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Inspection on 04/12/08 for Hillcroft Nursing Home

Also see our care home review for Hillcroft Nursing Home for more information

This inspection was carried out on 4th December 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The organisation had produced a range of up to date written information, with some alternative formats, such as use of pictures for people unable to easily understand the written information. The organisation had also circulated questionnaires and collated the information to show the homes good points and areas needing improvement. There were records to show that people living at the home had an assessment of their needs before they come to live there so that the staff had important information about them. The home was small, friendly, clean, comfortable and homely. The large communal lounge, dining room and conservatory encouraged the majority of residents to feel part of life at the home. They were able to see staff for the much of the time. The residents bedrooms we viewed were clean, comfortable and contained personal possessions. Comments from the CSCI surveys included, " The home is a pleasure to visit now smells and clean and tidy." The staff team were friendly and caring towards people living at the home. We saw a warm rapport and heard friendly banter between the members of staff and people living at the home during the visit. During discussions and observations staff appeared dedicated and they could explain the residents likes and dislikes and what to do to meet their needs. The responses we received indicated that the majority of residents liked living at the home, with comments such as, " is very happy and looks on other residents as her family", "staff very caring and kind", "unable to express wishes verbally, the staff take time and trouble to find out what she would like at meal times", "all staff and management especially the nursing staff have been totally committed to any action required", and " some excellent caring staff here". We noted that visitors were warmly welcomed to the home and offered refreshments. Comments from relatives included, "Enjoys his meals and his mealtimes and has been pleased to be ready to eat them." We saw that there was commitment to staff training and development with a ratio of 8 of 15 care staff qualified to the NVQ level 2 or above. There were also some senior staff undertaking the NVQ level 3 care award.

What has improved since the last inspection?

The registered persons had been issued with Statuary Requirement Notices following the inspections in January and February 2008. These Notices were to make sure essential improvements were made to the way care was provided, and the way medication and risks were managed. The essential improvements had not been made at the inspections undertaken in May and July 2008. It was positive that the way the home now plans each persons care was considerably improved with more detailed and specific written information providing staff with generally better guidance about each person`s needs and preferences. Health care assessments had also improved, with detailed measures in place to minimise risks of falls, pressure ulcers and risks involved in moving and handling people. However the actions required had not always been followed in practice.There were generally records on each person`s care file, showing that there was good access to specialist medical, chiropody and dental care. The previously poor quality of records of food, drinks and care of people in bed had also been considerably improved and there were better assurances that the care needed for these people was actually provided. We noted evidence that advice and support was now being sought from the GPs and community dieticians for all residents assessed as being at risk of poor nutrition or loosing weight. Though there was a record to show that the Malnutrition Universal Screening Tool was used as a measure for a person unable to be weighed, the nurses were not using it to accurately measure any further weight loss. At previous inspections it was identified that there had been serious deteriorations to the management and administration of medication for people living at the home. At this inspection there were some improvements, though concerns remained that peoples care plans would not provide sufficient guidance for staff, especially when administering medication on an "as required basis" or in accordance to special instructions. There was a requirement issued at previous inspections to review the numbers of staff on duty. This was because there were a number of people at the home with dementia, with associated behaviours. We noted some documentary evidence that action had been taken to record the dependency levels of people living at the home, however this was not sufficiently robust to show how it related to the review of staffing levels. Concerns remained about the depleted numbers of permanent nursing staff to provide guidance and there was evidence that care staff were still undertaking some ancillary duties and were expected to provide some activity stimulation. The redecorating and renewal programme had continued continuing with improvements to the ground floor corridors, with a colour scheme, which provided an attractive, calm environment for people living there. We saw that that some improvements had been made to health and safety at the home, for example a regular written accident analysis had been put in place to highlight any trends or increased risks, which needed to be controlled. There was an increased number of recorded accidents, which could indicate improved recording, however there were a concerning number of unexplained incidents of bruising and skin tears, which had not been thoroughly investigated.

What the care home could do better:

We noted that some people`s care plans and other records did not contain the detailed information to make sure that all staff, particularly agency staff were guided to meet each person`s individual needs and choices. There was an example of a person with advanced dementia preferences for rising, retiring and bathing being "at staff discretion". Another example was the absence of a plan for the administration of "as needed" medication to manage someones behaviour. This posed the risk that the medication could be given inappropriately and the person may suffer side effects. Theregistered persons must continue the development of the care planning processes to make sure each person`s plan is centred around their individual needs and that nurses and care staff follow the guidance diligently. For example where it is deemed necessary appropriate action must be taken to record observations such as blood glucose monitoring and blood pressure at the required intervals and report abnormal results to the appropriate health professionals. Although we noted some improvements to the systems for residents` prescribed medication, there were further areas of concern. Four additional requirements were issued to improve the systems for medication management and administration. These included safe storage and assessment of the competency of staff administering medication. This was to make sure all persons living at the home receive the medication as prescribed by their GP for their health and well being. We looked at a sample of risk assessments for people living at the home and though there were improvements, there were some areas, which were not being properly assessed or managed. Examples were that there were no recorded risk assessments for a person assessed with aggressive and paranoid tendencies and another person who had a risk assessment relating to occasional aggressive behaviour towards staff did not have a risk assessment relating to changing behaviour and increasingly frequent physical aggression towards other vulnerable people living at the home. The omissions meant that people living at the home were not sufficiently safeguarded from risks of harm. At previous inspections recommendations have been made to consider social stimulation for those people who spend all or the majority of time in their bedrooms to give them an increased quality of life, which has still not been actioned at the time of this inspection. Staff told us they only have time to do essential care tasks and would like to have more time to spend with people in their rooms, to read, chat or sing with them. We saw very little evidence relating to activities during the inspection visit. However we were made aware that an experienced activities co-ordinator had been employed for 15 hours each week and progress was being made to introduce more activities. We have issued recommendations at previous inspections for individual activities planners to be put in place for all persons living at the home, relating to their preferred individual activities, which have not been actioned. One person`s record showed only that she used to like sewing. There was no evidence of activities designed to meet the needs of people with dementia or sensory disabilities. The records of activities and social stimulation must be kept up to date and show refusals and any alternatives offered. We expressed our serious concern to the registered proprietor that as at previous inspection visits we found that there were incidents, and allegations, which had not been referred to the Local Authority in accordance with the multi agency safeguarding procedures, or notified to the CSCI as required in compliance with The Care Homes Regulations 2001. At previous inspections a requirement was issued to make sure referrals for any unexplained injuries were made to all relevant agencies to safeguard residents. Prior to this inspection visit we had received a retrospective notification from the acting manager about a suspicious injury potentially caused by a member of night staff. This person was eventually dismissed but without an appropriate investigation orother agencies, such as the police and social services involved. During our assessment of a sample of care records we found evidence of incidents of physical aggression from a person living at the home towards other vulnerable people being cared for at the home. These included throwing objects including water and juice over other people, which the acting manager acknowledged she had not thought to report. We also found a number of accident records of unexplained bruises and skin tears, which were not fully investigated or reported to other agencies, including the CSCI. This meant that because required actions were not undertaken at of any sign of potential abuse there were no assurances that residents would be protected from harm. An additional concern was the failure of the registered person to make sure all staff had received appropriate

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Hillcroft Nursing Home 135 High Street Wordsley Stourbridge West Midlands DY8 5QS     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jean Edwards     Date: 0 4 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 54 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 54 Information about the care home Name of care home: Address: Hillcroft Nursing Home 135 High Street Wordsley Stourbridge West Midlands DY8 5QS 01384271317 01384271112 christinedalwood@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs. Kailash Jayantilal Patel,Mr. Jayantilal James Bhikhabhai Patel Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 28 Number of places (if applicable): Under 65 Over 65 10 28 dementia old age, not falling within any other category Additional conditions: 0 0 Service Users to include up to 28 OP and up to 10 DE(E) Service Users to include up to 28 OP and up to 10 DE(E) Date of last inspection Brief description of the care home Hillcroft Nursing Home is situated in a residential area of Wordsley close to a main bus route, shops and other local facilities. The home has been converted from a traditional domestic dwelling and extended for its present purpose a care home providing nursing care to a maximum of 28 residents in the category of old age, many of whom have complex needs and require a high level of care. Ten of these 28 places can be allocated at any one time to older people who have a diagnosis of dementia. Hillcroft is registered to provide nursing care and therefore has a registered nurse on duty at all Care Homes for Older People Page 4 of 54 Brief description of the care home times. The home is on two floors. There is a lounge, dining area, conservatory, kitchen, laundry rooms, office, a number of bedrooms, toilets and an assisted bathroom on the ground floor housing. The home has an attractive garden to the rear and car parking space to the side. There are bedrooms, WCs and bathing facilities on first floor. The home has ramped access, a passenger lift, hoisting equipment and other aids and adaptations for safety, accessibility and independence. Care Homes for Older People Page 5 of 54 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection took place on 20 and 21 May 2008, followed by a Random Inspection on 8 July 2008. We, the Commission for Social Care Inspection (CSCI) undertook an unannounced key inspection visit. This meant that the home had not been given prior notice of the inspection visit. A lead inspector visited the home between 07:30 am and 9:40 pm and was accompanied by a second regulation inspector and for part of the inspection by a CSCI Pharmacist Inspector. We monitored the compliance with all Key National Minimum Standards at this visit. The range of inspection methods to obtain evidence and make judgements included: discussions with the registered proprietor, acting manager, nurse and staff on duty during the visit. We also had discussions with Care Homes for Older People Page 6 of 54 residents, and made observations of residents without verbal communications. Other information was gathered before this inspection visit including notification of incidents, accidents and events submitted to the CSCI. A number of records and documents were examined. The responses from people living at the home, relatives and heath professionals to the CSCI surveys have been included throughout this report. We toured the premises, looking at communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents bedrooms, with their permission, where possible. The home had published the weekly range of fees in the service user guide. The weekly fees range from 353 pounds to 540 pounds, with additional individual 30 pounds third party top up fees. There are additional charges for hairdressing and private chiropody. People are advised to contact the home for up to date information about the fees charged. What the care home does well: What has improved since the last inspection? The registered persons had been issued with Statuary Requirement Notices following the inspections in January and February 2008. These Notices were to make sure essential improvements were made to the way care was provided, and the way medication and risks were managed. The essential improvements had not been made at the inspections undertaken in May and July 2008. It was positive that the way the home now plans each persons care was considerably improved with more detailed and specific written information providing staff with generally better guidance about each persons needs and preferences. Health care assessments had also improved, with detailed measures in place to minimise risks of falls, pressure ulcers and risks involved in moving and handling people. However the actions required had not always been followed in practice. Care Homes for Older People Page 8 of 54 There were generally records on each persons care file, showing that there was good access to specialist medical, chiropody and dental care. The previously poor quality of records of food, drinks and care of people in bed had also been considerably improved and there were better assurances that the care needed for these people was actually provided. We noted evidence that advice and support was now being sought from the GPs and community dieticians for all residents assessed as being at risk of poor nutrition or loosing weight. Though there was a record to show that the Malnutrition Universal Screening Tool was used as a measure for a person unable to be weighed, the nurses were not using it to accurately measure any further weight loss. At previous inspections it was identified that there had been serious deteriorations to the management and administration of medication for people living at the home. At this inspection there were some improvements, though concerns remained that peoples care plans would not provide sufficient guidance for staff, especially when administering medication on an as required basis or in accordance to special instructions. There was a requirement issued at previous inspections to review the numbers of staff on duty. This was because there were a number of people at the home with dementia, with associated behaviours. We noted some documentary evidence that action had been taken to record the dependency levels of people living at the home, however this was not sufficiently robust to show how it related to the review of staffing levels. Concerns remained about the depleted numbers of permanent nursing staff to provide guidance and there was evidence that care staff were still undertaking some ancillary duties and were expected to provide some activity stimulation. The redecorating and renewal programme had continued continuing with improvements to the ground floor corridors, with a colour scheme, which provided an attractive, calm environment for people living there. We saw that that some improvements had been made to health and safety at the home, for example a regular written accident analysis had been put in place to highlight any trends or increased risks, which needed to be controlled. There was an increased number of recorded accidents, which could indicate improved recording, however there were a concerning number of unexplained incidents of bruising and skin tears, which had not been thoroughly investigated. What they could do better: We noted that some peoples care plans and other records did not contain the detailed information to make sure that all staff, particularly agency staff were guided to meet each persons individual needs and choices. There was an example of a person with advanced dementia preferences for rising, retiring and bathing being at staff discretion. Another example was the absence of a plan for the administration of as needed medication to manage someones behaviour. This posed the risk that the medication could be given inappropriately and the person may suffer side effects. The Care Homes for Older People Page 9 of 54 registered persons must continue the development of the care planning processes to make sure each persons plan is centred around their individual needs and that nurses and care staff follow the guidance diligently. For example where it is deemed necessary appropriate action must be taken to record observations such as blood glucose monitoring and blood pressure at the required intervals and report abnormal results to the appropriate health professionals. Although we noted some improvements to the systems for residents prescribed medication, there were further areas of concern. Four additional requirements were issued to improve the systems for medication management and administration. These included safe storage and assessment of the competency of staff administering medication. This was to make sure all persons living at the home receive the medication as prescribed by their GP for their health and well being. We looked at a sample of risk assessments for people living at the home and though there were improvements, there were some areas, which were not being properly assessed or managed. Examples were that there were no recorded risk assessments for a person assessed with aggressive and paranoid tendencies and another person who had a risk assessment relating to occasional aggressive behaviour towards staff did not have a risk assessment relating to changing behaviour and increasingly frequent physical aggression towards other vulnerable people living at the home. The omissions meant that people living at the home were not sufficiently safeguarded from risks of harm. At previous inspections recommendations have been made to consider social stimulation for those people who spend all or the majority of time in their bedrooms to give them an increased quality of life, which has still not been actioned at the time of this inspection. Staff told us they only have time to do essential care tasks and would like to have more time to spend with people in their rooms, to read, chat or sing with them. We saw very little evidence relating to activities during the inspection visit. However we were made aware that an experienced activities co-ordinator had been employed for 15 hours each week and progress was being made to introduce more activities. We have issued recommendations at previous inspections for individual activities planners to be put in place for all persons living at the home, relating to their preferred individual activities, which have not been actioned. One persons record showed only that she used to like sewing. There was no evidence of activities designed to meet the needs of people with dementia or sensory disabilities. The records of activities and social stimulation must be kept up to date and show refusals and any alternatives offered. We expressed our serious concern to the registered proprietor that as at previous inspection visits we found that there were incidents, and allegations, which had not been referred to the Local Authority in accordance with the multi agency safeguarding procedures, or notified to the CSCI as required in compliance with The Care Homes Regulations 2001. At previous inspections a requirement was issued to make sure referrals for any unexplained injuries were made to all relevant agencies to safeguard residents. Prior to this inspection visit we had received a retrospective notification from the acting manager about a suspicious injury potentially caused by a member of night staff. This person was eventually dismissed but without an appropriate investigation or Care Homes for Older People Page 10 of 54 other agencies, such as the police and social services involved. During our assessment of a sample of care records we found evidence of incidents of physical aggression from a person living at the home towards other vulnerable people being cared for at the home. These included throwing objects including water and juice over other people, which the acting manager acknowledged she had not thought to report. We also found a number of accident records of unexplained bruises and skin tears, which were not fully investigated or reported to other agencies, including the CSCI. This meant that because required actions were not undertaken at of any sign of potential abuse there were no assurances that residents would be protected from harm. An additional concern was the failure of the registered person to make sure all staff had received appropriate up to date training to recognise and respond to allegations or suspicions of abuse. The records showed only 5 care staff and 1 ancillary staff had attended the Local Authority sponsored training. None of the management or nursing staff had attended this essential training. This meant that the requirement issued at the previous inspection visit was not met. The registered persons must continue with the refurbishment and decoration of the home and with the replacement of furniture and facilities, especially the first floor communal areas including bathing facilities to make the home a safer and more comfortable home for people living there. The registered persons must keep staffing levels under review and make sure that there are sufficient experienced, competent staff to meet the needs of all persons accommodated at all times. We expressed our serious concerns about the declining numbers of permanent registered nurses employed and heavy reliance on agency staff, which meant that people would not receive consistent care from staff who knew and understood their needs well. We received comments about what home could do better, such as, shortage of staff at times.. Care staff also told us it was difficultduring the mornings getting very dependent people up, washed and fed, especially when three days out of seven a person termed, the feeder, was not on duty to help. At previous inspections we strongly recommended that staff should be provided with specific training to meet the needs of people living at the home, which included accredited dementia care, specialist diabetes care, responding to challenging behaviour, person centred approaches to care and skin care. There was insufficient evidence that this training had been provided or that there had been beneficial outcomes for people living at the home. Following the key inspection in May 2008 the registered proprietor provided the CSCI with an action and improvement plans, especially relating to the management of the home, which had shown a marked deterioration. At this inspection visit we were concerned that though there were some improvements, these plans had not been fully implemented. We noted that a temporary acting manager ahd been appointed at the end of July 2008, this person was a deputy manager from another home within the company. However there was no permanent management arrangement in place, which was compounded by the lack of robust contingency measures to ensure there were suitable trained, experienced, competent nurses consistently available to be left in charge on a day to day basis. We noted the registered persons explanation that it had Care Homes for Older People Page 11 of 54 been difficult to recruit a suitable manager or registered nurses given the homes poor quality rating. However as already identified we were seriously concerned that not all previous requirements were fully met relating to safeguarding and that these were not recognised by the people responsible for running the home. Furthermore the monitoring arrangements had failed to identify areas of care planning, risk management and medication practice needing improvement, highlighted at this inspection visit. An example was the failure to take action to remedy areas identified to the home at the BOOTS pharmacy audit in October 2008. The registered person must take care not to mislead people living at the home and their relatives about the seriousness of the areas of poor practice, especially by inferring that failures only concern paperwork, when it is actions or omissions in practice, which put people at risk. The management of this home must improve in order to meet peoples needs and reduce the risk of harm. 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 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 12 of 54 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 13 of 54 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has an up to date statement of purpose and service user guide in an easy to understand format, which means that people have good information to help them make decisions about their choice of home. There are comprehensive assessment tools and people living at the home have been regularly reviewed, which means that all their care needs should be known about and can be met. The home does not have a permanent manager is not fully staffed with a team of permanent registered nurses, which does not offer full assurance that continuity of care can be maintained. The home does not provide intermediate care, therefore Standard 6 is not applicable. Evidence: We noted that the copies of the homes statement of purpose and service user guide available in the reception of the home had been updated since the random inspection on 8 July 2008. We were told that these documents were also included in welcome packs, which also included copies of the homes complaints procedure, available in each Care Homes for Older People Page 14 of 54 Evidence: persons bedroom. It was positive to note that the service user guide was in an easy read format and contained information about the range of fees charged by the home, which meant that a previous recommendation had been met. This meant that people had good information to enable them to make informed decisions about the choice of home. We were told that there had been no new admissions to the home since the random inspection on 8 July 2008. The nurse in charge told us that there were 17 people and accommodated, with one person currently in hospital. The management of the home had generally provided the CSCI with notifications about changes relating to the people living at the home sent to the random inspection, which was positive. There was evidence from a sample of care records looked at and from multi-agency strategy meetings that everyone living at the home had received or been offered a review of their care needs and placement at Hillcroft Nursing Home since the random inspection in July 2008. There was also evidence that nursing staff the home had proactively sought advice and support for someone displaying changes in behaviour, which was positive. We were shown evidence that the residents contract and terms and conditions had been updated to include comprehensive information and progress was being made to re-issue the updated document to all residents and their families. There was a record indicating the outstanding contracts and terms and conditions to be signed and returned to the home and a copy could be kept on each persons file. This demonstrated good practice and compliance with an outstanding recommendation from previous inspections. Prior to this inspection visit an anonymous complaint had been made to the CSCI office, Birmingham, alleging staff shortages, lack of disposable gloves and poor moving and handling practices. The CSCI surveys returned also included, shortage of staff at times. We talked to the nurse in charge, staff on duty, some of the residents and relatives, we observed the daily routines and looked at the staffing rotas, taking account of the number and dependency of people living out the home, including two people being cared for entirely in bed. We noted that in addition to the registered nurse on each shift there were 4 care staff rotad on the early shift, and 3 care staff on the late shift. We saw from the rotas, confirmed in discussions that there were only 3 registered nurses permanently employed at the home to cover 21 shifts over seven days each week. One registered nurse was away on maternity leave. We discussed the homes use of agency nurses to provide the necessary cover but who may not have good in-depth knowledge of the residents needs, placing extra pressure on the permanent nurses and care staff. We observed that the majority of the 16 residents Care Homes for Older People Page 15 of 54 Evidence: required assistance of 2 staff for their mobility and often their personal care needs, and in addition we were told that 7 people needed to be fed with all meals, with others needing support or assistance to eat. We were told that there was someone called a feeder employed from 8:00 am to 11:00 am for four days each week to help feed people at breakfast but staff told us that it was difficult to get people up and ready and feed on the other 3 days each week. We also noted that there were evenings where care staff had to undertake catering duties at tea and supper times. On balance we felt that there may be some substance to the comments received that at times the home appeared short staffed at times. Care Homes for Older People Page 16 of 54 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning is generally adequate to identify peoples needs and provide staff with instructions to meet their needs, though there is not always the assurance that all their needs will be met. The arrangements for administration of medication do not always ensure people receive their prescribed medicines, which means that there may be risks to their health and well being. People are generally treated with respect and their right to privacy is upheld. Evidence: This home had been previously been served with a Statutory Requirement Notice to improve care planning and care records to assure all residents health and well being. The CSCI had received repeated assurance from the Registered Proprietor that all aspects of the notices had been actioned and care planning and care records were improved and monitored as satisfactory. This had not been evidenced at the Key Care Homes for Older People Page 17 of 54 Evidence: Inspection in May 2008 and at a subsequent monitoring visit on 8 July 2008, despite a written commitment from the registered provider in the form of an action plan for improvements submitted to the CSCI in June 2008. At this key inspection it was positive to note that plans to introduce new care planning, health screening and risk assessment documentation had been implemented. We looked at a sample of some of residents case files containing care plans, risk assessments and held discussions with residents and staff about how people were supported and given assistance to meet their daily needs. We noted that a new form had been introduced to show that residents or their relatives or representatives had signed the plans to indicate their involvement and agreement. Initially we had some difficulty with the accuracy of verbal information given to us during the inspection visit, for example in establishing how many people were being cared for in bed. We were told there were only two people nursed in bed. There were some similar discussions about home many residents were nil by mouth and how many people needed pureed and soft diets. Examination of records, observations we made throughout the inspection and discussions with staff confirmed that the needs of some of these residents had changed. An example was a resident who had new care plans put in place in June 2008, which indicated high risks related to wandering and aggression. However at the random inspection on 8 July when we looked at this persons daily notes and spoke to staff the indications were that this person was more settled. At that time there were no records of incidents of agitation or aggression. We noted at this inspection that this persons care records indicated that her behaviour had altered. The acting manager, only temporarily in post from July 2008 to January 2009, initially told us that this person was not displaying altered behaviour. We highlighted to her this persons the risk assessments, care plans, list of professional involvement such as requests to GP, social services and Community Psychiatric Nurse for reassessment and the administration of Promazine, an antipsychotic medication, on a PRN, as required basis. There were entries such as, social work department contacted, awaiting referral for altering behaviour. We were very concerned to note that though this persons care plan for handling episodes of aggression stated, if medication is prescribed on a PRN basis, please follow the protocol for giving and document. The acting manager acknowledged that although there was a generic protocol, there was no individual written protocol in place for this person. We saw from daily notes and the behaviour charts that variable doses of Promazine had been administered, sometimes 5mls was given, sometimes 10mls was given without an explanation. This meant that different nurses may be using different criteria and the medication may not be given in the Care Homes for Older People Page 18 of 54 Evidence: persons best interests and may result in unwanted consequences such as falls. The issues surrounding the administration of this medication for this person are highlighted further at the Complaints and Protection section of this report. We also raised our concerns about the record of Daily Needs, indicating preferences, the persons preferred time to get up, go to bed, personal hygiene, bath or shower, was recorded as, at discretion of staff. We discussed this document with the acting manager and asked what guidance staff would understand from this, and questioned at whose discretion and how would decisions be made. During discussions with the acting manager, we established that no consideration had been given to an assessment of capacity under the Mental Capacity Act and the persons abilities to make day to day decisions had not been considered. We also noted some inconsistencies in recorded information such as spiritual needs, recorded as, Unitarian no communion on a new form signed by the persons relative. However this information was inconsistent with assessment information also on file with religion recorded as Church of England. We saw Dentist, chiropodist, optician recorded. as and when needed, which did not correspond with assessment information, which indicated that regular chiropody appointments were required. On a positive note there were records that the person had received professional visits from the chiropodist on a very regular basis and also had regular dental checks. We looked at the care of people being nursed in bed. Whilst it was positive that there were nursing care plans for oral care, we spoke to a member of staff who told us that staff used gauze on a clean finger, or gloves for cleaning the persons mouth. In one persons bedroom we saw that there was Dentitex oral mouthwash on the bedside table, but no mouth tray or gauze. The carer told us that she must have used the last of the gauze in the bedroom. We noted that there was no clinical waste bag in the bedroom for used mouth care products. The carer explained that used gauze was disposed of in the white bags staff carried around with them for used incontinence products. We also note that this person had been treated for episodes of oral thrush, which made the need for good oral care practice especially important. We looked at other care records and noted that the reviewed Waterlow score relating to skin integrity of a person nursed in bed had decreased. We discussed the decreased score with the acting manager who could not explain why the score had decreased, when this person had in the recent past sustained a grade 4 pressure ulcer and the risks of susceptibility to skin damage remained. This was further evidenced by body maps and records of unexplained bruising and skin tears on this persons care file. There were records and body maps dated 12/8/08, has developed bruised area on right wrist, daughter aware. There was no Regulation 37 notification recorded as received at the CSCI office Birmingham. A further record dated 2/9/08, X continues Care Homes for Older People Page 19 of 54 Evidence: to sustain bruising to both arms. Significant bruising was illustrated but there were no photographs and actual measurements of injuries or wounds, and progress as they either healed or deteriorated, which would demonstrate good practice. We also discussed a nutritional assessment, where the reviewed score had also decreased, indicating a lower risk, despite chest infections and obvious weight loss. The nursing staff had used the MUST, Malnutrition Universal Screening Tool and recorded body weight as less than 20 kg, as cannot be weighed, but no record of regular mid-arm measurements. This meant that appropriate monitoring of nutrition and hydration may not be taking place. We observed a pressure relieving mattresses in place, for a very frail person, which was switched on to the highest setting, very firm. The care plan had no guidance for the pressure setting for the pressure relieving mattress, which meant that it may not be effective in preventing tissue damage. We looked at fluid, food, night checks and turn charts, which had improved since the random inspection 8 July 08. Food was itemised and portion sizes recorded. Three meals each day were recorded and some suppertime drinks such as Horlicks, for three nights for one person. Though this did not demonstrate less than 12 hours between last and first meal, which would demonstrate good nutritional practice. At the previous inspections we discussed with the registered persons and nurses the issues of social isolation for people nursed entirely in bed in their rooms. At the random inspection visit there were no records of a socialisation care plan or recorded interaction between the residents, who had been cared for in bed for lengthy periods, and staff or visitors. There were some references in daily progress reports of visits from relatives and at the time we were told by the nurse in charge that staff frequently popped in but she acknowledged there were no records to show this happened. At this inspection visit we did not see evidence of activity or social interaction care plans for people nursed in bed or in their bedrooms. Furthermore in discussions with care staff on duty, who appeared very caring, they indicated that they wished they had time to spend with these people, other than to give essential personal care, to talk, read or sing with them. They told us that it was difficult to assist everyone who needed help to get up, washed, dressed and be fed with breakfast in the mornings. We looked at the care being provided for a person with type 2 diabetes. It was positive that this person had a risk assessment relating to the risk of Hypoglycaemia. However the information was not sufficiently specific, it described giving an injection but no follow-up treatment to maintain the blood glucose level and information was inconsistent with the care plan to manage the diabetic condition. It gave details of Care Homes for Older People Page 20 of 54 Evidence: daily insulin and stated BM to be monitored x 2 daily, and gave a range of readings dependent on time of day, however this was not sufficiently specific and there was no indication of action to be taken for readings which were outside of the normal parameters. During discussions with the acting manager there was no evidence that the home had followed up the recommendation issued at the previous inspections, to involve the diabetic specialist nursing team in Dudley, for advice, support and specialist training for nurses and more basic training for care staff. We looked at the homes training matrix with the acting manager, which showed the only training date for diabetes, in October 2008, for one RGN currently on maternity leave. The persons care records did not demonstrate that the full range of diabetic screening for vision, foot and skin care, involving diabetic health screening practitioners was taking place on a regular basis. This person also had care needs in relation to renal failure. The care plan dated 25/9/08 Management of Renal Failure, indicated that Blood Pressure was to be monitored, recorded and any fluctuations be reported to the GP. However there was no evidence to show that this had been diligently followed up. We discussed this with the acting manager who acknowledged the omission and wrote to us following the inspection visit to provide assurances that the appropriate monitoring had been put in place. We noted that a persons previous assessment indicated aggressive and paranoid tendencies, at this inspection there were no current risk assessments in place relating to whether these were relevant and now needed. The daily notes indicated that the person was still exhibiting symptoms. This meant that the person may present risks to themselves, staff and other people at the home and without guidance staff may not provide the support and reassurance this person needed. We saw that one person had deteriorated and was being cared for in bed, after accident to their leg caused by a walking frame of another resident. There was no evidence that this had been reported to the CSCI office as a Regulation 37 notification. Following previous inspections the home had also been issued with Statutory Requirement Notices relating to risk assessments and the use of bedrails. The registered persons had not demonstrated compliance with the Notices to protect people from risks of harm at the two previous inspection visits. At this visit people needing the use of bedrails were generally better protected, with improved bedrails risk assessments and regular checks to make sure the equipment in place was used safely. There was only one set of bedrails in use, which did not have full length bumpers in place to protect the person against risks of injury. The acting manager wrote to us soon after the inspection visit to confirm full length bed bumpers had been provided. Care Homes for Older People Page 21 of 54 Evidence: We noted that each persons care plans were reviewed regularly. We looked at the review notes for a resident, which included the comments, family are happy with the care at Hillcroft. We were made aware that care staff were completing daily care records, which were additional to the daily progress completed by the nurse in charge of each shift, which was unnecessary duplicated effort, and the carers also recorded care delivered on the personal care matrix. However though this did not always demonstrate that each person had received their personal care according to their care plan. An example for one person showed that on Tuesday 2 December 08 bath/ shower, it did not specify which, although it did indicate hair washed, and for week commencing 17/11/08 there was no bath / shower recorded. This did not show whether the person had received their personal care or if it had been offered and refused. The pharmacist inspector visited the home as part of the key inspection on the 4th December 2008. The reason for the pharmacists visit was to assess the handling of medicines within the home in relation to regulation 13(2) of the Care Homes Regulations 2001. We found that the home was failing to record the receipt of all medication received into the home. We found that medication that had been carried over from previous months had not been accounted for in the records and as a consequence the home did not know whether this medication was being used appropriately. We found that when a person who used the service refused to take their tablet medication, the tablets were placed into a small bag and labelled with the name of the person concerned, the date and time of the refusal and the names of the medication that had been refused. The nursing staff were then indicating on the Medicine Administration Record (MAR) charts that the medicine had not been administered using a number of defined abbreviations. These small bags were then kept in the mobile drug trolley until the end of the monthly cycle and then the contents were disposed of by the nursing staff with a record being made in the disposal record book. We found a number of issues with this process. We found very little consistency in the abbbreviations used. We found when comparing the abbreviations on the MAR charts with the contents of the bags that a number of tablets were unaccounted for. we found that the home was not making any record of the disposal of liquid and dispersible medication. We found overall that the care plans were poor for containing information about the administration of medicines. When examining the records of one of the people who used the service we found no information about when the administration of the when required medication should take place and what time period should be allowed between the when required doses. We also found that due to the lack of this Care Homes for Older People Page 22 of 54 Evidence: information there was inconsistency in the administration of the when reqired medicine. We also found that the daily notes or behavioural charts used in the home either did not give an account of why the medicine was administered or did not fully explain the reasons for the administration. We also found that there was no information or confirmation of what to administer from the persons doctor about those medicines that had been prescribed using the term as directed. We also found that the care plans did not give an account of when changes were made to the administration of medicine by the general practitioners visiting the home. A previous inspection had raised the issue of a number medicines not being available in the home to adminster to the people they had been prescribed for. We found during this inspection that this issue was much improved and we only found one person who had not received one of their tablets for a period of three days because the home was waiting for the prescription to be produced. We found that the Controlled Drugs cabinet did not comply with the Misuse of Drugs (Safe Custody) Regulations 1973 because it had not been properly fixed to the wall. We found at this inspection that the home was not holding any Controlled Drugs. We found that the nursing staff were responsible for administering medication to the people who used the service. We found that the home did not assess the competency of these nurses to ensure that they were administering medication to the people in the home in a safe and accurate manner. We found that the home was administering influenza vaccines on behalf of the local doctors. We found that the home had no written direction from the doctors concerned nor had they obtained written consent for all of the people who had received the vaccine. We also found that the nursing staff carrying out this procedure had not been trained nor was the home prepared if one of the people receiving the injection had an allergic reaction We found that the room where the medication was stored was too hot. The records showed that the temperature was rising to between 26 and 28 degrees centigrade. The maximum temperature that medication should be stored at is 25 degrees centigrade. We found that the home was monitoring the maximum and minimum temperatures of the medication fridge on a daily basis. We found that for a period of approximately one month the minimum temperature had been recorded at 1 degree centigrade. We found in the fridge some insulin that had been dispensed before this period and therefore it was likely that this insulin had been subjected to the low temperature. The home was advised to dispose of this insulin. Care Homes for Older People Page 23 of 54 Evidence: We noted that people living at the home were treated respectfully, with staff using preferred names and talking at an appropriate pace and tone. Peoples privacy and dignity were generally maintained. Though there were two notable exceptions where verbal information was handed from one shift to another within the hearing of people at the dining tables. Another instance was in the evening of the inspection visit when we observed a person with an obvious malodour, wandering about, and a member of staff told us the odour was caused by incontinence. Care Homes for Older People Page 24 of 54 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at this home have limited opportunities to take part in activities. People are able to maintain contact with their friends and families and visitors are welcomed. Most meals are appetising, although there may not always be sufficient staff to assist people who have special dietary needs. Evidence: From the sample of care records we looked at we noted that rising, retiring, bathing or showering preferences were not always recorded in care plans and activities preferences were not recorded in any meaningful or person centred way. The issue of recording, at staff discretion, for the daily preferences for someone with late stage dementia is highlighted at the previous section, Health and Person Care, of this report. The routines of the home were not generally geared around each persons needs and preferences. From observations and discussions the routines were centred around staffing and how best they feel they could attend to each persons essential needs in the time available. There were notes of discussions in staff meetings around how bed baths could be done by night staff and baths and showers at other times of staff availability. Care Homes for Older People Page 25 of 54 Evidence: On arrival at the inspection visit we noted that there were six very dependant residents with complex needs already up, dressed and seated in the communal lounge and dining room. This was at 07:30 am. We spoke to one person who stated it was too early to get up but was happier to sit at the table waiting for breakfast than sitting the bedroom. This person was well groomed and smartly dressed. During breakfast time the care staff were busy getting residents up, one care assistant was occupied in dining room and kitchen and kept popping in and out to ask the people who were up if they wanted drinks and first part of breakfast, cereals, toast. The nurse in charge was occupied with administering the morning medication. We were told this was the usual practice, though someone termed the feeder employed from 08:00 am to 11:00 am four days out of seven to help to feed people at breakfast time was not on duty on the day of this inspection. Staff spoken to told us there were not enough staff and it was difficult to have sufficient time for each person, especially on days when the person employed to feed people was not on duty. Staff told us that the majority of residents required 2 care staff to assist them with their personal care and hygiene needs. We confirmed this when looking at care records and risk assessments. We observed the daily routines from a communal area and also talked to residents and visitors. We did not see evidence that recommendations relating to the daily routines, social stimulation, advocacy and improved support at meal times issued at previous inspections had been actioned. During the afternoon of the inspection visit we saw a member of care staff trying to engage with residents, attempting to encourage them to play a game with bean bags, without success. We heard some cheerful banter between some staff and some residents. However we were told during discussions with staff that a activities co-ordinator had started work at the home but generally there was no structured activities programme in place for group or individual activities. There was no evidence of activities suited to the needs of people with dementia, physical or sensory disabilities. We heard from a resident who told us that they were bored. Some care staff also told us that they would love to have time to spend with residents nursed in bed, so that they could read, talk or sing with them. We indirectly observed meal times during the day, spoke to staff and examined records and found that though food and fluid records were improved there was not always sufficient evidence that residents received a wholesome, appealing, balanced diet, at times convenient to them. We were told that the previous excellent cook had left the homes employ and a new cook had recently been employed. We saw that the basic daily breakfast menu was displayed on the tables. There were no pictorial menus in evidence, which would have helped people with dementia and other sensory impairments make better informed choices. It was positive that we heard staff ask Care Homes for Older People Page 26 of 54 Evidence: each person in the early morning whether they wanted turkey or tuna pasta for lunch and later in the day what choice of sandwich filling they wanted for tea time. It was uncertain as to whether people having soft and pureed diets were always offered at least two choices of meal options. Some efforts had been made and tables were set with all required cutlery and condiments. Some residents told us they liked the food and one relative who visited daily told us they thought the meals were good. Care Homes for Older People Page 27 of 54 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot have confidence their concerns or complaints will be listened to or investigated and the management practices do not protect residents from harm or abuse. Evidence: The homes complaints procedure was displayed on the main notice board in the hall of the home and also included within the Welcome Pack and within the service user guide. We discussed an anonymous complaint sent to CSCI around 29 Oct 08, regarding staff shortages, lack of gloves, said to be due to financial constraints and some people not using safe moving and handling techniques, such as using the hoist for transfers. The acting manager told us no concerns had been raised at the home. She denied the home had been short staffed or short of disposable gloves, though she stated sometimes these had been used inappropriately for personal care and this practice had been stopped. We spoke to a number of people during the inspection visit and considered responses to CSCI surveys returned to the Birmingham office. We also looked at questions and comments from the relatives meeting held at the home with the registered provider in October 2008. We concluded that there may have been times when the home appeared to be short staffed and we observed that staff did not always have the quality time needed for each person at the home. Staff told us that Care Homes for Older People Page 28 of 54 Evidence: there were sufficient disposable gloves available, which we also observed at this inspection. We were told that there had been a shortage of supply a few weeks previously but staff were unable to give any reason for the shortage. In relation to poor moving and handling techniques, we were satisfied with practices observed throughout this inspection visit but the poor care practice of one member of staff had been reported to the management of the home, with an inadequate response. Furthermore accident records showed an unusually high number of unexplained incidents of bruises and skin damage, such as skin tears. We reported that there had been no complaints or safeguarding referrals at the time of the random inspection on 8 July 2008. We asked to see the complaints log during this inspection visit. We were informed it could not be found but were told that there had been no complaints. There were some issues raised with the proprietor during a relatives meeting 9 October 2008. One person asked, why was my mothers given far too late. One of the organisations administrative managers and the acting manager said, that everywhere even hospital have staffing problems and we do our best to maintain staffing levels. If a member of staff does not turn up for a shift it does have a knock on effect to how the home is run. However our staff work very hard if they are short staffed and primarily look after the residents and leave other jobs until the next shift. It should only be on rare occasions when breakfasts are served late, as a general rule we like breakfast over by 10:30 am. However this is a nursing home and if someone is poorly our time goes out of the window. Another person at the same meeting stated, drinks are not being served in morning or at night. I have concerns about my mother not having enough fluid because she is bedbound. The homes management response was, We do understand your concerns regarding moms fluid intake and can assure you that processes are in place now to monitor fluid intake. Another relative commented that they visited twice each week and could vouch for drinks being served in the evening and that their relative always had a drink beside them. We noted that relatives had also been raised concerns in a recent review of the persons care conducted by Dudley Social Services about items going missing from the residents bedroom, though this appeared to have occurred earlier in the year. However there was no record of a response from the home and no indication of any action. The acting manager was unaware of the concerns raised. On a positive note we saw a number of cards and letters of thanks and compliments from relatives, displayed on the notice board in the reception area, complimenting the Care Homes for Older People Page 29 of 54 Evidence: staff and care at the home. At the previous key inspection in May 2008 we noted there were accident records, body maps and daily progress reports indicating bruises to a number of residents at various times. There was no consistency in how these were monitored, investigated or referred either as regulation 37 notifications. As previously reported there were no allegations or records of safeguarding concerns reported at the random monitoring visit on 8 July 2008. However, following Dudley Directorate of Adult, Community and Housing Services (DACHS) monitoring visit to the home over 3 days in November 2008, we were made aware of an incident, which the management of the home had not reported in compliance with Dudley Local Authority safeguarding procedures or notified to the CSCI in compliance with Regulation 37. Dudley DACHS commission and monitor services at the home. The report following the commissioning monitoring visit, concluded on 4 November 2008, stated, the audit revealed an incident recorded on the file of employee VC wherein VC was implicated in the causation of a physical injury to service user X by knowingly engaging in a moving and handling practice this Council considers neglectful. A subsequent referral in accordance with the safeguarding vulnerable adults procedures was not made and this constitutes a remedial breach of paragraph 6.5 of the General Service Specification of the contract held with this Council. Additionally a notification of this occurrence was not made to the Commission for Social Care Inspection in accordance with Regulation 37 of the Care Homes Regulations 2001. The commissioning manager and CSCI acknowledged that a retrospective Regulation 37 notification was submitted following the monitoring visit. However this was a breach of requirements issued at previous inspection visits and did not demonstrate that people at the home were protected from risks of harm. We discussed the incident with the acting manager and the chain of events was not entirely clear. Additionally records did not entirely clarify the management responses to information surrounding the incident. We requested to see all documentation relating to this incident. The accident record dated 27/10/08 at 07:50 completed by an agency nurse showed that she had been requested to check on a resident in the bedroom. The person had a 5cm torn skin flap, cause unknown and the nurse applied a dressing. The agency nurses entry in the residents daily progress report dated 27/10/08 stated, 07:50 called by care staff to have a look at X who had a skin tear on the left hand. On examination noticed a skin flap approximately 5 cm ? cause. Non adherent dressing applied to it and secured with a bandage. For close monitoring and skin flap to be reassessed for proper management. Relatives to be informed. Accident Care Homes for Older People Page 30 of 54 Evidence: form filled in. A later entry at 1500 hrs stated, inodine dressing applied to skin flap. Secured with bandage. Assisted with diet and fluids. 1700 hrs indicated relative informed of injury by phone. There was also a body map on file completed by a trained nurse employed by the home, which indicated a 5cm tear to the outer, medial aspect of the left forearm with considerable surrounding bruising highlighted. There were no photographs of this wound and no indication that a medical attention had been sought. At previous inspections in May and July 2008 we had expressed our concerns relating to complaints from trained nurses about the care practice regarding VC, which had not been investigated by the management of the home. We had made a retrospective safeguarding referral following the key inspection 20 and 21 May 2008. During this inspection visit we looked at the staff file for VC and saw limited supervision notes. There were two entries, one dated 20/6/08, spoke to V re incident with resident. Have given him guidance on ensuring residents privacy by closing doors. Curtains and ensuring mobile phone is not kept on person whilst on duty. Advised V to follow instructions of nurse in charge. If any problems to discuss with RGN on shift or come to discuss with management. Has not had any Common Induction Standards. Will arrange to get a copy for him and world review monthly. V. happy to undertake any training necessary to do job. Signed by previous acting manager. The second entry dated 30/6/08 stated, Common Induction Standards given. Discussed abuse V still has language barrier with understanding language at times. Was able to give me an example of abuse, carer shouts at resident. Is aware needs to develop his Englishlanguage to meet needs of service users. Signed by previous acting manager. There was also a file note dated 9 July 2008, this was the day following the CSCI random inspection visit. It stated, MC met with VC to formally discuss his work suitability for employment as a care assistant at Hillcroft in relation to CSCI concerns raised. V also told that he had to demonstrate that he could perform all aspects of his role and consequently V was instructed to enrol on an English language course to aid communication with service users and increase confidence with paperwork. V told that he and A. would be working on separate shifts as much as possible due to the nature of the relationship. V was told he needs to work more on his Common Induction Standards and that he could be mentored by senior carers, named. V agreed to all of the above. This was signed and dated 21/7/08. The home had obtained a statement from VC dated 29/10/08, which appeared to indicate that he was on night duty with an agency carer and an agency nurse. This did not demonstrate that the management were maintaining staffing levels to meet peoples needs. In the statement he alleges that at 11 p.m. he noticed that the other care assistant had fallen asleep, he further alleged that he tried to wake her during the Care Homes for Older People Page 31 of 54 Evidence: night to help with two hourly checks and tones but could not get a response. He alleged that the carer finally woke up at 05:00 am and did not answer any buzzers. The staff file also contained a record of a verbal warning dated the 31/10/08, which stated, spoke to VC today regarding matters brought my attention about a skin tear on Xs right wrist. Whilst it is not clear how the skin tear occurred, V has admitted that he turned X on his own. I have informed V that he must follow the correct manual handling procedures as part of his duty of care and have booked him for the manual handling course on 3rd November. I have told V any other incidents will result in dismissal. This verbal warning was signed by VC and the current acting manager, dated 31/10/08. There was a further letter dated 4th November 2008, following the Dudley Commissioning Managers monitoring visit informing the member of staff he was suspended pending further investigation. This was signed by the acting manager. There was a file note dated 04/11/08, relating to a conversation with Social Services to report to safeguarding issues surrounding the carer VC and a service user X at 6 a.m. on 27/10/08. The file note stated , The matter is currently being investigated. V admitted that he had turned X on his own despite knowing that this was not the correct procedure, resulting in the skin tear. He then informed the agency nurse on duty who then brought it to the attention of management later that morning. Since then V has received a verbal warning and has attended a manual handling course on 3rd November and is booked onto an adult protection course scheduled for 6th November. It is only today that the agency nurse on duty had voted contacted us and is sending us a written statement asap. This was signed by the acting manager. We noted that this was the action prompted by the Dudley DACHS Commissioning Manager during the monitoring visit. Handwritten letter from the agency RGN stated, re night duty worked on 26/10/2008, I would like to make a statement to confirm that I did not witness one of the staff members, care assistant, A. sleeping on duty. I saw her doing her normal duties. Between 6 and 7:30 a.m. on 27/10/08 A. came downstairs where I was attending to one of the residents to inform me about one of the residents upstairs who had a skin tear. There was a file note dated 06/11/08, which stated, V was today informed that his services are no longer required due to his poor conduct and the severity of his actions. He was informed that new information has come to light and that his conduct is not acceptable and that he is to come to the premises at any time in the future. This was Care Homes for Older People Page 32 of 54 Evidence: signed and dated 6/11/08 by the acting manager, and operational manager. There was a typewritten statement re VC headed 6/11/08, which stated, when on with V, he would not change the pads even if bowels had been opened. I went to go ahead a number of times and he would say, no leave it. Its the middle of the night. I didnt argue as I didnt want to make myself unpopular. I also felt intimidated by V. V was being aggressive and rough with the residents when changing their pads, washing and dressing. I shouted at him the once and he just said, what. Another time he ripped Ys vest when he was being rough. Then the worst incident of all, we were with X I was on the right-hand side of her bed against the wall putting on a clean sheet. V was still being rough with her, pulling her about, taking her nightie off. The skin tore on her arm. My stomach turned. I went downstairs to fetch the agency nurse. I dont know what V said to her as Z was shouting so I went to her. I told my family about the incident and said how I should report it but worried about how staff would treat me if I did. This was signed and dated by the care assistant 13/11/08. We noted that this was signed and dated seven days after the file note indicating that the alleged perpetrator had been dismissed. We could find no evidence of a formal investigatory meeting or disciplinary hearing and there was no letter of dismissal to this person, giving information about rights of an appeal. The verbal information given to us by the acting manager and later the proprietor did not entirely correspond with the records on file. We were initially told that the member for staff had been suspended pending an investigation and was then dismissed. We could find no record of the full information being shared with the local authority as the lead agency for safeguarding. The acting manager acknowledged that no referral had been made to the POVA registers, either as an interim safeguard or at the conclusion following the dismissal. She stated that the person had now left the country to return to Romania and therefore had not feel the need for referral to the POVA register. We discussed with her the possibility that this person may choose to return to the UK in the future to work as a carer. We instructed that the management of the home formally contact the POVA Manager, with full details of the incident and investigatory notes for a decision to be made asked whether this person should be placed on the POVA register as a safeguard for vulnerable people for future. We were also concerned that no safeguarding referrals had been made relating to a resident who was showing aggressive behaviour and was recorded as throwing water and orange juice over other vulnerable people living at the home. When we discussed the incidents of assaults on the safety of other vulnerable people with the acting manager she told us it had not occurred to her to consider these as safeguarding matters. We noted that although there was a risk assessment in place relating to this Care Homes for Older People Page 33 of 54 Evidence: persons occassional aggressive behaviour towards staff, there was no assessment of the risks of the changed behaviour towards other vulnerable people at the home, or the risks to herself. We also discussed our concerns about the use of Promazine medication to this person as a method of control without a robust protocol in place. We informed the acting manager and registered proprietor that we considered the omissions to be breaches of requirements for compliance with regulations to safeguard people issued at the previous inspection visits. We issued a PACE Code B Notice for evidence collected relating to the breaches and informed the registered proprietor that an internal CSCI management review would be undertaken to consider further action in relation to failures in the management of the home. A Statutory Regulation Notice was issued following the inspections 2007 and January 2008 instructing the home to improve its recruitment practices, with a compliance date of 29 February 2008. We found breaches of the Statutory Notice at the key inspection undertaken on 20 and 21 May 2008. We undertook a further random inspection on 8 July 2008 to monitor compliance with the Statutory Regulation Notices and we were able to report that recruitment practices had been improved. This meant that vulnerable people living in the home were better safeguarded from risks of harm. At the previous key inspection in May 2008 we reported very serious concerns about the lack of appropriate training relating the safeguarding of vulnerable adults. At the subsequent random monitoring visit on 8 July 2008 we were able to report that we found arrangements had been made for some staff to undertake Protection of Vulnerable adults training but noted that this did not include the management of challenging behaviour. We also noted that neither of these training needs were included on the homes training and development plan. At this inspection, whilst we noted that the topics were included in the staff training and development plan, only 6 of 22 care and ancillary staff had attended safeguarding training provided by Dudley DACHS since the last key inspection. The training records showed that none of the three trained nurses employed had received updated safeguarding or responding to challenging behaviour training. There was no record that one trained nurse, mainly working nights had received any training relating to safeguarding vulnerable people. This meant that people living at the home may not be properly protected from risks of harm by the nurses responsible for managing and running the home on a day to day basis. Care Homes for Older People Page 34 of 54 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the decor within this home is generally good with evidence of improvement through ongoing maintenance. The home generally presents as a safe, homely and comfortable environment for people living there. Evidence: We toured the environment with the registered proprietor. We found that the homes corridors required some attention as the decor looked tired and required some freshening up. This included the need for some redecoration to the walls and staircases with new carpets fitted. The registered proprietor acknowledged this and had now employed a handyman who was undertaking some work around the home at the time of our visit. The registered proprietor pointed out that the handyman had secured all wiring at the top of the ceilings in the corridors in the home and this is being boxed in to ensure that it blended in to the walls tidily. The home had a large lounge area that was divided into a dining area and felt very domesticated in style. Recently the lounge and dining area had been redecorated and an office area had been built in the lounge area which had large windows where management and staff could observe the lounge and dining area as they wished. However we were concerned to see that the nurses and staff did not have access to the office unless a member of management was at the home. We observed the nurses Care Homes for Older People Page 35 of 54 Evidence: giving information at shift handovers at the dining table, within the hearing of people living at the home. This breached rights to confidentiality, privacy and the Data Protection Act. The dining part of the lounge had tables and chairs arranged. Chairs had been arranged to promote social interaction as far as possible. We did not observe any planned activities being undertaken on the day of our visit but the lounge and dining area would be able to accommodate these. Part of the lounge which accommodated the television had lots of comfortable chairs and trays for people to put their personal items on as they wished. On the day we visited we observed people living in the home watching television, others were chatting between each other and visitors were seen in the afternoon. We observed that the television programmes that were being shown in the afternoon were specifically for children. Care should be taken to ascertain peoples preferences and provide age appropriate entertainment. People living in the home were seen to be moving around the home as they chose. The home had a lift, which people use to access the first floor area of the home. Bedrooms seen were personalised and reflected individual tastes, gender and cultural preferences. People were encouraged to bring in their own possessions in order to have familiar items around them to make their rooms as homely as possible. All bedrooms had hand washing sink, paper towels, liquid soap, and individually thermostatically controlled radiators. Two shared bedrooms had their own en-suite facilities. We found that some of the bedrooms had trailing wires from peoples beds, which posed health and safety hazards for people who live in the home together with staff members who would be at risk from tripping and sustaining injuries. It was concerning that we had to point this health and safety risk to the registered proprietor when we visited and it had not been observed prior to this. When we pointed this out to the registered proprietor we immediately asked the handyman to ensure that the wires are not trailing and later on in the day the registered proprietor showed that the wires in the bedrooms were no longer trailing. The Environmental Health Officer had undertaken a recent visit to the home to review the kitchen areas and awarded four stars to the home. This meant that the home should have good hygiene procedures in relation to food handling and this would minimise the risk of any cross contamination occurring. We spoke with the new cook about the type of meals that are prepared in the home for people with diabetes, some individuals required their food to be pureed, and there are people who were nil by mouth. The cook stated that she enjoyed cooking. We also looked at the food storage area of the home and found a good range of differing food supplies with brand names offered to people living in the home. Care Homes for Older People Page 36 of 54 Evidence: There were a number of assisted bathing facilities throughout the home, not all of which meet the needs of the people who live there. We were shown the ground floor shower room, which had concertina type doors and found that this room lacked the space that would be required if a person required assistance with showering. A member of staff confirmed to us that the bath water temperature was tested by the use of staff members elbow. We found no thermometer in the homes first floor bathroom and the registered proprietor stated that they would purchase a thermometer so that people can be reassured that they will not be at risk from scalding. Care Homes for Older People Page 37 of 54 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The numbers and skill mix of staff, do not always meet the needs of people living at the home. The home is heavily dependent on agency nurses, which means that people may not receive care to consistently meet all of their needs. The homes recruitment procedures generally provide better safeguards to protect people living at the home from risk of harm. Evidence: The home had received Statutory Regulation Notices following inspections in 2007 and January 2008, where serious failures relating to staff recruitment were identified, failing to provide adequate safeguards for people living at the home. At the key inspection on 20 and 21 May 2008 the management of the home had failed to demonstrate compliance with the Statutory Regulation Notices. Improvements to staff recruitment were subsequently found at the Random Inspection monitoring visit on 8 July 2008. We saw that the home had a new policy in place relating to the use of agency staff. The policy stated that agencies must provide a signed statement that they have 2 satisfactory references, PIN number, CRB and overseas police check where applicable. For Registered Nurses employed via agencies the home required a copy of the nurses PIN and date of birth, there was an instruction for the PIN number to be logged, the person in charge at the home must ensure a Care Homes for Older People Page 38 of 54 Evidence: photograph ID badge was worn, and an induction to be completed by the person in charge at the home, signed by the agency staff and a senior member of staff, with a record held on file. For care staff employed via agencies the home required a copy of the current CRB, a copy qualifications and training, and an induction to be completed by the home, signed by the agency staff and a senior member of staff, and photo ID must be worn. This policy was signed and dated 03/06/08. At the random inspection visit we examined the personnel files of 8 agency care workers and 3 RGNs, all of which contained required documentation. There were staff profiles, evidence of CRB clearances, confirmation of 2 references and evidence of training received. There were two files with no evidence of an induction. However we noted that it was positive that the acting manager produced a memo to RGNs at the home relating to the lack of an induction for 2 agency workers. She told us investigatory meetings were to be held in accordance with the disciplinary procedure. We also looked at personnel records for staff temporarily loaned from other homes owned by the registered proprietor. We noted that in main records had been put in place, though there were some omissions, such as only 1 reference for each person from the manager of their main place of work. The missing documentation did not by itself pose risks to people living at the home. At the random inspection visit we stressed to the registered proprietor and the acting manager the importance of maintaining staffing levels, which were sufficient to meet the residents needs and indicated that staffing levels must be increased with immediate effect to ensure residents health, safety and well being was not put at risk. We assessed the staff rotas, observed the daily routines and talked to residents, relatives and staff. We noted that there was one registered nurse together with four care staff that covered the early shifts, one registered nurse with three care staff that covered the afternoon shifts and one registered nurse with two care staff on duty throughout the night. We noted that a number of staff had left the home since the random inspection in July 2008. The home notably had staff vacancies for registered nurses and we were told that recruitment was taking place to fill these positions. The acting manager told us recruitment processes were almost complete for a new manager and 3 RGNs, with CRB disclosures awaited. From assessment of staff rotas and discussions we were told that the home used agency nurses to cover some of the nursing shifts, which could result in inconsistency for the people living at the home in respect of the care they receive in the chosen preferences. Care Homes for Older People Page 39 of 54 Evidence: We were given information that there were 16 people at the home with diverse needs and one person was in hospital. We saw evidence that the management had used 2 nursing agencies and a considerable number of staff to cover shortfalls. Copies of rotas generally did not demonstrate that consistent staffing levels were being maintained. We were told that same agency staff were used for consistency but from examination of accident records completed by Agency nurses we noted 7 different names from August to November 2008. There were also 10 named agency nurses on 4 weeks rotas in November to December 2008. In addition to the temporary acting manager the number of trained nurses had decreased to three RGNs, to cover 14 daytime shifts and 7 night shifts each week, a minimum 24 hours per day, totalling 168 hours per week. One RGN was absent on maternity leave, with no planned consistent cover arranged, even though the registered proprietor and management were aware of this planned leave of absence. Furthermore as there was no trained nurse planned to cover the late shift the day of the inspection 4 December 2008 yet another agency nurse, unknown to the management, staff or people living at the home, who had never been to the home before, was left in charge of the running of the home. We noted that the trained staff rotas for weeks commencing 16, 22 and 29 December were not covered at the date of this inspection 4 December, apart from a few shifts allocated to the two substantive trained nurses employed at the home. This did not demonstrate forward planning to ensure there were trained, experienced, competent nurses who knew, understood and could make sure the needs of people living at the home were being consistently met. We strongly recommended that the home put in place more robust contingency measures, such as agreeing a temporary employment of agency staff for a specified period, in order that all residents needs of can be met to consistently. In addition to care and nursing staff the home also employed kitchen, domestic, laundry, maintenance and administrative staff to provide for other aspects of peoples needs whilst living at the home. Over 50 per cent of staff have completed a National Vocational Qualification (NVQ) Level 2. This means that the home are meeting the recommended 50 of staff with this qualification and a further staff are enrolled onto a course and are working towards achieving this qualification. Some staff have achieved NVQ Level 3. This should ensure that a knowledgeable and skilled workforce can meet peoples needs individually and collectively. In the main staff were observed to interact well with the people living at the home and the atmosphere was calm, friendly and relaxed. We observed one member of staff Care Homes for Older People Page 40 of 54 Evidence: kneeling by a person who lived in the home interacting at some length about their day. Six staff files were reviewed and were found to contain all of the relevant information including two written references, POVA first checks (Protection Of Vulnerable Adults) and CRB checks. (Criminal Records Bureau). The organisation of files had improved and in the main information was easy to retrieve. Staff had been provided with job descriptions and there was evidence that people receive an induction into the home so that they are aware of their responsibilities. There were some gaps in the training matrix that we sampled does not reflect as to whether staff have received training in all areas, such as, COSHH (Control Of Substances Hazardous to Health), pressure area care (skin damage), care planning, bed rail safety, equality and diversity. Only one staff member indicated on matrix as having received training in the mental capacity act and the cook has not received any training in respect of infection control and/or taken part in fire drills but is scheduled to do infection control course on the 19 January 2009. However, training records indicated that some staff had received training in areas such as challenging behaviour, dementia awareness, fire safety, moving and handling, food hygiene, and infection control. Only 5 care staff, one ancillary staff and none of the trained nurses had received safeguarding training since the last inspection. Some staff have received training in more specialist areas, such as, palliative care (two staff in June 2008), death, dying and bereavement (two staff in March and May 2008), diabetes (one nurse in October 2008), and peg care, (One staff in 2006). Action should be taken to ensure that all staff have up to date knowledge in order to care for people living at the home and also need to develop in other areas, such as, diabetes as the home does have people with this medical condition living there. We found that a person living in the home did smell quite strongly of urine. We pointed this out of a member of staff who said that this person was incontinent and that is the reason for the smell. We highlighted respect and dignity issues, and the pad was checked once mentioned to staff member. Care Homes for Older People Page 41 of 54 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are no consistent management arrangements in place to demonstrate that the home is well managed and has effective leadership. People who live at the home cannot feel confident that their health, well being and safety can be assured. Evidence: There had not been a registered manager at Hillcroft Nursing Home since the dismissal of the previous person in July 2008. Serious managerial failings had been identified at the home since the Key Inspections in 2007. Statutory Regulations Notices were served on the registered provider and previous registered manager relating to the failures to have plans to maintain the health, well being and safety of people living at the home, with a timescale of compliance of 29 February 2008. Despite assurances from the provider that action had been taken to ensure full compliance with the Statutory Regulations Notices a full key inspection on 20 and 21 May 2008 and a further random inspection on 8 July 2008 identified continued failures to safeguard peoples heath and well being. Care Homes for Older People Page 42 of 54 Evidence: The acting manager, an experienced manager from another home owned by the registered proprietor, identified in the short term action plan, had not continued in the support role and had returned to her substantive home. We were told that the support initially provided by another experienced registered manager in the company had also ceased. The registered providers daughter, the operations manager, had informed us that the services of a care management consultancy had been engaged, but there was no involvement at this inspection and she later told us that this support had also ceased. We noted that the managerial arrangements for this home were being undertaken by another interim acting manager. This person was the deputy manager from another nursing home in Stafford, also owned by the registered proprietor. We were told that she had been in that post for four years and had previously worked at another home as assistant manager for two years. She informed us that she had completed the RMA (Registered Managers Award) two years ago. We established that the acting manager arrangement at Hillcroft Nursing Home was in place from the end of July 2008 until 05 January 2009. The acting manager would then be returning to her substantive post. We were informed that a newly recruited acting manager would be appointed from 05 January 2009 and the registered proprietor and current acting manager stated there would be a phased handover. From the assessment of staffing rotas we noted that the acting manager was now on rota for clinical shifts for some of the time, reducing the dedicated managerial time available for supporting staff, monitoring and improving outcomes for people living at the home. The acting manager told us she felt there were improvements to care plans, staff morale, staff training, staff supervision and recruitment of new staff. These included a new maintenance person, who had recommenced the redecoration programme, a new cook with revamped menus, and two new night care assistants. Staff spoken to told us that the acting manager was very approachable and supportive and they felt that there were improvements being made. We agreed that there were considerable improvements to the care plans, though there were areas where the written care assessments and care instructions were not being followed, posing risks to people living at the home. She told us that she planned to have a show room, and was waiting for delivery of furnishings. This would be to show any new people wishing to live at the home standard the home was aiming to achieve. She told us there were three registered nurses awaiting clearance to commence employment. Though we were provided with information later indicating that there was one RGN due to work full time and one RGN due to work one night duty each week. We discussed our concerns about the lack of stable staffing arrangements at the Care Homes for Older People Page 43 of 54 Evidence: home, especially relating to the number of trained nurses who were critical in continuity of good clinical and care practices to maintain and promote the health and well being of people living at the home. The number of registered nurses permanently employed and on rota at the home had fallen from five to three, with one nurse away on maternity leave. This meant that the home was heavily dependent on agency nursing staff. We noted the registered proprietors explanations that it was very difficult to recruit experienced, competent nurses, especially given the homes current poor quality rating and that they had tried to maintain some annuity by using the same agency nurses where possible. However this assertion was not supported with the evidence from records at the home. These included accident records from August 2008 to November 2008, which were signed by 7 different agency nurses and the trained staff rotas from November to the beginning of December 2008, which recorded the names of 10 different agency nurses, not including the agency nurse who had not been to the home before but required for the late shift on the day of this inspection visit. This posed the risk that people living at the home may not have their needs met consistently by trained, experienced, competent staff who knew them well. This was highlighted at the previous sections of this report, particularly in relation to lack of adherence to care plans, risk assessments and medication regimes. We also noted that the registered persons assessment of the dependency level of each person did not show a correlation with the Registered Nurse Care Contribution RNCC assessment for funding reimbursements nor for one person who had been assessed for additional funding from Social Services for Dementia care. We discussed the issue that this person had been referred for a reassessment for a potential move from the home. The acting manager confirmed that this person responded readily to diversions to manage potentially aggressive behaviour. There was conflicting information about the homes inability to meet this persons needs, especially as the home is registered to provide nursing care for up to 10 people diagnosed with dementia. We discussed our serious concerns, previously highlighted at the Complaints and Protection Section of this report relating to the management failure to report the injury to a person living at the home caused by night care assistant, as a safeguarding referral to Dudley DACHS and as a regulation 37 notification, until prompted to do so by the commissioning manager from the Local Authority during a monitoring visit in November 2008. The acting managers explanation was muddled and difficult to follow. After saying that the member of staff had been suspended and dismissed, she then indicated that although he had admitted to turning the resident on his own, he had not really understood what he was admitting to because his English was so poor, and he had been given a verbal warning. The acting manager had initially said that the member of staff had been dismissed but had not been referred to the POVA register because he had returned to Romania. We stressed that a referral should still be made because he may return to the UK and try to work as a carer again. From examination Care Homes for Older People Page 44 of 54 Evidence: of the records we informed the registered proprietor and the acting manager that the failure to make refer all allegations or suspicions of abuse was a breach of two previous requirements and records would be copied under the CSCI Statutory powers. During this inspection visit we also noted incidents of physical aggression from one person living at the home towards other vulnerable people at the home, which the acting manager acknowledged she had not thought to report in accordance with the multi agency safeguarding procedure or as notifications to the CSCI in compliance with Regulation 37. We required that the appropriate referrals be made retrospectively, which the acting manager agreed to do. We held lengthy discussions with the registered provider and acting manager about the safeguarding incidents relating to their challenge to the need to report either the incident relating to the member of staff or the incidents between vulnerable people living at the home. The failures to report and refer allegations, suspicions and incidents of potential abuse to other agencies did not demonstrate that the organisation understood their responsibilities to safeguard vulnerable people in their care from risks of harm. Additionally only very limited progress had been made to provide all staff with appropriate safeguarding training. We looked at the homes quality assurance system and noted that a nominated representative had made regular visits on behalf of the registered proprietor and provided the home with Regulation 26 reports about the conduct of the home. However there was insufficient evidence that clinical and care practices were monitored and evaluated effectively, as shown by the findings of this inspection visit, recorded in the health and personal care and complaints and protection sections of this report. An example was that the home had received an audit report from the pharmacy provider, BOOTS on 8 October 2008, which identified the following areas to be improved, the storage room for medication exceeded 25 degrees and an air conditioning unit was recommended, amendments to MAR sheets should be signed and witnessed, as directed instructions should be clarified with the prescriber and carried forward balances of medication stocks should be recorded on the MAR sheets. These actions were required to make sure people received their medication as prescribed, in safe and effective condition and that there was accurate audit trail of medication ordered, received, administered to each person. However the actions identified as part of the pharmacy provider audit had not been put in place at the time of this inspection visit, highlighted at the health and personal care section of this report. There was an annual development plan in place, however there were no timescales identified for some required actions. It was positive that the results of resident, relatives and stakeholder questionnaires had been collated and evaluated to identify the homes strengths and weaknesses. The registered proprietor told us that the home no longer holds small amounts of Care Homes for Older People Page 45 of 54 Evidence: residents monies for temporary safekeeping. This may raise issues of independence and access to money, which people may wish to spend as they wish. We were told that if residents wanted to use services from the hairdresser and private chiropodist money was paid from the home and the person or their representative was later invoiced for payment. We looked at a sample of the receipts for each transaction, whilst there were individual receipts from the private chiropodist, there were only communal lists receipts from the hairdresser. This did not demonstrate compliance with personal privacy and rights to view personal records or compliance with the Data Protection Act. At the previous Key Inspections the registered persons were made aware that following breaches of Regulation 37 notifications must be forwarded to the Commission of Social care and Inspection of any incident that has affected the health, safety or wellbeing of the service user at the care home, without delay. A warning letter of possible enforcement action was sent to the home in relation to the requirement following the Key Inspection 18/02/08. However there was evidence identified throughout the key report dated 20 and 21 May 2008 and at this inspection visit of failures to report incidents of unexplained bruising found in accident records, and body maps and allegations of abusive behaviour, which have not been reported. We looked at a sample of mandatory staff training records, fire safety and maintenance service records, which were generally satisfactory. We noted that there were some gaps in mandatory training, which need to be provided for all staff commensurate with their role. We looked at the accident records for the past 12 months. There were 31 recorded accidents relating to residents since the beginning of August 2008. We saw evidence that the acting manager had undertaken regular documented accident analysis but there was insufficient evidence to show that all unexplained injuries, especially bruises and skin tears had been thoroughly investigated. This meant that people living at the home may not be adequately safeguarded from risks of harm. An example may be incorrect moving and handling techniques from staff who may be unfamiliar with each persons needs, risk assessments and care instructions. Care Homes for Older People Page 46 of 54 Are there any outstanding requirements from the last inspection? Yes R No £ 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, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 18 13(4) The registered persons must 08/07/2008 ensure that action is taken to minimise and review all aspects of risk for each resident, with documented, up to date risk assessments and risk management strategies in place. This is to ensure that the health and welfare of people living in the service are safeguarded. Not Met at Random Inspection 08/07/08 2 27 12(1) The registered provider is 08/07/2008 required with immediate effect to ensure that there are at all times suitably qualified, competent and experienced persons working at the home in such numbers as are appropriate for the health and welfare of service users accommodated Care Homes for Older People Page 47 of 54 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 12 The registered persons must 30/01/2009 ensure that the all health care risk assessments and care plans include all of each persons assessed needs, and accurately reflect all changes to health and needs. This is to ensure care for residents health and well being is properly provided at all times. 2 9 13 Medication must be stored within the temperature range recommended by the manufacturer to ensure that medication does not loose potency or become contaminated. This is to ensure care for residents health and well being is properly provided at all times. 30/01/2009 3 9 13 Staff who administer 30/01/2009 medication must be competent and their practice Page 48 of 54 Care Homes for Older People must ensure that residents receive their medication safely and correctly. This is to ensure care for residents health and well being is properly provided at all times. 4 9 13 Appropriate information 30/01/2009 relating to medication must be kept, for example, in risk assessments and care plans to ensure that staff know how to use and monitor all medication including when required and as directed medication to ensure that all medication is administered safely, correctly and as intended by the prescriber to meet individual health needs. This is to ensure care for residents health and well being is properly provided at all times. 5 9 13 The records of the receipt, 30/01/2009 administration and disposal of all medicines for the people who use the service must be robust and accurate to demonstrate that all medication is administered as prescribed. This is to ensure care for residents health and well being is properly provided at all times. 6 18 13 The registered persons must 30/01/2009 ensure that ALL allegations or suspicions of abuse are Care Homes for Older People Page 49 of 54 referred to the designated person in accordance at the Lead Agency in accordance with the multi agency Safeguard and Protect Procedure without delay. The previous timescale was not met on 4/12/08 This is to prevent people living at the home being harmed or suffering abuse or being placed at risk of harm or abuse. 7 18 13 There must be suitable and 30/01/2009 appropriate arrangements in place that includes staff training to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Previous timescales of the 31/12/07 and 30/01/08 and 31/03/08 not met. This is to prevent people living at the home being harmed or suffering abuse or being placed at risk of harm or abuse. 8 27 12 The registered persons are 12/01/2009 required to undertake a documented assessment of residents dependency levels, and submit this assessment with a staffing proposal and a copy of 4 weeks staffing rotas for consideration by the CSCI. The registered persons are Care Homes for Older People Page 50 of 54 also required to include a documented analysis of the impact of ancillary duties undertaken by care staff so that all residents needs can be met. This is to ensure that all residents needs are met and their health and safety is assured. 9 31 9 The registered persons must 01/02/2009 submit an application to the CSCI Regional Registration Team Birmingham to register a manager for Hillcroft Nursing Home as a priority. This is so that the home is managed to assure the health, well being and safety of people living at the home. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 8 It was strongly recommended that advice from Diabetic specialist nursing service be sought for any person with diabetes, living at the home, with records of screening, support and advice offered and that a record be maintained of staff training in relation to diabetes. That advice from community dieticians be sought for all residents assessed to be nutritionally at risk, with records of support and advice offered and that a record be maintained of staff training in relation to nutrition. There should be a record of peoples preferred leisure activities and their choice of daily life and routines such as getting up and going to bed. This is a previous good practice recommendation and was not met on 20 May 08 or 4 December 2008. Page 51 of 54 2 8 3 12 Care Homes for Older People There is a review of those residents care who spend all their time in bed with only very minimal stimulation and a socialisation plan be introduced. This is a previous good practice recommendation and was not fully met on 20 May and 8 July 08 or 4 December 2008. That a regular documented audit of residents preferred activities be undertaken from which a structured weekly programme be devised and displayed in appropriate formats to encourage participation and individual weekly activity planners be introduced for each person to record planned and spontaneous activities, refusals and evaluation of activities offered, ensuring records accurately reflect participation, or none. Not met at inspection on 4 December 2008. That action be taken to ensure each persons individual spiritual needs are met, according to their wishes. Not met at inspection on 4 December 2008. 4 14 That action is taken to involve appropriate advocacy for decision making for residents lacking capacity, in relation to The Mental Capacity Act 2005. Not met at inspection on 4 December 2008. That each residents property inventory be fully completed on admission with clothing, furniture, valuables, hearing aids etc and thereafter kept up to date signed and dated by staff, resident and or relative. Not met at inspection on 4 December 2008. There should be appropriate organisation of meal time sufficient numbers of staff available at all meal times to ensure minimal disruption when residents are being assisted with feeding to ensure an enjoyable experience and adequate food and fluid are taken. This is a previous good practice recommendation and was not met on 8 July 08 or 4 December 2008. Staff should be made aware of the homes abuse policies and Dudley Councils Adult Protection procedures. It is advised that staff sign and date when they have read these documents. That behaviour care plans be expanded with fuller information to guide staff to understand behaviour triggers for individual residents and how to manage behaviour that challenges, such as agitation, wandering etc. This is a previous good practice recommendation and was not met on 20 May and 8 July 08 and 04 December 08. Consideration should be given to improving the decoration of the WCs shower and bathrooms to promote a more Page 52 of 54 5 14 6 15 7 18 8 18 9 21 Care Homes for Older People homely feel. This was a previous good practice recommendation not met on 4/10/08 10 25 That water thermometers be provided in the bathing facilities so that people can be reassured that they will not be at risk from scalding. That a separate hand-washing sink for staff be installed in the laundry to prevent the spread of infection. This was a previous good practice recommendation not met on 4/10/08 That advise should be sought for storing products in the sluice room from the Health Protection Agency to ensure good infection control practices are maintained. This was a previous good practice recommendation not met on 4/10/08 12 27 It was strongly recommended that the home put in place more robust contingency measures, such as agreeing a temporary employment of agency staff for a specified period, in order that all residents needs of can be met to consistently. That all staff receive training relating to the Mental Capacity Act and have an awareness of its implications for all aspects of their work. This is a previous good practice recommendation and was not fully met. A thorough training needs assessment should be undertaken with a consequent training plan and an up to date training programme. This is a previous good practice recommendation and was not fully met The registered persons should ensure that the quality assurance system in place is effective and includes quality monitoring systems to meet all elements detailed in standard 33, and especially focuses on outcomes for people living at the home to assure their health, well being and safety. That individual receipts be obtained for all financial transactions conducted on behalf of residents. The registered persons must make sure that risk assessments for the use of wheelchairs without footplates for individual people living at the home have been reviewed, with account taken of The Mental Capacity Act for persons who lack capacity. It is strongly recommended that wheelchairs have a regular, at least annual documented service and more regular recorded visual checks. 11 26 13 30 14 30 15 33 16 17 35 38 Care Homes for Older People Page 53 of 54 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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