Inspection on 07/07/10 for Hillcrest Care Home

This inspection was carried out on 7th July 2010.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hillcrest Care Home 24/08/10

Hillcrest Care Home 19/10/09

Hillcrest Care Home 09/12/08

Hillcrest Care Home 19/03/08

Hillcrest Care Home 21/03/07

Hillcrest Care Home 05/07/06

Hillcrest Care Home 06/12/05

Hillcrest Care Home 02/08/05

Hillcrest Care Home 22/03/05

Hillcrest Care Home 30/09/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 03/09/2010.

Random inspection report Care homes for older people Name: Address: Hillcrest Care Home Wear Street Jarrow Tyne And Wear NE32 3JN two star good service The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Kathryn Reid Date: 2 1 0 7 2 0 1 0 Information about the care home Name of care home: Address: Hillcrest Care Home Wear Street Jarrow Tyne And Wear NE32 3JN 01914890200 01914286343 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Jaqueline Karen Wallace Type of registration: Number of places registered: Conditions of registration: Category(ies) : Hillcrest Care Homes Limited care home 49 Number of places (if applicable): Under 65 Over 65 0 49 dementia old age, not falling within any other category Conditions of registration: 49 0 The maximum number of service users who can be accommodated is: 49 The registered person may provide the following category of service only: Care Home with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 49 Dementia Code DE, maximum number of places 49 Date of last inspection Care Homes for Older People Page 2 of 19 Brief description of the care home Hillcrest Care Home is a purpose built three-storey building located within the busy town centre of Jarrow. The building has 49 single bedrooms all of which have an ensuite bathroom. Access around the building is made easier by a passenger lift or there are two staircases, which are located at either end of the building. There are a number of communal areas, such as lounges, dining rooms and quiet areas. A fireplace with surround and easy chairs is located in the corridors of both the first and second floor and provides a popular place where service users can choose to spend their time. A staff call system, which is accessible to the service users, is provided in all parts of the home. The laundry and staffroom are located on the second floor of the home. There is a garden to the rear of the home and parking facilities are available for the convenience of visitors. The home is registered to provide care to 26 people who have varying degrees of dementia and 23 people who are elderly. Fees for the home vary further information is available from the home. Additional charges are made for toiletries, newspapers magazines, and hairdressing. Items, which are included in the cost, are listed in the home s terms and conditions. Care Homes for Older People Page 3 of 19 What we found: This is an overview of what the inspectors found during the inspection. This service was assessed as providing good outcomes for people at the last key inspection in October 2009. We have reviewed our practice when making requirements. Some requirements from previous inspection reports may have been deleted or carried forward to this report as recommendations. This will only happen when it is considered that people who use the service are not being put at significant risk of harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Before the visit we looked at information we received since the last visit to the home. This includes how the service dealt with any complaints, changes to how the home is run, the views of people who use the service and the managers views of how well they care for people. Unannounced visits were made on 7, 9, 20 and 21 July 2010. Three inspectors were involved overall, including a pharmacist inspector on 9 July 2010. These visits were made following receipt of several concerns from the Local Authority and Primary Care Trust, regarding care delivery and peoples safety. The registered manager was in charge when we first visited, but then went on leave and was not available at further visits. We were assisted by the Operations Director who took charge of the home on a full time basis, and the Responsible Individual who also took an active role in assisting us and receiving feedback. During the visit we talked with people who use the service and several staff of varying designations. We looked at information about people who use the service and inspected other records which must be kept. We checked whether the staff had the knowledge, skills and training to meet the needs of the people they care for and we looked around the building to see whether it was clean, safe and comfortable. CARE DELIVERY We found that arrangements to provide proper care and treatment for people living at the home were not in place and identified many examples where care delivery was inadequate. Staff were not communicating safely or appropriately with each other and vital changes to peoples medical conditions and health care needs were not being addressed. For example, one person had any eye infection and leg wound which were not being treated. Another person had a leg dressing which required urgent attention and a third person was not receiving sufficient assistance and support with personal hygiene. We had to intervene and prompt staff in relation to care delivery and to keep people safe during the inspections. For example someone who required a pureed diet due to a problem with choking was about to be given a normal meal. Another person had not been given their regularly required analgesia for several days. People living upstairs on the dementia care unit were severly restricted in where they Care Homes for Older People Page 4 of 19 could go and all bedroom doors were locked as were the doors to the large, bright dining room. We were told that this was to protect people from harming themselves or interfering with other peoples property. People on this floor spent very little time outside in the garden area. They were mostly pacing the corridors, visibly frustrated and in some cases upset with each other and staff. The majority of people on the dementia care unit were not wearing slippers or shoes and staff gave various reasons for this such as not having any footwear or not wanting to wear them. There was no meaningful activity observed on either floor until the final visit when an activities person told us she was unaware of any activities programme and had received no training to assist her in her work. We found that all of the electrical pressure relieving mattresses were set at their maximum settings which did not correspond with peoples body weights posing a risk of skin damage. The assessment and management of individual nutritional needs was insufficient. We observed that the quality of mealtime events, in particular the evening meals were poor. Crumpled table cloths were used in the dining room and there were no place settings. Condiments were not provided and drinks were served upstairs in cups without saucers. Two evening meals were poorly presented when three small sandwiches and a bun on a teaplate were put in front of people. There was no effort to make the meal more attractive or tempting with colour such as salad or taste such as crisps. Baked beans were served on toast which was cold and leathery. Clothes protectors were not used when needed, resulting in soiled clothing. On 21 July the breakfast meal was not served until after 9.30am and people were restless and asking for drinks and their breakfast. The teatime meal is served between 4 and 5pm which meant that people were not receiving main meals for a period of over 16 hours. The catering staff told us that they had no specific diet sheets or individual care plan instructions to follow for people identified at nutritional risk. On 20 July there was no information on display about what meals were on the menu and staff told us that they did not know what was for lunch. Preference sheets were not used and staff told us that people were offered a choice before the meal. The cooks who were on duty when we visited 20 and 21 July were both temporary. They told us they planned the meal on the basis that half of the residents would have the first choice on offer and the other half the second choice. We found that fluctuations in peoples body weights were unexplained and had not been further explored. In some cases this had not been shared with the GP. There was widespread use of nutritional supplements. Their use did not correspond with the medication charts, individual care plans, instructions from dieticiens, speech and language therapists and the member of staffs understanding of individual needs. Only tea was offered in between meals and we were told that no-one on the upstairs unit liked coffee. We were also told that no-one on the ground floor unit took sugar with their cereals or porridge. Staff gave conflicting information about the types of snacks provided between meals. Care Homes for Older People Page 5 of 19 The catering staff told us they had never been asked to provide finger foods for anyone, although we saw the need for these described in several nutritional care plans. We found additional evidence of institutional and unacceptable practice throughout the home which staff described as the norm and have always done it this way. They said this had been led by the manager. There was no evidence of any person centred care delivery and staff told us that they all just mucked in and worked together . One carer told us she had done all her pad checks at 10am, another told us at lunchtime that he was doing the feeds. We identified that several people had been got up, washed and dressed by the night staff. However there was a shortage of information as to exactly what type of wash had been provided and in several cases it was not possible to identify when people had received showers or immersion baths. Beds had been stripped to the mattresses and some remained unmade into the late morning, when in one instance access to the bed was urgently needed. We found that at least two people had returned from hospital without the homes management team being aware. One person, who required nursing care and who was clearly unwell, had been readmitted by a carer. There was no evidence of any nurse intervention or nursing assessment since her return. The management team did respond to our feedback after each visit and new care charts had been introduced when we arrived on 20 July 2010. However staff required guidance and supervision when completing these in order to present meaningful and up to date information. Supervision and support for people on the first floor improved. More emphasis on staff interactions and meaningful activities was still required to support the dedicated activities person. The custom and practice of locking all doors upstairs had been addressed but staff were still having to get used to this change in their practice. We met with some visitors and relatives who had varying experiences of the quality of care delivery. Many were aware of the change of management and were keen to be involved in the home. A residents and relatives meeting was scheduled to take place on 21 July 2010. MEDICATIONS As part of the visit a pharmacist inspector checked how medicines were being handled. We checked medicines stocks, medicines records and observed part of the medicines rounds. At the end of the visit we took some photocopies of the records because we found medicines were not always being handled safely. When we arrived at the home on 9 July 2010 the morning medicines round had just started. We observed staff preparing and giving medicines and found some were not given at the right time. Medicines that should have been given half to one hour before food were wrongly given at breakfast because the medicines round had not been properly organised. All three staff that were giving the medicines out said it was normal practice to give people their medicines at mealtimes. Giving medicines with food that should be given before food can be harmful because it can stop them working properly. Care Homes for Older People Page 6 of 19 We checked the records of medicines received into the home and found them overcomplicated, which sometimes made accounting for them difficult to do. When we checked the stock of medicines in the specially dispensed system provided by the pharmacy we found they were usually given and recorded correctly. However, medicines supplied in packets and bottles could not always be easily accounted for and our checks showed some people had not been given them properly. One liquid medicine used to treat epilepsy had been missed or given at the wrong dose on numerous occasions as was another liquid medicine used as a laxative. A medicine used to prevent blood clots was missed twice in the last three weeks and an antidepressant tablet was missed at least nine times in the last three weeks even though the record was signed that it had been given. People who live in the home should not miss prescribed medicines because it could seriously harm their health and wellbeing. We found medicines stock to be poorly managed. We found numerous medicines had not been promptly disposed of at the end of each month and the records of this disposal were disorganised making it difficult to account for them. Of particular concern were medicines not being given to people because they had run out of stock and had not been reordered in time. For example, one person missed their medicine used for angina for fourteen days and another person missed their anxiety medicine on the day of our visit. We also saw several people missing their medicines because staff could not find the stock even though our checks showed these medicines were available to give. For example, a recently prescribed antibiotic eye drop was not given on the morning of our visit and other people missed doses of medicines used for Parkinsons disease, depression and a nutritional supplement. Missing prescribed medicines can seriously affect the health and wellbeing of people who live in the home. We looked at how medicines liable to misuse, called controlled drugs, were handled. The cupboard used for storage although reasonably secure was not lawfully attached to the wall so we gave some advice about how to put this right. A special register was used to witness the handling of controlled drugs and this was usually used correctly. However, a strong pain relief patch that should be replaced every three days had not been applied on time on several occasions over the last two weeks. On two occasions the patch was applied a day late and for the previous six days this person had no pain relief patch applied at all. Staff and managers were unaware of the problem and were only alerted to this by our inspection. Failing to give people their pain relief medicine can seriously affect their health and wellbeing. We looked at how the managers made sure staff were competent and made sure medicines were being handled safely. We saw some evidence of regular checks but these had clearly been ineffective as in the previous month many of the issues we found had not been identified by the managers. No formal assessments of staff competence had been carried out but the managers told us some were planned. There was no evidence of staff having recent medicines handling training even though we highlighted this on our last inspection. Having regular effective audits, medicines handling training and thorough assessments of staff competency will help to make sure medicines are handled safely by suitably skilled staff. Care Homes for Older People Page 7 of 19 We found that drug errors relating to record keeping and administration had been made when we returned on 20 and 21 July 2010. In view of the serious nature of our findings in relation to medicines two Statutory Requirement Notices were issued to the provider and registered manager on 23 July 2010. CARE PLANNING We examined the health and care assessments, care plans, evaluations and daily reports for eleven people in the home and found them to be inadequate. The management team were aware of this and had already commenced a review. Full details of our findings were provided both during and after our visits. Examples of the shortfalls in recording included: The storage of important information and communications in office diaries rather than in peoples individual records. Failure to make reports on a daily basis and failure to ensure that daily reports contain meaningful and relevant updates on peoples conditions and what care they have received. Entries had been made without nurses input and countersignature where needed. Inadequate records when people came back from hospital admissions. Inadequate recording of peoples wounds and skin problems. Failure to fully describe the types of specialist equipment in use and how it was to be used. Failure to review care plans at least monthly or when any notable event, such as new instruction from the dieticien, has taken place. A lack of consistency and quality when creating care plans. Information in care plans was often not specific to that person and we saw generalised statements about good practice, for example in relation to safety - keep doors and windows locked. Documents, relating to information such as nutrition, where the care plan, nutritional assessment and medicine records gave conflicting information. Inaccurate completion of health and care assessments. For example someone had been assessed as low risk of pressure damage and nutrition when they were in fact at high risk. No written evidence of peoples own input or agreement to their care plans or input from their relatives or representatives. STAFFING It was difficult to assess what staff training and supervision had been provided without the input of the registered manager. However we did find that there were no records at all for the nursing staff and some gaps within the records for the carers and anciliary staff. In particular staff supervisions were not up to date. There were not enough staff with up to date first aid training to ensure that a qualified Care Homes for Older People Page 8 of 19 first aider was on duty every shift, which is required. Three carers on the first floor told us they had not received any training in caring for people with dementia. We saw that staff were clearly lacking in awareness and expertise in understanding and meeting the needs of people with challenging behaviours. This was made worse by the high use of agency and bank staff who were not used to individual preferences and care needs. Staffing numbers varied from day to day and there was minimal input from nurses who held a mental health nursing qualification. The clinical lead nurse had left, and a new lead nurse was due to commence. The registered manager does not hold a nursing qualification. PREMISES We were unable to spend much time examining the premises but did find that the upstairs unit smelt unpleasant and felt hot and airless. We found that the upstairs floor was in a poor and neglected state of decoration and repair. There was no visual stimulation, points of interest, attractive colour scheme or signage expected in a specialist dementia care unit. The decor and the environment on the ground floor was better, but there were many general maintenance issues, such as missing plugs, in need of attention. Staff were not double bagging used incontinence pads resulting in offensive odours. Storage appeared to be a problem and we had to intervene to have large quantities of nursing equipment and supplements removed from peoples bedrooms. The use of stairwells for storage of items and equipment should be checked and agreed with the fire safety officer. A relative raised concern over the stability of occasional tables in the entrance foyer which would not support somones weight and which she knew had led to a previous accident. MANAGEMENT We were told that the line management of the registered manager had changed and that a new area manager had taken over the Regulation 26 monthly visits on behalf of the provider. The manager was unable to provide any record of a Regulation 26 visit for May 2010. A visit made on 21 June 2010 had identified some concerns but it was apparent that quality assurance systems and audit checks had failed to identify more serious issues. This matter is being further investigated. The additional serious concerns identified at this inspection have been shared with the provider who has been warned that additional enforcement action will follow if standards at the home are not quickly improved and maintained. We will continue to monitor the home closely and are working with the Local Authority and Primary Care Trust to ensure that people are kept safe and receive good standards of care. Care Homes for Older People Page 9 of 19 What the care home does well: What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 2. Care Homes for Older People Page 10 of 19 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 11 of 19 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 Ensure that all service user 24/09/2010 plans clearly identify how each individual service users health and welfare needs are to be met. Put in place effective arrangements to ensure that all service user plans are reviewed at least monthly or sooner as dictated by changes in individual service users needs. Put in place effective arrangements to ensure that where appropriate, service user plans are revised to reflect individual service users changing health and welfare needs after consultation with the service user or their representative. This is to ensure that service users health, personal and social care needs are set out in an individual plan of care. 2 8 12 Make adequate, proper and 27/08/2010 prompt provision for the care Page 12 of 19 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action and treatment of service users generally and in accordance with the following specific requirements: Ensure that all staff are provided with appropriate handover information about the conditions and care needs of service users in their care at the start of each shift. Ensure that the personal hygiene needs of individual service users are met. Put in place effective arrangements to ensure that guidance and instruction provided by multi-discipiinary professionals about the care and treatment of service users, is relayed to all staff and followed at all times. Put in place effective arrangements to ensure that all staff, including those who prepare food, are aware of individual service users nutritional needs and to ensure that food provided to service users meets their individual nutritional needs. Ensure that any specific equipment is used correctly and that staff are competent and suitably instructed in its use. This will promote and Care Homes for Older People Page 13 of 19 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action maintain service users health and ensure access to health care services to meet assessed needs. 3 9 13 Put in place effective 09/08/2010 arrangements to ensure that all medication is safely administered to service users in accordance with the prescribers directions. Put in place effective arrangements to ensure that clear and accurate records of all medications received into the home and adminstered to the service users are maintained, including reasons for non administration. Put in place effective arrangements to ensure that medications are stored correctly and are organised so that staff can find and administer them in accordance with the prescribers directions. To make sure that service users are protected by the homes procedures for dealing with medicines 4 9 12 Put in place effective 09/08/2010 arrangements to ensure sufficient stocks of medicines are kept in the home so that medication is administered to service users in accordance with the prescribers directions. Page 14 of 19 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Put in place effective arrangements to ensure medicine stocks are properly organised so that staff can find and administer them in accordance with the prescribers directions. This will make sure that service users receive their medicines on time and when required. 5 12 16 Consult with service users about a programme of activities and provide facilities for meaningful activity and recreation with regard to individual needs. This will provide service users with leisure and social activities that suit their expectations and capabilities. 6 15 16 Provide, in adequate 27/08/2010 quantities, suitable, wholesome and nutritious food which is varied and properly prepared, presented and available at such time as may be reasonably required by service users. This is to ensure that service users receive an appealing, balanced diet in pleasing surroundings at times convenient to them. 7 19 23 Provide the Commission with 27/08/2010 written proposals, together with timescales, for the Page 15 of 19 27/08/2010 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action refurbishment and upgrade of the premises to include: Specific design features and facilities to assist service users with dementia. Proposals to improve and manage storage arrangements. So that service users will live in a safe, well maintained environment. 8 27 18 Ensure that at all times 27/08/2010 suitably qualified, competent and experienced staff are available to meet the varying health care needs of the service users. To ensure that service users needs will be met 9 30 18 Undertake a comprehensive 24/09/2010 review of the training provided to current staff at the home and produce an accurate record of all training provided to individual members of staff. Ensure that as a minimum each member of staff receives training in: Understanding dementia Managing challenging behaviour Safeguarding adults Care Homes for Older People Page 16 of 19 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Mental Capacity Act and Deprivation of Liberties safeguarding. Ensure that all staff with responsibility for administering medication are trained to do so. Ensure that sufficient staff are employed at the home that are trained in first aid so that there is at all times a minimum of one person on duty who has received first aid training. So that staff will be trained and competent to do their jobs. 10 33 24 Ensure that effective 27/08/2010 arrangements are in place for monthly review of the quality of care delivery at the home. This is to make sure the home will be run in the best interests of the service users. 11 36 18 Ensure that all staff are appropriately supervised. Staff will be supported and their performance will be monitored 24/09/2010 Care Homes for Older People Page 17 of 19 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 38 Liaise with the fire authority regarding the storage of items within stairwells. Care Homes for Older People Page 18 of 19 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop Helpline: Telephone: 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. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for noncommercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. Care Homes for Older People Page 19 of 19 - 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. 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