Inspection on 07/05/09 for Heath House Care Centre

This inspection was carried out on 7th May 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Heath House Care Centre 28/04/08

Heath House Care Centre 14/06/07

Heath House Care Centre 03/10/06

Heath House Care Centre 20/09/05

Heath House Care Centre 10/05/05

Heath House Care Centre 04/11/04

Heath House Care Centre 16/07/04

Heath House Care Centre 17/02/04

Heath House Care Centre 12/12/03

Similar services:

Ashcroft Hollow Nursing Home

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

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

Key inspection report CARE HOMES FOR OLDER PEOPLE Heath House Care Centre 81 Walkers Heath Road Kings Norton Birmingham West Midlands B38 0AN Lead Inspector Karen Thompson Unannounced Inspection 7th May 2009 08:00 DS0000024852.V375370.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. DS0000024852.V375370.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address DS0000024852.V375370.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heath House Care Centre Address 81 Walkers Heath Road Kings Norton Birmingham West Midlands B38 0AN 0121 459 1430 0121 486 1728 lizansah@aol.com www.schealthcare.co.uk Exceler Healthcare Services Limited 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) Vacant at present Care Home 50 Category(ies) of Dementia - over 65 years of age (50), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (50), Old age, not falling within any other category (50) DS0000024852.V375370.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - over 65 years of age (DE(E)) 50 Mental Disorder, excluding learning disability or dementia - over 65 years of age (DE(E)) 50 Old age, not falling within any other category (OP) 50 The maximum number of service users who can be accommodated is: 50 28th April 2008 2. Date of last inspection Brief Description of the Service: Heath House offers nursing care for up to 50 older adults with mental health needs. This includes both dementias and those with enduring mental illness. The premises have been converted with an extension of an existing property and are situated to the south of Birmingham. The home is located close to public transport links. The building is divided into two units, Heathside and Walkers Lodge. There are car parking facilities to the front of the premises and an enclosed garden area to the sides and rear. The accommodation provides a mixture of single and shared rooms. All bathing facilities are shared, although some bedrooms have en-suite toilets. There are communal dining areas and lounges on the ground floor, together with the kitchen, offices and laundry, large conservatory (designated smoking area) and some bedrooms. The first floor consists of bedrooms and bathing/toilet facilities but has no communal space and is accessed by stairs or shaft lift. Fees vary and are dependent on the needs of the service users. Items not covered by the fees include toiletries, private treatments such as physiotherapy DS0000024852.V375370.R01.S.doc Version 5.2 Page 5 and chiropody, hairdressings and newspapers. The current scales of charges for the home range from £372.81 to £875 per week. The home retains the nursing element of the fee, which is paid by the Primary Care Trust. For up to date fee information the public are advised to contact the home. DS0000024852.V375370.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that people who use this service experience Poor quality outcomes. This was an unannounced inspection; the home did not know we were coming. It was carried out by two inspectors who were there for a two day period and a Pharmacy Inspector carried out an inspection on the 14th May 2009. The focus of inspection undertaken by us is upon outcomes for people who live in the home and their views of the service provided. This process considers the care home’s capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to plan the inspection, which included notifications received from the home and an Annual Quality Assurance Assessment (AQAA). This is a questionnaire that was completed by the providers representative and gave us information about the home, staff, and people who live there and any developments since the last inspection and their plans for the future. At the time of the inspection forty two people were living in the home and information was gathered from speaking to and observing people who lived at the home. Three people were case tracked and this involved discovering their experiences of living at the home by meeting and observing them, looking at medication administration and care files and reviewing areas of the home relevant to these people in order to focus on outcomes. Case tracking helps us to understand the experience of people who use the service. We talked to three people living at the home and five members of staff at length to ascertain what life was like living in the home. Some people at the home were unable to communicate their views verbally to the inspectors so direct and indirect observation was used to inform the inspection process. People living at the home, visitors and members of staff were spoken to in order to gain their views and comments. Surveys were given to the homes temporary manager to distribute to people living at the home, relatives and staff. No surveys were returned back to us. A warning letter was sent to the provider’s representative following this inspection due to a number of serious concerns identified during this inspection in relation to recruitment practice, tissue viability, medication management and possible deprivation of liberty. The weekly fee for living at the home is £379.81 and £875. The home retains the nursing element contribution. Items not included in this fee are hairdressing, chiropodist and toiletries. Third party contributions may apply in some instances. For up to date information on fees please contact the home. DS0000024852.V375370.R01.S.doc Version 5.2 Page 7 What the service does well: There are good systems in place to ensure residents’ finances are protected. There are a few staff that are dedicated and committed who want to provide good care to people living at the home. Relatives can visit people living within the home and this helps to maintain relationships that are important to them. What has improved since the last inspection? What they could do better: The organization is currently undertaking a lot of activity to try and address the serious concerns and shortfalls within the home identified by the various agencies in an attempt to improve the experiences of people living in the home. The home lacks good leadership across all areas of the running of the home. Currently the home is not run in a way that meets the needs and expectations of the people living there. Some of the arrangements fail to ensure peoples health is protected and promoted. Overall communication systems with everyone within the home must improve so that concerns can be dealt with appropriately. Managers must take responsibility for how matters are communicated so that staff that staff are able to meet the needs of people living at the home DS0000024852.V375370.R01.S.doc Version 5.2 Page 8 Pressure relieving equipment needs to be available for those who are assessed at risk. This equipment must be fit for purpose to protect the well being of people living in the home. A review of the manual handling equipment should take place to ensure that staff have the means to safely move people at the home according to their individual assessment needs. Persons living in the home should not have their rights restricted unless this has first been discussed in line with the Mental Capacity Act to include social services the family and the persons GP. via a multi disciplinary process. People living in the home are not always supported by suitably trained staff in the right numbers to meet their needs. Staff training records need to be reviewed and following this an action plan drawn up to meet the deficits identified in staff training. Recruitment procedures at present do not ensure that people living at the home are protected these need to be reviewed Staff need to be aware of what equipment is available and working to ensure that people living at the home do not have to wait excessive amounts of time for care and equipment. The medicine management must improve to safeguard the health and well being of the people who live in the home. The Statement of Purpose must accurately reflect the overall care provided so that people are clear what is offered. There must be greater awareness by staff of their role in promoting privacy and dignity for people in the home so that their rights are promoted and protected. The home needs to improve the way that it provides care to people who suffer with dementia so that their safety, dignity and well-being is respected and promoted. The provision of food and the dining experience for people living at the home must be reviewed and action taken to ensure people receive food and drinks that meets their nutritional and cultural needs needs. Record keeping across a number of areas needs to improve for example notifying the Commission of events, care planning records and complaint management etc. The home should contact its local Environmental officer to ensure that they are compliant with the new no smoking legislation. DS0000024852.V375370.R01.S.doc Version 5.2 Page 9 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. DS0000024852.V375370.R01.S.doc Version 5.2 Page 10 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 DS0000024852.V375370.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1. 3 People using the service experience adequate quality outcomes in this area. The arrangements in place do not ensure that people can be confident that their needs will be met on admission to the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A copy of the Service Users Guide was given to the inspectors at the time of the visit. It states on the front of the Guide that these are also available in audiocassette form. The provision of Guides in other formats was discussed at the time of the inspection visit with the management team who were present. DS0000024852.V375370.R01.S.doc Version 5.2 Page 12 We were advised that the organisation is looking at producing the Service User Guide in other formats. At the previous key inspection it was recommended alternative formats for the Service Users Guide be explored. The current Guide contains information that needs to be updated to reflect recent staff changes. Since February 2009 there have been no new admissions to the home. Southern Cross volunteered to suspend admissions to the home following concerns raised via the safeguarding process that is administered by Birmingham Social Services and the ability to meet new persons needs. We did not assess this standard at this inspection. No intermediate nursing care is provided at the home. DS0000024852.V375370.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9.10.11 People using the service experience poor quality outcomes in this area. The arrangements for meeting people’s health and personal care needs including medication are not always being adequately, consistently and appropriately met which puts them at risk of harm. The medicine management was poor. Reliance on antipsychotic medication to control behaviour was seen in the dementia unit. Audits put in place by the management had failed to address the maladministration of some medication. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The care records of three of the people living at the home were looked at in detail and other records were sampled. Care plans are based on the assessment that is completed before the person moves into the home. The DS0000024852.V375370.R01.S.doc Version 5.2 Page 14 care planning documentation is comprehensive with an array of risk assessments taking place such as skin integrity, nutrition, falls, moving and handling and body mapping. Care plans are evaluated monthly. Care plan records sampled did not always clearly show that individual needs were being fully planned for or evaluated. There was also evidence that reviews by external health professionals had highlighted missing information in the care planning documentation. This was concerning as poor assessment and care planning does not identify all needs and these will go unmet. The nutritional risk assessment is done monthly. If concerns are identified then various strategies can be put into place to reduce the risk and maintain nutritional status. One of the strategies is to initiate weekly weights and implement the Betty Blue system. The Betty Blue system is where food is placed on a plate with a large blue pattern. This acts as a visual reminder to staff to monitor food intake. People whose food intake is monitored by the Betty Blue system also have their food intake recorded. It is recorded in portion size only, so is not detailed as to what the person has eaten. From the records sampled it appears that the weakness in this system has been between nutritional risk assessment and initiating the Betty Blue system. Records sampled demonstrated that people could be steady and constantly losing weight for some months before strategies were put in place to correct this. Approximately 25 of people living in the home are recognised as losing some weight. The catering team have not received any training in meeting the nutritional needs of people with dementia. The home is failing to recognise that dementia effects the persons ability to eat not just in remembering to eat but in the type of foods needed and its timings. Continence assessments remain the same as the previous inspection and are reactive and do not identify what type of incontinence the person has so that the cause can be eliminated or modified and individual strategies can be put in place to promote continence. Continent supplies had been identified as an issue at the random visit of Aug and Sep 2008 and the home had been borrowing continence supplies from another home in the area. Staff confirmed that towards the end of the month supplies did run low but they hadnt borrowed from another home for some time. Continence products are kept in each persons room and the store cupboard was found to contain only one packet of continence pads on the day the new supplies were delivered. This means the homes stock control system is run on the just in time principle. The PCT tissue viability team undertook an assessment of all peoples skin integrity during April 2009. A comprehensive written report was given to the home following completion of the audit. Only five pressure relieving seating cushions were found in the home and the majority of these were found to be unfit for purpose and were condemned. Eighty five percent of pressure relieving/reducing mattresses were also condemned. The PCT tissue viability service had carried out a tissue viability audit of all people living in the home August 2007 and a significant number of mattresses were condemned at this DS0000024852.V375370.R01.S.doc Version 5.2 Page 15 audit and have not been replaced. The Commission was informed in April 2008 at the key inspection that pressure relieving mattress would be replaced as part of a rolling programme but this has not occurred. This is concerning as it places people at risk. The audit carried out April 2009 identified that seventeen percent of the people living in the home had some form of pressure ulcer. The tissue viability team also found one person living at the home to have a pressure ulcer which staff had not acknowledged in the care planning records or had provided treatment for. This person was found to lack the appropriate seating in place to meet their needs. Staff informed us of the care needs of people living in the home. What was concerning to us was that people known to staff to demonstrate behaviour that challenges did not have this recorded in their care planning documentation. Staff told us what they would do if a person they were looking after demonstrated behaviour that challenged. We found there was absolutely no connection between the levels of behaviour that challenges experienced by and recounted by the staff and the information recorded in the care plan a situation that is unsafe placing staff and people cared for at risk of harm . Concerns were identified at the previous key inspection of April 2008 in relation to management of behaviour that challenges. This was followed up at the random inspection of August/September 2008 and improvements were observed in care planning and monitoring of this behaviour so the requirement was moved to a recommendation. Now the situation appears to have regressed to a point where these incidents are not even being acknowledged or recorded. The care plans do not reflect all peoples needs . Consequently staff are not adequately prepared and left vulnerable. It also means people living at the home are not having their needs met. During the inspection a person living at the home was observed to be sitting in a kirton/bucket chair. These chairs act as a form of restraint, making it difficult for the person to get out of the chair. The homes management team were unable to demonstrate via documentation and discussion with person concern and other professionals as to the decision making process for the use of this chair. The home needs to demonstrate that this has been done in the best interests of the person for sound medical reasons. Hoists were available in the home to assist with the transferring and moving of people living in the home. Staff were observed to be only using one hoist on the first day of the inspection. We had been informed by the management team that all five hoists in the home were working although staff informed us they were only able to use the one hoist. This was discussed with the management team and there appears to have been confusion on both the management and staff team’s part as to how many hoists were available for use. On the second day of our visit we found four hoists available for use. Whatever the reason for this confusion staff were only using one hoist. We were also informed that there were only five slide sheets for moving people within the home and ten had been ordered recently. Staff were only using the DS0000024852.V375370.R01.S.doc Version 5.2 Page 16 five slide sheets available in peoples bedrooms around the home. On further investigation a box of thirteen slide sheets were found under the stairwell in the home. These slide sheets were neatly folded and did not appear to have been used recently. The management team were advised to bring these slide sheets out into general use, as ideally every one requiring movement via a slide sheet should have their own to reduce the risk of cross infection. Leadership and communication in this area of practice had evidently failed. The body mapping charts and our observations of some of the bruising on people living at the home may be due to incorrect manual handling technique. This is confirmed by observations by other health professionals. At the random inspection of August/September 2008 the inspectors asked to use a vacant bedroom to conduct staff interviews. They were shown to the bedroom of a current person living at the home. Conversations with a member of staff at this inspection revealed that this room was used by the chiropodist to carry out treatment for a number of people living at the home. The use of this persons bedroom by external health professionals was discussed with the manager of the home at the time of the visit and the letter that followed. Prior to commencing this inspection we were informed by an external health professional that they had been offered a bedroom on the ground floor, which was occupied by someone already living in the home. This practice is completely unacceptable and fails to protect their privacy and access to their own bedroom at times when used by others. End of life care planning is not taking place. In one instance the wishes of a family member had been discussed and documented in relation to sudden changes in medical condition but while the wishes of the family member were recorded; the family member could not impose these wishes on their relative, as they did not have power of attorney for health and well being. The home needs to ensure staff are aware of the legal implications of actions they carry out based on someone elses wishes. The pharmacist inspection lasted two and a half hours. Five peoples medication, Medicine Administration Record (MAR) charts and care plans were looked at to assess the medicine management within the home. Two nurses responsible for the administration of medicine were spoken with and all feedback was given to the interim manager and operations manager. The manager had recently moved the medication room to a small room downstairs. It was too hot to safely store medication within in compliance with the medicines product licences. This may affect the stability of the medicines so they may not work as intended. There was inadequate locked storage space to store all the medicines received into the home. Anyone gaining entry to the medication room would also have access to the medicines within. Two medication trolleys held the current medication. These were too small to hold all the medicines resulting in the medicines for each person being DS0000024852.V375370.R01.S.doc Version 5.2 Page 17 scattered throughout the trolley and not kept in an ordered fashion according to resident. This may increase the risk of error if the nurse cannot easily find the medicine to administer. Audits indicated that some medicines had been recorded as administered when they had not been, others had not been administered at all and some had been administered at a sub therapeutic dose and not as the doctor prescribed. The management had installed a lengthy auditing system of daily counting medicines dispensed in traditional boxes. Nursing staff had accurately counted the medicines and recorded the quantity but had failed to work as a team and act when it was apparent that some medicines had not been administered even though they had been signed as such. Previously a system had been installed to check the prescription prior to dispensing but this had not been undertaken for this cycle of medicine received into the home. This had resulted in the nurses failing to recognise that one medicine used to treat Parkinsons disease had not been prescribed and two days had elapsed until a supply was obtained. In another case an inadequate supply of medicine had been prescribed, dispensed and received into the home so the medicine would be unavailable for the last few days of the cycle. However as nurses had recorded they had administered the medicine even when they had not an actual surplus was seen. This is of serious concern that nursing staff are failing to follow their own policies and procedures in the safe handling of medicines. One medicine had been dispensed in two boxes and one box was put in the surplus cabinet until it was required. The nursing staff on duty had failed to find this supply and did not administer the medicine to the resident for two days until it was found. Again the regular audits undertaken by the nurses did not identify this to prevent this happening. One nurse had even signed she had administered the medicine even though the internal auditing system indicated that none were available to administer. Another medicine had been prescribed to be administered on alternate days. It had been administered alternate days but staff had recorded they had administered it daily even though they could not have done. Again staff are failing to follow companies procedures and also their professional standards Gaps were seen on the MAR charts. In one instance the medicine had not been administered and the reason for non-administration not recorded. Cream management was poor. All creams appeared to be routinely ordered and there were huge quantities of unopened creams on the premises. Staff had recorded they routinely applied the cream following the doctors instructions but in reality this did not occur as some creams were not available to apply or showed little signs of use. DS0000024852.V375370.R01.S.doc Version 5.2 Page 18 One eye drop was found in the medicine refrigerator that was out of date. It could not be evidenced whether this was still in use or not. If it had been used it may have increased the risk of an eye infection. Just over a quarter of the people who live in the home living on the dementia unit were prescribed nutritional supplements. We, were assured that this was already under review as many residents had gained weight. It was felt and agreed by the management that there was an over reliance of antipsychotic medication used in the dementia unit and they have already began to liaise with the appropriate healthcare professional to obtain full medication reviews. The care plans were poor. It was difficult to know all the residents underlying clinical conditions from these and would not help the nursing staff to fully support the peoples clinical needs. There were inadequate care plans for various medical conditions. For example there was no care plan detailing the side effects of one medicine for nursing staff to use to identify potential life threatening toxic symptoms or important blood tests that should be requested. All Controlled drugs (CD) balances were correct and the CD register reflected the entries on the MAR chart. Storage of CDs were adequate within the home. The two nurses spoken with during the inspection had a reasonable knowledge of the medicines they handled. Relevant medical textbooks were available for reference albeit one year out of date. The home has a supply of homely remedies to administer against a policy to each person if they suffered from a minor ailment, for example a headache. These are supposed to be purchased from the pharmacy but one box had been prescribed and dispensed and the label partially removed. This is of concern, as all medicines remain the property of the person they are prescribed to and should not be administered to anyone else. The managers assured the commission that each nurse had been assessed as competent to safely handle medication but agreed to reassess them as soon as possible and take appropriate action to rectify and improve the poor medicine management seen. DS0000024852.V375370.R01.S.doc Version 5.2 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12.13.14.15 People using the service experience adequate quality outcomes in this area. People living in at the home would benefit from the opportunity to take part in a wider range of activities so that they are enabled to lead a more stimulating and fulfilling life. People are supported to maintain contact with family and friends so that they are able to maintain the relationships that are important to them. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Arrangements for visiting the home were flexible for relatives enabling them to visit at time that suited them and the person living in the home. One relative informed us that they could have meal with the person living at the home if they wanted to. DS0000024852.V375370.R01.S.doc Version 5.2 Page 20 There are two activities co-ordinators working in the home, they work Monday to Friday and start at 7am in the morning. Between 7am and 10:30am the activities co-ordinator helps with breakfasts assisting those who require help. The notice board confirmed an array of activities were taking place in the home and also that people living at the home did go out to various places e.g. the local church and the garden nursery. The AQAA given to us on the first day of the inspection visit stated the home wished to develop their activities programme and incorporate more trips out of the home. Discussion with the management team during our visit revealed that they now had access to a mini bus. The management team are looking at reviewing how activities are to be provided which may involve a change of activity hours and days. It is noted that the organisation identified this as an area of improvement at the last key inspection and this still has not been implemented. The mealtime experience was observed to be unhurried and staggered so that people could eat their meals at a pace that suited them. At the previous inspection the two dining rooms were accessible by an adjoining door. This door way has now been closed off. The closing of the doorway is part of the plan to divide the home into two units specialising in different care needs. The one dining room (Walkerside) is directly adjoined to the main kitchen. The breakfast and lunchtime meal was observed to served from a hot trolley on the Heathside of the building. Staff were then bringing meals round to people sitting on the Walkerside of the building. The result of this was people had to wait for their meal and were left for periods in the dining room unsupervised. This was discussed with the management team and they will be looking at improving this system so that meals are served simultaneously and with staff present in the dining rooms at all times. Staff were observed to offer discreet assistance to people at meal times. The menu is varied and diverse. A significant number of people living in the home have dementia and the practice of offering a choice of meals needs to be reviewed. People with dementia are asked what they would like from a written list in the morning. This form of communication is not ideal. The management team felt it would be more appropriate to actually show someone the two meals, so they could choose at the time of the meal. We will look at this suggested change of practice at the next inspection. Carers had commented to us that some people with dementia prefer to eat their food with their fingers. Provision of snacks and finger foods was discussed with the management team. The organisation have introduced snack boxes in other homes in their group and they need to look at how to increase the calorie intake for people with dementia living in the home as a number people living in the home have experienced weigh loss. The AQAA stated the catering manager discusses menus with service users on a weekly basis and keeps a record of all comments. Records held by the catering manager have recently been introduced but they do not contain comments made by people living at the home. At the previous inspection visit DS0000024852.V375370.R01.S.doc Version 5.2 Page 21 of April 2008 it was noted that cultural diets were not being fully catered for. We were told at the April 2008 inspection that this would take place and it is concerning that it is only now being addressed twelve months later and only following a social workers review. Cultural dietary needs are not being meet and the lack of a proactive approach to meeting these demonstrates a lack of awareness by people working for the organisation as to how fundamental these are to a person’s identify. DS0000024852.V375370.R01.S.doc Version 5.2 Page 22 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 People using the service experience adequate quality outcomes in this area. The systems and arrangements in place at the home do not ensure that people can be confident that their views are listened and responded to. Overall the home is failing to safeguard peoples health and well-being to ensure they are promoted and protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a complaints procedure that is available enabling people to raise concerns where necessary. Relatives were aware of the procedure to make a complaint. The AQAA supplied to use did not contain the number of complaints received by the home in the last twelve months. The home’s complaint log contained 8 formal complaints since the previous key inspection. The type of issues raised varied and were across all four units within the home. The home has a system in place to record complaints. Recording of investigations and the outcomes was found to be poor in a number of instances. This is concerning as it suggests that the home does not have systems to resolve concerns or the DS0000024852.V375370.R01.S.doc Version 5.2 Page 23 ability to put appropriate systems in place to prevent re-occurrences of the same issues. During conversations with staff their understanding of how to protect people living at the home was mixed. They would report adult protection matters to the most senior person available but beyond this they were unsure of what would happen. Some staff have received training in the Mental Capacity Act. . DS0000024852.V375370.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. Some improvements are needed to ensure that is suitable to meet the needs of all people living there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We were informed in August 2008 of plans to divide the home into two separate units. During this inspection we were informed that this had recently taken place. Both people living at the home and staff felt this had been a positive move. The home atmosphere was a lot calmer. We were told that the DS0000024852.V375370.R01.S.doc Version 5.2 Page 25 home hopes to build upon staff knowledge and expertise within the two specialism in the home, which they felt previously was being diluted. Both units have access to a lounge area and dining room. The conservatory at present is used as a smoking room. We were advised at this inspection that the conservatory is soon to become a no smoking area. The home was in the process of creating a small smoking room for residents. The management team need to contact environmental health to ensure they are complying with the Health Act 2006, which not only protects people living there but staff working in the home. People can access the garden from the conservatory and from the dining rooms. The garden perimeter fence has been mended and the garden gate now has a lock fitted. This reduces the potential risk of intruders into the grounds. Across both units there are four shower rooms and four bathrooms. On the first floor Heath side are two bathrooms. The bath should allow for assisted hoisting equipment to be used. The hoists available were tested and these did not allow for people living in the home to access the bath. We were told there was an assisted bathing facility downstairs and that people living at the home either used the upstairs shower or when downstairs for a bath where the equipment was available. This means the dignity and choice of people whose bedrooms are on the heathside first floor is compromised. Twenty five people have en-suite toilet facilities (all single rooms) and further toilets are available in all bathrooms and shower rooms. Some people living at the home share their rooms with other people (there are five shared rooms in total). Some areas of the home looked tired and were in need of redecoration and refurbishment. DS0000024852.V375370.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 People using the service experience poor quality outcomes in this area. People living in the home are not always supported by suitably trained staff in numbers to meet all their needs. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There were forty two people living at the home on the days of the inspection visits. The management team provided staff duty rotas, which stated that there were two qualified nurses on duty for the home both day and night. Staffing levels have been reviewed since the previous inspection and we were informed these would be reviewed again in the near future. The plans to move the activities co-ordinators hours to further in the day and weekends we were informed about at the last inspection. If this is to eventually take place this will mean more staff will be needed at breakfast time, as at present part of the activities co-ordinators role involves assisting at breakfast. The numbers of staff working at the home do not match up when compared to the AQAA completed by the management team and rotas. DS0000024852.V375370.R01.S.doc Version 5.2 Page 27 A sample of staff recruitment files were inspected and it was found that information was missing in respect of the recruitment process. The organization should review the processes that allow staff to be taken on and paid for working in the home before all recruitment checks have come back. The information supplied to us demonstrates that eight people left the home in December 2008. We discussed with the management team why this had occurred. They were unable to give an explanation. We were however informed that the date of leaving might have been the date entered onto the system. Either way this still indicates a high number of people leaving within a very short period. This would have compromised the stability and continuity given to people living at the home. It is advised that exit interviews are conducted to establish if there are any trends or reasons for staff leaving the home. The homes training matrix did not identify which members of staff had achieved an NVQ2 or above in care. Some staff spoken to at the time of the inspection informed us that they had this qualification or equivalent. The Service User Guide stated that 20 carers had NVQ 2 or above in care. The AQAA stated the number of permanent staff with NVQ 2 or above in care as being 6. The NVQ 2 qualification demonstrates that staff have obtained a certain level of competence and skill but from the information supplied it is not possible to say how many carers have achieved this. We were informed by the management team that the induction programme now complies with the Skill Care Council. The inspector was not able to see staff booklets in relation to the induction programme as we did not encounter any staff that had recently come to work at the home. There have been issues with the quality of training received by staff and the organisation has taken steps to rectify this. Staff informed us that the quality of training they had received recently was good and informative. They did however feel a little overwhelmed by the whole of training they had received recently. This was discussed with the management team who appreciated staff concerns but they felt it was in the best interest of people living at the home that staff had training that they felt was of a quality to meet people needs. Since April 2008 training has taken place in challenging behaviour, bed rail safety, customer care, mental capacity and continence. It appears that continence management training did occur in August but stopped after our visit in September. This is concerning as we had identified concerns with the management of continence and this was on of the main reasons for our random visit August and September 2008. The training matrix does not identify how many staff have received manual handling training. We were told this had taken place but not how many staff had received it. If we compare the manual handling training with some of the unexplained injuries and poor knowledge and use of equipment it does raise level of concern. (see Health and personal care section) DS0000024852.V375370.R01.S.doc Version 5.2 Page 28 We were shown documentation to demonstrate that trained staff had been assessed for competency in the management and administration of medication. The concerns identified in relation to medication management indicate a lack of competency of trained staff in this area. DS0000024852.V375370.R01.S.doc Version 5.2 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31.32.33.35.36.38. People using the service experience poor quality outcomes in this area. The Home is not being run in order to meet the best interests of people living in the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There has been no Registered Manager in the home since November 2008. There is a clear trail of a downward decline in the homes overall performance since last year. DS0000024852.V375370.R01.S.doc Version 5.2 Page 30 Representatives from Southern Cross are at present supporting a manager working in the home. We were informed that a care manager is working in the home full time, who is being supported by a regional manager, regional director and a clinical lead nurse. The organisation has voluntarily suspended admissions to the home whilst a number of concerns are being investigated by other agencies. Communication systems have been implemented by the new management team between the various levels of team members. The shortfalls identified in the care provided for people living at the home suggest these are not working which impacts on the health and well being of people living at the home. The AQAA given to us was not found to be an accurate reflection of what we found to be occurring in the home. The lack of reliable information calls into question the management arrangements for the home. Supervision had been taking place for staff but prior to April this appears to have been done in group supervisions. Staff informed us that they preferred the one to one supervisions as it allow them to express and explore any concerns. Whilst supervision does not have to be one to one and can be in groups, the organisation needs to explore what works best for their staff group. Finances for people living in the home were discussed with one of the homes administrators. Money is held in a bank account, which has sub accounts for each individual person’s money. The administrator stated that if cash is needed it can be obtained for people living at the home. The administrator stated that the provider audits the accounts and the home is never aware when these audits will take place. A sample of records relating to health and safety checks were looked at. The home was unable to find the hoist servicing inspection certificates, they were asked to forward these to us following the inspection. The Gas safety certificate only looked at the gas boiler in the home and had not looked at the gas kitchen equipment. We checked a number of accident records. We then cross referenced these with the regulation 37 notifications which the home is required to sent to us in the event of the health and well being of people living at the home being compromised. We found that we were not always being informed of these events. DS0000024852.V375370.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 2 3 1 2 x 2 3 3 STAFFING Standard No Score 27 1 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 1 x 3 1 x 1 DS0000024852.V375370.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12(1) Requirement Arrangements must be in place so that people who use the service are supported to receive adequate nutrition. This will make sure that their nutritional needs are met. Food records must be sufficient in detail to enable the homes staff and managers to determine whether the diet is satisfactory in relation to nutrition. Tissue viability equipment identified as condemned by the tissue viability service must be replaced with a suitable alternative to ensure the safety and well being of people living at the home. Tissue viability equipment identified by the tissue viability service as needed for people living in the home must be provided. To ensure the safety and well being of people living at the home. A review of all the communal seating must take place to ensure that it meets the tissue viability needs of people using DS0000024852.V375370.R01.S.doc Timescale for action 30/08/09 2. OP7 12(1) Sch 4 13 30/08/09 3. OP8 23(2) (c) 30/08/09 4 OP8 23(c) 30/08/09 5 OP8 23(c ) 30/08/09 Version 5.2 Page 33 6 OP8 13(4) 7 OP8 13 8 OP8 13 9 OP7 12(1) 10 OP9 13(2) the seating. Following this review a timescale for replacement should be drawn up for no later than six months Persons living in the home should not be have their rights restricted or be placed at unnecessary risk unless this has first been discussed in line with the Mental Capacity Act to include social services the family and the persons GP. Via a multi disciplinary. Unexplained injuries must be investigated and action taken to promote the safety and wellbeing of people living in the home which may include a safeguarding referral. Manual handling equipment must be available to ensure people have the type appropriate to their assessed needs and is available in sufficient quantity so it is accessible to staff and in working order. This will ensure people are transferred safety People with behaviour that challenges must have these acknowledged and recorded in their care plan with the appropriate assessment, monitoring and evaluation of these needs taking place. This will ensure that staff are provided with guidance on how to meet these needs which both protects them and the person living at the home. The medicine chart must be referred to before the preparation of the service users medicines and be signed directly after the transaction and accurately record what has occurred. This is to ensure that the right DS0000024852.V375370.R01.S.doc 30/06/09 30/06/09 30/06/09 30/06/09 30/06/09 Version 5.2 Page 34 11 OP9 13(2) medicine is administered to the right service user at the right time and at the right dose as prescribed and records must reflect practice A system must be installed to check the prescription prior to dispensing and to check the dispensed medication and the medicine charts against the prescription for accuracy. All discrepancies must be addressed with the healthcare professional. This is to ensure that all medicines are administered as prescribed at all times All medicines that are administered must be in date and stored correctly in accordance with their product licences. They must be held in locked cabinet at all times. This is to ensure that all administered medicines stability is not compromised and they are safely held on the premise Any quality assurance system installed must assess individual staff competence in their handling of medicines. Appropriate action must be taken when these indicate that medicines are not administered as prescribed and records do not reflect practice. This is to ensure that individual nursing staff practice is assessed on a regular basis and appropriate action is taken if audits indicate that nurses do not administer the medicines as prescribed. Staff practice of using persons living at the home bedrooms for other uses should be cease. This DS0000024852.V375370.R01.S.doc 30/06/09 12 OP9 13(2) 30/06/09 13 OP9 13(2) 30/06/09 14 OP10 12(4) 30/06/09 Version 5.2 Page 35 15 OP11 12(1) person bedroom is there private space and it impacts on their privacy and dignity (recommendation made at Sept 08 visit not implemented) All staff must receive end of life care training that is appropriate to their position to ensure peoples needs are meet in an appropriate manner and comply with current legislation and guidance. The home must ensure that staff are trained and knowledgeable about the safeguarding procedures to ensure all peoples are protected. Staff recruitment must be robust. To protect people living at the home Staff must receive manual handling training and records kept to demonstrate this has taken place. Records in relation to hoist servicing carried out to meet the LORI must be available in the home. This will demonstrate peoples well being and safety is being promoted and protected. Gas safety certificates must be available for all gas equipment in the home. This will demonstrate that everyone in the home welfare is protected and promoted 30/08/09 16 OP18 13(6) 30/08/09 17 OP28 19 Sch 2 18(1) 30/06/09 18 OP30 30/08/09 19 OP38 23(2) 30/06/09 20 OP38 23(2) 12/07/09 DS0000024852.V375370.R01.S.doc Version 5.2 Page 36 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that the Service User Guide be reviewed and amended. Also the Service User Guide should be available in pictorial form for those resident that might find the information more accessible in this format. (Recommendation from April 2008 key inspection) Trained staff working at the home should re-familiarise themselves with the NMC Record Keeping document. It is recommended that all medicines are stored in locked cabinet at all times including the medicines that are due to be destroyed or returned. It is recommended that the quality assurance system is changed to ensure that the medication round is completed in a timely fashion and at least four hours is left between medication rounds (Not looked at during these inspection visits. 5 6 OP10 OP12 Staff must receive training and supervision in promoting and protecting peoples privacy and dignity. The home should review its activity provision to ensure it meets the needs and wishes of people living at the home. Following this review strategies should be put in place to ensure changes take place in relation to activites Catering staff should attend training in meeting the nutritional needs of people with dementia Alternative formats for ascertaining the food choice of people with dementia should be explored, these could be picture menus or showing people the food that is on offer for that particular meal etc. The home must review the mealtime experience for peoples in the home, to ensure that cultural needs are meet and the food is served at the appropriate temperature and time along with staff in each dining room DS0000024852.V375370.R01.S.doc Version 5.2 Page 37 2 3 OP7 OP9 4 OP9 7 8 OP15 OP15 9 OP15 to supervise. 10 11 12 OP16 OP16 OP19 Management of complaints must be reviewed so that they are dealt with appropriately and sensitively and do not reoccur. Complaint files should be organised to ensure that information is available and does not hinder the smooth running of the home. The home must review its smoking policy and procedure and it is recommended that they contact their local Environmental health officer for advise and guidance in meeting the new legislation. Recommendation first made Sep 2008 Assisted bathing facilities should be fully functional so as to not impact on persons privacy and dignity. Following a staffing review the finding should be implemented to ensure that people who live at the home have all their needs fully meet Exit interviews should be conducted on staff leaving the home to establish why people are leaving and whether this is preventable Trained staff working at the home should re-familiarise themselves with the NMC The Code Standards of conduct, performance and ethics for nurses and midwives to promote and protect the health and well being of people living in the home. Training records should be reviewed to ensure that information is available to allow for planning and meeting staffs training needs The home must ensure that the induction is compliant with the Skills Care Council Recommendation first made April 2008 not looked at during this visit. The management team must review the systems of support for staff to ensure the workforce can perform appropriately. The management team needs to capture the commitment of those staff who show an excellent level of commitment by ensuring these members of staff are supported to have the skills and competencies to deliver care that meets peoples needs. Communication systems at all levels must be reviewed to ensure people who live at the home have all their needs met. 13 14 15 16 OP22 OP27 OP28 OP29 17 18 OP29 OP30 19 OP32 20 OP32 DS0000024852.V375370.R01.S.doc Version 5.2 Page 38 21 22 23 OP36 OP29 OP38 The system for staff supervisions should be reviewed to ensure these are not all group, but allow for individual supervisions to occur Full competency testing of trained nursing staff is carried out and any shortfall identified will be addressed appropriately The Commission must be notified of incidents affecting the health and well being of residents so that the home can monitor between inspection visits. Recommendation first made April 2008 DS0000024852.V375370.R01.S.doc Version 5.2 Page 39 Care Quality Commission West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway, Birmingham B1 2DT National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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