Inspection on 09/07/08 for Coton House

This inspection was carried out on 9th July 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 04/11/08

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

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Coton House 55 Coton Road Penn Wolverhampton West Midlands WV4 5AT Lead Inspector Deborah Sharman Key Unannounced Inspection 9th July 2008 09:15 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 Coton House DS0000020885.V368957.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. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coton House Address 55 Coton Road Penn Wolverhampton West Midlands WV4 5AT 01902 339391 F/P 01902 339391 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) Coton Care Limited Mrs Kalwant Chahal Care Home 27 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (27) of places Coton House DS0000020885.V368957.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 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 18th October 2007 2. Date of last inspection Brief Description of the Service: 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 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. Coton House DS0000020885.V368957.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. This inspection was carried out over 2 days. One Inspector carried out this unannounced key inspection on the first day, 9th July between 9.15 am and 7.30 pm. Two Inspectors carried out the inspection on the second day 11 July 2008 between 2.30pm and 8.00pm As the inspection visit was unannounced this means that no one associated with the home received prior notification and were therefore unable to prepare. As it was a key inspection the plan was to assess all National Minimum Standards defined by the Commission for Social Care Inspection as ‘key’. These are the National Standards, which significantly affect the experiences of care for people living at the home. We carried out this inspection at short notice and earlier than we had planned following learning of some concerns that were subject to adult Protection investigations by Social Services. Therefore we had not asked the home to submit its annual return (AQAA) to us and neither did we send surveys to interested parties in advance of the inspection, as time did not allow this. During the course of the inspection we used a variety of methods to make a judgement about how service users are cared for. One of the proprietors was on site when we arrived, manager. They supported the process of inspection documentation and answering questions throughout proprietor who also took a full part in the inspection as was the registered by providing the day. The second joint process later joined us. We were able to speak to two visitors during the inspection and we also had sight of completed questionnaires distributed by the home to relatives. Not all had been returned at the time of inspection, but those that had, gave us a picture of how the service is viewed by third parties. We attended a residents’ meeting on the first day, which was well attended. The purpose of the meeting was to give the opportunity to residents to comment on their care, the food provided and to decide upon a day trip to either the park or garden centre at some point during the summer. Residents said they were generally satisfied but seating arrangements meant that residents were not fully engaged and questions put to them were leading. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 6 Over the two days we assessed the care provided to five people, including current and discharged residents. We looked at care provided in detail for some of the five and looked at aspects of care for others. To do this, we used care documentation, observation and where possible discussion with a relative and residents. We also sampled a variety of other documentation related to the management of the care home such as training, recruitment, staff supervision, accidents and complaints. We toured the premises and we were able to observe the care of residents during this time. All this information helped to determine a judgement about the quality of care the home provides. What the service does well: What has improved since the last inspection? The Manager has attended training courses to update her knowledge and skills and she is now receiving regular formal supervision. The level of improvement overall however is disappointing. Only one of six requirements made previously to improve the service has been met. Other actions have been taken however particularly in respect of improving the environment. Bed rails are no longer used as they are not now required and risks to vulnerable people using them have therefore been removed. Extensive work has been undertaken in the garden to provide a suitable, safe and pleasant external area for residents’ enjoyment. It has been fully landscaped to provide wide paths, a barbecue and an external sound system so music can be played to sooth residents. A sound system has also been installed in the lounge to ensure that Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 7 all residents can hear the television. There has been some redecoration and carpets in a number of communal rooms have been replaced with alternative flooring. What they could do better: We consider the service to have deteriorated since the last inspection and a lot of work is required to ensure it meets an acceptable level. In essence the service must ensure it improves how it assesses the needs of prospective residents before they are admitted. They should always seek information from a range of available people and must develop their assessment tool in line with current research and agreed good practice to ensure it helps them to assess people’s specialist needs. This will enable them to be confident they can meet residents’ needs before they are admitted. This will avoid putting residents and staff at risk from trying to meet the needs of people they are not trained or competent to care for. We found one resident to have been admitted without sufficient information. Staff clearly were not able to meet her needs, she was distressed for the majority of her stay with no evidence of well being. This culminated in bruising incurred when according to records untrained staff restrained her to avoid further injury to herself and others. Staff must be provided with more guidance about how to meet care needs and risks to individuals must be assessed and reviewed. Care provided must be monitored so people’s changing needs and health needs can always be met. For example we found that staff were recognising, reporting and recording changes in the skin condition of one resident but action was not taken until after the resident had developed a pressure sore. This is a clear failure in management systems. A similar situation is currently subject to investigation for a second person. Medication systems are also not being managed accountably. This is placing people at risk of not receiving medication as prescribed and we identified practice which put the resident at clear risk of being overdosed in error. There is little within the home that demonstrates they are dementia care specialists. Assessments and care planning tools are lacking and hinder the provision of appropriate care, as does knowledge of dementia and how it affects people’s lives. We found that the environment is not as enabling as it could be for people with dementia and physical challenges. It is positive that residents’ meetings are held, but the format does not enable residents to fully engage in the process to the best of their ability. These matters require review based upon current dementia care best practice. The home has a low turnover of staff but staff appointed continue to be recruited unsafely. A new recruit appointed since the last inspection has been allowed on to the premises over a period of time whilst training, with access to Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 8 vulnerable adults and information about vulnerable adults without any pre employment checks having been received. The providers tell us they are aware of their responsibilities but we found this not to always be the case. We are concerned that matters affecting the health and welfare of residents have either not been notified to us and or not notified to us in a timely manner. Matters only came to light as families reported their concerns. Documentation completed by the management about one of the two incidents currently subject to adult protection investigation, materially differs from the accounts of staff. This does not demonstrate an understanding of responsibilities or that the home is always managed accountably. The Manager however is not being provided with the time to oversee and monitor the service and staffing numbers must be addressed to ensure this is possible. The Proprietors and the registered manager have assured us that all necessary steps will be taken to ensure that peoples needs are identified and met, risks are reduced and to ensure the quality of the service improves. We will be closely monitoring progress and will consider issuing Statutory Enforcement Notices where regulations continue to be breached. 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. Coton House DS0000020885.V368957.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 Coton House DS0000020885.V368957.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): 1, 2, 3, 4. Quality in this outcome area is poor. People cannot always be confident that the care home can support them. This is because there is not always an accurate assessment of their needs that they, or people close to them, have been involved in. There is insufficient information available to tell the home all about them and the support they need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A Statement of Purpose and Service User Guide, which are brochures to tell people about the service offered, are up to date. We were told that they are currently being transcribed into more accessible formats. Following a Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 11 misunderstanding, it remains for the Proprietors to ensure their continued intention to only provide care for people with mild dementia is clearly stated in their brochures. There are some positive aspects to pre admission procedures. We found that information from funding authorities was available about the person and in addition the home is carrying out assessments with the person present. It was positive to see the offer of a place being put in writing on the basis that it was felt the home could meet the needs identified. However additional steps must be taken to ensure that assessments are robust, that specialist needs including dementia are fully identified and that professionals and families have the opportunity to contribute to the assessment particularly where the person lacks capacity. Information provided to the home was not fully used to explore in detail the needs of a resident admitted. The placement eventually failed following a traumatic period for all with outcomes for the service user being particularly poor, with little evidence of well being for the duration of the stay. Another resident has been recently admitted with an eye condition. The assessment does not explore this. No details have been obtained about how it affects the person or support required to overcome any barriers to daily living that it poses. Therefore no steps have been taken to make the necessary adjustments to the environment to ensure needs can be met. Personal risks prior to admission have not been identified to enable measures to be put in place to reduce risks to residents. Contracts have been provided to advise people of their rights and responsibilities. It is positive that residents and their representative have signed the contracts. However, contracts should be further developed to ensure that responsibilities for funding are clearly identified and comply with 2006 regulations. This will ensure that financial responsibility is clear to those signing the contracts at often what is a traumatic time of change for them. A resident we spoke to could not remember much about his admission as he was upset and worried at the time. He hasn’t been offered accessible information about the home. . Coton House DS0000020885.V368957.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, 10. Quality in this outcome area is poor. People’s health, personal and social care needs are not always met. The home has a plan of care that the person, or someone close to them, has been involved in making but it lacks sufficient detail to adequately guide staff how to provide the care needed and deterioration in health is not always monitored. Some people are not being supported to take their medication safely. Some people therefore, particularly those with more complex health needs are at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are in place for each resident and are beginning to be reviewed. However insufficient detail within the care plan means that reviews of it are not meaningful. From looking at the care provided to five people we learned Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 13 that care plans are not person centred and do not provide guidance about how diagnosed dementia impacts on the person’s life. Ways of overcoming the barriers dementia imposes or ways of maintaining existing skills and interests are not identified. Care planning shows how the home is allowing dementia to be a barrier to people’s quality of life. For example, we learned how a resident is a devout Christian and all her life had gone to church weekly. Her recent care plan states she is ‘C of E’ and that she ‘doesn’t go to church anymore.’ A review of the care plan on states she ‘likes to go to church. This has now stopped due to dementia’. There are no opportunities provided for people to meet their spiritual needs. Staff told us that ‘no one is religious’. There is insufficient health detail in care plans to guide staff to provide care in accordance with peoples needs and wishes. For example where a resident is at risk of pressure sores and staff have identified changes in skin condition, neither plans nor action were put in place to minimise risks. The person went on to develop a grade 2 pressure sore. The care of a second resident assessed as at risk of pressure sores and needing intensive care was not sufficiently reviewed and appropriate care cannot be evidenced. Whether she developed a pressure sore is subject to investigation. We could not determine that cream was being applied to reduce the risk of pressure sores. Staff reported using it. However it is not being prescribed for the two people whose care we looked at, is not recorded in medication records and for the one person still resident was not available on the premises either in their bedroom or in the medication room. Care plans do not explain how people’s personal care should be carried out to ensure that it is carried out appropriately and in accordance with the person’s known preferences and wishes. Lack of such guidance affects people’s experiences of care. For example since we last inspected, the minutes of a staff meeting in December 2007 show personal care to have been carried out too infrequently. During the week in question only 3 people had been showered. Medical tests on one resident in response to a thick green offensive vaginal discharge showed there to be no infection. Staff have recorded that the Doctor had advised that she must be kept clean and dry. Perusal of personal care records prior to and after the advice shows it not to have been adhered to, with showers being provided every ten days. This is insufficient to maintain personal hygiene and health. We could see that for another resident only bed baths were provided, as the home was not sufficiently equipped to provide a bath that could meet her needs. A plan of care is not in place for a resident with skin cancer. There is no guidance to inform staff where on the body this is, when it occurred and what if any treatment has been provided or is to be provided. Such omissions do not enable staff to know and meet residents’ needs. Positively however health changes to another resident were noted and acted upon. Cancer in this case has been diagnosed and with support from a relative, we could see that prescribed treatment is being provided. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 14 Falls incurred by people are not reviewed, indicating the service is not doing all it can to keep people safe and prevent accidents happening again. Fibre score sheets are completed to identify residents at risk of constipation but there is no evidence for those whose care we looked at, of action taken to minimise risks identified. There is no evidence that residents noted as ‘sick’ or ‘not well’ had been monitored and their condition evaluated. Where records indicated a new resident had had loose bowels from 27 June to the day of inspection 11 July, medical advice had not been sought as neither had swelling identified to another resident’s leg. Where people require moving and handling, staff confirmed that they always carry this out in pairs for their and residents’ safety. There are shortfalls in guidance available however. As a result we found that the wrong size hoist sling had been used putting the resident at risk of a moving and handling accident although this had been addressed before we inspected. No accidents however have been recorded and staff and managers said there have not been any. Staff told us that food and fluid records are put in place when residents are at nutritional risk. None were in place for a resident who was deteriorating prior to hospitalisation. Staff told us that none were needed for this particular resident as she wasn’t at risk. Monitoring systems were not put in place a week before hospitalisation when records show her diet to have been poor. Records also show her to have lost 13kg in weight in the previous 12 months, with no evidence that this was intentional or being managed safely. Other than ‘at high risk’ and ‘staff to be patient’ there was no guidance available to support staff to manage a dementia resident’s challenging behaviour. The service is not accustomed to meeting such extreme needs and although staff are aware of how to diffuse situations, they had no further ‘tools’ available to them to positively manage this service user who could not respond to low level interventions. Record entries by staff indicate little understanding and some intolerance of the disruption caused. There was no evidence of well being for this resident throughout the majority of her stay and it ended in bruising following what appears to be a restraint by untrained staff. There is evidence however that the service persistently sought medical advice in respect of this person but struggled to cope with the frequent changes to medication prescribed in an attempt to manage behaviours. Medication stocks are not being managed accountably by fully logging in drugs received and returned from the premises. Omissions in these processes means that they cannot evidence through the audit process that drugs have been administered in accordance with prescribed direction and errors cannot be properly investigated. An increase in the strength of one medication to 50mg was written in Medication Records, directing staff to administer 50mls up to Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 15 four times daily instead of 5mls up to four times daily. We can see the resident was given the medication four times per day but omissions in stock control records means the service cannot evidence whether the correct doses were actually given or whether the person was inadvertently overdosed for this period of time. Additionally for this resident, the Doctor advised the home to cease one medication and start another. We can see that on one day, the resident had both; the second being started half way through the day following delivery. This was not checked for safety with the GP before taking the decision to do this. On another occasion prescribing directions were to take a medication twice daily, but was transcribed by staff onto the medication records as to be taken up to four times daily. Records show it was administered as four times daily for seven days, doubling the prescribed quantities in error. A second person is not being used to verify the accuracy of directions transcribed by hand to avoid the risk of human error. There is also an increased risk of medication errors as a result of insufficient information in care plans and the way medication administration records are organised, making it difficult to distinguish one person’s records from another. Following discharge from hospital a resident was supplied with 4 enemas but these are not recorded onto the home’s premises as received. We have not been able to assure ourselves that these were carried out to meet the residents health needs. We looked at how the home manages less complex medication regimes and found this to be more satisfactory. Some residents therefore are at risk from the way that medications are currently being managed and administered. Steps have been taken to stop staff combing peoples hair communally with the same comb and we did not see this happening at any time during the course of this inspection. Since then however, managers have had to address the matter of staff using a mobile phone whilst toileting a resident. It is positive that once this came to light it was addressed but for a staff group largely trained to national standards, this is unacceptable and highlights the need for a greater level of management. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. Group activities are available but there is less emphasis on supporting people to follow their individual interests. The home is not responsive to people’s spiritual needs. Residents enjoy their main meals but are less satisfied with food available to them at teatime. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff feel that activities have improved. We could see that entertainers have been booked for the year and visit frequently to provide art and craft, fitness, singing and keyboard entertainments. Relatives feel welcome and can visit when they want to. Relatives have been informed of the entertainment programme for the year and a garden party to officially open the new garden in the presence of the Mayor has been planned. Staff described how they do try to engage residents in individual activities and said that they have plenty of time to do this. They described talking to a resident, an avid reader about the books she reads and a visitor said that she often sees staff talking with residents. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 17 Other than with relatives, residents have little opportunity to access the community. We attended a residents’ meeting where residents were given the option of a visit to a garden centre or park at some point over the summer. Both should be considered to meet the preferences of everyone rather than the majority. The way resident meetings are managed should also be reviewed to ensure that people are fully engaged and can contribute as much as possible. The size of the group should be considered as well as the position of seating and questions should be open questions rather than closed and leading. As discussed earlier, residents have no outlet currently to meet their religious needs. We observed the main meal at lunchtime. People can eat in their rooms or in the dining room and we observed there to be sufficient staff to meet the needs of those who require help. One resident was seen to be eating independently prompted by a staff member when necessary, enabling skills and dignity to be maintained. Where required, food was provided pureed. Food provided accorded with the menu and people were eating different meals they had chosen earlier. The minutes of residents’ meetings and observation of discussion in the meeting we attended, indicated there is less satisfaction with food provided at teatime. We observed tea to be tinned spaghetti on toast with ‘angel delight’ for dessert. One resident who needed to eat soft food could not eat the toast and had spaghetti on its own. Managers should take steps to review menus with someone qualified to advise on the nutritional value for people adhering to soft food diets. We could see that one resident’s request for fresh vegetables has been responded to but we could not see that residents’ requests on more than one occasion for jacket potatoes at tea time had been met. We spoke to staff about how they maintain residents’ fluid intake. They described how they provide drinks at least 2 hourly and in between if requested by a resident. We observed juice to be available with meals and a hot drink to be offered immediately afterwards. A visiting relative confirmed this. Staff described how jugs of drink are available in residents’ rooms and who require support to access this. They said that food and fluid intake records are maintained when there is a concern, but that these had not been implemented for a service user whose care we were looking at, as there was no concern. Records show that her diet intake was poor at least a week before she was hospitalised and this should have been more closely monitored, particularly as for over a year the resident had lost a substantial amount of weight, with no evidence that this was planned. This is currently subject to an adult protection investigation. Again it appears that those with higher dependency levels are more at risk. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 18 We spoke to a resident we had met at the previous inspection. She had been concerned previously that she had had to continually remind staff that she is diabetic but told us that she no longer needs to do this. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is poor. Systems are not sufficiently in place to protect people from injury arising from restraint. Systems are also not fully protecting people from the risk of neglect as there is insufficient monitoring and management of key changes to people’s health and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Complaints information is available at the ‘nurses’ station by the entrance to the home. It is not in an easy access format and is not readily seen given the height and angle of its position. It is not accessible to people living at the home who were seen to visit this area of the building infrequently. A complaints log is available and has been recently checked by managers but no complaints have been logged as received since November 2005. We spoke to a visiting relative who described the manager and Proprietors as very approachable and she was delighted with how a concern she had raised had been received and dealt with. It was in relation to laundry and said that it has never been a problem since. Staff also said they were happy that managers listen and act upon any concerns they may raise. However in practice we have found this not to be the case. Serious and ongoing changes to residents skin condition were being reported by staff and not acted on by managers. Discussion showed the manager is not having sufficient time to manage the Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 20 service and has not been able to read staff members’ written reports. However, she acknowledged that staff also report changes to her verbally and she could not explain, other than time limitations, why she had not acted upon the concerns staff were raising about skin changes until the wound had developed. The manager readily accepted that this is a poor outcome for the service user. Investigations about care provided to two residents are currently subject to investigation under safeguarding adults procedures. It has highlighted shortfalls in the service’s understanding of their responsibility to report all safeguarding matters and incidents affecting residents’ health and welfare. Staff are not equipped to manage people whose behaviours challenge. Shortfalls in admissions processes are not ensuring that the home always only admits people it can safely care for. Records completed by staff indicate staff restrained a resident who escaped from the home whose behaviour was putting her and others at risk of injury. Staff however are not trained to do this and bruising was sustained to joints – the wrists which are vulnerable body parts. There is no understanding at any level within the home of the legal context or their responsibilities in terms of physical intervention. This puts people at risk. Staff have received brief training about abuse in a video format and could define what it is and their responsibilities to report it. All windows above a high drop were inspected for safety. Windows were found to be suitably restricted to avoid the risk of accident. The management of service users’ finances was assessed. Systems protect service users’ financial interests with full accounts being available for each individual. Vulnerable people are not being sufficiently protected by the home’s recruitment practice. New staff, although supervised, are engaging in induction training on the premises before any checks have been received. As such they have access to vulnerable people and information about vulnerable people. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is poor. The physical environment does not always meet the specialist needs of the people who use the service. Consideration particularly has not been given in its design and layout to the needs of people with dementia. There is a strong urine odour within the home, which is unpleasant for people living, working and visiting, indicating that people’s continence needs are not being supported effectively and risking people’s health from cross infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of improvements have been made since the last inspection. These include replacement flooring in the reception, conservatory, dining room and the lounge. At the time of inspection a vacant bedroom was being redecorated Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 22 and we could see that damage incurred to the ceiling by a leak had been repaired and redecorated. The garden at the rear has been newly landscaped with wide paths, a barbeque area, a new storage shed, CCTV in garden and outdoor speakers so music can be piped outside to calm residents. Corridors in the old part of the building now need to be prioritised for redecoration. A tour of the environment showed it to be safe with no evident hazards although the powerful odour on arrival and throughout much of the home is unpleasant for residents and visitors. This indicates shortfalls in toileting regimes and infection control. Guidance in care plans to ensure staff know how to meet individual toileting requirements is inadequate. Residents like their bedrooms, which are spacious and clean with good quality furniture. Portable heaters have been provided which could cause burns or trips. These have not been risk assessed. A recent food safety visit by an environmental health officer identified a number of actions required, which the proprietor said have been met including a newly formatted cleaning rota to ensure residents food is prepared in a clean and hygienic environment. Handrails are provided in corridors but much more attention is needed to ensure the environment meets the needs of people with dementia and physical conditions. It is a considerable distance between the lounge and dining rooms and steps have not been taken to encourage free movement between the different areas of the home. Lighting and the layout of a bedroom had not been considered for a person with visual challenges. Likewise we identified, through observation, difficulties imposed by the design and layout of dining furniture. A physically dependent service user whose care we looked at was seen to be sitting at the dining table in her wheelchair. A staff member accidentally knocked the table causing the resident to stir. She was found to have her left leg jammed between the wheelchair and the ornate iron sculpture of the table leg. The knock caused her discomfort as she was seen to have a dressing in situ on the knocked leg. This caused her companion to show us his sore hand, which he said he was always knocking on the square edges of the glass dining table. We would suggest that glass dining tables are unsuitable for people with dementia and difficulties with vision. We also observed a resident struggling within limited space to exit the dining table with the help of staff. Tables are organised in small groups but the layout is ineffective for residents’ meetings where most residents have their backs to each other and proceedings, limiting their engagement in the meeting. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. Outcomes for service users are mixed who generally seem to be satisfied with the approach of staff. However we have evidenced a mix of good and poor practice, which influence people’s experiences of the service they receive. People cannot be assured that they are safeguarded by the homes poor recruitment practices, as checks on new staff are not carried out before they work on the premises. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No concerns have been expressed about staffing levels. The Manager however cannot continue to always be the fifth carer on duty as this is taking her away from meeting her management responsibilities. Arrangements must be made to provide an additional person to cover this role and the manager must make it clear on the rota whether she is undertaking a care or management function. The manager ackknowledged that this had been suggested at the previous inspection. Four staff are provided in the evening on the basis that retiring times are staggered and this is manageable. Staff meeting minutes report night staff describing being rushed and it was agreed that one resident could be left until later. We tried to establish from assessments and by talking to Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 24 him about this whether he found this acceptable, but he was not able to express his viewpoint to us. This should be kept under review. Following a fatal accident by a service user in 2006 in the lounge, steps have been taken to stagger the staff handover to ensure that staff are always available to supervise residents. Staff and managers confirmed that this is still the case. Observation and feedback however tells us that staff are not always available in the lounge to supervise residents. Responsibilities should be divided on a shift to account for supervision in the lounge particularly as the lounge is physically a significant distance from other key areas within the home and staff will be unaware of events in the lounge. The home has a low staff turnover providing continuity to people living there. One person has been appointed since the last inspection. This new staff member started working on the premises in a training and shadowing capacity before any pre employment checks had been received. Discussion with this staff member indicates she was supervised, was not left alone and did not provide any personal care. However she was in people’s bedrooms observing care being provided, and had access to vulnerable people and information about vulnerable people. There are no extenuating circumstances as the service is not exceptionally short of staff and does not have a high staff turnover. This is unsafe and unacceptable practice and is a breach of the requirement made at the previous inspection. We requested the rota for the time of induction training and it was not made available until the second day. This new starter was not included on the rota as required to evidence her induction training. This does not account for who was working on the premises and does not assure us that a named accountable individual was responsible for her supervision to protect residents in line with the 2006 regulations. Positively, the staff member speaks highly of her induction feeling it prepared her well. We could also see that formal supervision has been provided early in her employment. Other staff confirmed they receive supervision regularly. Delegating some supervisory duties to the assistant manager has facilitated this and this is a marked improvement since the last inspection. Staff are satisfied with the training they are provided with and feel it equips them to carry out their roles. Person Centred planning training has not been provided to staff when there were clear reasons for doing so outlined after the previous inspection. Also no progress has been made to increase the numbers of staff trained in first aid. In light of outcomes from this inspection, the provider assures that steps are now being taken to address these areas. Training, some of it brief, is provided in key areas such as medication, moving and handling, abuse, falls prevention, fire awareness and dementia training. The training matrix does not account for when these courses were undertaken so does not help managers to know when training expires or refreshers are due. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 25 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, 38. Quality in this outcome area is poor. The Manager is not being provided with sufficient time to lead and manage the home effectively. This lack of management means that service users’ needs are not always being met and at times they are at risk. Furthermore systems are not in place to help the service to improve and develop. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is now enrolled to undertake the Registered Managers Award to qualify her for role to a nationally agreed standard. She has also undertaken a number of training courses to update her skills and knowledge Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 26 recognising that this had lapsed. She is now also being provided with recorded supervision. The provider is carrying out Regulation 26 visits which demonstrate staff and service user satisfaction. Following the last inspection a quality assurance tool has been developed and agreed by managers but has not been implemented. It incorporates many useful areas for monitoring but nothing about service users or their care. Therefore the home still does not have in place a system to help them to self assess the quality of service they are providing. Surveys however have been sent by the service to relatives who have expressed a good level of satisfaction with the service. Comments to date include: Clean and well run, staff friendly and helpful and happy with standard of care Staff very helpful, happy with standard of care and homes atmosphere and comfortable presentation. Staff are always helpful, looks very clean, occasionally there are odours, since arriving my relative has looked much healthier and happier Too warm at times, menus look inviting, always clean and pleasant smelling, everyone friendly and helpful, enjoys having hair done every week Free of odour ‘most of the time’ Very clean, nice and cosy, warm Discussion with the proprietor highlights the need for an effective quality assurance assessment tool as at the beginning of inspection he described how he is ‘very happy’ with how the home is being managed. The management team believed all requirements made at the last inspection to have been met. One of six are judged to have been met. This inspection has shown shortfalls in management that are impacting on some residents’ health and welfare. The manager works constantly as a carer and this does not afford her the time to oversee, monitor and improve care received by residents. Following feedback, we were assured that this will be addressed by appointing an additional level 3 NVQ staff member to the team. The service has not always reported matters affecting the health and welfare of residents to us. These include hospitalisations, pressure sores and restraints. The home must also report all safeguarding matters to the Local Authority in accordance with locally agreed procedures The home is being well maintained. Equipment used by residents has been serviced to ensure it is safe for use. The proprietor stated that improvements required in recent visits by the Fire Service and Environmental Health Department had all been made. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 27 Staff meetings are held and minutes show they are used to set standards and expectations for care. The tone and issues addressed with staff within meetings in conjunction with other outcomes for service users found at this inspection indicates a team that needs to be managed more closely on a dayto-day basis. It is to be hoped that releasing the manager from constant care duties will give her time to take actions required to improve the care provided. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 1 1 X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 1 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 2 X 1 Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation Requirement Timescale for action 09/07/08 14(1)(a)(c Accommodation must not be ) 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 this inspection 9.7.08 Care plans must be kept under review so that changes to a resident’s condition are acted upon and staff are guided to meet each resident’s needs New requirement arising from this inspection 9.7.08 2. OP7 15 (2) (b) 09/07/08 3 OP8 12(1) The care home must be conducted so as to: a. Promote and make proper provision for the health and welfare of service users b. Make proper provision for DS0000020885.V368957.R01.S.doc 31/08/08 Coton House Version 5.2 Page 30 the care and, where appropriate, treatment, education and supervision of service users. New requirement arising from this inspection 9.7.08 Steps must be taken to assess and identify those service users who are at risk of developing pressure sores. Appropriate intervention must be taken to minimise the risk of pressure sores developing and this must be recorded in the individual’s plan of care and reviewed on a continuing basis. This will protect residents from risk to their health. New requirement arising from key inspection October 2007. Original timescale set for compliance was 30/11/07. Not met at this inspection. 5 OP8 13(4)C Service users at risk of falling must be identified. Appropriate action must be taken for service users identified as at risk of falling. This will ensure that unnecessary risks to the health and safety of service users are identified and as far as possible eliminated. New requirement arising from this inspection. Medication management must be 09/07/08 reviewed to ensure that: Medication Administration Records account for the numbers of tablets / dose administered Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 31 4. OP8 12 09/07/08 31/08/08 6. OP9 13(2) 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 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 this inspection. 7 OP9 13(2) Arrangements must be made 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. 31/08/08 8 OP18 13(6)(7)( 8) Requirement arising from this inspection. The policies and practices of the 30/09/08 home must ensure that physical and / or verbal aggression by service users is understood and dealt with appropriately and that physical intervention is used only DS0000020885.V368957.R01.S.doc Version 5.2 Page 32 Coton House as a last resort and in accordance with Department of Health guidance. On any occasion on which a service user is subject to physical restraint, the registered person shall record the circumstances, including the nature of the restraint. This will protect service users from abuse and or from the risk of abuse including deprivation of liberty and injury arising from restraint. New requirement arising from this inspection. The environment must be reviewed to ensure that with regard to the number and needs of the service users that: The physical design and layout of the premises to be used as the care home meet the needs of the service users, and That the size and layout of rooms occupied or used by service users are suitable for their needs New requirement arising from this inspection. Effective strategies must be 30/09/08 implemented to keep the care home free from offensive odours. This will provide service users, staff and visitors with a more pleasant and hygienic living and working environment. New requirement arising from this inspection. The registered person must not DS0000020885.V368957.R01.S.doc 9 OP19 23(2)(a)(f ) 31/12/08 10 OP26 16(2)(k) 11. OP29 19 09/07/08 Page 33 Coton House Version 5.2 employ a person to work at the care home unless full and satisfactory information has been obtained. This will ensure that risk to residents from new staff is minimised. New requirement arising from key inspection October 2007. Original timescale set for compliance was 18.10.07. Not met at this inspection. 12 OP31 10(1) Steps must betaken to enable the registered manager, with regard to the size of the care home, the Statement of Purpose and the number and needs of the service users to manage the care home with sufficient care, competence and skill (providing sufficient time for her to discharge her responsibilities fully.) New requirement arising from this inspection. Notice must be given to CSCI without delay of any occurrence defined by regulation and CSCI guidance. This will include The death of any service user including the circumstances The outbreak of any infectious disease Any serious injury to a service user Any serious illness of a service user Any event in the care home which adversely affects the wellbeing or safety of any service user Any theft, burglary or accident in the care home DS0000020885.V368957.R01.S.doc 31/08/08 13 OP37 37 09/07/08 Coton House Version 5.2 Page 34 Any allegation of misconduct by the Registered Person or any person who works at the care home Any notification given orally must be confirmed in writing. New requirement arising from this inspection. Suitable arrangements must be made for the training of staff in first aid and in the meantime the current situation should be risk assessed. This will ensure that staff are trained to respond appropriately in the event of an accident or incident. New requirement arising from key inspection October 2007. Original timescale set for compliance was 31.03.08. Not met at this inspection. 15 OP38 13 (4) The use of freestanding portable heaters in service users bedrooms must be reviewed and risk assessed. Action must be taken to reduce any risks identified. This will service to minimise risks to residents from the potential of trips and burns etc. New requirement arising from this inspection. 31/08/08 14. OP38 13(4) 09/07/08 Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 35 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 OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be reviewed to reflect the range of needs (i.e. mild dementia) that the home intends to provide for and should include all information required under amendments to regulations. New recommendation arising from key inspection October 2007. Not met at this inspection. 2 OP8 Nutritional screening should be undertaken on admission and subsequently on a periodic basis. Results should be acted upon and kept under review. Appropriate action should be taken when records show a pattern of weight gain or loss.. New recommendation arising from this inspection. Steps should be taken to ensure that service users have the opportunity to exercise their choice in relation to religious observance. New recommendation arising from this inspection. Steps should be taken to review meals provided at teatime to ensure they are nutritionally balanced and accord with residents’ collective and individual wishes and preferences. New recommendation arising from this inspection. Staff should be provided with training in person centred planning and person centred care. New recommendation arising from key inspection October 2007. Not met at this inspection. 6 OP33 Effective quality assurance and quality monitoring systems based on seeking the views of service users and their representatives should be implemented to measure success in meeting the aims, objectives and Statement of Purpose of the home. The format of residents meetings should be reviewed to Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 36 3 OP12 4 OP15 5. OP30 ensure that all residents are as fully engaged as possible and that their views are obtained in a manner that does not lead. This should include an annual development plan for the home based upon a systematic cycle of planning, action and review, reflecting aims and outcomes for service users. New recommendation arising from this inspection. Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Extracts may not be used or reproduced without the express permission of CSCI Coton House DS0000020885.V368957.R01.S.doc Version 5.2 Page 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!