Inspection on 28/08/08 for Kings Court Care Centre

This inspection was carried out on 28th August 2008.

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

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

Other inspections for this house

Kings Court Care Centre 29/11/06

Kings Court Care Centre 05/12/05

Kings Court Care Centre 19/05/05

Kings Court Care Centre 02/11/04

Kings Court Care Centre 11/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 19/12/2008.

CARE HOMES FOR OLDER PEOPLE Kings Court Care Centre Kent Road Swindon Wiltshire SN1 3NP Lead Inspector Susie Stratton Unannounced Inspection 28th August 2008 9:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kings Court Care Centre Address Kent Road Swindon Wiltshire SN1 3NP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01793 715480 01793 715490 kingscourt@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd Mrs Helen Marshall Care Home 60 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) The maximum number of service users who can be accommodated is 60 29th November 2006 2. Date of last inspection Brief Description of the Service: Kings Court Care Centre is situated in the Old Town area of Swindon close to the town centre, local shops, churches and local bus routes. The centre comprises of a two-storey purpose built nursing home with general nursing and dementia nursing units on separate floors. All rooms are single and have en suite facilities. The garden has been landscaped and provides a pleasant and attractive environment for service users to enjoy. The home is part of the Southern Cross group and the registered manager is Mrs Helen Marshall. There are registered nurses on duty at all times in both units, supported by care assistants. Ancillary support includes activity, catering, domestic, maintenance and administration services. The current range of fees is £469.44 to £750 per week. A service users’ guide is available in each resident’s room and in the front entrance hall. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection, which included visits to the service and takes into account the views and experiences of people using the service. As part of the inspection, 30 questionnaires were sent out to residents and their relatives and one was returned. Comments made by the person in the questionnaire, in questionnaires for the Annual Service Review which was carried out in March 2008, and observations made on site visits have been included when drawing up the report. As part of this inspection, the home’s service file was reviewed and information provided since the previous inspection was considered. A random inspection was performed on 10th October 2007, this was in response to a complaint. At that inspection, one requirement and two good practice recommendations were made. We also received an Annual Quality Assurance Assessment from the home. This was their own assessment of how they are performing. It also gave us information about what has happened during the last year. We looked at the quality assurance assessment and the information on home’s file. This helped us to decide what we should focus on during the visit to the home. As Kings Court is a larger registration, site visits took place over two days, the second site visit was performed by two inspectors. The first site visit took place on Thursday 28th August 2008, between 9:50am and 4:55pm and the second site visit took place on Thursday 4th September 2008 between 9:15am and 5:45pm. Mrs Marshall, the registered manager was on duty for both the site visits. We performed a summary of findings to her at the end of the inspection. During the site visits, we met with four residents, five visitors and observed care for 16 residents for whom communication was difficult. We observed care provision across the home, including staff interaction with residents in the four sitting rooms and two dining rooms. We also performed a short observation on five residents, using our established procedures. We reviewed care provision and documentation in detail for eight residents, one of whom had been admitted recently and considered specific matters for a further five residents. As well as meeting with residents, we met with the manager and her deputy, five registered nurses, five carers, one of whom was on their induction, the chef, the maintenance man, the administrator, the activities coordinator, a cleaner and both laundry people. We toured all the building and observed practice, including lunch-time meals and activities sessions. We observed Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 6 systems for storage of medicines and observed five medicines administration rounds. A range of records were reviewed, including the complaints log, accident records, staff training records, staff employment records and maintenance records. What the service does well: What has improved since the last inspection? What they could do better: Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 7 At this inspection, 24 requirements and 20 good practice recommendations were made. Some of the information in the service users guide should be up-dated to provide more specific information on the services offered by the home, to fully inform prospective residents and their supporters. Full and accurate care plans must always be put in place when a resident has a nursing or care need, to direct staff on actions needed to meet the resident’s needs. Care plans must always be up-dated when a resident’s need changes to provide information on residents’ current nursing and care needs. Care must always be provided in accordance with the resident’s care plan, or if it is not possible for any reason, this must be documented. Full records of the care provided must be in place, these must be completed when care is given or to ensure that they are accurate and fully inform of residents’ conditions. Only Controlled Drugs may be stored in Controlled Drugs cupboards, this is to restrict access to such drugs. Where residents need homely medicines via an invasive route, there must be a treatment plan to advise registered nurses on their use. To prevent vulnerable people from having access to medicines, the medicines trolley must always be secured when it is not under direct observation. Registered nurses must always sign the medicines administration record at the time drugs are given, to ensure that the record accurately reflects medicines administered to residents. In order to prevent risk of medication error, the registered nurse must be able to concentrate on performing the medicines round and not be distracted by performing other roles. Care plans relating to drugs which can affect daily lives, such as aperients, painkillers or mood-altering drugs, need to be further developed to assist professionals in assessing their effectiveness. All staff must ensure that they respect residents’ privacy and dignity at all times, including calling them by their own names, explaining what they are going to do before starting to provide care and ensuring that they are well presented as much as possible, including clean fingernails and brushed hair. The home needs to consider how it meets residents’ diverse social and cultural needs and develop records to support this. The home must ensure that residents who are unable to self-advocate are protected from risk of abuse and must inform relevant bodies of any suspicions of abuse in a prompt manner, in accordance with local procedures. All concerns reported to staff should be documented, to inform the home’s managers. All areas of the home must be clean and well-maintained, particularly the lower ground floor. All equipment and furnishings must be suitable for purpose and not present a risk to residents. Support kitchens must be maintained at acceptable standards of hygiene. The laundry must be clean and effective Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 8 systems, which conform to principals of preventions of risk of spread of infection, must be in place. The home needs to perform a formal written review of staffing levels, to ensure that it has the correct numbers and skill mix of staff to meet residents’ needs. Dementia care training needs to be further developed to equip staff to effectively manage residents with this complex care need. There must be written evidence to show that staff are fully supported and supervised in their role. All items handed in for safekeeping must be documented and an audit trail be developed to ensure that residents’ possessions are protected. Systems need to be developed for the naming of residents’ clothes, to prevent their loss in the laundry. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3. The home does not admit for intermediate care, so 6 is N/A Quality in this outcome area is good. This judgement has been made using available evidence, including visits to this service. Prospective residents will be supported by the home’s admission process, however developments are needed in the information provided to prospective residents and their supporters, particularly including contractual information. EVIDENCE: The home has a statement of purpose and service users’ guide, to inform people about the services provided. The statement of purpose is well presented and easy to read. The service users’ guide is very detailed and includes a range of areas that will be of interest to prospective residents and their supporters, including details of the hairdressing service, chiropody, optical services and other areas of interest, such as visits to the home from a firm supplying clothing for older people. The guide also includes information from the GP service who are contracted by the home to provide a service. Staff confirmed that, as stated in the guide, residents can choose their own GP if Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 11 they wish but that in practice all people in the home are generally looked after by this GP. The guide needs some development in certain areas, to fully inform people. For example it states that residents get a choice of meals, which they do if they are able to eat normally but, as staff informed us, they do not, if they need a liquidised meal. Staff informed us that on the dementia care unit that residents’ rooms were now locked during the day, to protect residents’ property and ensure safety of all residents. This policy is not included in the guide. The policy on restraints is included, but the use of aids such as cocoons is not. The systems for management of moneys is detailed but not the system for items handed in for safekeeping and this is indicated as we observed that for several items of value had been handed in for safekeeping. The guide states the numbers of staff but does not detail the number of staff on duty per shift in different areas of the home, to fully inform people. Whilst information is included on terminal care and dementia care, there is no detail in the guide on staff skills, equipment or facilities to meet peoples’ needs in these areas. The guide does include the policy on emergency admissions, however it could benefit from more detail on how the home is meets the needs of people who need urgent or respite care in the context of their other care provision. The guide also includes a survey of residents and their supporters as to their satisfaction with the service but it relates to the previous owner and was completed in 2006. As it is understood that a more recent survey has been completed by the new providers, it would be advisable for this to be included in the guide. We looked at the service user contract. The contract that “the element of nursing care paid directly to the Proprietor by the Health Authoirity agency will; be retained by the Proprietor and fees referred to in this agreement exclude the fees”. The contract also states that the service user/representative is responsible for naming of clothes. We met with two people who had been recently admitted and one person who had been admitted for respite care. None of the residents were able to discuss their experience of admission with us. However we were able to discuss the process with one relative who reported that “we came and looked” at the home and had reviewed information about the home on the internet, comparing it with others in the area. They reported that the home had “answered all my questions” and that “since [my relative] has been in I’ve been very happy, the care is absolutely excellent”. Staff commented that they were fully informed by the manager or person in charge at the time, of the details of nursing and care need for residents who were being admitted, so that they could prepare to meet the person’s needs. They reported that this was both verbally and in writing. One member of staff commented on the “brilliant” communication in this respect. We looked at the records of people recently admitted and the person admitted for respite care and they were completed in detail and Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 12 reflected what we observed and staff told us. One person also had a very detailed assessment from their previous care provider. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence, including visits to this service. Poor record-keeping and systems for management of health and personal care mean that not all residents have their needs met or are treated at all times with respect and dignity. EVIDENCE: Kings Court provides nursing and care to people with a range of nursing and care needs relating to both general and dementia care needs. Generally people who are largely physically frail but who may also have additional mental health needs are cared for on the ground floor and people who have prime needs for dementia care but may also have general nursing care needs are cared for in two units on the first floor. There is one larger unit and one smaller, quieter unit on the first floor. We looked at the nursing and care of several residents across all the areas of the home. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 14 We found that nearly all residents had clear and detailed care plans relating to their nursing and care needs. For example one resident had a very clear care plan about their dietary needs, which detailed their likes and dislikes. Another resident who experienced continence difficulties had a clear care plan relating to their needs, which included the continence aids to be used, which were consistent with the aids observed in their en-suite facility. All residents considered in detail had clear care plans about their manual handling needs. Where a resident was not able to use a call bell, there were plans in place to direct staff on how their safety was to be ensured. Staff spoken with knew the needs of their residents. For example one member of staff was able to explain why one resident went to bed during the afternoons, another member of staff was aware of the progress of one resident’s skin where they were vulnerable to pressure damage and another member of staff about how a respite care resident responded to their regular admissions. One member of staff reported on how they were regularly informed of residents’ conditions by having two hand-overs a day. A registered nurse commented on the quality of the report from the night staff. Only one person responded to the questionnaire and they reported that the staff “are so very caring and affectionate on the whole”. One resident reported on how helpful the staff were to them. One relative spoken with was highly complimentary about the care provided reporting, “they DO see to [my relative]”. We observed a range of care practice throughout the inspection. One carer was observed during our short observation to take time to slowly and gradually support a resident in getting up from their chair, when they used a hoist. Another carer was observed to promptly report to the nurse in charge when a person refused to eat their meal. One registered nurse was observed to be very kindly and supportive to a resident when they dropped their tablet by mistake. The home uses a standard pressure damage risk assessment, as directed by the providers. The tool used appears to be too imprecise to identify residents at risk of pressure damage. One person sustained pressure damage in June 2008, but their pressure damage risk assessment stated they were was at that time low risk of pressure damage. Their assessment remained so at the site visits. Two other residents who had sustained pressure damage were also assessed using the tool, as being low risk of pressure damage. The risk assessments had been correctly completed. This was discussed with staff, who were clearly using other informal measures, including observation, to actually assess if a person was at risk of pressure damage. Without a tool which functions in practice, people at risk may be missed and relevant actions not be taken in a timely manner to reduce risk of pressure damage to residents. For example one resident who was reported by staff to have sustained minor pressure damage and another resident who was assessed as being at medium risk of pressure damage, did not have care plans to direct staff on how this damage or risk was to be reduced and did not have standard interventions in Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 15 place such as a turn chart, to ensure that the persons’ position were changed regularly, as they could not do this themselves. In other areas, some people did not have care plans where they would have been indicated. A resident had skin applications in their en-suite, which gave all the appearance of being used, but no directions on when and how often they were to be used. One person’s records included very clear directions from the dietician which had not been included in their care plan. Other care plans could benefit from more precision. Some care plans use terms, which are not measurable like “regularly” or “often”. One resident who was an insulin dependant diabetic had a clear care plan about most of the management of their diabetic condition but whilst it documented in measurable terms what blood sugar levels would be considered to be indicative of hypoglycaemia, it did not do this for hyperglycaemia and this is indicated, so that staff can be advised of when to take actions to meet this particular resident’s needs. Several people were provided with pressure relieving aids but there were not always documented in their records. Residents with mental health needs did have care plans about these needs. One resident had a clear care plan about their behaviours in relation to removing their clothing and how these needs were to be met. Some care plans were generalistic in tone stating, for example that the person had “aggressive” or “restless” behaviours but did not state the type of aggression, whether verbal or physical aggression or when it happened, for example during the evening, when they needed the toilet or when approached by certain people. This is needed, to assist in analysis and evaluation of different approaches towards such complex behaviours. Staff spoken with reported on a range of approaches to support residents with complex behaviours. A registered nurse reported that one resident with dementia responded well to the atmosphere of the snoozelum room. Another registered nurse reported that a resident with restless behaviours responded well to being assisted to bed for a rest during the afternoon. Those staff spoken with reported that where residents showed aggression towards each other, that they diverted residents away from each other. During our short observation we observed one resident being verbally aggressive towards another resident, including pulling at the resident’s clothing at times. Staff in the area were busy at the time, so this behaviour was observed to continue for half an hour before the resident stopped their behaviours. Care plans are evaluated on a monthly basis. However not all care plans are up-dated when a resident’s condition changes. One resident’s care plan stated that they were up in a chair during the day, however they were observed to be cared for in their bed throughout the first site visit. The registered nurse knew why this was, but their care plan and pressure damage risk assessment had not been reviewed at the time their care needs changed. Another resident had Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 16 a care plan relating to the importance of ensuring that their nails were clean. One of the person’s hands were clean but the fingernails on the person’s other hand was not. This could have related to the person’s complex behaviours but there was no evidence that this had been reviewed or considered, to ensure that the care plan could be met. One resident whose care plan stated that they needed their drinks thickening because of swallowing difficulties to a syrup consistency had their drinks thickened to a jelly consistency. These was no record to indicate if this was because their swallowing difficulties had deteriorated further. The home uses monitoring charts to ensure that residents’ needs are met. A range of concerns were presented by these charts. Some people who were cared for mainly in bed or chair and were unable to move their positions independently did not have charts to show that their positions were changed at the regularity indicated by their condition. Some people had directions in their care plan about how their needs were to be met. For example one person’s care plan stated that they were to be checked on hourly as they could not use their call bell and were cared for using a cocoon, however there were no records that this was taking place, apart from some notes in their daily records stating that this had taken place. If a person is assessed as needing such checks, there must be records to show that this has taken place. Another person’s care plan stated that they must be moved two to three hourly but their turn chart only showed changes of position at night and not on a two to three hourly basis. As a person’s risk of pressure damage does not decrease when they are sitting out of bed, they still need to be assisted to change their position, to prevent pressure damage. Turn charts were also not completed at the time that care was provided. For example one resident whose charts were reviewed at 13:30 had no records that their position had been moved since 8:50 however when their chart was inspected at 15:10, it stated that they had been turned at 11:00 & 12:15. It also stated that they had been placed on their back at 12:15 but when they were visited at 13:30 they were on their right side. Another resident who was regularly observed between 12:45 and 16:45, was observed to be on their left side throughout each observation until 15:30, with no turn chart in place. At 16:45 the person had a turn chart in place, indicating that they had been turned regularly through the day. Residents who needed assistance had food and fluid monitoring charts in place. As with turn charts, these records were observed not to be completed at the time care was given. Throughout both days of the inspection, it appeared that for nearly all people, records were not completed when care was given. On the first day of the inspection, a resident’s food chart indicated that they had not been given anything to eat since lunch the day before and there were no records of their being given breakfast or lunch on the day of the inspection. However at 16:35, all parts of their form had been completed. At 13:30, one resident’s chart indicated that they had not taken in any fluids from 8:30 but by 15:30, their chart indicated that they had been given drinks at 11:00, 12:30 and 13:00. If records are not completed contemporaneously, they will Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 17 not be accurate and not inform relevant people about the actual situation for the resident. Nearly all charts reviewed indicated that the resident had eaten all their meal and drunk 200mls of liquid. This is unusual, as many frail elderly people will have difficulty in consistently always taking in a full drink or may not eat all their meal, for example if they do not fancy part of it. One resident’s records which had been completed retrospectively, stated that they had drunk 100mls of a drink when their cup showed that they had only drunk about a quarter of the drink. Another resident had two drinks left by them, the levels of which were observed not to change between 9:30 and 15:30. As noted in the section on Choice above, the home has a contract with a local GP service, who provides medical care to residents. All staff spoken with reported on the good working relationship with the GP, how the GP visited the home regularly and would also visit when requested. Staff also reported that they had close working relationships with a range of other professionals, including the speech and language therapist, dietician and tissue viability nurse. The tissue viability nurse reported to us on how prompt the home were in calling them in if their advice was required, to ensure that the resident’s condition was promptly treated. During the inspection, we observed four medicines administration rounds, reviewed medicines records and storage systems for medicines. All medicines were securely stored, in a safe manner. Controlled drugs were checked and found to be correct. The Controlled Drugs cupboard on the ground floor is nearly too small for the number of drugs needed to be stored there and if any further residents were prescribed such drugs, the home would have a problem in safe storage of such drugs. In both Controlled Drugs cupboards, items other than Controlled Drugs, such as money, a watch, two yellow metal earrings, a hearing aid were being stored in the cupboard. This is contrary to the Medicines Act, which states that only Controlled Drugs are to be stored in a Controlled Drugs cupboard. This is to reduce the amount of access to Controlled Drugs. Full records of Controlled Drugs, drugs brought into the home and disposed of from the home were maintained. Where medicines administration records needed to be changed by hand, this was always signed and counter signed. Where drugs are dropped, refused or “found”, there were clear systems for documentation and management of the drugs. All medicines administration records were fully completed. One potential error in the administration of a medicine which needed to be given fortnightly was observed during the inspection. This was promptly rectified. Were a person needed to be given a drug by regularly injection, there were clear records of site rotation, to prevent tissue damage. Where a person wished to self-medicate, a risk assessment was completed. This was regularly reviewed. One person was being administered their medicines in a covert way. There was a clear care plan, which was regularly reviewed and consents obtained from relevant parties about this. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 18 The home has a homely medicines policy, which is regularly reviewed by their GP. The policy includes some invasive preparations for management of constipation, which are not usually observed in such policies. If such preparations are needed, our pharmacist inspector states that residents’ need to have treatment plan for using these medications, which would include/exclude any residents for whom it is not appropriate and other methods to be used first. Several residents are prescribed drugs which may affect their daily lives, such as mood altering drugs, painkillers or aperients. Some people had care plans referring to these in a generalistic way but others made no reference to them. Where residents are prescribed such drugs, it is advisable that care plans detail the drugs and their affect for the resident, so that they can be evaluated regularly and relevant persons informed. The home has four medicines administration trolleys, one for each area of the home. All medicines are administered by registered nurses. Registered nurses were observed to be variable in their attention to security of the medicines trolley. On two medicines rounds the registered nurses were observed to leave the medicines trolley open for periods whilst they gave medicines to residents. For two other medication rounds, the registered nurse locked the trolley but left the key in the lock. Both practices are of risk as residents with complex behaviours, including dementia, could be at risk if they were able to access a medicines trolley. Some of the registered nurses read the medicines administration records, to inform them of what the resident was prescribed, others worked only from the monitored dosage containers. None of the four registered nurses were observed to initial the medicines administration record when the resident had taken their drug. This is contrary to the home’s procedure and nursing and midwifery guidelines. If medicines administration records are completed before or after a medicines round, they will not be an accurate record that the resident has taken their prescribed medication. Registered nurses were observed not to be able to concentrate on the administration round and be engaged in other duties, particularly supervising carers or residents as well as giving out medications. For example one resident asked for a second dessert and the registered nurse became involved in making sure that they were given one. Other registered nurses had to ensure that residents had drinks by them, so that the resident could swallow their tablets. We observed how staff in the home met residents’ needs for privacy and dignity throughout the two days of the inspection and we observed a wide variance in approach by staff. Staff were observed to consistently knock on residents’ doors prior to entering their rooms. Two members of staff were observed to assist a resident to the toilet. One member of staff had to leave the toilet to obtain something for the resident and on their return was observed to carefully knock on the toilet door and to await a reply, prior to going back into the toilet. There was a wide variety in approach towards using residents’ own or preferred names. Some staff consistently always called Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 19 people by their names, other called residents by generic terms of endearment such as “darling”, “sweetie” or “love”. In a care home were most people have dementia, this is not appropriate as it further confuses residents and they will not be sure of whom is being addressed. Some staff worked hard to ensure that residents were involved when caring for them. One carer was observed during our short observation to come into the room and address several residents as well as the one they were coming to assist. Another carer was observed to come into the dining room to see if residents needed assistance, with clear eye contact with a range of residents and being supportive to a resident who needed help. However, this was not mirrored by all staff. One carer approached us and said “can I take this one now?”, without addressing the resident or using their name. Another carer was observed to push a resident to a sitting area in a wheelchair and whilst they were leaning over the resident putting the wheelchair’s breaks on, to say to another carer “I’ll put this one over here for the time.” There was also a variability in approach to residents. One registered nurse was observed to very slowly and gently wake someone up and give them time to wake up, before they administered the person their prescribed medication. A carer was observed to approach a resident who had fallen asleep after lunch whose head was resting on the table with their arm down the side of the chair and move their arm and lift their head, without attempting to awaken the person and warn them of what they were going to do first. Another carer was observed to go up to a resident who was lying asleep in a recliner chair with their legs crossed, to uncross the person’s legs and then move the chair, without waking the person first or explain what they were doing. We observed how residents’ personal care needs were met. Some residents had well brushed hair, clean finger nails, mouths and noses. One member of staff was observed to quietly and without fuss remove a used continence pad from a chair where a resident had placed it, so that other people were not aware of the resident’s actions. However several residents were observed not to have clean fingernails or brushed hair and whilst it is appreciated in a care home where people have dementia, that people may refuse such actions to be provided, records should be maintained of this, and this was not the case for two people considered in detail. One very frail person who was not able to move or assist themselves, had an unclean nose. One person who had behaviours associated with their use of a commode, which staff knew about, did not have this documented in their records. In the absence of documentation, external people such as visitors, social workers, healthcare professionals or us will not know if in such cases staff have omitted care, or not been able to provide care due to the resident’s current condition. On the first day of the site visit, there were two rails with a large number of un-named residents’ clothes displayed in the corridors, with notes asking relatives to look at them and identify any which belonged to their relative. There were also quantities of un-named clothes, including socks, tights and Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 20 stockings in the laundry. This was discussed with both laundry staff who reported that they always appeared to have a large number of un-named clothes. Mrs Marshall reported that this was an ongoing issue and that she had thrown away un-claimed clothes a few months ago. She also informed us of the steps, such as those described above, to identify the owners of clothes. It was discussed by us that frail, elderly people may not have relatives who are able to name clothes themselves and that the home needs to develop a policy and procedure to ensure that residents’ clothes are marked on admission or other steps taken, for example, some homes use marked, washable bags which are kept in residents’ rooms where their personal clothing can be placed and the clothing can then be laundered in the bag. Further steps need to be taken by management in this area to ensure that residents’ own clothes are returned to them and reduce any risk of communal use of clothing. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 21 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. Lack of written evidence suggests that people’s choices, preferred daily routines and preferences may not be respected by staff at all times. Menus provide a nutritional balanced diet for residents and residents are usually supported at mealtimes. EVIDENCE: There were several colourful displays of arts and crafts around the home which residents had made. We saw some group sessions taking place, including music and movement and relaxation. Residents were seen walking freely in and out of the arts and crafts room, talking to the coordinator and waiting for next session to start. The arts room had various materials for arts and crafts, we were told that the coordinator did not have an allocated budget but she could buy whatever she needed. Previous inspections had identified that activities could be improved by increasing the staff hours available to support recreation. We met with the full time activities co-ordinator who had been at the home for two years. We were Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 22 told of various social events that had taken place and that she was trying to coordinate more short outdoor trips. However the amount of events and trips largely depends on volunteers from staff and families in order for this to be achieved. There are many residents in the home who have diverse, complex mental, physical and social care needs. It remains evident that the staff resources available were not enough to ensure that residents, social, emotional, cultural and psychological wellbeing are being met. This was also evidenced in individual care files, where plans were not in place to identify these needs and how they were going to be met. We were told that attempts are made to meet with residents and relatives to develop social profiles in order to gain an insight to lifestyles before coming in to the home and to determine likes and dislikes, hobbies and personal preferences. The content of the social profiles was sparse in some cases, particularly where residents were unable to give this information due to the progression of their dementia and where relatives input had not been forthcoming. One person considered in detail did have a clear care plan about their family supports and social care needs. Another of the people who was considered in detail was under 65. Their care plans did not reflect the fact that they were a comparatively younger person and any needs they may have had in relation to this. Whilst residents’ religion was documented, none of the records considered in detail noted if practice of religion was an important factor or not in the person’s life. We asked about one resident who was from an ethnic minority, whose first language was not English and who stayed in their room all day. We asked how the resident was stimulated and were told that music and story tapes were put on in the resident’s room. We asked if the resident understood the English music and story tapes but they said they did not know. We were told that the resident’s relatives visited. Residents have a record of activities that they participate in, however this is similar to a tick chart and does not indicate whether the activity was enjoyed or beneficial to the resident. The coordinator told us that she asks the residents if they enjoyed the session but there was no written evidence to support this. Visitors were observed to be able to come into the home when they wished. The visitors that we met with reported that they were made welcome by staff. Most people we spoke to felt that they were contacted by staff when needed, for example if a resident’s condition changed, however one relative did not feel they had been contacted about an emergency situation. A resident’s records also showed that they had been taken unwell very early in the morning but that the next of kin had not been contacted until after lunch, with no explanation as to why this was in their record. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 23 Many of the residents were not able to converse with the inspector, so we relied on discussions with staff to identify how residents exercised choice. One carer reported that residents tended to gradually go to bed after the evening meal, as they wished, but that night staff did not request that all or certain residents be in bed by the time they came on duty. They also reported that some residents would be up and dressed when they came on duty but others would not. Additionally, they reported that day staff did not expect that the night staff to get a certain number up each day. During the observation, we observed two members of staff asking residents if they wanted to attend a singing activity in the main sitting room. One resident reported that they had a caged bird in the home and that they appreciated being able to chose to bring it in. The issue of ensuring that residents’ personal items were kept safe in the dementia care wing was reported to have been the subject of much discussion, particularly following a complaint made to us about this matter. The registered nurses reported that at present it had been decided to lock all room doors in the dementia care unit, until a solution has been found to the issue. It is understood that the provider is considering arrange of alternatives to ensure that residents on the dementia care unit can have their rights to choice up-held while ensuring that their own items are safeguarded. Whilst this is the policy, residents and their supporters need to be informed about the practice in the service users’ guide. We spoke with the chef and it was evident that she and her team work efficiently and effectively together and work hard to provide a good service to the residents in the home. Although there is a menu plan for the residents, each resident is able to choose what they would like to eat on a daily basis. The chef explained that they will often prepare different choices than those on the menu, including omelettes and a selection of meats/fish with salad. On admission the home completes a diet notification form, which clearly indicates personal preferences, likes and dislikes for individual residents. The chef told us about a new system being used in the home whereby menus are developed via a computerised system. The system uses a nutritional assessment tool to determine that the menus reflect a nutritionally healthy balanced diet. The chef explained that if a daily menu indicated too much fat or not enough potassium it would identify this so that the chef could make adjustments to ensure that the menu contained all the required nutrients and vitamins that residents require. The chef is responsible for managing her own budget and stated that it was ample to provide the variety of food required and the good standard of produce they access. All food is freshly prepared in the home on a daily basis including, cakes, pastries, soup and fruit salad. Meal-times were observed on both site visits. Meals are brought up to the four dining areas from the kitchens in heated meals trolleys. It was noted as good Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 24 practice that registered nurses were actively involved in mealtimes in all areas of the home. Registered nurses were aware of the systems to ensure that all residents were served their meals, and they were shown to fully work in practice. Meals were individually served and were observed to be hot and steaming when given to the residents. Aids to encourage independence, like plate guards and specialist plates were provided. Some of the specialist plates were becoming old and stained and should be replaced to enhance the mealtimes. Many residents needed assistance to eat their meals. Where a resident needed verbal prompting, this was noted to take place. For example one resident who was served in their room was observed to loose concentration and not eat their meal. We observed that this had been noted by care staff within 15 minutes and action taken to support the resident. Another resident refused their meal, a carer returned several times to support them and encourage them. Staff response to supporting residents to eat their meals was variable. Many sat down with the resident to support them but some, stood up to assist the resident to eat. This is not advisable, partly because it is complex to converse and support people in engaging in conversation if the carer is standing up but also, more importantly many of the residents, due to their medical conditions had some difficulty in swallowing and so the carer needs to be at a height where they can observe that the resident is swallowing safely. When the meal was completed, most staff ensured that the resident was comfortable before leaving them. However one resident who was observed being fed their dessert had evidence of their dessert round their mouth for a period after the carer had left them to perform other roles. During both site visits, it was observed that jugs of water had been removed from residents’ rooms for washing up and were not returned until later in the afternoon. This was commented upon by one visitor who reported that they would have liked a jug so that they would give their relative a drink if they wanted one. A carer who was taking jugs of water round the rooms at 3:30pm reported that they were taken in the morning but that drinks were always available in the sitting rooms. This is not ideal, as some residents need drinks to be readily available to support them in taking in adequate fluids and relatives can be very helpful in supporting residents to drink. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 25 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 17 Quality in this outcome area is poor. This judgement has been made using available evidence, including visits to this service. Residents are protected by the home’s complaints policy and some staff knowledge on safeguarding adults. Residents with dementia care needs will not be protected by the homes’ systems, which have the potential to put residents at risk. EVIDENCE: Kings Court has a complaints policy, which is displayed in the main entrance area and is available in the service users’ guide. The person who responded to the questionnaire reported that they knew how to raise a complaint but did not know who they would speak to if they were not happy with the care provided. Most residents and their visitors reported that they knew who they could raise issues with. One reported “I’d see the boss, I’m well in with the boss”, another “Staff have listened to me and done something about my few suggestions” and another “If I bring up problems staff listen and do something if I’m not happy”. However two people who contacted us reported that they have raised issues at times and been told not to complain. We looked at the complaints log and this showed that formal complaints are investigated and responded to within the home’s policies timescales. We have received two formal complaints since the last inspection. Both were handed back to the home for their own investigation. One complainant was not satisfied with the home’s response and this continued after further investigation. A random Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 26 inspection was carried out by us on 10/10/07 in response to this complaint and one requirement and two good practice recommendations were made as a result of this inspection. The requirement related to matters which had been identified at the previous inspection. Information from a range of sources, including visitors and other persons indicated that some people consider that they have raised concerns with the home. Some of these are documented for example, one issue raised by the relative of a resident was documented in the night hand-over book. However others have not been documented and the deputy manager reported that often, as such matters were sorted out at the time or were not considered by the person raising the issue to be a complaint as such, that they are not documented. It is advisable that all such matters are documented, so that the manger can be made aware of all matters raised with staff and to ensure that recurring matters can be identified and that staff respond in a consistent manner. Staff spoken with showed an awareness of how to report matters of concern relating to vulnerable adults. It was noted as good practice that the local safeguarding adults procedure is made available to residents and their supporters in the service user’s guide. Mrs Marshall and her deputy are fully aware of the local procedure to safeguard adults and have worked within it, including making referrals to support people who may be at risk. One referral has been made by the home in support of a vulnerable person since the last inspection. One matter which should have been referred via the local procedure had been reported since the site visits. It was not referred via the local procedure until prompted by us. Although all staff spoken to were aware of the importance of safeguarding vulnerable persons, some of the attitudes shown by certain staff in Standard 10 above could be considered to be a symptom of institutional abuse. Action needs to be taken by management to ensure improvements in staff performance to uphold residents’ privacy and dignity. The home uses both safety rails and cocoons (a device similar to a sleeping bag, with long sides, which are then tucked under the mattress, to prevent a resident from being at risk of falling out of bed). Where such devices were used, care plans, which are regularly reviewed, are put in place. All necessary consents were obtained for the use of this type of equipment. Mrs Marshall was asked why, rather than use cocoons, profiling beds are not placed in their lowest position and crash mats used, as is regarded as current good practice. She reported that this was because their current profiling beds did not lower close to the floor. It is advisable that the home do invest in such profiling beds, so that the use of cocoon restraints can be reduced to the lowest possible level. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 27 One person who raised a complaint with us and one person in their questionnaire have raised issues about residents being left without observation and support for extended periods. One person commented “Very often group left without observation and service well over 60 mins – usually afternoons.” During our short observation, we noted that five residents were left for 35 minutes without observation. During this period, two members of staff did come into the sitting room but action was not taken to support one of the residents who was the subject of noisy aggressive behaviours by another resident. We also observed that there were periods in other parts of the home where residents were left without supervision from staff. One registered nurse reported that a member of staff was always allocated to the sitting room in her area during the afternoon but that they also had other duties to perform, such as taking round the tea trolley, this meant that we observed that residents were not supported for at least 50 minutes. This is of concern as Kings Court cares for some residents with complex behaviours, some of whom have the potential to be aggressive towards others. Discussions with staff and management indicate that residents are left unsupervised because staff have duties elsewhere, this is an area which needs to be analysed and assessed and solutions identified, which may need to include additional staff being on duty, to ensure resident safety. Considering this is a matter which has been raised previously and during complaints, it should have been the subject of the regular management visits by the provider and action taken to address it before this inspection. One complaint which was sent to us related in part to how residents on the dementia unit who needed to be in bed were to be kept safe from other residents, who could on occasion interfere with them or even show violent behaviours. Mrs Marshall investigated this complaint, replying about the home’s policies and procedures on this matter, including the use of child gates and that at the time of her reply, there were no people who needed to be cared for in bed on the unit. During this inspection, we observed that one resident returned to bed during the afternoons. We observed on two different occasions, that different residents had wandered into and around the resident’s room, touching their items and one resident was observed to be shaking the resident’s safety rails while they were in bed. The resident was on occasions not able to respond and on other occasions was observed to be made restless by these behaviours. This is a clear risk to both residents. We discussed with staff how they were ensuring the safety of residents in this case and they responded that they tried to keep an eye on the situation as much as possible. Since the site visits, an actual case of physical abuse from one resident to another who was in bed, has been reported by the home. We discussed standard devices such as pressure pads used in other homes but they reported that they did not have any such equipment in the home. Considering that this is a matter which has been the subject of a complaint and is not a new issue, it is not clear why the providers have not identified this as an issue, during their monthly visits and taken appropriate action to ensure residents’ safety. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 28 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. Residents will be supported by an environment which meets some of their needs, however the environment needs attention to an range of areas, including cleanliness and up-grading of some furniture. There is the potential for people to be put at risk by practice in support kitchens, the laundry and facilities in parts of the lower ground floor. EVIDENCE: Kings Court is a purpose-built facility. Accommodation is provided over two floors, with a passenger lift in-between. There are communal rooms in each zone on each floor. There are a range of bathing facilities provided, which are suitable for people with a range of different disabilities. Much of the home is in need of attention, with scrapes visible on corridor walls, doors and door frames. Whilst some of the bathrooms have been attractively decorated, with Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 29 friezes on the walls, others show areas of damage to the paint-work and plaster. For example in the disabled shower room on the dementia care unit, a member of the domestic staff was observed having to brush up plaster from the floor, where plaster had fallen. Some of the rooms were nicely presented but others needed attention to their paintwork. Corridor carpets and some bedroom carpets showed signs of staining, with ingrained stains in some areas. Other carpets and flooring were sticky and some areas showed signs of odour. Kings Court employs a maintenance man who attends to day-to-day matters in the home and the garden areas. He reported that staff are meant to write in a folder kept in the nurses stations to document areas which need attention. He reported that staff also inform him verbally about areas as well. Records seen showed that some matters were reported. However three matters were noted in the home on the first site visit, two of which could have presented a minor risk to health and safety. These has not been documented on either the first site visit or the second site visit, a week later, and had not been attended to. The home also employs domestic staff. They were observed to be very much in action during both the days of the inspection, working hard to clean carpets, door-frames and individual resident bedrooms. They were supportive to staff and residents, for example waiting until residents were in the dining rooms with the doors closed before causing noise by vacuuming the corridors or helping care staff move furniture, to prepare for an activity in the dining room. The manager reported in the home’s annual quality assurance assessment that a new carpet cleaner had been purchased and new cleaning schedules drawn up, to identify who was responsible for cleaning what, when and how. The lower ground floor needs much attention. It was reported by several staff that water comes into the area during heavy rainfall and areas of loose plaster were noted in several areas on the lower walls. The area includes the residents’ hairdressing room as well as the kitchen, laundry and staff areas. The flooring was coming up along some seams in the flooring and could present a tripping risk, particularly to residents who have a shuffling gait. Mrs Marshall reported that they ensured resident safety when the hairdressing room was being used by making sure a member of staff was always with a resident. This will mean they are not available to support residents on the floors. Mrs Marshall reported that the providers know about this matter and is the subject of discussion between the current and the previous providers, however she does not have a date yet for the works to be commenced. The home has a range of equipment provided to support disability, including different types of hoists, variable height beds and pressure relieving equipment. The dementia care unit has been provided with a snoozelum room, to support residents, particularly when they are feeling distressed. Some new furniture has been provided, for example the ground floor sitting room has new chairs for residents. Other areas need attention. All of the chairs in the dementia care unit examined had “bottomed out” i.e. the cushion Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 30 of the chair no longer provided support under the resident’s sacral area. This needs attention, as it could put residents using these chairs at risk of pressure damage. Many of the propad chair cushions (cushions used for medium risk of pressure damage) were not intact and so could not be wiped down. As well as being unattractive in appearance, as they could not be properly cleansed, in a care home where many of the residents experience continence needs, this could present a risk to cross-infection. Where residents needed recliner chairs, these were provided. Many of these chairs were also loosing their plastic coating, some had been repaired in areas using tape. Some chairs were not clean, with evidence of in-grained food and other debris. One chair was cloth covered and threadbare, there were no records in the resident’s notes to indicate that it belonged to them. The condition of such equipment and furniture needs attention. Some residents had their own wheelchairs, for other people who need to be moved around the home by wheelchairs, these are provided communally by the home. There was evidence that wheelchairs are regularly maintained. Several of the residents are different heights and builds and so will need different sizes of wheelchairs for their comfort. Some staff felt that there was enough variety of wheelchairs to suit the different sizes of residents but others, and one relative, did not. This relative reported that they felt their relative was sometimes uncomfortable in some of the wheelchairs provided by the home. The home needs to pay attention to cleanliness. Some people who completed questionnaires as part of the annual service review earlier in this year echoed this. One resident was observed to be transferred using a standaid hoist. The hoist had a dried-on brown deposits on its side and spots of brown staining and debris on the stand-plate. In one dining room, on both days of the inspection, the inner handles of the doors had dried-on deposits. The home uses wooden tables and chairs for mealtimes, on both days, dried-on deposits were observed in cracks, sides and under surfaces. Issues here may relate to the age of the tables and chairs, causing them to be complex to thoroughly clean. There are robust policies and procedures in place for risk assessments in the kitchen using the “Critical Control Points and Monitoring System”. Areas covered include, daily cleaning schedules, purchasing and receipt of goods, storage, preparation of food, and cooking, serving, cooling and reheating. Monthly hygiene audits take place and the staff meet on a daily basis to discuss any issues, which are then fed back via the head chef with the manager of the home. The kitchen was very clean, well equipped and spacious. Stores exhibited a good range of foods. Documentation was provided to show that required temperature checks were being carried out on fridges and freezers and that food was also being probed after being cooked prior to serving. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 31 All four dining areas have support kitchens and attention is needed to them. On both site visits and variably in different fridges, there were containers with food-stuffs in them. Some containers were labelled with the item in them and dated but all included items which were not. All of these support kitchens had microwaves in them. Microwaves were observed to be used for storage of some items, for example left-over porridge, toast or cakes. All of the microwaves showed dried-on food debris. These kitchenettes also included cups so that relatives could help themselves to drinks. Several of the cups were stained and some had been put away with debris still in them. Mrs Marshall reported that the person with responsibility for monitoring these kitchens was away on sick leave. These matters will be reported to the local Environmental Health Officer. The home has a laundry where residents’ clothes and flat linen is laundered. The laundry needs attention. The areas behind the dryers was clean but during both site visits, the areas behind the washing machines showed dust and debris. Dust in laundry areas often contains micro-organisms. If such dust is not vacuumed away, micro-organisms can multiply and be transported round the home on staff footwear with a risk of cross infection. The plinths to the washing machines were not intact. Plinths needs to be intact and able to be wiped down, as they present an area of high risk to cross infection as they can easily become contaminated whilst laundry machines are loaded. The laundry room is in the lower ground floor and, as for areas of the lower ground floor, the flooring was lifting at the seams in places, with debris accumulating underneath. This again is regarded as a risk to cross infection where dust and debris accumulates. Such areas also present a risk of tripping injury to staff. Both laundry staff reported that contaminated and potentially contaminated items were placed in red alginate bags. Both laundry staff reported that care staff usually, but not always complied with this policy. They reported that were staff do not comply with the policy, that they have gloves and aprons which they can use to protect themselves. Neither laundresses reported that they generally informed management of when staff did not comply with the home’s policy of potentially infected linen, which they should do, so that the managers can ensure that all staff are aware of their responsibilities in this area. Bed linen and Kylie sheets (a continence aid) are placed in the same bags and are then separated in the laundry. It is advisable, to reduce risk of cross infection that laundry is separated at source and not in the laundry room. The laundress was fully aware that Kylie sheets need to be washed in certain ways to ensure they continue to be effective. Several of the Kylie sheets were deteriorating, probably due to age. These need to be replaced, as they will not longer be effective as a continence aid. Clean, washed laundry bags were placed on the laundry floor near the washing machines. As there was dust and debris visible in the laundry and staff were re-sorting laundry in the room, this is a risk to cross infection and clean laundry bags need to be placed away from the floor. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 32 We discussed prevention of infection with nursing and care staff. All said they had a good supply of protective equipment including gloves and aprons. Registered nurses reported that all clinical dressings are performed using aseptic technique. It was observed at mealtimes that staff wore blue disposable aprons. The home supplies hand-cleansing equipment for visitors to use. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 33 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. There is a lack of evidence that residents’ needs can be are met by the numbers of staff on duty. Residents are protected by the homes recruitment policy and procedures. Staff receive training to help provide the skills needed to meet the residents needs but more attention is needed in supporting staff in an understanding of how to meet the needs of people with dementia. EVIDENCE: Mrs Marshall is aware of how the home is staffed and has a budget which has been set by the provider, within which she works. Evidence from this inspection, previous inspections and staff indicate that the dependency of residents has increased over time. There is no evidence that the current provider has performed a formal review of dependency levels in the home, since it purchased the home, to ensure that the numbers and skill mix of staff are able to meet residents’ nursing and care needs, this is despite it being recommended at the previous inspection. Mrs Marshall reported that she is able to consider dependency when admitting residents and when a prospective resident’s dependency is high, can decide not to admit a person with less complex needs. None of the staff spoken to felt that they were short of staff. They all consistently expressed a loyalty to the management team, reporting on how supportive they were. The one person who responded to the Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 34 questionnaire described the “staff shortage” in the home. This was echoed by some people who responded to questionnaires as part of the annual service review, earlier this year. The site visits provided evidence that a review of staffing is indicated. Residents were not supervised at all times in the sitting rooms, as staff had to perform other roles. Care staff did not have the time to support residents in activities. Staff are not completing documentation contemporaneously. One person who had developed minor pressure damage was observed not to have their position moved for in excess of five hours. Care staff were observed performing non-caring roles, one carer was observed taking round water jugs and glasses, this is usually a catering assistant role. Carers were observed to have to take tables and chairs out of dining areas and then back, to create more space to support residents’ activities. The manger reported that due to the risks presented by the lower ground floor, care staff now escort all residents to hairdressing. All these take care staff away from their roles of looking after residents. Four staff records were looked at during the inspection. Police checks are being carried out when employees are recruited. These checks help ensure that staff are suitable and fit to work with vulnerable people and helps protect vulnerable residents from potential risk of harm. There were also two professional references obtained for all recruited staff, which further demonstrates the suitability of all new employees to work in the home. Upon recruitment staff are given a handbook, which contains many of the homes policies and procedures including manual handling, health and safety and first aid. The staff are also given a copy of their job description so that they are aware of their roles and responsibilities. Copies were seen signed by the staff in their records alongside a copy of their contracts of employment. We met with one very recently employed member of staff. They confirmed that they were working supernumerary and that they felt supported in their role. They reported that much of their induction was self-directed learning using DVDs, followed by completing a questionnaire, to test their learning. When we met with this person, they were watching a DVD on safeguarding adults. The home supports staff with NVQ training. Each staff record included a training matrix and the inspector was able to see that training for Manual Handling, Health and Safety, Fire Safety and COSSH had been completed and that future course dates had been organised for staff. The manager told us about the residents that live in the home and some of the complex health care needs that staff manage and care for. Additional training is accessed from various community resources to ensure that these needs can be effectively met. Such training has included, Stoma Care, Peritoneal Dialysis, Supra-pubic Catheterisation, and Management of Percutaneous Endoscopic Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 35 Gastrostomy (PEG) Feeding. Staff training records also showed that they had received training on medical conditions such as Parkinson’s disease to help ensure a better understanding of the needs that residents in the home may have. One registered nurse reported to us that they accessed the internet to inform them of how to meet clinical care needs. Since the previous inspection the home had accessed various courses to increase their knowledge and awareness in palliative care. The courses attended are specific to staff roles and responsibilities and includes Coping with Loss and Bereavement, Planning for End of Life and Administration of Medicines through Syringe Drivers. One trained nurse in the home is the recognised palliative care representative who works closely with General Practitioners and palliative care nurses in the local community. She has attended training in the Gold Standards framework (GSF). The framework aims to improve palliative care provided and focuses on optimising continuity of care, advanced planning, symptom control and support to residents, relatives and staff. The manager told us that the home had reliable community links with specialists in Dementia Care including an NHS Consultant. The home is also looking at courses accessed through the Alzheimer’s Society and that the Deputy Manager and other staff in the home would be attending the training. Staff records showed that in house training was given in dementia Awareness and staff confirmed that they watched a video and then answered questions about it to test their understanding. Four staff were spoken with about the training. Only one member showed a satisfactory insight into dementia and how to care for people with the disease. Two staff members had very limited knowledge and one staff member had not attended any training in dementia. Their knowledge and understanding about needs associated with dementia was weak and suggests that staff are not skilled to meet the specialist physical and emotional needs of individuals in the home. This finding is supported by observations of staff interactions with residents in Health and Personal Care above. We asked the activities coordinator about any training they had received in order for the to be able understand the complex needs of the residents and what dementia training they had received. We were told that they had not had any relevant training. Their knowledge in types of dementia was poor. We asked them if they felt that the training in dementia would be particularly useful to support their role in understanding dementia and how this could be interpreted through residents’ behaviour and subsequent needs. The coordinator agreed it would be useful but that they had had to rely on reading books and finding out information where they could from other resources. When this was discussed later with the manager we were told that the coordinator had been offered various courses both mandatory and those relating specifically to their roles and responsibilities within their job description and that they had failed to attend any. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 36 In light of this we told that manager that we found the coordinator’s behaviour disrespectful of the inspection process and that they had been purposefully misleading. We told the manager that we would expect this matter to be investigated through the homes disciplinary policy and that evidence of attendance on such courses for this member of staff must be produced so that we can be assured they are suitably knowledgeable to fulfil their role and meet the residents’ needs. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 37 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including visits to this service. There are systems in place to ensure that residents are supported by the home management, however deficits in some areas, mean that a range of areas need to be more effectively managed. EVIDENCE: The home is managed by Mrs Marshall. Mrs Marshall has managed the home for several years, she is an experienced manager and deputy nurse. She is supported by a deputy. The home has been purchased by a new provider since the last inspection and Mrs Marshall reported that they have been introduced to the new provider’s policies and procedures and have now fully introduced them across the home. Mrs Marshall completed a comprehensive Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 38 annual quality assurance assessment and submitted it to us prior to the inspection. In this document, she stated that the home had addressed the matters raised in the previous inspection report, this was found not to be the case for one of the areas raised relating to completion of residents’ care charts. The home is regularly visited by a senior member of the provider’s management team. Their visits do not indicate that they have considered the requirements or recommendations from the last inspection, which it would have been anticipated that they would, as this is a significant area for ensuring that the home are complying with our standards and guidelines. Their monthly reports also did not indicate that they have reviewed matters in any detail in relation to residents, particularly areas noted in complaints and concerns, such as ensuring the safety of people in sitting rooms or residents in the dementia care unit who are not able to leave their beds. The visits also do not note the areas of concern relating to the lower ground floor, general cleanliness of the home and equipment deficits. The report for June did not document the pressure ulcer, which records showed had developed during that month. Whilst it is clear that care plans are reviewed during monthly visits, there is limited evidence of more detailed review, which would have identified that records are not being completed in a contemporaneous manner. One visit took place at night and the report showed that issues had been identified and that appropriate action had been taken by management. As noted above, the home submitted a detailed annual quality assurance report as part of this inspection. This document does note the issues relating to the home’s basement area but does not give a date for work to be completed to make the area safe. The document reports that all divan beds have been replaced. The report notes that corridor areas need redecorating but does not give a date for works to be done. The report notes the high levels of dependency, which was confirmed by the inspection. It also accurately reflects the sex, age and ethnicity of the client group, as shown during the inspection. The document states that none of the residents have developed pressure ulcers during the past 12 months. This was confirmed verbally by the manager at the time of the inspection, however it was found to be an incorrect statement during the inspection. During the inspection, we checked both Controlled Drugs cupboards. Both contained items which must not be stored in Controlled Drugs cupboards, such as money, watches, a hearing aid and some earrings. Some items were labelled with peoples’ names, others were not, only one had a date on it to show when it was put in the cupboard. In order to ensure the safety of residents’ personal belongings, there must be a full audit trail of all items handed in for safekeeping, including the date they were handed in, who they belong to and other relevant information. The home is subject to regular medicine audits, so it would have been anticipated that this matter should have been identified during such audits. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 39 There is an annual appraisal process, which ties in with the supervision arrangements. The manager has established a formal recorded supervision procedure for all staff. A plan is devised for discussion relating to the residents, work issues, staff issues, personal development and training. However supervision with staff was not up to date. This is indicated as a range of areas, particularly in Health and Personal care above, have been identified during this inspection. Such matters, particularly in relation to ensuring residents’ privacy and dignity should have been identified and action taken during supervisions to ensure that staff are supported in developing appropriate skills in this area. As noted in Health and Personal Care above, many records were not accurately completed in a contemporaneous manner. This means that records cannot be relied on to provide information on residents’ current condition and responses to treatment. Some rooms contained information and instructions about nursing or care. Whilst the information was clear, these should be dated and signed, to ensure that timely evaluation takes place and to inform of who has made the directions. The home has systems to ensure that equipment and services are regularly maintained. This includes wheelchair servicing, hoist servicing and checks on hot water temperatures. Staff were observed to perform manual handling in a correct manner, working together. A registered nurse was observed to actively supervise and support a care assistant throughout a manual handling procedure. The home maintains clear records of accidents to residents, including skin tears and unobserved bruising and regular audit of accidents takes place, including during monthly visits by the provider. It is recommended that thought be given to increasing the staff hours available to support social activities. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 40 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 3 2 2 X X X 1 STAFFING Standard No Score 27 1 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 1 1 2 3 Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 41 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Timescale for action 31/10/08 2. OP7 3. OP7 4. OP7 5. 6. OP9 OP9 Where a resident has a care need or a risk, a full care plan must be put in place to direct staff on how the resident’s care needs are to be met and risk reduced. 15(2)(b,c) Where a resident’s nursing or care needs have changed, their care plan must always be revised to reflect their current needs. 12(1)(a,b) Management must ensure that care is always provided in accordance with the resident’s care plan and if this is not possible, the reasons for this must be documented. 17(1)(a) Full records must be maintained S3(3)(k) of nursing and care provided to a resident, records must be accurate and completed at the time care was provided. 13(2) Only Controlled Drugs must be stored in the Controlled Drugs cupboard. 13(2) Where residents need homely medicines which are administered invasively, a treatment plan for using such medications, which DS0000015920.V371025.R01.S.doc 31/10/08 31/10/08 31/10/08 31/10/08 31/10/08 Kings Court Care Centre Version 5.2 Page 42 7. 8. OP9 OP9 13(2) 13(2) 9. OP9 13(2) 10. OP10 12(4)(a) 11. OP12 12(4)(b) 12. OP18 13(7) 13. OP18 13(7) 14. OP19 23(2)(b) 15. OP22 23(2)(n) excludes/includes residents for whom it is not appropriate and other methods to be used first. The medicines trolley must always be secured during the medicines round. Registered nurses must always check the medicines administration record before administering a drug and sign for the medicine at the time that the resident takes the drug. The registered nurse must be able to concentrate on medicines administration during the drugs round and not have to perform other roles as well. Management must ensure that residents’ privacy and dignity is respected at all times, particularly in relation to residents with mental health needs, when caring for residents and addressing them. The home must evidence, that they have actively considered residents’ diverse social, emotional, cultural and psychological needs and all staff are aware of how such needs are to be met. The home must always ensure that all reports of suspected abuse are referred to appropriate authorities in accordance with local procedures. The home must set up systems to ensure that residents who are cared for in bed and are unable to move, are kept safe from other residents who may interfere with them or cause them harm. The provider must submit an action plan detailing when the lower ground floor will be made safe for residents and staff. The provider must ensure that DS0000015920.V371025.R01.S.doc 31/10/08 31/10/08 31/10/08 31/10/08 30/11/08 31/10/08 31/10/08 30/11/08 31/12/08 Page 43 Kings Court Care Centre Version 5.2 16. OP26 13(3) 17. OP26 16(2)(j) 18. OP26 13(3) 19. OP26 13(3) 20. OP27 18(1)(a) 21. OP30 18(1)(c,i) 22. OP35 17(2) S4(9)(a) all equipment and furniture, including recliner chairs and chair cushions are fit for purpose and do not present a risk to residents. The provider must ensure that all items such as hoists, chairs, pressure relieving cushions, tables and door handles have intact surfaces so that they can be cleaned and that all debris is promptly removed. Support kitchens must be maintained correct standards of hygiene, with items stored in fridges correctly labelled, all areas, equipment and crockery kept clean. All of the laundry must be clean and free of debris, the washing machine plinths must be intact and wipable, cracks in the flooring must be sealed and no items should be stored on the floor. Management must be informed of all occasions when staff do not comply with the home’s policy on management of potentially infected and infected laundry, so that they can take appropriate action to reduce risk of spread of infection. A full review of staffing numbers and skill mix must be performed and submitted to us, taking into account resident dependency and staff roles. All staff must be trained in dementia care. Dementia care training must be in sufficient detail to fully support staff who are caring for people with complex dementia care needs. All items handed in for safekeeping must be safely stored and a full written audit trail of the items handed in DS0000015920.V371025.R01.S.doc 31/10/08 31/10/08 31/10/08 31/10/08 31/12/08 31/01/09 31/10/08 Kings Court Care Centre Version 5.2 Page 44 23. 24. OP36 OP37 18(2)(a) 17(1)(3) (a) maintained. There must be written evidence that all staff have been supervised in their role. All records relating to residents must be accurately and contemporaneously completed. 31/01/09 31/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP1 OP7 OP7 OP8 OP9 OP9 Good Practice Recommendations The service users’ guide should provide full information on all the services offered by the home as detailed in the inspection report. Care plans and documentation should use precise, measurable terminology and all interventions and relevant information be documented. Care plans relating to mental health needs should fully describe the resident’s behaviours and interventions to be taken to meet need. The home should use a more precise tool to fully identify residents at risk of pressure damage. A larger Controlled Drugs cupboard should be provided on the ground floor. Where residents are prescribed drugs which can affect their daily lives, such as mood altering drugs, aperients or pain killers, care plans should be put in place to assist in the evaluation of treatments used. The home should develop effective systems to ensure that residents’ personal clothing is individually labelled with their name. Activities records should indicate if residents have enjoyed activities and/or if they have been beneficial to them. It is recommended that thought be given to increasing the staff hours available to support social activities. Not addressed by this inspection. When residents need to be assisted to eat their meals, the member of staff assisting them to eat should always sit down with the resident to support the mealtime as a social DS0000015920.V371025.R01.S.doc Version 5.2 Page 45 7. 8. 9. 10. OP10 OP12 OP12 OP15 Kings Court Care Centre 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. OP15 OP16 OP18 OP19 OP19 OP22 OP22 OP26 OP26 OP37 activity and to ensure that the resident is swallowing safely. Fluids should always be available in residents’ rooms. All concerns or issues raised with staff should be documented and be available for review by management. The home should invest in profiling beds which will go down to the floor to reduce the use of restraints such as cocoons and safety rails. The home should ensure that all areas of the home are maintained to the same standards in relation to their carpets and décor. Management should ensure that staff report all matters relating to maintenance in accordance with the home’s procedures. The home should ensure that it has a range of different wheelchairs for communal use, which will suit a range of residents with different heights and builds. All deteriorated Kylie sheets should be replaced. The home should replace its old dining room furniture with furniture which is easier to clean. All laundry should be sorted at source and not re-sorted in the laundry. All directives about individual care provision in residents’ rooms should be dated and signed by the person who has drawn up the document. Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 46 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Kings Court Care Centre DS0000015920.V371025.R01.S.doc Version 5.2 Page 47 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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