Inspection on 06/05/08 for Knights Court Nursing Home

This inspection was carried out on 6th May 2008.

CSCI found this care home to be providing an Adequate 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

Knights Court Nursing Home 16/04/09

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 25/01/06

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Knights Court Nursing Home 107 High Street Edgware Middx HA8 7DB Lead Inspector Mr Ram Sooriah Key Unannounced Inspection 10:30 6 and 7thMay 2008 th 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.V362545.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. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Knights Court Nursing Home Address 107 High Street Edgware Middx HA8 7DB 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 knightscourt@lifestylecare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd Care Home 80 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (maximum number of places: 40) 2. Dementia - Code DE (maximum number of places: 40) The maximum number of service users who can be accommodated is: 80 30th July 2007 Date of last inspection Brief Description of the Service: Knights 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. Lifestyle care Plc has been taken over by Southern Cross Healthcare from the 26th February 2007. The home is found off the Edgware High street and it is easily accessible by buses, the underground and by car. The bus and tube station is about five minutes walk away. The home benefits from a large parking facility for at least ten cars. 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 residents in 4 units. Each unit is selfcontained and has a kitchenette area, lounge/dining areas, bathrooms and toilets. All the rooms are single and are en-suite. The Camelot and Avalon units are on the ground floor and the Merlin and Excalibur units are on the 1st floor. The Merlin unit is registered for twenty elderly residents with dementia requiring nursing. The Excalibur unit has also recently been registered for twenty residents with dementia care needs, when it was previously registered Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 5 to provide care for elderly residents requiring nursing. The other two units can each accommodate twenty elderly residents with nursing needs. The 2nd floor contains the laundry, kitchen, managers office and staff areas. The home charges £575 to £900 depending on the needs of the residents and the funding authorities. The funding authorities have their own fee systems. There were 63 residents in Knights Court at the time of the inspection. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This is the first key inspection for the period 2008-2009. The unannounced inspection started on Tuesday 6th May from 10:30-19:00 and continued on Wednesday 7th May at 08:15-14:15. After the fieldwork we were able to give feedback to Angie Knight, operations manager, and to Charlotte Bonsu Kyeretwie, acting manager. During the inspection we talked to some residents, a few visitors to the home and to some members of staff. We toured some of the premises, looked at a sample of records and observed care practices. We also received four comment cards from residents and five from relatives of residents. The operations manager kindly completed an Annual Quality Assurance Assessment (AQAA), which was forwarded to the commission. This was completed satisfactorily. The AQAA has been used where possible in writing this report. We would like to thank the residents and visitors for talking to us to share their experiences about the service, all people who returned comment cards and the operations manager, the acting manager and all Knights Court staff for their cooperation and support during the inspection. What the service does well: Residents and their relatives are encouraged to visit the home and are offered the opportunity to ask questions prior to them deciding if they want to move into the home. Prospective residents’ needs are assessed by the acting manager to make sure that the home would be able to meet the needs of the residents. The residents and their relatives are also able to ask questions about the service at this stage. Once admitted residents/representatives are given a contract/statement of terms and conditions to make them fully aware of their rights and obligations. All residents presented as clean and appropriately cared for. Clothes were appropriately ironed and suitable for the weather. One relative commented that ‘my relative’ appearance is always clean and tidy. She is always in clean and matching clothes’. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 7 Residents had individual care plans that are kept in good condition. These are reviewed at least monthly. The home has a good programme of activities that take into consideration the general and individual social and recreational needs of residents. It benefits from a group of volunteers: the friends of Knights Court that is involved in fund raising and in assisting with the provision of activities. Residents benefit from a well maintained home with a redecoration programme that is adhered to. All residents have single bedrooms that are also maintained and in a good state of redecoration. Furniture is generally in good order. One relative said ‘the home is warm’ and ‘residents are able to enjoy the privacy of their bedrooms’. The home is well supported by the deputy manager who has been acting in the absence of a manager. The operations manager is also very involved in the management of the home to ensure improvement of the service. Health and safety issues are addressed as required and maintenance of equipment is carried out as appropriate to make sure that people who use the service are safe. What has improved since the last inspection? What they could do better: The home says that residents and their relatives receive information about the service and are encouraged to visit the home to find out more about the Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 8 service that the home offers. Three out of four residents said that they did not receive enough information at the point of moving into the home. There is therefore some room for improvement in this area. It was noted during the inspection that the information that is provided in some of the bedrooms of residents was out dated by about four years. Although this issue was immediately addressed, the home should have systems in place to prevent this from happening. In a few instances residents’ were allocated to units, which did not cater for their needs. The home must therefore make sure that all the needs of residents are appropriately considered prior to accepting the residents and to allocating the residents to the various units. Care plans were not always as individualised as they should have been and have not been kept up to date when there have been changes in the needs of residents. A number of issues were noted with the management of medicines, which could be putting residents at risk. These must be addressed to promote the safety of people who use the service. There was evidence that pain management in the home could be further improved to provide for the welfare of residents. This could be achieved by using the appropriate pain assessment tools and making sure that staff are competent and have a good understanding of pain management. Staff could be more involved in interacting and engaging with residents. This may require a review of the number and deployment of staff as well as the skills and competencies of staff. One relative commented that ‘the meals are regular although quality could be better’. Another said that ‘the menu needs to be better thought out to provide more variety’. The findings during the inspection with regards to the standard of catering suggests that regular feedback is required about the menu and the meals and that these must be addressed promptly to resolve the issues. Whilst the standard of redecoration of the home is generally good, some of the bedrooms of residents are not as personalised as they could have been. This included bedrooms on the dementia care units, where a familiar environment can lead to improving the orientation of residents who may have some degree of cognitive impairment. The staffing levels were the subject of three complaints to the home and of one complaint made by a number of relatives of residents, to the head office. It was clear that residents/relatives thought that the staffing was not adequate to make sure that the needs of residents would be met. It is therefore an area that requires attention, as people would not raise this as a concern if they were satisfied with this aspect of the service. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 9 Some members of staff were not knowledgeable about the abuse (safeguarding adult) policy and procedures of the organisation and were not clear about the whistleblowing procedure. Despite having provided training in this area some members of staff appear not to be competent. This was also noted in other areas where training was provided to staff. For example staff have been provided training in customer care and in dementia awareness, but the standard of interaction and engagement of staff with residents was not as good as this should have been. The home does not have a registered manager as is required by legislation, but there was clear evidence that the home was actively recruiting a manager. It is imperative for the service to have a capable manager who will lead by example and who will ensure continuous improvement of the service. The service has in the past been rated as poor, is now adequate, but must aim to be good. Appropriate records must be available in the home to fully audit the management of residents’ personal money. In cases where residents do not have relatives, decision should be made with regards to residents being referred to the Court of Protection. 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. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1-4 Residents who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives receive some information about the service to enable them decide if they would like to use the service. Residents’ needs are assessed prior to them being offered a place in the home but the needs may not all be taken into account when accepting a resident to the home and allocating hi/her to a unit. EVIDENCE: The deputy manager stated that copies of the service users’ guide (SUG) are provided to all residents or to their representatives when the residents move into the home and that there is a SUG in each of the residents’ bedrooms. While touring the premises we noted that the SUG’s that were in residents’ bedrooms were dated 2004. These were out of date with regards to some of the information that they contained and when this was pointed out to the deputy manager she immediately arranged for new copies of the SUG to be placed in each bedroom of residents. The new version was up to date and Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 12 contained all the necessary information as required by legislation. The AQAA states that, “Prospective residents and their families are supplied with all the written information needed in order for them to be able to make a choice about the Home before they visit”. The AQAA also showed that residents or their representatives are invited to visit the home, to meet staff and other residents and to ask questions about the service. Three out of four residents said that they did not get enough information about the service before moving into the home. One resident said that ‘I visited the home but did not receive any information in the post’. While this is an area where there could be improvement it must be noted that at times residents are funded by local authorities who have contract beds with the home. We checked whether residents who were newly admitted to the service have received a contract/ statement of the terms and conditions of stay in the home. Two residents were chosen at random and their files checked. It was noted that each had a contract/statement of terms and conditions. This is commended as the home makes sure that residents or their representatives are fully aware of their rights and obligations while they live in the home. The preadmission assessments of two residents were inspected to check whether the home carried out appropriate needs’ assessments prior to offering a place in the home to residents, to make sure that the needs of the residents would be appropriately met in the home. This is also required for the home to allocate residents to the various units as they do not all accommodate residents with similar needs. These were in place in the care files and were on the whole appropriately completed. Whilst looking at the care records of two residents who were accommodated on a dementia care unit, we noted that none of them had clear dementia care needs. They might have had mental health needs, but the unit is not registered for people with mental health needs and staff are not trained to care for this group of people. There was little documentation to support the rational for admitting these residents on a dementia care unit. One resident said, “There are no other residents that I can talk to and some of the residents wander into my room and touch my things. Staff do not always have the time to talk to me”. We therefore concluded that the home was not able to conclusively demonstrate how it was going to meet the needs of a few residents and that admission of the residents to the various units in the home was not always carried out according to the residents’ needs. Knights Court Nursing Home DS0000022931.V362545.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): 7-11 Residents who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are not comprehensive and individualised enough to make sure that all the needs of residents were appropriately addressed. The home does not demonstrate convincingly that it is meeting all the healthcare needs of residents. A few issues are noted with medicines management, which could be putting residents at risk. Care practices in the home do not always promote the privacy and dignity of residents. The end of life care that residents receive may not always be according to their needs as their wishes and instructions are not always recorded and identified. EVIDENCE: We looked at the care plans of six residents and spoke to two of them about their care. We also observed the delivery of care and interaction and engagement of staff with residents particularly on the dementia care units. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 14 The care plans varied in degree of comprehensiveness. Some were very well completed and appropriately described the needs of residents and the action to take to meet these needs, but others were not so good. The assessment of the needs of residents generally addressed the physical needs of residents but tended to miss issues such as sexuality, dying and likes and dislikes. One dementia care unit tended to use the dementia care assessment for all residents while the other dementia care unit did not always use this assessment format. When completed this can be very useful and provides all the necessary information about the dementia care needs of the individual. There were appropriate risk assessments in place that addressed the safety of residents and in cases where the liberty and freedom of residents might be curtailed such as by the use of bed rails. For example one resident had a risk assessment with regards to being let out of the dementia unit and of the home. Another resident at risk of bruising also had an appropriate risk assessment in place. It was noted that these were in the main agreed with residents or their relatives. Care plans on the whole addressed the needs of residents and were reviewed at least monthly but these were not always amended to reflect changes in residents’ needs. One resident who was re-admitted to the home from hospital has not had the care plan on tissue viability reviewed. It said that the resident was getting up at 08:30 and going to bed at 19:30 when the resident was confined to her bed. Another resident had a care plan for weight loss when she has in fact been gaining weight. The care plan for a resident who needed supervision said to use ‘covert supervision’ but did not clarify what was covert supervision. Another resident who threatened staff with an object did no have a care plan or risk assessment in place to address this issue to ensure the safety of staff and other people. It was noted that residents or their relatives were not always involved in the care planning process. There has not been much improvement in this area, if not there has even been a regress. One resident who manages her own affairs said that she has not been consulted about her care. Relatives raised concerns during a relatives meeting that they have not been invited for an internal review of the care plans as per the home’s policy. Care plans did not always take into consideration the cultural and religious needs of residents and these aspects of care were not always incorporated into the care plans of residents. It was not always clear whether residents were practising their religion and whether they needed support in these areas. The home accommodates a number of Jewish residents. The care plan of one resident who was Jewish did not always address an assessment of the needs of the resident with regards to the meals that he/she took, activities that he/she enjoyed and care of the dying. One relative commented that ‘they (the home) Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 15 cater for the majority but nor for the minority’. The operations manager stated that she planned to arrange training for staff in person centred care and making care plans more reflective of the individuality of residents. There were two residents with pressure ulcers in the home. One was admitted with the pressure ulcers and the other resident developed them in the home. There was evidence that appropriate pressure relief equipment was provided to residents who had pressure ulcers or who were at high risk of developing pressure ulcers and that care plans were in place addressing the action to take to promote healing of the pressure ulcers. Care plans also included the time for residents to sit out and the repositioning regime in place to manage the pressure ulcers. From the care records it was noted that referrals were made to the tissue viability nurse for advice about the management of the pressure ulcers. Whilst there was a body map, care plan and progress notes it was noted that there were no photographs or wound mapping in place to monitor the progress of the ulcers. In fact there were no photographs of residents who have been recently admitted either in the care records or in the medicines charts to help with the identification of residents. It was noted that a resident who had pressure sores, did not have a pain assessment or even prescribed analgesia. She had a care plan, which said ‘if in pain please give prescribed analgesia, if not prescribed liaise with GP’. The resident was not prescribed any analgesia. We were informed that the resident was still waiting to be registered with a GP. There were at least two other residents who were on strong painkillers. They did not have pain assessment charts to monitor if the analgesia was effective in controlling the pain. We asked a nurse if she understood what was ‘breakthrough’ analgesia, (a pain killer which is given as required, in addition to regular pain killers as part of a medication regime to manage pain). She was not aware of this. Residents are seen by the GP and the optician on a regular basis. They are also referred to the hospital for medical and healthcare reasons if required. Feedback during the inspection showed that there is not a good NHS service from the dentist and the chiropodist. These services are provided by the local PCT and the operations manager stated that the home would make the necessary contacts to resolve these issues. Other services such as physiotherapy and occupational therapy are provided by the community services after referral by the GP. During the inspection we observed the interaction of staff with residents on the dementia care units. We noted that on arrival on the Merlin unit that there were no staff in either of the lounges and that residents were left without supervision. One resident was talking repeatedly which seemed to distress other residents. Two other residents were mobilising with their Zimmer frames in the lounges. The radio was tuned to one of the stations that played modern music. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 16 On one occasion we noted a member of staff imitating the same type of noise that a resident was making. One resident said that he was cold and a carer said that he was not cold as it was a hot day. However that resident was sitting opposite a window and could have been getting a draft. Another resident who was getting up to go for a walk was told to ‘sit down’. On another occasion a carer was heard saying ‘look at the way he is walking’ while making comment about the way a resident was walking. We overheard a member of staff saying ‘good boy’ to a resident after the resident followed an instruction. Five relatives commented that staff did not always have the time to interact and engage with residents because there are not enough of them and two mentioned that staff might not be experienced and competent enough to care for the residents. As a result of the above we concluded that some staff members still lack basic understanding of dementia care even though there was evidence that most members of staff have had basic dementia care training. Staff may have had the training but have learnt little from the training and therefore may require more in depth training in this area. The deputy manager said that more staff would be trained in the ‘Yesterday, Today and Tomorrow’ programme in dementia. The home accommodates a number of frail residents and as they get frailer there are a number of them who pass away in the home. Therefore staff do have experience caring for residents who are dying. However it would have been good if the end of life care that the residents received, represented their documented wishes and instructions. The operations manager stated in the AQAA that the home ‘provide care to residents towards a peaceful death using the Liverpool Care Pathway (LCP)’. In another part of the AQAA it was mentioned of the plan to introduce the Gold Standard Framework (GSF) also to manage end of life care. It is positive that the home was looking at using the LCP and the GSF to provide ‘good outcomes’ for people who require end of life care. The care records contained sections addressing dying, fears for the future and instructions with regards to resuscitation. We noted that the section of the care plan addressing the resident/relatives’ instructions with regards to resuscitation was on the whole appropriately completed, but care records did not always contain comprehensive information about end of life care of residents and about their hopes, fears, wishes and instructions with regards to their future and death. One resident who was very frail did not have such a care plan. Care plans on end of life mentioned that staff ‘should allay their (residents’) fears and anxieties … and assist with spiritual needs’. These were however not identified and described and it was therefore not clear how the residents’ needs with this aspect of care would be met. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 17 Medicines management was inspected on the Excalibur, Avalon and Merlin units. The standard of medicines management varied from units to units. Medicines were kept in two clinical rooms that were air-conditioned. It was noted that none of the air-conditioner units was working at the time of the inspection. One was not switched on and the other was reading a fault. There were daily records of the temperature, which indicated that at times the temperature was 25 degrees centigrade or above. On the day of the inspection a thermometer read 28 degrees centigrade. No one seemed to have noted or taken action to address this issue. There were some good practices in the home such as recording the amounts administered when a variable dose of medicines had been prescribed and clearly identifying, on the medicines chart, the location where creams and ointments were to be applied. Most medicines were signed when administered or a code was used if not administered. In one case a medicine was not signed on a number of occasions to indicate whether it was being given. It was noted that the amounts of a few medicines were not recorded when received into the home. We were informed that risk assessments were in place when medicines were crushed/disguised to be given to residents. In two cases that we checked there were risk assessments in place. In one case however we noted that a resident’s whose medicines were being crushed did not have a risk assessment in place. An eye medicine, which had expired, was still on the trolley and there was no freshly opened container of the eye medicine. The management of controlled medicines was carried out to a good standard and robust records were kept. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 18 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): 12-15 Residents who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from a range of activities that are provided in the home but staff could be more involved in the provision of activities and could engage to a larger extent with residents Meals that are provided to residents are suitable to meet their needs, but the system of feedback about the meals must be more effective to make sure that issues are addressed before they escalate. EVIDENCE: The home has a full-time activities coordinator mostly for the Avalon, Excalibur and Camelot units and a part-time activities coordinator who is mostly located to the Merlin unit. The full time activities coordinator was on annual leave at the time of the inspection, so the other activities coordinator was responsible for coordinating the activities in the home. There was a yearly plan for activities based on the various holidays and special occasions and there was also a monthly plan. The home benefits from a few volunteers (The Friends of Knights Court) who are involved in fund raising and in supporting the activities coordinator in arranging suitable activities, Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 19 including outings, to promote the quality of life of residents. They are commended for the wok that they do. Care records contains appropriate information about the social and recreational needs of residents and care plans were in place addressing these identified needs of residents. There was evidence of some activities being arranged for residents during the inspection but most of the times residents were seen in front of the TV. On one unit the radio and the TV were on at the same time. On one of the dementia care units, the radio was tuned to a station playing modern music. We observed that the interaction of staff with residents mostly included staff giving instructions to residents rather than a one-to-one communication and engaging with the residents. One relative stated in the relatives’ meeting in March that ‘there are some members of staff that do not talk to residents at all’. Another said in the comment card that ‘it is heart breaking to see them (residents) just sitting and falling asleep’. As mentioned previously a number of relatives said that the lack of interaction is related to the fact that there are not enough staff and to the lack of skills and competencies on the part of staff. There was evidence of some outings being arranged for residents, but this was limited. We were informed that the home books a mini bus to take residents out for trips to places of interest. There is normally an annual trip to the seaside. The home uses the ‘NUTMEG’ menu system from Southern Cross, which looks, not only at variety but also at the nutritional content of meals. Relatives of residents have raised concerns in a letter that they wrote to the management of the home and in the relatives’ meeting about some of the meals that are provided by the home, mostly about the quality of the meat that is provided and about using pre-packed food rather than making food from fresh ingredients. We were also informed during the inspection that some of the meat that was provided to the home was not of suitable quality for the residents and that this situation has now been resolved. It seems that the comments and concerns that have been raised by residents had been taken on board and were being addressed. However the standard of catering should not have been allowed to drop and dissatisfaction about the meals should have been noted earlier and action should have been taken to resolve the issues to prevent an escalation to an extent where relatives felt the need to write to the head office. On the first day of the inspection lunch consisted of chicken breasts, mixed vegetables, cauliflower and potatoes. There was lemon meringue pie for desert. Supper consisted of spice onion soup, sandwiches or bugger in a roll Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 20 and jelly or ice cream for desert. There was also evidence that residents were asked about their choices, which were recorded and sent to the kitchen. We also noted that residents were offered other meals if they did not eat what was on the menu. We thought that the meals that were provided were suitably varied and nutritious for residents. We spoke to a visitor during meal times and on the whole it seems that there has been an improvement in the provision of meals. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 21 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 and 18 Residents who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who complain can be confident that their complaints are taken seriously and will be dealt with appropriately as per the complaints procedure. Staff did not seem to be familiar with the abuse (safeguarding adult) policy and procedure and with the whistle blowing procedure to ensure the protection of residents. EVIDENCE: The complaints procedure was available in the foyer and in the service users’ guide, which were available in the bedrooms of residents. There was also a suggestion box in the foyer of the home. The complaints register was inspected. Since the last inspection in July 2007 there has been thirteen complaints. Of these two were about wrong fees being requested, five were about care issues and three were about staffing levels. All complaints were appropriately investigated and responses were sent to the complainants. Two of the complaints also included referrals being made to the safeguarding adult team for Harrow. These were not substantiated after investigations were carried out. A number of relatives of residents wrote a letter to the head office to complain about a number of aspects of the service. These were not recorded in the complaints register but we were told that this was recorded at the head office. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 22 Following this letter, the operations manager met with the relatives of residents and together with the deputy manager drew up an action plan to address the issues. The Commission as part of its remit carries out inspection about specific areas to get information about the national picture. On this occasion we looked at as well the service would deal with issues about safeguarding adults. We spoke to three members of staff and found that none of them were familiar with the term ‘safeguarding adults’ but they were familiar with the term abuse. One member of staff had not received training on this matter and two have had. One has not read the safeguarding adult policy and procedures, one has read it but could not remember what it said and the third person was able to say what the policy and procedure was about. Two said that they would report any suspicions or allegations of abuse to the person in charge without delay and the third said that they would ‘calm and ask the resident’. Two have not heard of the whistleblowing procedure and the third was able to say something about it. The person in charge knew exactly what to do if a suspicion or allegation of abuse is reported to her. In the past she has dealt with allegations and suspicions of abuse appropriately. We therefore concluded that whilst training is provided to nearly all staff on abuse (safeguarding adult) and whilst they know that there is an abuse policy and procedure they do not always read it and their knowledge is not always tested and reinforced such as during supervision. They all needed to be familiar with the whistleblowing procedure. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 23 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, 24 and 26 Residents who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment is generally suited for the residents that are accommodated in the home. The standard of cleanliness could be improved to make sure that the home is cleaner. EVIDENCE: We noted that the grounds of the home were not appropriately maintained on the first day of the inspection. Lawns, shrubs and bushes were not kept trimmed and maintained. There were no flowers in pots or in hanging baskets to present the home in a more pleasant and attractive manner. We were informed that the home did not have a gardener and that it was the handyman’s responsibility to maintain the grounds of the home. On the second day of the inspection he was observed attending to the lawn. We hope that as summer approaches, there will be more input into making the grounds of the home a more pleasant environment. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 24 The exterior of the building was in the main in good condition. The inside of the home was maintained and there was evidence of ongoing maintenance and redecoration. A few bedrooms have been recently redecorated and according to the redecoration plan of the home, other bedrooms have been identified for redecoration, including at least one where there was a hole in the plaster. Carpet has also been replaced in some bedrooms. We were informed that the home plans to have all the communal areas redecorated in the near future. Communal areas were appropriately furnished and it was noted that a few additional items of furniture have been provided on some units. Most lounge areas have a television. However the television in one of the small lounges on the Excalibur had a small television (most likely a 14-inch TV). It is recommended that a bigger TV be provided, where there are small TV’s in communal areas to make sure that residents can see the picture more clearly. Bedrooms of residents were on the whole appropriately decorated and furnished. Most residents have an adjustable bed and at least one seating facility. Some were personalised to a good standard with pictures, photographs and personal items of decoration. However there were a few bedrooms in the home still with bare walls and few items of decoration. This might be seen as impersonal to some observers. In our view there are still improvement that can be made in this area. The beds in a number of bedrooms were untidy and have not been made appropriately. Residents’ clothes were also at times placed untidily in the drawers. One relative commented that ‘my mother’s room is very messy’ We noted that the home was clean in most areas. A few ‘not so obvious’ areas were not as clean as they should have been. These included beds’ frames, tops of picture frames and top of televisions that were on brackets. The home was mostly free of odours except for a slight odour in one area on the Avalon unit. One of the sluices was used to store chair cushions and frames. The sluice areas must not be used to store things as this could lead to cross contamination, since the sluice is the ‘dirty area’ of the home. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 25 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): 27-30 Residents who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the home states that it provides adequate staffing levels, feedback from a number of sources suggests that there are times when this did not seem the case. To further improve the robustness of the recruitment procedure, a full work history is required to make sure that the checks have been thorough. Staff receive training to make sure that they are competent to care for residents but the impact of the training must be evaluated to make sure that the training is effective in changing practices and in improving the quality of the service. EVIDENCE: There are normally one trained nurse and three carers on each unit during a day shift. At night there are one trained nurse and three carers for the Camelot and Avalon unit on the ground floor and one trained nurse and a carer for the Excalibur and Merlin units each. Staffing has been the subject of three complaints to the home and of concern to the relatives of many residents. The complaints were investigated by the organisation and were found not to be substantiated. The AQAA states that the home provides adequate staffing levels. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 26 According to the minutes of the relatives meeting in March, issues surround the lack of staff and staff not being replaced when there are shortages such as when staff are sick. Relatives raised concerns that they have noted that at times there were not enough staff to feed residents which resulted in food getting cold, not enough staff to give baths and showers to residents and to take them to toilets and to change the incontinence pads which resulted in many becoming wet. They also mentioned that residents were going to bed early to alleviate the work load, staff at times lacked skills and competence and that a number of staff did not interact and communicate with residents in an appropriate manner. They added that a few members of staff sat in other areas and not with residents and were more concerned about the paperwork than to engage with residents. One relative mentioned that her relative is not always changed for bed. She said that ‘ he gets in bed with day clothes on. If a good nurse is on she sees that he is changed. One nurse just does not bother’ All five comment cards from relatives suggested that the home does not have enough staff. They say that as a result staff do not have the time to interact and engage with residents and that at times there is not enough staff in the communal areas. One said that she has come often to the home when there is no one in the communal areas between 13:30 and 14:30 as staff are busy attending to residents in the bedrooms or on their lunch breaks. We have also noted that there were no staff in the lounges of the Merlin unit when we started the inspection at about 10:30. One comment card from residents said that there is usually enough staff on duty, two said sometimes there are enough staff and one said there are never enough staff. We have discussed the issue of skilled and competent staff in the section under Health and Personal care. Two comments cards from relatives mentioned that staff are not always experienced and qualified to care for the residents. One said that ‘the home should only employ carers with appropriate qualification/experience’. Another relative mentioned that ‘there is a large turnover of staff, so new staff have to get to know residents and how to deal with them’. A third was concerned about staff leaving and new staff coming to work and who did not have enough experience and skills to care for the residents. The operations manager stated that staffing is always under constant review and that agency staff will be used where indicated. The AQAA also said that the home at times provide more than the staffing level that is required. However it is clear from the above that there is a strong feeling that staff levels as well as the deployment of staff in the home need to be reviewed in line with the needs of residents We looked at the personnel files of four members of staff to check if appropriate recruitment procedures were being followed. We noted that each Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 27 employee had an application form, two references, evidence that they could work in the UK if from abroad and a valid CRB check prior to them being offered employment. On one occasion an applicant was offered a letter offering him/her a job but this was before a number of checks was completed. We were informed that the wrong format letter was sent and that all applicants are offered a job if they have been successful at the interview and subject to the appropriate checks being completed. We found that two applicants did not have a fully completed work history and that as a result it was not clear if there were gaps in the employment history. We spoke to three care workers. Two said that they have received an induction and one could not remember but there was a record to show that the member of staff has had an induction. The home uses the induction package from Southern Cross Healthcare, which is based on the common induction standards from Skills for Care. We were informed that all members of staff receive induction at the point of starting to work in the home. A training matrix was kindly provided for inspection. This showed that most members of staff were up to date with statutory training which normally included safe working practices and health and safety topics such as fire safety, health and safety, food hygiene and manual handling. Training was also provided in a number of clinical areas and in areas required to ensure the wellbeing of residents including pressure area care, customer care and care planning. About half the staff team in the home have also received training in dementia awareness. From the training matrix we noted that five members of staff have received the yesterday, today and tomorrow training in dementia. This was not a lot considering that there were 2 units (about half the staff team) for dementia care. The deputy manager stated that she has identified some days to offer this training to staff. However as shown in section 2 of this report under Health and Personal Care, despite staff having had training on ‘Dementia Awareness’ and ‘Customer Care’ this has not necessarily led to changes in practice and improvement of the quality of the service for people with dementia care needs. The AQAA showed that out of 38 care staff there were 9 carers with an NVQ level 2 or above and 17 carers were in the process of working towards an NVQ level 2 in care. As a result the home does not yet have 50 of care workers trained to NVQ level 2 or above. We asked three members of staff if they receive supervision at least every two months or six times a year. They said that they do not receive regular supervision. The AQAA identified that this is an area where improvement is required. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 28 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 &38 Residents who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the home was being appropriately managed by the deputy manager with support from line management, the home did not have a manager who would assume the legal responsibility of managing the home and ensuring the safety and welfare of all residents who live in the home. The home has a quality management system to measure the quality of the service. The management of residents’ money was not supported by good and appropriate records. Health and safety issues were addressed to ensure the safety of all people who use the premises. EVIDENCE: The previous registered manager has resigned her post in February of this year. At the time of the inspection the home did not have a manager although Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 29 there was clear evidence that the home has been actively recruiting for a manager. The deputy manager was the acting manager and was being supported by the operations manager. The AQAA said that a new manager will be appointed within 2 months (from 15th May2008) The deputy manager has arranged for a relative’s meeting in February 2008 and there has been a follow up meeting in March 2008, which was attended by the operations manager. The meeting was attended by about twenty relatives of residents and a number of issues were raised. Relatives stated in the meeting that they have not had relatives’ meeting on a regular basis and have not been able to discuss issues that concerned them. The operations manager stated that relatives meetings would be held every three months. Staff meetings have also been held to offer staff an opportunity to discuss issues and to get their views about the service that the home provides. Minutes were kindly provided for inspection. As a significant number of issues were noted during the inspection and raised by relatives of residents, it is paramount to appoint a capable manager who will lead by example, and make sure that resources are appropriately allocated to ensure that residents’ needs would be met as far as possible. The home uses the quality assurance procedure and quality management system of Southern Cross. This consists of monthly audits, which are then validated every two months by the operations manager. These were being carried out. A customer survey for the year was in the process of being completed. There were reports available for inspection following monthly visits by the operations manager. The home is also ISO 9002 accredited. The management of residents’ personal money was inspected. The personal money of residents is pooled together in one account. A list of people who had money in the account and the amount of money that they had, was not available and therefore we were not able to fully inspect the management of residents’ personal money. We were informed that the home is in the process of opening a main account with sub-accounts for each individual resident that would then bear interest. Some residents also had a small sum of money in the home for day to day expenses. The records for 2 residents were checked. It was noted that the balances were correct and that receipts were kept for expenses. Residents’ valuables and property were recorded at the point of admission or when these were brought in for them. The records were in the main signed and dated. Records about safe working practices and the management of health and safety were comprehensive. There was evidence that hoists, lifts and items of Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 30 equipment were maintained and serviced. There were records of health and safety checks, including fire detector checks, emergency lights check, wheelchair checks, water temperature checks and there was also evidence that action was taken as required to address any issues that had been noted. A fire emergency plan and a fire risk assessment were in place. A health and safety risk assessment was also up to date. There were minutes of the health and safety meetings and these showed that action was being taken to address issues that were raised during the meeting. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 32 Are there any outstanding requirements from the last inspection? 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 OP4 Regulation 14(1,2) Requirement To make sure that the needs of residents are being met, the home must be able to demonstrate that residents are accepted in the home according to their assessed needs and placed in a unit according to their individual needs. The home must make provision to make sure that residents have up to date photographs in the care plans and medicines charts to easily identify them, and to take photographs of wounds and pressure ulcers to monitor the healing process. The care plans of residents must be individualised and completed comprehensively. Changes in the needs of residents must be recorded. Care plans must as far as possible take the cultural, religious and ethnic aspects of residents into consideration. This is necessary to make sure that the needs of residents are being addressed. To make sure that residents or their relatives are fully involved DS0000022931.V362545.R01.S.doc Timescale for action 30/06/08 2 OP7 17 31/07/08 3 OP7 15(1,2) 31/07/08 4 OP7 15(2) 31/07/08 Knights Court Nursing Home Version 5.2 Page 33 5 OP8 12(1) 6 OP8 OP10 12(1) 7 OP9 13(2,4) 8 9 OP9 OP9 13(2) 13(2) 10 11 OP9 OP11 13(2) 15(1,2) in the care of the residents, they must be consulted when care plans are drawn up and when these are reviewed. Residents must have a pain assessment when they have pressure ulcers, when they are on strong painkillers for pain or where their care plans indicate that the level of pain should be monitored. Staff must have training in understanding pain management where required. This is necessary to make sure that residents are as pain free as possible. Staff who look after residents with dementia must be trained and competent in these areas. This is necessary to make sure that the residents receive a high standard of dementia care and that the privacy and dignity of residents are upheld at all times. There must be effective monitoring of the clinical rooms’ temperature to make sure that medicines are stored at the right temperature. The air conditioning units must be repaired where required. To ensure the safety of residents medicines that have expired must not be administered To ensure the safety of residents appropriate risk assessments must be in place in cases where medicines are being crushed or disguised. All medicines must be signed when administered to make sure that there is a clear audit trail. Residents’ care records must address the end of life care of residents and their hopes, fears and wishes for the future to make sure all the needs of residents are fully addressed. DS0000022931.V362545.R01.S.doc 31/07/08 31/08/08 30/06/08 30/06/08 30/06/08 30/06/08 31/07/08 Knights Court Nursing Home Version 5.2 Page 34 12 OP12 23(2) (m,n) 13 OP18 13(6) 14 OP26 23(2)(d) 13(3) 15 OP27 18(1)(a) 16 OP28 18(1)(c) 17 OP29 19 Staff must be more attentive to make sure that the TV is not on as the same time as the music system and that the music that is played is according to the needs of the residents. All staff must be familiar with the abuse (safeguarding adult) policy and procedure of the home as well as with the whistleblowing procedure to make sure that residents are as safe as possible. All areas in the home must be kept clean, including areas that are relatively difficult to reach such as bed frames and the tops of picture frames and TV’s that are on brackets. The sluice must not be used for the storage of items that could be a vehicle for cross contamination. Bedrooms must be kept tidy and the beds must be made appropriately to give an air of tidiness. The home must carry out a written review of the number, skills and qualifications, and deployment of staff in the home in line with the concerns that are raised by relatives in the home and some of the findings during this inspection. A copy must be forwarded to the Commission. The registered person must ensure that a minimum of 50 of carers working in the home achieve an NVQ level 2 or 3 qualification in care to make sure that care staff are fully competent to care for residents. As part of the recruitment checks, applicants must have a full work history and all gaps in employment must be explored during interview with records kept. DS0000022931.V362545.R01.S.doc 30/06/08 31/07/08 31/07/08 31/07/08 31/05/09 31/07/08 Knights Court Nursing Home Version 5.2 Page 35 18 OP30 18(1)(c) 19 OP30 18(2) 20 OP31 8 21 OP35 17 To make sure that the training that is provided to staff is useful and effective, the impact of the training must be evaluated in term of changing practices and attitudes and improving the quality of the service. To make sure that staff are competent and supported in the job that they do, care and nursing staff must receive supervision at least every two months or six times a year. The home must have a registered manager as soon as possible as this is a legal requirement and to provide stability to the home, direction and support to staff and a reassurance to all stakeholders that the home is being managed to a high standard. Clear records must be available about the personal money of residents to enable a full inspection of the management of this aspect of the service. 31/07/08 31/07/08 31/07/08 31/07/08 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 Refer to Standard OP1 Good Practice Recommendations The service users’ guide in residents’ bedrooms must be kept up to date at all times to make sure that residents have all the up to date information about the service. The home should make sure that residents receive adequate information about the service before they move in to decide if this is the right place for them. That regular services be sought from a dentist and chiropodist to make sure that the healthcare needs of residents are being fully met. DS0000022931.V362545.R01.S.doc Version 5.2 Page 36 2 OP8 Knights Court Nursing Home 3 OP15 4 OP19 That the system in place to receive feedback about the meals that are provided be reviewed to make sure that issues that are raised are addressed before the issues escalate. It is recommended that a bigger TV be provided, where there are small TV’s in communal areas, to make sure that residents can see the picture more clearly. Knights Court Nursing Home DS0000022931.V362545.R01.S.doc Version 5.2 Page 37 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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