Inspection on 25/01/06 for Knights Court Nursing Home

This inspection was carried out on 25th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Knights Court Nursing Home 16/04/09

Knights Court Nursing Home 06/05/08

Knights Court Nursing Home 30/07/07

Knights Court Nursing Home 12/03/07

Knights Court Nursing Home 21/06/06

Knights Court Nursing Home 06/06/05

Knights Court Nursing Home 07/02/05

Knights Court Nursing Home 11/07/04

Knights Court Nursing Home 22/01/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Knights Court Nursing Home 105-109 High Street Edgware Middx HA8 7FH Lead Inspector Mr Ram Sooriah Unannounced Inspection 25th January 2006 10:00 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 Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 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. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Knights Court Nursing Home Address 105-109 High Street Edgware Middx HA8 7FH 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) 020 8381 3030 020 8381 3040 Life Style Care Plc Care Home 80 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (60) of places Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: Knight’s Court Care Centre is a purpose built care home and was opened on the 27th November 1998. It is part of Lifestyle Care Plc, a provider of care homes mostly for the elderly. The home is found off the Edgware High street and it is easily accessible by buses and the underground. The bus and tube station is about five minutes walk away. There are shops, coffee shops, restaurants and other local amenities in close proximity of the home. The home consists of a main 3-storey building with a 2-storey wing on each side. It provides accommodation for 80 service users in 4 units. Each unit is self-contained and has a kitchenette area, lounge/dinning areas, bathrooms and toilets. All the rooms are single and are en-suite with a washbasin and toilet. The Camelot and Avalon units are on the ground floor and the Merlin and Excalibur units are on the 1st floor. The 2nd floor contains the laundry, kitchen, manager’s office and staff areas. The Merlin unit is registered for 20 elderly service users with dementia requiring nursing. The other three units can each accommodate twenty elderly service users with nursing needs. There were 76 service users in the home during the inspection. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains the findings of the unannounced inspection which took place on the 25th-26th January. The inspection lasted for about 16 hours over a period of two days. The unannounced inspection was the second statutory inspection for the period 2005-2006. The inspector had the opportunity to observe care practices in the home, sample some of the care records, health and safety records, training and personnel records. He also spoke to visitors, service users and staff. He was able to verify some of the findings when he gave feedback to Wendy McDonough, the regional manager, and to Valerie O’Brien, the newly appointed manager for the home. There have been a number of changes with regard to the manager of the home during the past year and there were times when the home did not have a permanent manager. This has lead to some period of unrest and could explain why a number of issues in the home remain to be addressed and why perhaps improvement is some areas has not happened. However it is important to note that despite the period of unrest, most service users and visitors to the home remain pleased with the quality of the service. This is evidenced by comments cards received by the inspector. 17 comments cards were received from visitors/relatives to the home. 14 respondents were overall satisfied with the level of care in the home, 2 were partly satisfied and 1 was not satisfied with the care that his/her relative, who was accommodated on the Merlin unit, receives (see standard 4). The inspector believes that this is due mostly to a core staff group who continue to work hard and who ensure that the service users are looked after appropriately. Comments cards had statements such as ‘staff are lovely… and helpful’; ‘staff are most amicable’; ‘staff are pleasant and welcoming’. Comments cards however showed that 9 out of the 17 respondents thought that staffing levels were not adequate and one respondent thought that at times staffing levels were not appropriate (see standard 27). A comment card said ‘with a little care and thoughtfulness, knight’s Court could be first class’ The inspector has used the findings of the comments cards in the report to support his findings. He therefore would like to thank all respondents for returning the comments cards. These are most important in providing insight and feedback about the quality of the service that the home provides and to draw attention not only to the things that need improving but also to the good things that the home does. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 6 The inspector would like to thank all service users, visitors and staff who engaged with him during the inspection. He is also grateful for the assistance and cooperation of Wendy McDonough, regional manager; Valerie O’Brien, the manager; and all staff in the home. What the service does well: What has improved since the last inspection? What they could do better: The assessment of the needs of service users must be more comprehensive to ensure that all the needs of service users are identified so that care plans are formulated to meet the identified needs. The assessment of needs also provides a benchmark against which efficacy of the action plans to meet the needs of service users, can be measured. The standard of the care plans must also improve to ensure that they address all the needs of service users, including short-term needs. Service users and relatives must agree to care plans and risk assessments not only when the care plans are drawn but also when these are reviewed. Staff must have an increased understanding and awareness of ‘personhood’, of ageing service users and of those with dementia as well as of the therapeutic interventions that are needed on their part to ensure the ‘well-being’ of these service users. They must understand that care is holistic and that they play a major part in the delivery of this care. The standard of cleaning, decoration, and fittings and fixtures in the home must improve to ensure a high quality and hygienic environment for service users. The registered person must monitor accidents/incidents occurring in the home carefully and must investigate the likely causes where these are not clear in order to prevent, as far as is possible, similar accidents/incidents from happening again. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 7 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. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 8 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 Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 The needs assessments of service users were not comprehensive enough to ensure that all the needs of service users will be identified. The numbers and skills of staff continue to cause doubts as to whether the needs of service users can be fully met in the home. EVIDENCE: The inspector looked at six care records. He noted that all service users to the home have had pre-admissions assessments, which have been carried out either by the manager or by the deputy manager. The needs’ assessments of the relevant funding authority were also available on the file of new service users to ensure that all the needs of service users were clearly identified. Once admitted to the home the assessments of the needs of service users were in some cases good, but in other cases were lacking. They continue to lack basic information like service users’ pattern of sleep and the likes and dislikes with regard to food. The section on communication in one occasion failed to identify that the first language of the service user was not English. In most cases it dealt with verbal communication and did not deal with nonKnights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 10 verbal communication such as ability to read or write in cases where speech or hearing might be impaired. It did not also address the disposition of service users with regard to communication and to whether they like to engage in conversation or whether they like to keep to themselves. The pattern of sleep was at times described as ‘normal’ and the pattern for ‘opening the bowels’ was also described as normal. As a result the assessments of needs were not individualised enough to differentiate that what might be normal for one person might not be normal for another person. The mental health assessments of service users, particularly with regard to those accommodated on the dementia unit continue to lack with regard to giving a picture about what the mental health needs are. For example a description of the mental health needs could include things such as inappropriate behaviour with regard to shouting, swearing, physical assault, depression, elation, hallucinations and the likely triggers for these. The home has three units for elderly service users requiring nursing care and one unit for service users with dementia. Staff on the units for service users requiring nursing care were in the main familiar with the physical needs of service users. The inspector spent some time on the Merlin Unit observing care practices. Just as during the last inspection, he noted little interaction between staff and service users other than when this was linked to direct care giving. In one case a member of staff carried out an intervention with a service user without explaining the service user what she was going to do. On another occasion, a service user called a member of staff, who did not respond to her. On other occasions staff communicated openly with each other in front of the service users, ignoring them. The provision of care continues to be task orientated with little interaction with service users. A comment card mentioned that ‘carers give the impression that they do not want to be with service users’ and that ‘they sit next to residents but not ‘with’ them’. There were also a few examples of good practice when staff fed service users and interacted with them or when staff involved one service user in some small chores in the kitchenette, although a risk assessment should have been in place on that occasion. However, there were enough instances identified by the inspector, which would justify a need to ensure that staff working with service users with dementia care receive suitable and in depth training with regard to ‘dementia and personhood’ to ensure that staff are sufficiently competent to care for these service users (see last paragraph page 23). Without this improvement will not be made. This would apply not only to the Merlin unit, but to the other units as well. The inspector was informed that an additional member of staff has been recruited for the morning shift on the Merlin unit. There have not been any changes with regard to staffing on the other units despite one of the previous managers completing an analysis of the staffing needs in the home. 9 comments cards out of 17 said that there was not enough staff on duty and one said that ‘at times’ there was not enough staff. One mentioned that this Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 11 might be the reason why service users are not always toileted regularly and why information about service users was not provided promptly to next-ofkins. There was therefore a strong perception that the staffing levels needed to be reviewed and improved as well as the skills of staff in the home. This was a previous requirement, which has not been fully met and which must be met for the home to fully demonstrate that it can meet the needs of all service users accommodated in the home. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 Service users had appropriate care plans in most cases. In a few cases a care plan was not in place where new problems have been identified to ensure that service users will receive the necessary care. Although the manager and her staff were aware of the healthcare needs of service users, records did not always demonstrate that the home was meeting all the healthcare needs of service users. While staff showed service users respect when they interacted with the service users, a few instances were noted when the privacy and dignity of service users were overlooked. Records about the future of service users and about their wishes and instructions with regard to death and funeral were not always comprehensive to ensure that the needs of service users with regard to this aspect would be met. EVIDENCE: Care plans were in good order and kept in the nursing offices on each unit. There was some variation in the comprehensiveness of care plans from units to units. Some units seemed to be more thorough with regard to the review of care plans and risk assessments. The inspector noted that on at least one of Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 13 the units, care plans and risk assessments were not always reviewed monthly or according to review dates which have been set up. There was also an absence of appropriate care plans in cases where service users had short term or new problems, which needed a plan of action to ensure that these needs were addressed and resolved. These included cases of acute illnesses when service users required careful monitoring and interventions to support them through that period of illness. Care plans in some cases were signed by relatives and in a few cases by the service users themselves, when these were drawn. There was little evidence of further involvement of the service users/relatives in the review of care plans. The home has a number of general risk assessments and some more individualised risk assessments. Some care plans contained risk assessments for example about not giving a jug of water to a service user because the latter could not reach it, another risk assessment gave the reason as ‘because the service user has dementia’. The inspector would argue that these were not valid reasons for these types of risk assessments to be in place. Nurses agreed with the inspector that if a jug of water were to be in the room, it would be easier to offer a drink to a service user who is confined to his/her bed. If it is not possible to provide a jug of water, then consideration should be given to the provision of a closed container such as a bottle. The manager informed the inspector that she has plans to improve the content of care plans. She has drawn a model care plan, which has been sent to each unit so that staff can then draw care plans in a similar manner to the model. Service users in the home were registered with a GP, who visits at least once weekly. There was evidence that service users were referred to the GP as required. Other healthcare professionals also had input in the care of service users. One service user was recently referred to the dietician. In that particular case it seemed that the prompting for the referral had come from the social worker during a review meeting. The service user had already lost about 9 of her body weight about two months prior to that. There was also a lack of records to show that service users were seen at least yearly by the dentist and optician. During the time of the inspection there were three service users with pressure sores, which were healing. There has been progress in the standard of care delivered in this area and the home is commended. Records kept with regard to pressure area care were generally comprehensive, but in one case there has not been a recent picture and review of the sore according to the plan of care. There were a few cases where service users were unwell. Some were receiving treatment and there was therefore a need for regular monitoring of the service users’ condition to determine if the treatment was effective. There was however a lack of the monitoring of vital signs in cases for example when Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 14 service users were on antibiotics for chest infections or urinary tract infections. It was therefore not always possible to determine the deterioration of service users’ condition at an early stage. Most service users were observed to be appropriately dressed and groomed. Three service users were noted to be without any slippers on the Merlin unit and at least two female service users were not wearing any tights/stockings or socks. While the inspector agrees that in some cases service users may refuse to wear socks/tights or slippers, the incidence of the above seems to be quite high on that unit compared to other units in the home and in other care homes and seems to indicate a practice. One comment card mentioned ‘the lack of attention to detail’. The inspector also observed that a number of male service users on the Merlin unit were not shaved. No appropriate reason was provided for this. A number of service users had risk assessments in place in cases where service users were not offered a call bell. The inspector noted that some service users had their bedrooms’ doors opened, while they were in bed. They were therefore visible to people passing down the corridor. As well as balancing the need to observe service users, the wishes of service users to have their doors opened, the fire regulations with regard to having fire doors closed, there is also a need to maintain the privacy and dignity of service users particularly of those who are unable to express themselves. Some of the interactions of staff with service users as described in the previous sections of this report also showed that maintaining the dignity and respect of service users were sometimes overlooked. On visiting the Merlin unit at about 18:30, the inspector observed two female service users who had been changed in their nightdresses. They had cardigans on and were walking down the corridors quite alert and not ready for bed. It is recommended that the manager review the need to change service users into their nightdresses, when they are clearly not ready to go to bed. The inspector observed that the clothes of service users were not always put away tidily in the drawers and wardrobes of service users. Medicines management in the home was generally good with a few omissions. There were a few cases in the medicines chart where staff have not signed when they have given the medicines or entered a code if these were not given. There were also a few cases where medicines were not recorded when received in the home. The inspector noted that a service user was on two similar medications, when he was discharged from hospital with only one of the medicines. The inspector was unable to trace when the second medication was prescribed and why. The home had been asked to investigate this issue. A service user was receiving all his medicines via his feeding tube, but there was no risk assessment in place and the route of administration on the chart was indicated as ‘oral’. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 15 There is a special page in the care records where details about instructions and the wishes of service users with regard to death are recorded. These are not always filled in appropriately. There is one part, which says ‘in the event of death’ and most of the time staff have completed that section by saying contact relatives, instead of elaborating on what care service users wanted to receive when that time comes. The manager understood the need to have this information on file, rather than trying to get this information later on when service users are already unwell and relatives are distressed. The Commission is always notified of deaths in the home. Monitoring with regard to this aspect shows that the home manages the deaths of service users in an appropriate manner. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 15 Records with regard to the social and recreational needs of service users were not comprehensive. Without this there is no guarantee that service users’ needs with regard to this aspect, will be met. The home provides a range of meals to meet the needs of service users. There was however room for improving the variety of meals provided for suppers. EVIDENCE: The home employs a full time activities coordinator. Service users and visitors provided good feedback about the activities being arranged in the home. On the day of the inspection there was a meeting for the ‘Friends of Knight’s Court’ which is a small group of people who got together mostly to support in providing appropriate activities and outings. The inspector was informed that the home was in the process of recruiting a person to provide activities particularly on the Merlin unit. The care plans contained sections to be completed about the social and recreational needs of service users. These were not always completed appropriately and care plans were not always in place to address the needs of service users with regard to this aspect of care. A proper life history and background knowledge of service users with dementia, would allow all staff to engage the service users in topics which might be remembered by service users and which are interesting and close to them. If the principles of holistic care are considered, the provision of activities and the engagement of service Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 17 users in social and recreational activities should not only be within the remit of the activities coordinator, but of all care staff. The main kitchen was clean and tidy. It is responsible for the preparation of all the main meals in the home. There is a full time chef, a weekend chef and kitchen assistants. Service users were in the main pleased with the meals, which were provided in the home. Some mentioned the lack of variety with regard to the suppers. One comment card said that ‘the suppers leave much to be desired’. The suppers normally consisted normally of a choice of sandwiches and a cooked meal. There was also a choice of an omelette or a salad. Inspection of the menus seems to indicate some repetitiveness in the content of the suppers during the four-week cycles. Egg on toast, spaghetti/ravioli on toast, macaroni/cauliflower cheese appeared every week of the four-weekly cycles at least once. The manager stated that the suppers would be reviewed to take this into consideration. The inspector noted that the choices of service users’ with regard to meals were recorded on the previous day. The meals were served in dining areas. There is one dining area on each unit and these were generally well prepared to provide a congenial environment for service users to have their meals. Management of the main kitchen was very good. The kitchen was very clean and all appropriate records were being kept. The inspector was also informed that a snack is available to service users in the evening if they request this. However, in view that there is about 15 hours between supper and breakfast it is recommended that the snacks are offered to service users rather than service users requesting for these. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 18 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home takes all complaints seriously and deals with them appropriately. The home has dealt with most allegations and suspicions of abuse in an appropriate manner. In a few cases staff in the home have not been quick enough to refer or discuss some of these cases with line management or with the relevant authorities. EVIDENCE: The inspector looked at the complaints register. A number of complaints have been entered into the register including verbal complaints/concerns. Although the number seems significant, this is probably due to good record keeping. All matters, which have been raised by service users or their relatives, seemed to have been recorded. The records also showed that all concerns have been addressed in an appropriate manner and within the time scale. Although the substance of the complaints did not seem to repeat, showing that the issues have been addressed appropriately, the laundry seems to be a weak area (4 out of 19 complaints between 28/8/5 and 28/12/5 make reference to laundry and to the management of service users’ clothing). The home has had a number of cases where there have been allegations or suspicions of abuse. In most cases the management of the home has cooperated with the various authorities and provided the venue for the meetings. They have also been open in discussion and have acknowledged areas for improvement. In some cases however, staff have not always been quick in following the Protection of Vulnerable Adult policy and procedures of Harrow and in alerting line management and the relevant authorities. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26 The standard of decoration and cleaning in many areas of the home was not very good to ensure a pleasing and homely environment where service users can be cared for. EVIDENCE: The grounds of the home, including the car park area, were in the main tidy and in keeping with the time of the year. The exterior of the building was also in good condition. There is an electronic pad in the front of the home which staff and regular visitors to the home have the code to gain access to the home. There was a sign on the door that the home has CCTV camera on the outside of the home. There has been some redecoration in the home. The reception area and the main corridors have been repainted. A number of bedrooms have also been repainted. However some areas of the home were starting to look tired and worn. For example the wallpaper and the carpet in the lounge of the Merlin unit was poor. The manager said that the wallpaper for that lounge has been ordered and that the lounge will be redecorated as soon as this is received. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 20 Some bedrooms also needed to be repainted. Some had marks/holes on the plaster where items of furniture have rubbed/knocked against it. The carpet in many rooms was also stained/faded. Some items of furniture were also broken and needed to be repaired/replaced. A number of beds were noted to have headboards, which did not fit the frame of the beds properly. A service user who had clear nursing needs and who was on a pressure relief mattress was observed on a divan bed, which was placed against the wall. Staff commented that they had to move the bed physically to attend to the service user on either side of the bed, as it did not have any castors. As a result of the above and to ensure that the home continues to provide and improve on the quality of its environment, the registered person must prepare a comprehensive redecoration and refurbishment plan and start to address the issues in an order of priority. There has been some improvement in the personalisation of a few of the bedrooms on the Merlin unit. The inspector noted that there have been attempts to personalise the rooms according to service users tastes and backgrounds. Pictures of a service user when he was younger were noted in his bedroom and this provided a focal point for the service user. This was good practice and showed what can be achieved. However quite a few bedrooms remained bare and not personalised. It is important that service users bedrooms are appropriately personalised so that these provide not only a homely environment, but also allow service users to recognise their bedrooms particularly when they have a memory impairment. The manager was aware of this issue as minutes of a recent relatives/service users’ meeting held by the manager included an item, where the manager encouraged relatives to bring items to personalise the bedrooms of service users. She also stated that the home was looking to acquire duvets for the beds. Most areas of the home were free from odours. There was however a slight odour of urine in some of the bedrooms on the Merlin unit. The cleaning of the home was also not as good as it could have been. The carpet in many bedrooms, particularly near the beds, was stained/dirty and unsightly with spillages of food and drinks. There were also stains/spillages on the walls of some bedrooms and some communal areas. Some bed frames were dusty as was the top of some wardrobes. The cleaning of the kitchenettes areas could also be improved, particularly beneath the work surfaces. As a result the inspector judged that the cleaning in the home needed to improve to ensure that issues with regard to odours and dirty carpets/walls are dealt with thoroughly and appropriately. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Evidence suggests that the staffing levels and the skills of staff were not always appropriate to meet the needs of service users. The home has a good recruitment process. Staff in the main receive training to meet the needs of service users including training in dementia care and elderly care. The depth of these training and the outcomes of these training were however not always clear with regard to adopting good practices in the care of the elderly. EVIDENCE: The Camelot, Excalibur and Avalon units had each three carers and a trained nurse on duty during the day. There were four carers and a trained nurse in the morning on the Merlin unit and three carers and a trained nurse in the afternoon. At night there are a trained nurse and a carer for the Excalibur unit and the same for the Merlin unit; and three carers and a trained nurse for the forty residents on the Avalon and Camelot unit. There has been a slight improvement in the staffing on the Merlin unit during the mornings, but not on the other units. A staffing analysis carried out by the manager who has recently left showed the need to increase staffing on each unit during the day and at night on the Camelot and Avalon units. The current manager stated that she would be reviewing staffing again by looking at the dependencies of service users. As stated in standard 4, there is ample room to improve the skills of staff with regard to caring service users with dementia. 9 out of 17 comments cards from relatives and visitors to the home suggest that there is not enough staff in the home. One of them mentioned that this leads to ‘insufficient attention to the personal hygiene of service users and teeth not being cleaned’ (see section under ‘Choice of Home’) another said that ‘service Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 22 users are put in their chairs in the lounge where they stay for most of the day with little interaction’. The inspector looked at four personnel files. They contained all the necessary information as schedule 2 of the Care Homes Regulations 2001. There was evidence that CRB checks have been received for each member of staff before they started work in the home. The home has a health questionnaire for new applicants, but it did not clarify if staff have had appropriate immunisation to work in a social and health care area. Inspection of the four personnel files and the training that these members of staff have received showed that most of them have received statutory training and other training, which have been arranged in house. The manager has provided the inspector with a training programme and part of a training plan, which she has started. The aims and objectives of the plan were sent to the inspector but the links of the training programme with the aims and objectives were not made and the actions to meet the aims and objectives were not sent. The home had a requirement during the last inspection that the training plan is based on the individual training profiles of staff. The staff nominated or the numbers of staff to attend the training were also not identified. Without this it would not be possible to measure the outcomes and success of the training plan. It is recommended that the manager now look at the actions, which need to be taken to enable the home meet the aims and objectives of the learning plan and based the plan on the individual training profiles of staff. There was evidence that a range of training was being provided for staff including in dementia care, managing aggressive behaviour and in mental health. However the home should now monitor the outcomes of the training that it provides to ensure the effectiveness and usefulness of the training in promoting good practice and changing poor practice. This was particularly applicable in relation to dementia care. Staff have had training in this area but the outcomes of this training on the care of service users were not evident. The home should also monitor the content of these training courses to judge if they are appropriate to make staff competent in looking after service users with dementia. Courses in some cases can take place over a period of days if not weeks but can also take place over a couple of hours. The fact that staff have received training in dementia does not therefore necessarily make them competent to care for service users with dementia. As well as reviewing the length of the courses, there is a need for those who have had training to be tested and for them to reflect on what has been learnt and how to apply the knowledge, which has been received in the delivery of care. The deeper and the more comprehensive the content of courses the greater the likelihood that staff will be appropriately trained. Most of these courses are also likely to contain an element of reflective practice. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 and 38 The manager, with the support of the management team, provided the reassurance that she will be able to discharge her responsibilities fully. The organisation has good systems for the management of service users personal monies. Service users were on most occasion safe in the home. A few issues were identified which could put service users at risk. EVIDENCE: The fact that a number of standards were partly or not met and that little improvement was achieved since the last inspection is probably due to the fact that the home has not had a stable management team. The current manager took her post in December. She is a trained nurse and has managed a care home in the past. She indicated that she would be undertaking the NVQ level 4 in management in the near future. She was aware of the issues that needed to be addressed in the home. The minutes of a Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 24 service users’/relatives meeting held prior to the unannounced inspection showed that a number of these issues were discussed in the meeting. She is closely supported by the regional manager who is familiar with the home, as the latter previously managed the home. The administrator was not on duty during the inspection and therefore the inspector was unable to look at the management of the personal monies of service users in detail. The regional administrator was however in the home on the day of the inspection and she stated that she would be conducting audits to monitor service users personal monies. Access to the monies of service users is only possible by head office staff who carefully review the requests from the home administrators. They also require copies of receipts to substantiate the requests. Personal monies paid by local authorities are credited as and when they are paid, to service users individual balance. There was therefore the possibility to reconcile the money which was received with what was spent and with the balance. Overall the inspector judged that there are good systems in place for the appropriate management of service users money. The inspector looked at the health and safety records in the home. Most were up to date. Some certificates, which were not available for inspection at the time, were later forwarded to the inspector. The home had a fire risk assessment, which was up to date, and a health and safety risk assessment, which needed to be reviewed. The manager stated that she was in the process of updating the health and safety risk assessment. There are small kitchenettes on each unit, from which food is served to service users. The inspector noted that the kitchenette on the Merlin unit could have been cleaner and that the fridges on the Merlin and Avalon units contained a number of food items with no date of opening, no names of service users and some of which have passed their expiry dates and had already gone bad. The inspector saw that there were two broken chairs in the lounge of the Merlin unit. These were taken away when the inspector pointed these out. However staff in the home should be vigilant enough to be able to identify health and safety issues and to take appropriate actions if this is required. The inspector noted the presence of risk assessments/care plans dealing with the bruises of service users. One said ‘bruises of skin secondary to old age’ another said ‘at risk of spontaneous bruising’. The inspector also noted that out of 23 accidents/incidents, which occurred during the period from 28/12/05 to 24/01/06 on the Merlin unit, 12 of these did not have a reason or a cause. Most of these accidents/incidents included bruises and skin tears, which were observed on service users. There was no indication that there was some sort of investigation to look into the likely causes of the accidents/incidents in view of having a preventative plan of action in place. The manager stated that she would be monitoring all accidents in the home and will devising a form for this. A from was later sent to the inspector. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 25 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 X x 2 2 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 x x 2 Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14(1,2) Requirement The registered person must ensure comprehensive assessments of the needs of service users in the home, including assessments of the mental health needs (Previous requirement- timescale 15/5/5 not met) The registered person must ensure, either by training or otherwise and by continuously reviewing the skills and numbers of staff, that staff are skilled and competent to meet the needs of service users. The service user’s plan must set out in detail the actions that need to be taken to meet the health, personal and social care of service users. Care plans must be reviewed at least monthly or according to the review dates as indicated within the care plans. The registered person must ensure that referrals to the appropriate healthcare professional are done in a timely manner. There must be enough DS0000022931.V281248.R01.S.doc Timescale for action 30/04/06 2 OP27OP4 18(1) 30/04/06 3 OP7 15(1) 30/04/06 4 OP7 15(2) 31/03/06 5 OP8 13(1)(b) 30/04/06 Knights Court Nursing Home Version 5.1 Page 27 6 OP8 12(1) 7 OP10 12(1) 8 OP9 13(2,4) 9 OP11 15(1,2) records in the home to show that service users are seen at least yearly by the optician and dentist. Service users’ vital signs must be monitored within appropriate intervals of time, when they are unwell, such as in cases when they have chest infections or urinary tract infections. All service users must be dressed appropriately and must have a high standard of personal hygiene (Previous requirement- timescale 15/8/5 partly met). The registered person must address the following issues with regard to medicines: • Ensure that all medicines charts are signed appropriately when a medicine has been administered or a code used when not administered. • Ensure that the amount of all medicines received into the home is recorded as appropriate • Ensure that nurses who administer medicines have as good knowledge of the medicines that they administer and that any anomalies are clarified before administration of the medicine. • Ensure that appropriate risk assessments are in place when medicines are being administered in an altered state and that the route of administration is clearly identified on the medicines chart. The registered person must ensure that the care plans of DS0000022931.V281248.R01.S.doc 31/03/06 31/03/06 31/03/06 30/04/06 Knights Court Nursing Home Version 5.1 Page 28 10 OP12 16(2) (m,n) 11 OP18 13(6) 12 OP19 23(1)(a) 13 OP24 16(2)(c,d) 23(1) 16(2)(c) 14 OP24 15 OP24 23(2)(n) service users contain comprehensive information about the wishes and instructions of service users with regard to end of life care and about managing the death of service users (Previous requirement- timescale 31/8/5 not met). There must be a comprehensive assessment of the social and recreational needs of service users and a care plans must be in place when needs have been identified (Previous requirement- timescale 31/8/5 not fully met). The registered person must ensure that the relevant PoVA procedures are followed when there are allegations or suspicions of abuse. The home must have a comprehensive redecoration and refurbishment plan to ensure that the home continues to provide a high quality environment for service users. The bedrooms of service users must be personalised to a high standard according to the tastes of the service users . The registered person must ensure that the bedrooms of service users contain appropriate furniture, which is in good order (Previous requirementtimescale 31/8/5 not fully met). Adjustable beds must be provided for service users requiring nursing. The registered person must also consider positioning the beds to allow access to staff on either side of the bed. Appropriate headboards must also be provided for these beds. DS0000022931.V281248.R01.S.doc 30/04/06 30/04/06 30/04/06 31/05/06 31/05/06 31/05/06 Knights Court Nursing Home Version 5.1 Page 29 16 OP26 23(2)(d) 17 OP38 13(3,4) 18 OP38 13(4); 12(1) The registered person must ensure that there are no odours in the home and that the carpets/walls are kept clean at all times. All food stored in the fridges of the kitchenettes must be appropriately labelled and dated when opened. Regular checks must be made to ensure that all food, which have passed their expiry dates, are disposed of promptly. The registered person must ensure that all accidents in the home, including unexplained injuries to service users, are appropriately investigated and monitored for the safety of service users. 31/03/06 31/03/06 30/04/06 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 Refer to Standard OP7 OP8 OP8 Good Practice Recommendations The registered person should involve service users/representatives not only in drawing care plans but also in the review of care plans. It is recommended that photographs or wound mapping are carried out at least monthly to monitor the progress of pressure sores. The home should consider providing a jug of water to all service users within an appropriate and realistic risk assessment system. If this is not possible then consideration must be given to the provision of a closed container such as a bottle. It is recommended that the manager review the need to change service users into their nightdresses, when they are clearly not ready to go to bed. The registered person should consider whether service users bedrooms’ doors need to be kept open, taking their DS0000022931.V281248.R01.S.doc Version 5.1 Page 30 4 5 OP10 OP10 Knights Court Nursing Home 6 OP15 7 OP15 8 9 OP29 OP30 10 OP30 privacy and dignity into consideration and balancing that with other reasons for the doors to be opened. The registered person should review the menu particularly with regard to the content of the meals for the suppers to ensure that there are not many repetitions and according to the tastes of service users. In view that there is about 15 hours between supper and breakfast on the following day, it is recommended that snacks are offered to service users rather than service users requesting for these. That the immunisation status of new employees is considered and monitored as part of the recruitment process. It is recommended that the manager look at the actions, which need to be taken to enable the home meet the aims and objectives of the learning plan, based on the individual training need of staff. It is recommended that the home identify a process for monitoring the outcomes and efficacy of the training that it provides for staff in view of promoting good practice and changing poor practice and in order to make staff ‘competent’ to do their job. Knights Court Nursing Home DS0000022931.V281248.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 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. 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