spoke to told us that two staff always use the hoist with him in accordance with the care plan and that he always feels safe using it. Care planning is insufficient however. Guidance states that correct moving and handling measures are to be followed without describing what this means. This would not adequately instruct new or temporary staff. The guidance does not define which hoist to use or which sling or size of sling is required. Using the wrong one in error could cause an accident and injury. We observed a staff member remove a hoist sling from the residents bedroom whilst we were talking to him. We were told that two people use hoists and that one sling has been removed from use as a service engineer had assessed it as being worn. The two residents both of whom are incontinent are sharing one sling without their being time to wash it between uses. This is poor infection control and given that sling sizes are not noted in care plans we couldnt determine if the one sling was the right size for both people. The manager said a trainer has assured her that the sling is appropriate for the two people. This matter is complicated by the fact that we couldnt satisfactorily evidence who owns the one hoist as on the day we received contradictory information. We have asked that evidence be supplied to us because it would not be appropriate for the resident to have funded essential care and safety equipment and if he has, even less acceptable for it to be borrowed for use by another resident in the home. Effective contingency arrangements should be in place. We were told that a new sling has been ordered but we queried the time taken to obtain a replacement. The manager said she will pursue this. Care planning is not currently person centred although person centred training has been provided since the last inspection. For example, choices and preferences are not always adequately considered and this is affecting care. For example people may not be bathing or showering as often as they might like to because this has not been agreed with them and staff are not adequately guided how to encourage people to Care Homes for Older People Page 7 of 16 bathe when this is required regularly to support good health. We were told that one person whose care we looked at does not like to shower or bath. The new care plan does not explain this or the need for good personal hygiene to prevent infection as a result of catheterisation. Goals have not been set for shower frequencies based on the preferences of the person to support and encourage showering. Genital soreness was identified on one occasion and was discussed with the district nurse. She advised to wash and monitor. Records show he has had one bath and one shower in two months since 7 September 2008. We talked to the resident who said he is happy with the frequency he showers but indicated that his willingness to shower is determined by which staff are on duty. This indicates that staff need support to adjust their approach. He is however having a twice daily wash. We can see too that he is receiving all catheter care but what this means is unclear and is not defined for staff in the care plan. Records for a second person we looked at showed they are having a shower or bath once per week. Records for a third resident show a gap of one month between showers and daily washes three times per day. We discussed this with the resident who did not raise this as a problem. Similarly, although in place for one person, preferred rising and retiring times have not been agreed or recorded for another. This resident said he is happy with the time he is supported to go to bed. However he is not happy with the time he is expected to get up. He said he is supported to get up by night staff at 6.30am and that this is necessary to ensure the homes routine. He would prefer to get up at 9am. We talked to staff and looked at records. We could see that he can be aggressive. Staff explained that he is not a morning person. He has told us this too but his care plan does not reflect this and steps have not been taken to ensure his preferences are met and the reason for conflict is reduced. Similarly a point of conflict for him appears to be where he sits. He said staff prefer him to sit in his chair as it is healthier than sitting in bed all day. Staff told us he would stay in bed all day if they let him. Discussion with him informed us that he does not find his chair comfortable. Perusal of accident records showed us that he has also slipped out of it. This has not been reviewed. Accident records also showed us another person living at Coton House who is physically dependent has slipped out of her wheelchair. There is not a risk assessment in place for use of the wheelchair and nothing has been done since the accident to ensure that this risk is diminished. We have advised that an occupational therapist is consulted to ensure the safety and comfort of both people. Since the last inspection staff have received training in the management of behaviour. A resident we spoke to told us he gets cross with staff sometimes when they dont do things right and he said that in response they can be hot tempered. He said he knows this because of the tone of their voice rises. He was keen to add though that the staff are alright and if asked to give a score for his care he would give 8 out of 10. From talking to staff we can see they are aware of behaviour management techniques such as distraction and walking away, returning later when the person has calmed and they say that they do this. They are not recording how they manage aggressive situations only that the person was aggressive and that they managed. They now need to develop their understanding of behaviour triggers and how they can unknowingly affect and escalate peoples behaviour including being aware of and controlling the tone of their voice. Following the last inspection when the home was rated poor, an improvement plan has been submitted to us. It states that portable heaters have been removed from Care Homes for Older People Page 8 of 16 bedrooms and that they were used prior to the fitting of double glazing and are not now deemed necessary especially as all rooms have fitted radiators. We have found that three portable radiators have been reinstated in three different bedrooms. As the improvement plan states, a risk assessment has been completed although it is very brief in content. One persons states it is placed behind the bed out of reach. We talked to this person who said he is warm enough. We looked at the portable radiator. It is placed behind furniture where it would not be a tripping hazard but is close to the headboard and may present a hazard should the person fall out of bed. We also observed extension leads in use behind the bed which should be discussed with the fire service who have recently announced their intention to inspect the home. We discussed the use of portable heaters with the manager and deputy manager who explained that temperature control is a problem in the old part of the building and the three bedrooms supplied with portable heaters are in the old part of the building. We advised that the heating system be reviewed in the old part of the building to determine why it is considered necessary to use an additional heating source and to explore safer alternative solutions. Since the last inspection the improvement plan tells us that five bedrooms have been fitted with wooden safety flooring which can be easily cleaned to prevent unwanted smells. We entered one of these bedrooms and the urine odour was powerful. Odour was also present in a second bedroom and we were told there are plans to replace the flooring. This should be discussed where possible with the resident. The reason for ongoing odours in rooms where flooring has been changed should be reviewed and acted upon. Odours in the entrance to the home were more acceptable on this occasion. We noticed staff administering eye drops and carrying out manicures for a number of people consecutively without changing their gloves. Training in infection control has not yet been provided as other training needs to be completed first but the manager is aware of the need for staff to do this. Systems therefore to support care have improved but still need to be tightened. Issues subjected to adult protection processes have been investigated by Social Services and since this inspection the matters have been closed. A number of recommendations to improve practice were made but the conclusion was that there had not been any wilful neglect. We looked at how new staff are recruited and assessed this for all four staff who have started employment since the last inspection. Three of these people remain employed. The improvement plan states that all staff will not be allowed on site until such time as CRB and POVA records have been received regardless of whether it is for work or training purposes. We found practice to be generally acceptable although not fully in line with regulation or stated intention in the improvement plan. We have advised against accepting references addressed to whom it may concern. We saw no evidence that references are being requested in writing to help ensure authenticity although they are being validated by telephone. Similarly for another new employee we found that although two references had been obtained including from a recent employer a reference had not been sought from the persons last care employer to determine if there were any concerns which led to them leaving. Care Homes for Older People Page 9 of 16 In exceptional circumstances, it is permissible for staff to be recruited on a POVA first check without a full CRB, if all other checks and references are in place. We found that one person has been appointed on a POVA first without a full CRB. This was the person for whom two references were available but without a previous care employer reference. Records tell us that the appointment on a POVA first was discussed with CSCI but the action is contrary to the stated intention in the improvement plan. We could see that prior to receipt of the CRB that the person attended training on site. We have concluded that this person worked under supervision as they were supernumerary to usual staffing ratios. The person was not on duty so we could not ask them about their experience. We have advised the Manager to ensure that in these circumstances the rota must indicate who is responsible for their supervision. We have also advised the manager about a number of other ways that rota management should improve. Staff full names and designations should be recorded to better account for who is on duty and to demonstrate care staffing ratios. Currently only staff first names are on the rota so it is not clear if they are the cleaner, cook day or night staff. An agency staff member was used for the first time for a few days and with only a first name provided it would be difficult with the passage of time to trace this staff member if required. Similarly we have advised that liquid paper is not used to amend care records. Training and supervision meetings with staff are being well recorded with the manager with supervision records showing particularly effective processes. We have advised that the manager check with Skills for Care whether the current induction training package for new staff complies with new induction standards. In conclusion we can see that progress has been made and peoples immediate health needs are being identified and responded to. Apart from medication we have not identified the number of concerns that we did at the last inspection four months ago. The process of improvement has begun. It is important that this is now maintained and developed to address the areas identified within this report. It is essential that the manager continues to be provided with the necessary time training and support to enable her to sufficiently manage and improve the service. What the care home does well: What they could do better: Medication systems remain poor. We have identified that the poor systems have the potential to put people at risk and do not evidence that people are receiving their Care Homes for Older People Page 10 of 16 medication as prescribed to support their health and welfare. Care plans would benefit from more detail to ensure that there is sufficient guidance for staff and staff must more be more familiar with the details of these for individual people. It is particularly important that care plans determine how dementia is impacting on individual peoples lives and steps that staff can take to overcome the barriers specific to those people. Odours must be more effectively managed to provide a more pleasant and dignified environment for people as well as ensuring that the risks of cross infection are minimised. The manager must review accidents to take steps to reduce the risk of repetition and staff must demonstrate that they are always monitoring changes in health by recording what they have done and observed even where conditions seem to be improving. Also staff need to know how to improve their infection control practice on a day to day basis 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 set out on page 2. Care Homes for Older People Page 11 of 16 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These requirements were set at the last inspection. They may not have been looked at during this inspection, as a random inspection is short and focussed. The registered person must take the necessary action to comply with these requirements within the timescales set. No. Standard Regulation Requirement Timescale for action 1 3 14(1)(a)(c) Accommodation must not be 09/07/2008 provided to a service user at the care home unless so far as it shall have been practicable to do so There has been appropriate consultation regarding the assessment with the service user or a representative of the service user. New requirement arising from inspection 9.7.08. Not assessed at random inspection November 2008 and carried forward. 2 9 13(2) Medication management must be reviewed to ensure that: Medication Administration Records account for the numbers of tablets / dose administered when there is a choice e.g. `one or two tablets as required? And; Stocks of prescribed medication are available at all times for all residents and are not permitted to run out. This will ensure that 09/07/2008 Care Homes for Older People Page 12 of 16 medication stocks can be accounted for, that amounts of medication administered to service users are known to avoid the risk of under or overdosing. Appropriate stock control will promote service users health and well being by enabling them to take medications as prescribed. New requirement arising from key inspection October 2007. Original timescale set for compliance was 31.10.07. Not met at July 2008 key inspection or at random medication inspection 16.10.08. Carried forward. 3 9 13(2) Arrangements must be made 31/08/2008 for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home to ensure that medications are administered safely, accountably and in accordance with prescribed direction to ensure the health, safety and well being of residents. Requirement carried forward. Care Homes for Older People Page 13 of 16 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 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 1 8 Steps should be taken to ensure that staff always evidence how they are monitoring identified changes in peoples condition. Records should state when the issue has been monitored and what was found on each occasion until satisfactory improvement is documented When people are identified as at risk or at very high risk of pressure sores the advice of District nurses should be sought about turn programmes so programmes can be individualised to the persons specific health needs as well as facilitate effective sleep The advice of an Occupational Therapist should be sought in relation to the suitability of the bedroom chair and wheelchair for the two people whose care we looked at and for whom accidents are recorded. Steps should be taken to review, with a competent heating engineer, the central heating output in the old part of the building to determine why it is necessary to provide additional heaters and to explore safer alternative options The reasons for persistent malodour should be reviewed with results acted upon. This may include seeking the advice of Wolverhamptons Infection Control Nurse Page 14 of 16 2 8 3 22 4 25 5 26 Care Homes for Older People Until staff commence Infection Control training steps should be taken to ensure they know how to improve their infection control practice 6 29 Where applicants have worked in the care profession a reference should always be sought from the last care employer even where this is not the most recent employer. This will determine if there are any reasons why the person left that employment and may be unsuitable. The current induction programme for new staff should be reviewed with The Skills for Care Agency to ensure it meets up to date standards Rota management should improve to better account for who is working in the home and to better demonstrate how staffing ratios are provided. Eg staff full names and designations should be recorded and this includes for any temporary staff All accidents should be reviewed by the manager so trends can be identified and so that action to prevent reoccurrence is considered and acted upon The Fire Service should be consulted about the use of electrical extension cables in the home. 7 30 8 37 9 38 10 38 Care Homes for Older People Page 15 of 16 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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