Inspection on 04/11/09 for Knoll House

This inspection was carried out on 4th November 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Knoll House 04/03/10

Knoll House 13/01/09

Knoll House 03/04/07

Knoll House 01/08/06

Knoll House 21/12/05

Knoll House 06/09/05

Knoll House 07/01/05

Knoll House 19/08/04

Knoll House 10/02/04

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Maple Lodge

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Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Knoll House The Avenue Penn Wolverhampton West Midlands WV4 5HW     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Tina Smith     Date: 1 9 1 1 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 36 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Knoll House The Avenue Penn Wolverhampton West Midlands WV4 5HW 01902335749 01902333575 knollhse@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Elysian Care Limited care home 32 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 32 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 (OP) 32 Physical disability (PD) 32 Date of last inspection Brief description of the care home Knoll House provides accommodation, personal and nursing for up to 32 people with physical disabilities and older people. The care home is near local shops and public transport, and has car parking. The detached property has single and twin bedded rooms, two lounges, dining room and garden, with a passenger lift to the first floor. Communal bathrooms and toilets are on both floors. Three offices are on the ground floor. Care Homes for Older People Page 4 of 36 Over 65 32 0 0 32 1 3 0 1 2 0 0 9 Brief description of the care home Fee information is in the statement of purpose. Weekly fees are £361 for personal care. For nursing care there is an additional contribution paid by the local Primary Care Trust after their assessment. Fee information applied at the time of our visit; up to date enquiries should be made to management. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The home was last inspected on 13/01/09 when four requirements were made and the quality rating improved to good. Prior to our visit, the home sent us their Annual Quality Assurance Assessment (AQAA), with information about the running of the home, what has improved and is planned for the future. Information from the AQAA and from other sources was also used when forming judgments on the quality of the service. We received 12 out of 32 surveys from people, relatives and staff. The home sends us notifications about legally required events, and we receive reports from other sources. A key inspection was brought forward because of ongoing multi-agency safeguarding concerns. The AQAA self assessment shows learning from statutory agencies but lacks critical analysis of health and safety, barriers and plans to address them. Two regulation inspectors visited the home on 04/11/09 for 11 hours. The home was Care Homes for Older People Page 6 of 36 not told we were coming. We looked around, observed mealtimes and medication administration. We spoke with 9 people, 6 staff and saw three peoples care and health records. A regulation inspector visited on 05/11/09 when we made two immediate requirements about medication safety and environmental hazards. On 19/11/09 the regulation inspector was joined by a pharmacist inspector. We spoke with several staff, management, contractors and a health professional, examined the medication system in depth and looked around the home. We made four further immediate requirements on this visit about medication, cleanliness and the environment. Records on the running of the home were checked about: staff, training, medication, maintenance and contractors, complaints, incidents, health and safety risk assessments. We saw the homes public information, certificates and quality monitoring. Policies and procedures were seen or discussed about medication, infection control, clinical procedures and human resources. The Manager and Personal Assistant to the Director were present throughout our first two visits, joined by a Director who is the responsible individual for Elysian Care Ltd. on our second visit when we discussed our findings. Over two visits, six immediate requirements were made to protect peoples health, safety and wellbeing. A full list of requirements and recommendations are at the end of this report. We are considering enforcement action and will oversee an improvement plan to check compliance that ensures sustained improvement. Care Homes for Older People Page 7 of 36 What the care home does well: What has improved since the last inspection? There is an activities coordinator who undertook fundraising for activities, day trips and celebrations. Events are advertised on posters with photos and in the Knoll House Gazette newsletter. After people were consulted, holy communion increased, an outing to the Botanical Gardens took place, and menus were changed. People were registered to use Ring and Ride so they can go out independently. In response to family and multi-agency concerns, a shift report system was introduced so that changes in people and their conditions are known. Local links were developed for more rapid access to specialist advice and treatment about pressure sores, falls and nutrition. Extra nursing equipment was purchased. The homes approach to nutrition improved. Bedrails were reviewed after a council contract monitoring visit and those no longer fitting beds were disposed of. Policies and procedures were reviewed about equality and diversity. Dignity in Care, a government campaign, was promoted to staff. Colour schemes and wallpaper were chosen by people in redecorated bedrooms. Communal rooms were decorated. Signs now label some rooms so people can find their way around. Since the last inspection the provider complied with Environmental Health statutory notices to improve food hygiene standards and clinical waste management. Care Homes for Older People Page 8 of 36 Between and since our visits the manager and nurses reviewed medication policies and procedures twice, and with the provider has reviewed staff roles, managerial and administrative time and ways in which they work together. Training has now been booked over the next four months to update staff knowledge and skills. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accessible information about the home and services helps people decide if it is suitable. An accurate pre-admission assessment helps to ensure that the home is able to meet all peoples needs. Evidence: Seven surveys from people and families told us that they had enough information about the home and a contract, to decide if it was suitable. The statement of purpose says that in addition to personal and nursing care ... the Directors have now decided to offer a highly professional but personal care service to elderly clients experiencing confusion and developing dementia care needs. This is new and lacks clarity on peoples primary needs, boundaries, and the training of staff in dementia as no specialist approach is set out and the home is not registered for dementia care. Information is in large print and Plain English so that people with sight and cognitive difficulties will find it accessible. The home plans to make information available in other formats and languages. Care Homes for Older People Page 11 of 36 Evidence: The admission process starts with an information pack for enquirers who are encouraged to visit the home, complete an application and have an assessment by the council or Primary Care Trust. On our visit there were 23 people living in the home and one person had a short stay. Most people have lived in the home for over 12 months and had reviews with statutory agencies and the home recently. We looked at three records of people who came to live in the home during the past year and spoke to service users to compare their experience. A comprehensive pre-admission assessment is undertaken by qualified staff, in hospital or in the community, and information was gathered from health and social care professionals before the home confirmed needs could be met. Admission took place a few days later, but only one record showed whether the person or family visited the home in advance. During a one month trial period, preferences are identified and a care plan is agreed and signed with people and their representatives, and the homes assessment of risks is discussed. The AQAA said that the home improved their terms and conditions for people funding their own care. Enquiry questionnaires were introduced so that management can learn more about unsuccessful enquiries. The manager plans to make all staff feel confident showing people around and dealing with enquiries as there is limited administrative and managerial capacity. There is useful information about a variety of topics in reception, but we did not see the homes newsletter. Care Homes for Older People Page 12 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be confident that their personal care needs will be met when they want, to sufficiently promote their dignity. Health needs are not effectively monitored or met and medicines are not stored safely or administered as prescribed. Evidence: In surveys and on our visit people said that they usually have the care and support they need and that relatives expect. One said, the staff are friendly and caring in their attitude to residents and visitors. They keep the residents clean and well fed. Surveys told us what the home could do better: have more time to attend to peoples needs, e.g. taking to toilet when requested, not 10 minutes later; feeding people who cannot do it. There is no separate unit for people with nursing needs, which means that the nurse on duty and care staff can be needed in several places at the same time. We tried the call system on behalf of one person wanting assistance. Staff came within a few minutes but asked the person to wait a short while as they were busy with someone else. Care staff are not flexibly deployed in the morning to assist with the needs of Care Homes for Older People Page 13 of 36 Evidence: people requiring the highest levels of care. Care plans note how often people want to bathe, however bathing facilities were limited. On our visits people appeared well groomed and clean. There appear to be good standards of personal care but there are insufficient records kept about daily tasks undertaken or checked to confirm that needs and preferences are met. We were not satisfied with explanations about people who remained in their nightclothes. Most peoples hair and clothing is in keeping with gender, lifestyle and culture. Staff are all female, so men do not have choice of who helps them with personal care. Since our last inspection families, health and social care professionals and notifications from the home made us aware of a variety of care, equipment and treatment issues affecting peoples health and safety. Staff needed to improve specific skills such as wound care and bandaging, nutrition, preventing medication error, the safety of bedrails and seeking medical and specialist health advice early enough when health conditions deteriorate. Statutory agencies have been working with the home to encourage improvements and on this visit we wanted to check progress. People have access to GPs and consultants, dentists, chiropodists, dieticians, and opticians. The home requested our assistance to improve access to tissue viability specialists on peoples behalf, after experiencing delay when they tried to request help early. Nurses and the manager have no training to assess risk, and nurses have not yet updated a range of clinical skills. This is scheduled to start in the New Year. We confirmed that up to date guidance about pressure sores is in use, as posters on display were dated 2003. A variety of staff need training in infection control, manual handling and hoists. Pressure relieving equipment matched peoples needs, and care staff demonstrated knowledge about air flow mattress settings and bedrails. Staff assisted people safely with hoists, using the correct sling size in their care plan. We checked and found all bedrails fit snugly with bed bumpers and there was no risk of entrapment. There were risk assessments but staff training in safety and maintenance had not taken place and there were no records of checks. The manager improved nutritional care. Staff had training and there is a new and effective approach for care and catering staff ensuring dietary needs are met. Nutritional supplements are now prescribed for people who were losing weight and they are now gaining weight. There are good records of food and fluid intake. Weights are monitored monthly. We discussed introducing best practice to identify people at risk of malnutrition. Care Homes for Older People Page 14 of 36 Evidence: The AQAA told us that the home improved the medication system by two staff conducting audits. After sampling the medication system and policy on 05/11/09 we told the manager that the medication policy and procedure did not protect people, medication was not auditable and recording was not accurate. Uncertainty about a prescription was followed up by the manager as agreed. We advised an urgent audit of stocks and made a requirement about immediate risks from poor medication security and storage. Medication could go missing, which is a public safety risk, or not be available when needed as occurred earlier in the year. Medicines must be stored in line with their produce license to remain effective health treatment. We were concerned about the extent of medication risks and potential impact upon people with unstable health conditions. A pharmacist inspector came to assess in depth the way the home was managing medicines on behalf of the people who used the service. In summary the medicines management systems within the home was not safeguarding people. The manager agreed with our findings that no one can currently confirm medication is administered to people as prescribed for their health. Medication security improved and although storage changes were made, the system and checks were not robust. Over three visits we found medication stored in a variety of conditions that fell outside safe ranges, going on for some time. We advised disposal of the contents of the drugs fridge and obtaining new supplies on 19/11/09, which included several peoples insulin. Prescribed and un-prescribed creams were insufficiently labeled to check use by dates and ensure they are only used for that person, were stored in one persons room on a shelf above a hot radiator. We expressed concern that someones prescribed gel was likely to have been used when their own ran out, posing cross-contamination risks to two peoples health. The controlled drugs cabinet had not been secured to the wall and the home was not complying with the Misuse of Drugs (Safe Custody) Regulations 1973. Medication records were poor, sometimes completed for the wrong month, an error compounded by all the nurses responsible for the medication system. Nurses could not evidence or explain to our satisfaction whether people had their prescribed medication when there were multiple gaps in records, unused and unrecorded medication we found, as well as excessive supplies. We found examples where records were signed but the medication was not being administered. The quantity of variable doses, and reasons for not administering medication were not clear. Stock control was choatic and records did not always account for medication received into the home, carried forward from the previous supply or disposals. The ability to audit is compromised. Supplies of medication run out, which means that people would not have their Care Homes for Older People Page 15 of 36 Evidence: symptoms relieved. One person was managing their own medication which shows that independence is promoted. However there was no assessment or management of associated risks to either the person or other people in the home. We found no monitoring programme in place to ensure that the person was taking their medication and it was not securely kept. Overall care and medication records contained little or no information or guidance for staff about when required and as directed medication and this had not been queried with the prescriber or pharmacist. Prescription changes and discontinuations were not explained. The length of treatment was not always clear, or the administration of medicated creams. There was one example where the home sought a medication review when someones condition improved, but the plan to slowly reduce the medication was not always followed. The home does not have an ongoing system to train and update staff to their roles with medication administration or to assess and monitor medication competence in accordance with the homes policies and procedures. Some nurses were signing records for creams and medications they did not administer or observe. A carer trained in medication told us that they regularly administer medication and spot check untrained care staff applying creams, but some nurses wont let them sign the records. We advised resolution as a team. We made four immediate requirements over two visits about medication and care plans to protect the health of several people in the home. On each visit all the inspectors discussed with the manager how medication systems, policy and practice could be improved. The response was insufficient to protect people; the medication system and practice is unsafe. Care Homes for Older People Page 16 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have support to maintain contact with friends and relatives, and some lead independent and flexible lifestyles. Other people do not have enough stimulation or choice. Food is nutritious and tasty; dietary and cultural preferences are met. Privacy is respected. Evidence: People and relatives told us what the home could do better: no stimulation for most of the residents most of the time; there could be more activities for residents to take part in, also outings...CDs of 1940s/50s music could be played...or have a sing-along. Music, after all, is such a wonderful therapy. Some routines are flexible but we saw two people waiting in their rooms for help to get up in the morning between 10:15 and 11:30 am. One room was dark with curtains drawn and people would have benefited from a radio on while they waited. Rooms have door locks so that people can have privacy when they want. There is a pay telephone in reception where people cannot talk privately, but the service user guide invites people to use the office telephone at no extra charge. Everyone has contact with relatives or friends and the home keeps them informed if Care Homes for Older People Page 17 of 36 Evidence: there are changes. One person prefers to remain in their room, one is nursed in bed. People who are frail spend the day under close observation of care staff in recliners in one lounge. Communal televisions are not routinely left on and one person in another lounge told us that they can change the channel if they want. The Care Supervisor acts as an activities coordinator for five hours a week, which people and relatives told us was an improvement but insufficient. Some people attend day centres, go out with friends and family or have visitors at the home. They are able to follow their own interests in their rooms, have their own books, music, TVs and radios. The homes public information says that at least one annual day trip is provided, there are shopping trips and daily walks - we saw no evidence of walks or shopping trips. The AQAA told us that the home improved peoples independence by registering people with Ring and Ride. On our visit the manager said that no one makes use of this service. The AQAA said that equality and diversity policy was revised; the make up of staff and facilities meets cultural preferences; religious and secular celebrations take place and activities for British and Asian cultures. But not everyones religion or sexuality were known so we wanted to know how diverse needs are met. On our visits no provision was made for people who are Hindu and other religions, and the manager said that Diwali was not celebrated this year, but Holy Communion is held more often at peoples request. Families and friends assist people to attend worship and celebrations in the community. We did not see any books, music or films in Asian languages, as the AQAA led us to expect, but there were large print books for people with sight difficulties. Staff knew people well and conversed in their preferred language. No activities took place. There are people who need individual support for stimulation and exercise to avoid risk of social isolation and decline, and this is not planned for. Mealtimes were staggered and unrushed and people could eat when and where they wanted. People had sensitive help to eat from the nurse, care staff and some relatives. Some food is prepared with nutritional supplements, which is creative. Food is fortified so that people can eat small portions but have high calorie content and nutritionally balanced meals, which is best practice. There was a vegetarian alternative on the menu to match the needs of several vegetarians in the home. We shared a meal with people and the food was tasty. People ate well, including those on liquidized and soft diets. The menu reflects some diversity and cultural alternatives can be provided on request. One cook specializes in Caribbean cooking, another in Asian cooking. Some people have nutritional plans to lose weight, with advice from specialists, and told us about their success. One person is unable to have their insulin before meals as prescribed, and we asked the council to urgently re-assess their Care Homes for Older People Page 18 of 36 Evidence: needs with health services as they are not being met by current arrangements. Care Homes for Older People Page 19 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples views about the service are not sufficiently sought and there is no analysis of complaints and incidents to learn and develop the service from peoples experience. Safeguarding and neglect are not fully appreciated or acted upon, and recruitment checks on staff are not robust. Evidence: A complaints policy is in reception and in Welcome Packs in peoples rooms. People know how to make a complaint and a relative said that they always try to sort any problems. The policy states that the home provides a written response within 7 days. The AQAA told us that there were minimal complaints, 12 in number and none were upheld. As this is a large number of complaints we wanted to see their nature and the homes response. Some complaints were upheld as they resulted in apologies, cleaning more thoroughly, removing cat litter, finding missing clothing and replacing eyeglasses when lost. However the complaints log did not always have timescales, a summary of findings, investigation and outcomes including complainant satisfaction and some were not satisfied with initial actions. Complaints about the lack of activities, cold daughts and lack of bedlinen change had no outcomes. So we cannot confirm that everyones rights were protected or dignity promoted. Some matters are not complaints. Some were whistleblowing and disciplinary concerns but showed no action taken. Some were safeguarding matters that the Commission and council were not notified about and the manager could not recall. Care Homes for Older People Page 20 of 36 Evidence: These are examples of a lack of understanding of safeguarding and accountability. People are not fully protected from abuse as recruitment checks on staff continue to be of concern from the last inspection. There were 6 safeguarding investigations since April 2009. Two were reported by the home, including the protection of peoples property and financial interests. Two multiagency investigations found no abuse, and one partly substantiated neglect as the home did not seek medical attention early enough. An internal investigation and action took place about medication errors but as we found, problems were not eradicated to prevent recurrence and the home stopped reporting on this. Some medication errors constitute institutional neglect. The home is working with statutory agencies to develop and improve their service and safeguarding. Staff, including shiftleaders, have not all had training to recognise and report abuse and neglect in accordance with local protocols and the homes policies and procedures, but we are told there is a plan to address this. Individual and professional responsibility needs to be clarified and the duty of care and the law understood. Disciplinary action and professional body reporting needs to be taken when warranted so that people and the Commission can have confidence that safeguarding is taken seriously at Knoll House. Concerns from our inspection were reported to the multiagency safeguarding strategy group. There were also a range of examples where peoples rights are promoted. The manager introduced a system to gain daily consent from people, assess mental capacity and need for Deprivation of Liberty Safeguards. No authorisations have been necessary. We would advise that the manager reviews people cared for in recliner chairs who are too frail to get out by themselves, some of whom also have limited communication as these chairs restrict freedom of movement. There are posters about local advocacy services so that people can have independent support to express their views and to make serious decisions. Care Homes for Older People Page 21 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Knoll House is homely and comfortable but people cannot be confident that the environment is sufficiently clean, safe or well maintained, and there are insufficient bathing facilities. Peoples health and safety has been put at risk. Evidence: The home is in a residential area. The atmosphere is friendly and helpful, and it is warm and generally comfortable. Some rooms have signs with symbols to help people find their way around or to indicate a hazard such as oxygen. There are many corridors, some sloped. Its not easy for confused people to orient themselves, and we recommend sections of the home have different colour schemes so they are distinguishable. Decoration of the home could also reflect the diversity of people living and working there. There are two numbering systems for doors - one for fire purposes and another for nursing purposes, and this is very confusing. It also means that maintenance records are not accurate, and the wrong conclusions can be reached by managers. Some people are in shared rooms, used as single rooms for those needing more space for aids, equipment or personal possessions. Rooms are very individual and personalized. We were concerned to find one person in a bedroom with a hole in the ceiling from a leaking roof and perished plasterwork from guttering leaks. The persons room was moved with their consent and repairs were made in between our Care Homes for Older People Page 22 of 36 Evidence: visits. The premises are in a poor state of repair with no clear plans about this. For example a hallway cupboard door fell off its hinges when we opened it; there were sharp broken tiles and cracked toilet pans. People were at risk of scalds from excessively high water temperatures up to 58.7 degrees C. People were at risk of slips, trips, falls and injuries from careless and poor working practices of staff, workmen, and lack of signage when there were hazards or out of order equipment. A weighing chair blocked access to a communal toilet. Cleaning fluids and materials were left unattended and a cupboard lock was broken; sluice room doors were not kept closed. The statement of purpose sets out the homes bathing facilities: a ratio of 1 assisted bath to 8 service users. On 19/11/09 there were only two communal bathrooms in use for 23 people living in the home, although some people have en-suite facilities. The bathrooms in use had other hazards for people such as a broken shower head, soiled toilet paper wrapped around a bath plug, on the floors and behind pipes. Standards of cleanliness were too low and there were insufficient controls to prevent the spread of infection, especially during a swine flu epidemic. The Primary Care Trust (PCT) audited the homes infection controls twice and since their last visit on 30/09/09 the homes records and Regulation 26 reports do not identify timely action to address high risks to health, such as preventing crosscontamination in the laundry room, which was in a poor state of repair and could not be cleaned. Although there was improvement the home has not yet achieved a minimum compliance award. On our visits we found sufficient gloves, aprons and paper towels. Mops had no storage or coherent colour coding. Bathrooms and toilets had a build up of grime and limescale, mildewed and perished sealants, and flooring appeared dirty. A number of bed bumper covers were torn. It was likely that people could not wash their hands with soap because liquid soap dispensers throughout the home required considerable dexterity. Staff tended to use anti-bacterial gel that people could not reach from wheelchairs. In these conditions, infections can harbour. All the soap dispensers have now been replaced, are suitable and used, but slippery spills on the floor of a toilet are building up. There was no scheme to prevent the build up of bacteria in the water supply, but this was tested as clear by our third visit. The front door was not secure; this was repaired by our third visit to prevent intruders. There are security and fire precautions, but the signing in book was not used by workmen so their safety cannot be assured in the event of a fire. We reported Care Homes for Older People Page 23 of 36 Evidence: concern to the West Midlands Fire Service when the home could not evidence that 5 yearly electrical circuit checks had not been undertaken as they required in 2008, and was 7 months overdue. When a certificate was presented as requested, following engagement of a contractor, the outcome was unsatisfactory and electrical work is being undertaken. The home recently complied with Environmental Health statutory notices to improve food hygiene standards, kitchen equipment and 80 bags of clinical waste which had accumulated, following a complaint from a family. There is now a new clinical waste contractor. Immediate requirements were made on two visits when there were unnecessary and recurrent hazards to peoples health and safety. Providers did not sufficiently risk assess or manage the environment, working practices or facilities for people beyond examples we told them about and staff did not notice, remove or report hazards they were commonplace and often not acted upon. The handyman and staff have not had sufficient training in health and safety or infection control. In response to successive requirements, action plans have addressed many of the hazards, and improvements are rapidly progressing. The home has kept us updated and has formed a refurbishment plan that exceeds basic health and safety and will be of benefit to people when completed. Care Homes for Older People Page 24 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements need to ensure smooth and safe running of the home. Training, competency checks, and updated clinical skills are needed so that peoples conditions and needs are effectively risk assessed, monitored and met. Recruitment checks on staff as well as working practices do not fully protect people. Evidence: Most people and relatives are satisfied with the care they receive but they may need to wait a short time for staff support. However one survey comment prompted closer examination of staffing: resource availability needs to be reviewed frequently. It is essential that sufficient staff of all grades are available at all times including weekends and nights. On our visits there were enough staff to assist people with eating. Staff were very busy at other times. A nurse and six care staff are usually on duty until 10pm, then two waking night staff. If catering staff are off/ill, care staff do the cooking, however only half the care staff have safe food handling training. The administrator works for three hours on weekdays. The manager is supernumerary three days a week and provides additional cover if short of nurses. The workforce is diverse; staff are matched to people, however there are no male staff and there are six men in the home. We confirmed with the manager that rotas were not accurate as catering staff were recorded as care staff, which may mean that there are staff shortages. There is low use of temporary staff and there are bank staff for Care Homes for Older People Page 25 of 36 Evidence: consistency. The home had a high turnover of staff (12) since January 2009. The layout of the building poses additional challenges to staff availability in the absence of a nursing wing. Shift leaders (nurses) and the manager could more flexibly deploy staff so people with higher support needs have the help they need at busy times. Roles and responsibilities have not been clear. Staff appropriately share information about people by handovers. Qualifications of staff meet minimum standards. There have been multi-agency concerns about staff skill and training deficits, for instance about bedrails and clinical skills. Staff have not had sufficient or timely opportunity to undertake or refresh mandatory and clinical training to manage the complexity of peoples conditions. In response to these concerns, a training plan was recently formed and we checked that courses are booked. At times, nurses have had conflicting clinical advice from local health specialists. During our inspection a group of staff attended a seminar about Parkinsons Disease. The manager confirmed that nurses do not have regular clinical meetings and have insufficient time or training in the supervision of care staff. Until there are accurate rotas, staff have sufficient training, oversight and appraisal of their performance we cannot confirm that there are competent staff at all times. For example, some nurses have not refreshed first aid training in resuscitation so people wont have the benefit of best practice in an emergency. Care Homes for Older People Page 26 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management roles and systems are not accountable, responsive or robust, and are not protecting peoples health and safety. Evidence: The manager has been in post for many years. They are an experienced nurse, with NVQ 4 qualifications in care and managers award, who is registered by the Commission. They are approachable to people and staff. The manager updated staff practice, policies and procedures in some areas that benefit people, such as legal rights. The AQAA shows us that the manager knows some of the things they need to improve but it lacked accuracy and sufficient analysis of the barriers for service development and how these are to be overcome. Management capacity has been reduced in response to falling occupancy levels. The manager and responsible individual have delegated roles without ensuring there is sufficient staff development, oversight, robust and responsive management systems. There have been acknowledged breakdowns in systems for medication, timely repairs, Care Homes for Older People Page 27 of 36 Evidence: maintenance, servicing and refurbishment. The premises, training and working practices have been allowed to deteriorate until standards are too low. Management have delayed compliance with the law involving three regulators during the past year, e.g. checks on staff, fire and food safety. Remedial action is now progressing. Rising complaints and safeguarding concerns illustrate the effects of falling standards on people using the service and their families and these were not reflected upon in completion of the AQAA. Responsibility needs to be shared and the management team needs to establish accountability, effective leadership and a team approach as there are strengths to build upon. There has been a lack of transparency at times and a lack of self critical internal audits which does not give us confidence that the management team can identify appropriate risks, maintain a consistent approach and resolve problems at their root source to prevent recurrence. Regulation 26 reports about unannounced quality monitoring checks need to be signed off and followed up until they are actioned. Environmental risks and facilities for people with sensory and physical impairments, confusion or dementia need to be anticipated in their best interests. The Director expressed commitment to working with the Commission to rectify whatever we specify. In contrast, we advised that the provider needs to be self sufficient by updating their knowledge of health and safety law, care regulations and best practice. The home lacks a health and safety culture and peoples views are not sufficiently sought. Although there are residents meetings, quality assurance questionnaires have not been used in the past year. The service has under-developed quality standards of their own, monitoring systems and analysis of incidents and complaints to develop the service and meet rising expectations of care quality and facilities. We checked how the home manages peoples personal allowances and found robust accounts that tallied; spending is in keeping with peoples needs and wishes. There is a code of conduct that prohibits staff from involvement in peoples financial affairs or benefitting from wills. Sustaining improvements will take time however we advised that the law is changing and management need to keep abreast of new registration requirements and timescales affecting care homes. Care Homes for Older People Page 28 of 36 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 29 19 A robust and rigorous recruitment procedure must be implemented. 30/01/2009 To ensure that people are suitable to work with vulnerable adults. (Not Met on 04/11/09) Care Homes for Older People Page 29 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action 1 9 13 13(2): The registered person 06/11/2009 must ensure medication is securely stored within 48 hours, including medication in use and for disposal, and in accordance with its product licence so that it is available when needed, does not go missing, and remains stable and effective. People need safe medication as prescribed by doctors for their health. (Not met on 19/11/09) 2 9 13 13(2): You are required to 20/11/2009 set up a system to be able to demonstrate that all warfarin is administered as prescribed within 24 hours. This is to ensure that a person has essential medication as prescribed for their health. (Not met on 17/12/09) 3 38 13 13(4)(a)(c): The Responsible 06/11/2009 Individual registered with the Commission must undertake a robust risk assessment and take any necessary immediate actions within 48 hours to eliminate hazards and minimise risks to peoples health and safety. People must be protected from scalding water temperatures and immediate environmental hazards, and Page 30 of 36 Care Homes for Older People Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action have accessible liquid soap. Measures needing longer term actions to prevent the spread of infection or illness, the build up of bacteria or to attend to essential maintenance, refurbishment, redecoration and repair of peoples rooms and laundry room must be planned with appropriate timescales to the risk posed to people living in the home. People need to live in a safe environment. (Not met 19/11/09) 4 38 13 13(4)(a)(c): The Responsible 27/11/2009 Individual must take action to eliminate environmental hazards and infection control risks, and ensure cleanliness in toilets, bathrooms, sluice rooms, the laundry and hallways to minimise risks to peoples health and safety. People must be protected from injury, falls and the spread of infection or illness. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 18 18(1)(a): Staff must be 16/12/2009 suitably qualified, experienced and determined Page 31 of 36 Care Homes for Older People Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action to be competent before they administer medication to people, and be checked periodically to re-confirm competence. People need confidence that staff protect their health. 2 9 13 13(2): Care and medication records must be detailed so that staff know how to use and monitor all medication as intended by the prescriber, e.g. as directed and when required. Medication needs to be administered safely and correctly to meet individual health needs. 3 9 13 13(2): The receipt, administration and disposal of all medication must be recorded accurately so that the home can evidence that each persons medication has been administered as prescribed. This is to protect peoples health. 4 9 12 12(1): There must be an effective system in place to request, obtain and retain adequate supplies of prescribed medicines for people. 16/12/2009 16/12/2009 16/12/2009 Care Homes for Older People Page 32 of 36 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Medication for individuals must ordered and stored so that it is available when needed for peoples health. 5 17 37 Notifications must be made to the Commission in accordance with current guidance, including medication errors. This is so that the Commmission can ensure peoples rights and interests are protected. 6 18 13 13(6) Safeguarding reports 16/12/2009 must be made to the council about incidents in accordance with local protocols. People are protected from abuse and neglect by organisations working together 7 30 18 18(1)(c)(i) Staff must have 28/02/2010 training appropriate to the roles they are to perform. All staff and managers must have training to recognise and report abuse. People need to feel confident that they are protected and their needs will be met. 04/01/2010 Care Homes for Older People Page 33 of 36 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 3 1 10 12 The statement of purpose should be reviewed to make the service clear to the public. People should be consulted about dignity, and periodic audits are recommended to maintain standards. Consultation with people should be undertaken about a programme of activities and exercise matching their interests and promoting healthy lifestyles. A summary complaints log should be maintained and be available for inspection, reflecting how peoples rights are promoted. People cared for in recliners which restrict freedom of movement should be reviewed in accordance with the Mental Capacity Act and Deprivation of Liberty Safeguard codes of practice. A single system of room numbering should be adopted, and varied colour schemes for sections of the home so that people can find their way around with more ease, and accurate maintenance records can be kept. Rotas must be an accurate reflection that there are sufficient and appropriately skilled staff on duty at all times so that peoples needs are met. An assessment of the level of first aid training required by staff in accordance with their roles should match peoples needs for help in an emergency. A review of staff roles, lines and systems of accountability and staff oversight is advised to ensure management exercise their responsibilities. Quality assurance questionnaires are recommended so that the service can learn from the experience of people and their representatives. Staff must have supervision, a minimum of six times per year. Robust review of the homes health and safety risk assessments should be undertaken, informed by health and safety law, regulator(s) guidance, care regulations and national safety alerts. Periodic analyses of incidents and accidents should identify any patterns that can be learned from or acted upon to Page 34 of 36 4 16 5 17 6 20 7 27 8 30 9 31 10 33 11 12 36 38 13 38 Care Homes for Older People Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations prevent recurrence for the individual or others living in the home. Care Homes for Older People Page 35 of 36 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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