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Inspection on 01/12/09 for Lickey Hills Nursing Home (2 Units)

Also see our care home review for Lickey Hills Nursing Home (2 Units) for more information

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

What the care home does well

People`s needs are assessed before they move into the home to enable the home to find out all about them, and the support they will need.Lickey Hills Nursing Home (2 Units)DS0000004122.V378587.R01.S.docVersion 5.2Staff address people who use the service by their preferred name and in a kind and sensitive way. Regular visits are made to the home by two general practitioners from the local practice. The home provides transport for people to get out and about in the community, which is suitable for people in wheelchairs. Multi-denominational church services take place in the home once a week. A person who uses the service represents this and other homes for older people owned by the provider at national meetings to make sure people are able to contribute and have ‘a voice’ in how they wish to see the service improved. Visitors are made welcome in the home and are able to see people in the privacy of their room. The home has a complaints procedure and the manager records complaints received. Criminal Records Bureau checks are carried out for all new staff prior to appointment to ensure people are protected from harm. The home employs male and female staff from a multi-cultural background. People who use the service are able to manage their own monies and the home also holds monies for people and is able to act as appointee, which they do for one person. This is managed very well and the records are well maintained.

What has improved since the last inspection?

The home has replaced some of the worn and stained carpet in Rednal unit with laminate flooring. There has been improvement to the provision of specialist diets particularly for people who are losing weight. The home are now recording the outcomes of all complaints they received to enable them to audit them more accurately.

What the care home could do better:

No requirements made at the last key inspection in July 2009 have been met by the home. There is one new requirement made in this report. Care plans need to be improved to make sure they have enough information for staff to understand the care people require. They need to be reviewed as people`s needs change so that people can be sure their needs will be met. The health and social care needs of the people who use the service need to be promoted and staff need to act upon outcomes of assessments and instructionsLickey Hills Nursing Home (2 Units)DS0000004122.V378587.R01.S.doc Version 5.2 from health professionals to ensure people are not placed at risk of harm through neglect of care. Improvement is needed to the storage and management of medication to ensure medicines are being stored safely and securely and they do not deteriorate which can make the medication ineffective and possibly harmful to the people who use the service. They should review the adequacy of the size of the laundry and the safety of its location in the home, including consideration to the health and safety of the people who work in the laundry. They need to provide the correct numbers and skill mix of qualified and unqualified staff to meet the needs of the people who use the service; so that people can be confident their health and social care needs will be met and they will be protected from harm due to neglect of care. More thorough records should be kept for the recruitment of staff for example showing in the records of interviews that the home has explored any gaps in employment history to ensure people are fully protected from any potential harm. Staff should receive training about new legislation which impacts on the care of people who lack mental capacity to ensure they have a clear understanding of how this impacts on the care of the people who use the service. Where the home is holding larger sums of money for people, they should transfer this money to an individual higher interest bearing account so that they ensure they are acting in the `best interests` of people at all times. Notifications about incidents which occur in the home need to be sent to us without delay to demonstrate the home are taking appropriate and prompt action for all incidents in the home to ensure the health and welfare of the people who use the service is promoted and they are protected from harm.

Key inspection report CARE HOMES FOR OLDER PEOPLE Lickey Hills Nursing Home (2 Units) Warren Lane Rednal Birmingham West Midlands B45 8ER Lead Inspector Sandra Bromige Key Unannounced Inspection 1st December 2009 08:45 DS0000004122.V378587.R01.S.do c Version 5.3 Page 1 This report is a review of the 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. 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. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.2 Page 2 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 Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lickey Hills Nursing Home (2 Units) Address Warren Lane Rednal Birmingham West Midlands B45 8ER 0121 445 5532 0121 447 7835 lickey.hills@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Ltd 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) Manager post vacant Care Home 97 Category(ies) of Dementia (47), Old age, not falling within any registration, with number other category (97), Physical disability over 65 of places years of age (47) Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.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: Physical disability - over 65 years of age (PD(E)) 47 Old age, not falling within any other category (OP) 97 Dementia (DE) 47 The maximum number of service users who can be accommodated is: 97 Age: Dementia (DE) age 55 and above. 2. 3. Date of last inspection 20th July 2009 Brief Description of the Service: Lickey Hills Nursing Home is situated in a picturesque area of Barnt Green close to the Lickey Hills visitors centre. It comprises of two units, one catering for the elderly physically frail (Cofton Unit) and the other for people who have care needs arising from dementia related illnesses (Rednal Unit). Both units offer facilities for male & female residents who require nursing care. Both units are on two floors and all rooms, single and shared have en-suite facilities. This report reflects inspections of both of the units in the home as it is registered as one service. Up-to-date information relating to the fees charged for this service is available on request from the home. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is zero star. This means the people who use this service experience poor quality outcomes. This was an unannounced inspection and a visit to check compliance with three Statutory Requirement Notices served following a random inspection on 7th October 2009. Two inspectors and a pharmacist inspector spent one day at the home talking to people who use the service and the staff, and looking at the records which must be kept by the home to show that it is being run properly. The focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. We looked in detail at the care provided by the home for three people. This included spending time observing the care they receive, discussing their care with staff, looking at care files and focusing on outcomes. Tracking peoples care helps us understand the experiences of people who use the service. There have been 18 safeguarding referrals to Worcestershire County Council since the last key inspection in July 2009. The majority of the referrals have been about incidents that have happened on Rednal unit. We carried out a random inspection on 7th October 2009 and due to the outcomes of care we found for the people whose care we tracked, we referred four people who use the service into safeguarding due to neglect of care. These allegations of abuse are currently being investigated. In December we received three notifications about medication incidents that had happened in November 2009. The notifications told us that eight people who use the service had not received the medication as prescribed but staff who were from a recruitment agency had signed to say they had given it. Four people had not received their medication as there was none in stock in the home and one person had two missing tablets. The home is not protecting people from harm due to neglect of care. We have shared this information with Worcestershire County Council who is the lead agency for coordinating safeguarding investigations. What the service does well: Peoples needs are assessed before they move into the home to enable the home to find out all about them, and the support they will need. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.2 Page 6 Staff address people who use the service by their preferred name and in a kind and sensitive way. Regular visits are made to the home by two general practitioners from the local practice. The home provides transport for people to get out and about in the community, which is suitable for people in wheelchairs. Multi-denominational church services take place in the home once a week. A person who uses the service represents this and other homes for older people owned by the provider at national meetings to make sure people are able to contribute and have ‘a voice’ in how they wish to see the service improved. Visitors are made welcome in the home and are able to see people in the privacy of their room. The home has a complaints procedure and the manager records complaints received. Criminal Records Bureau checks are carried out for all new staff prior to appointment to ensure people are protected from harm. The home employs male and female staff from a multi-cultural background. People who use the service are able to manage their own monies and the home also holds monies for people and is able to act as appointee, which they do for one person. This is managed very well and the records are well maintained. What has improved since the last inspection? What they could do better: No requirements made at the last key inspection in July 2009 have been met by the home. There is one new requirement made in this report. Care plans need to be improved to make sure they have enough information for staff to understand the care people require. They need to be reviewed as peoples needs change so that people can be sure their needs will be met. The health and social care needs of the people who use the service need to be promoted and staff need to act upon outcomes of assessments and instructions Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.2 Page 7 from health professionals to ensure people are not placed at risk of harm through neglect of care. Improvement is needed to the storage and management of medication to ensure medicines are being stored safely and securely and they do not deteriorate which can make the medication ineffective and possibly harmful to the people who use the service. They should review the adequacy of the size of the laundry and the safety of its location in the home, including consideration to the health and safety of the people who work in the laundry. They need to provide the correct numbers and skill mix of qualified and unqualified staff to meet the needs of the people who use the service; so that people can be confident their health and social care needs will be met and they will be protected from harm due to neglect of care. More thorough records should be kept for the recruitment of staff for example showing in the records of interviews that the home has explored any gaps in employment history to ensure people are fully protected from any potential harm. Staff should receive training about new legislation which impacts on the care of people who lack mental capacity to ensure they have a clear understanding of how this impacts on the care of the people who use the service. Where the home is holding larger sums of money for people, they should transfer this money to an individual higher interest bearing account so that they ensure they are acting in the best interests of people at all times. Notifications about incidents which occur in the home need to be sent to us without delay to demonstrate the home are taking appropriate and prompt action for all incidents in the home to ensure the health and welfare of the people who use the service is promoted and they are protected from harm. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details 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. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before they move into the home to enable the home to find out all about them, and the support they will need. The service does not provide intermediate care EVIDENCE: In October 2009 the owner of the home agreed not to admit any further people for three months due to the poor outcomes for people who were using the service. Due to this we were not able to look at pre-admission assessments for any new people who have started using the service since the last Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 10 inspection. The previous two key inspection reports have judged this outcome group as good. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 healthcare needs are not being met and medication is not being stored safely which places people who use the service at risk of harm. Peoples dignity is not being maintained at all times. EVIDENCE: We inspected the home on the 7th October 2009 to look at the management of health and personal care and the quality of the information in the care records. We found poor outcomes of care for the people who use the service and a poorly completed care records. On the 15th November 2009 we received a quality improvement plan from the owner telling us how and when they were going to ensure they achieved compliance with the regulations to ensure people who use the service receive good outcomes of care. The improvement plan for health and personal care Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 12 told us they would achieve compliance by 30th November 2009 in all areas except consultation of people who use the service and/or their representatives about their individual plan of care. We were told by the area manager at the beginning of the inspection that all the care plans on both units had been reviewed. We tracked the care of three people who use the service and we found some poor outcomes of care for these people. For example, we saw from the records that people were not receiving baths when they are due. We spoke to two care staff and they told us there is a bath rota in place, but they are unable to complete this because of the staffing levels. One carer said they are lucky if they get one bath a week. We asked staff if the people who use the service are given choices about their individual healthcare preferences and they told us only the residents who are able to vocalise get what they want. Another carer said only the ones that could vocalise have a choice of what time they get up and go to bed. One person had recently been diagnosed with a chest infection but there was no care plan for the management of this acute illness. We saw the care plan for this person was not being followed with regard to their preference for times of getting up and going to bed. The care plan did not provide information about the management of a wound. At 12:35hrs we went to speak to a person whose care we were tracking. This person shared a bedroom with another person. When we entered the room we saw both people were in bed with the curtains drawn, the main light was switched on and a radio was on. The person whose care we were tracking was in their nightclothes and did not appear to have received any personal care or a drink. We saw a beaker of fortisip (a prescribed food supplement) drink on the table dated 30th November at 15:00hrs and the beaker was full. The other person in the room was also in bed. The person looked uncomfortable and the bottom sheet was crumpled beneath them so they were now lying on the plastic cover of the pressure relieving mattress. The last entry on their fluid chart was dated 28th November at 19:00hrs, three days before. A carer came into the room and they told us these two people had been given porridge this morning but they had not been washed and had not been given a mid morning drink. The carer told us there were six further people who were still in bed and had not received a wash that morning. Care staff appeared to be under pressure and when we spoke to them they became tearful. One carer told us, I used to enjoy coming to work we cant do everything we are short staffed trying to do our best. We found another person had developed a pressure sore and the information about the current status of the pressure sore and its treatment was unclear. The additional care plan for the pressure sore was started on the 10th September 2009 and it said the pressure sore needed to be reviewed daily, but the records did not show this had been done. The records did show that the Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 13 pressure sore became worse. There was an entry dated 11th September stating manager trying to contact the tissue viability nurse (TVN). We could not find any information to show this had been completed. We asked the manager (designate) and she told us she was unable to contact the TVN and had asked one of the trained nurses to do this. We asked this trained nurse if a referral had been made to the TVN and she said, I dont believe there has. A photograph of the pressure sore had not been taken until 30th November. We spoke to care and trained staff who had given personal care to this person that morning. We asked them about the current status of the pressure sore and the information they gave us was not the same as in the care plan. We looked at the accident records and saw a number of entries dated November 2009 where people who use the service had been found with skin tears on their leg, a big bruise on a persons right hip, a wound on their left shin consistent with a bump. The accident records were poorly completed and there was no information to show the home had investigation how these injuries had been sustained. The pharmacist inspector also visited the home on 1st December 2009 to check the management and control of medicines within the service. A random unannounced inspection on 7th October 2009 had identified that medicine management systems needed to be improved. The purpose of this inspection was to check compliance with the requirements relating to medicines. We arrived at 10.20am and stayed until 5.20pm. We looked at medicine storage on Rednal and Cofton units, some care records and medication administration records. We spoke to staff, the manager and the area manager. The area manager informed us that there had been further medicine issues since 7th October 2009 including a medication error, which was being investigated. We found that the home had introduced a daily check on medicines. We saw that a running stock balance was recorded onto each medicine administration record (MAR) after each medicine had been given. This was recorded on a daily basis. We acknowledged the positive introduction of this checking system which helped to keep a daily check on peoples medicines and ensure that medicines were given as prescribed by a medical practitioner. We found that the storage temperatures of medicines were not being monitored each day and medicines were not being stored at the correct temperature, which had also been identified at the previous inspection on 7th October 2009. For example, on Rednal unit we saw temperature records for October and November 2009. Medicines should be stored below 25 degrees Celsius. We saw six temperature readings recorded which were above 25 degrees C and on the day of the inspection, 1st December 2009, the temperature reading was 28 degrees C. The majority of the temperature readings recorded for October and November 2009 were below 25 degrees C, however when we looked at the thermometer we noted that it was not at eye level. In order to read the correct temperature we had to remove the Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 14 thermometer from the wall. A member of staff informed us that the room did get very hot and stuffy. When we looked at the medication stored in a cupboard we saw that two bottles of a liquid medicine, Lactulose, did not appear to look the right colour. Lactulose is normally a straw yellow colour; however the Lactulose we saw was a very dark orange colour. We contacted the manufacturer of the Lactulose and we were informed that the Lactulose may have been affected by storage at a high temperature and it should be stored below 25 degrees C. We looked at the temperature records available for the medicine refrigerator on Rednal unit. Medicine requiring refrigeration should be stored between two to eight degrees C. There were seven gaps in the records with no temperature reading recorded. We saw eight temperature records for October and November 2009 which were below the safe storage range for medicine. No action had been taken to ensure the medicine was stored correctly. We saw that insulin was stored in the refrigerator, which must be stored between 2 to 8 degrees C to ensure it does not deteriorate. This means that peoples medication was not stored correctly within the recommended temperature ranges and increases the risk of deterioration making the medicine ineffective and possibly harmful to the people they are being given to. Medicines were not given to people at the correct time as prescribed by a medical practitioner. For example, on Rednal Unit we saw that the morning medicine round for people upstairs did not finish until after midday. We were told by the agency nurse that the medicine round for upstairs had started late at 0900 hours and had still not finished at 1200 hours. We looked at the medicine chart for one person who had not received their 0900 hours morning medicines until after 1200 hours. We saw that they were to be given two tablets for the treatment of diabetes, two tablets for the treatment of high blood pressure and one tablet to calm their behaviour. We saw that the medicine record had been signed as given at 0900 hours but it had not been given until after 1200 hours. We looked at the care plan for diabetes dated 5th October 2009 which stated that the person was to be given prescribed medication as per MAR chart at the correct time because the person is prone to hypoglycaemic attacks. This means that people were at risk of harm because they were not being given their prescribed medication according to the directions of a medical practitioner and also did not ensure that there was an adequate gap between doses to ensure the safety of residents. We found prescribed medicines available in the home, which had not being given to people as prescribed by a medical practitioner. For example, we looked at the medicine administration records (MAR) for one person on Rednal unit and saw that a prescribed shampoo for the treatment of a fungal infection had not been signed by staff for application. We saw no record for the receipt of the medicine. We saw an entry in the care plan for the person dated 4th November 2009 which stated that the shampoo was to be used as directed. We were told by the pharmacy that they had supplied one bottle of the shampoo on 4th November 2009. We found a bottle of the shampoo in the Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 15 medicine cupboard dated 4th November 2009, which had not been opened. This means that a diagnosed fungal infection had not been treated with the prescribed medicine. We found gaps on the MAR charts where there were no signatures for administration of the prescribed medicine or a code documented with a reason why the medicine was not give. For example, on Cofton Unit we saw one MAR chart with no signature for administration for a medicine prescribed once a week at 0730 hours before food for osteoporosis. We saw that there was no signature for administration for the morning of the inspection, 1st December 2009. We checked the medicine available in the home together with the trained nurse and found that the tablet had not been given as prescribed. The trained nurse gave the tablet at 16.30 hours and recorded this on the MAR chart. We were told by the trained nurse that sometimes medication records were not documented and she was aware of this issue. We saw a second person had not had six of their medicines signed for administration at 1800 hours on 29th November 2009. This means that the medicine records were not always clear whether a medicine had been given or if not a reason was not documented, which increases the possibility of a medication error. We found that codes were documented onto the MAR charts that were not clearly defined or explained. For example, on Rednal Unit we saw that a medicine prescribed twice a day for treating high blood pressure had not been given as prescribed. We saw that a code x had been documented on the MAR chart for three administrations between 27th to 28th November 2009. The code x was not defined on the front of the MAR chart. We looked at the back of the MAR chart and saw an entry dated 27th November 2009 that the medicine was not to be given tonight 1800 hours, none at all tomorrow and back to normal dose on Sunday. As advised by Doctor. We looked at the persons daily notes for 27th November 2009 and found no records about the medicine not being given or a reason. The area manager informed us about this medicine error when we arrived in the home and the home manager told us that the medicine error was being investigated. We acknowledged that the home had informed a Doctor and were investigating how the error had happened. The poor medicine records and lack of detailed documentation means that it was difficult for the home to investigate and determine how to ensure this medicine error did not happen again. We found a medication error that had not been reported and investigated by the home. On Rednal unit we saw that a medicine prescribed twice a day to help calm a persons behaviour had not been given as prescribed. We saw that a code o had been documented on the MAR chart for two mornings on 21st and 22nd November 2009. The code o was defined on the MAR chart as missing tablet. We looked at the back of the MAR chart and saw two entries dated 21st and 22nd November 2009 which stated that the medicine was missing in the blister pack. We saw that the receipt of 56 tablets was recorded. There was no record to show if a Doctor had been contacted. It was Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 16 not clear from the records why medicine had not been administered using tablets from the end of the blister pack. There was no record to explain why the tablets were missing. We were told by the home manager that this medicine error had not been reported and could not give any further explanation but agreed that this should not have happened. This means that the person did not have their prescribed medication for two mornings, which increased the chance of the person becoming upset and anxious. Medicines were being given hidden in food or drink also known as covert administration of medicines without clear instructions for staff to follow. For example, on Rednal Unit we found that seven people were to be given their medicines covertly. We looked at one person who was to be given all of their medicines dissolved in a drink. We saw a document signed by a relative, a nurse, a Doctor and a pharmacist which stated the medicines could be given dissolved in drink. The document was not dated. We looked in the persons care plan and there was no assessment recorded to explain the reasons why covert administration was required or how the medicine was to be given. There was no information available on the MAR chart to inform staff how to ensure the medication was given safely. The home manager informed us that she was aware that there was a lot of covert medication being given and is aware that this issue needs to be looked at. This means that the health and wellbeing of people living in the home are not safeguarded. Prescribed medicines that were no longer required were not always disposed of correctly. For example, on Rednal Unit we saw a bottle of a cough medicine stored inside a medicine cupboard. The name of the person it was prescribed for had been crossed out on the pharmacy label. The date on the bottle was 25th February 2009. We saw a plastic box labelled homely remedy stored in a locked cupboard in the clinic room. We saw a small white box inside the container with no label attached. Somebody had handwritten senna tablets 7.5mg onto the box. We could see that a label had been removed from the box. We counted two tablets inside the box, which we identified as senna tablets. This means that we found evidence that medicines prescribed for people were not being disposed of correctly and were being kept without the persons knowledge and used again. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has been some improvement to the provision of meals in the home particularly for people who are at risk nutritionally, although people cannot be confident their social and nutritional needs will be provided to ensure they receive the stimulation and nutrition they require in order to meet their care needs and protect them from harm. EVIDENCE: On the 15th November 2009 we received a quality improvement plan from the owner telling us how and when they were going to ensure they achieved compliance with the regulations to ensure people who use the service receive good outcomes of social and nutritional care. The improvement plan stated the activity co-ordinator to be involved in updating Keeping Active care plan. A care plan we looked at for one person for relationships was a good care plan and had incorporated the information Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 18 provided by the family about this persons life history. We saw the activity coordinator had written regular entries in the keeping active care plan but we did not see any evidence to show the named nurse had reviewed this care plan. The minutes of a relatives meeting held on 24th October 2009 shows the manager (designate) told relatives at present there is only one activities organiser, which is an impossible task with 95 residents, so X (persons name) will be helping out with activities until the post is filled. We saw the activity co-ordinator in the lounge on Rednal unit with one person and they were listening to music. We spoke to the activity co-ordinator and she told us she works 0900 to 1700 Monday to Friday and covers both Cofton and Rednal units. We spoke to a carer about activities and they told us they have relaxation in the mornings, three times per week, afternoons they paint and are in the process of making Christmas cards. They have had one trip to a local garden centre. We were given a copy of the current weeks activity programme. This shows the activity co-ordinator spends three hours in each unit each day with the exception of a Wednesday when she spend one hour in each unit and one hour for the weekly church service which is available for people from both units. The programme shows group activities and one-toone time with people who use the service. The home is registered for 97 people and as acknowledged in the minutes of the relatives meeting it is currently an impossible task for one person to provide activities for 97 people. The quality improvement plan sent to us after the last inspection on 7th October told us about the changes they have made in the home for the menus and meal service. The home now provides breakfast to most people in their bedrooms. We looked at the service of breakfast in both units. At 8:45hrs on the first floor of Rednal unit we observed a two tier trolley with cups, bowls of porridge, bowls of scrambled egg with tinned tomatoes poured over, scrambled egg and tinned tomatoes on toast. The food was uncovered and on asking the carers we were informed that this arrangement had been in place for the last two weeks, and that the food goes cold. The carer told us the trolley had been on the unit for at least 10 minutes, the bowls of food were felt and they had gone cool. Carers told us that 18 people required assistance with their food on this floor. Care staff told us that the moral is very low amongst staff and they were distressed. We saw one person sitting on a chair in the corridor eating their toast. We saw people being served breakfast downstairs on this unit and the food was kept warm in a hot trolley. We saw people on both floors on Cofton unit were served breakfast in their bedrooms or the dining room and the food was being kept warm in hot trolleys. We discussed the breakfast routine with the area manager and we were informed that this was a new systematic approach to working, with an additional member of staff being used. We advised them it was not acceptable to continue to serve hot food to people upstairs on Rednal unit without a means of keeping the food hot. Towards the end of the afternoon the manager (designate) told us they had ordered another hot trolley for Rednal unit and it would be delivered by Thursday that week. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 19 There has been some improvement to the food service in the home and the provision of specialist diets for people who are losing weight. At 1100hrs we saw two carers in lounge on Rednal unit serving quiche, scone and jam, fresh fruit with hot drinks. We saw people were offered a choice. We spoke to a trained nurse who told us the food is improved and people have much more choice, and at meal times they choose what they want from being offered the choices on plates to see. We saw people being assisted with lunch on Rednal unit. They were given a choice of turkey burger or boiled ham with parsley sauce. We saw two people being assisted appropriately with their meal. One lady was observed in the lounge with her head on the table mat with her plated meal in front of her. The activity co-ordinator and managers were assisting people with food. We spoke to the chef and she told us the budget for food was alright, and is able to provide fresh fruit and vegetables daily. She told us since changing the routine of the meals that people are eating more food. They now use the show and tell method on Rednal unit. She told us at the moment they have 16 people on special diets who are known to be losing weight on Rednal and eight people on Cofton unit. The kitchen is providing special porridge with cream added, adding more protein to food and cream and milk to desserts. People are being offered nutritional snacks at 1100hrs and 1500hrs for example, quiche, fruit, cake, scones with cream and jam, egg mayonnaise and flapjack. In the evening there are sandwiches for supper for those that need them. We tracked the care of someone who was losing weight. The nutritional screening assessment dated 1st November shows an outcome of high risk for this person and the form stated refer to GP for dietician review. We could not see any evidence of a referral to the GP. We saw the managers daily audit for Rednal dated 26th November and this person is listed as needing weekly weighing. There was no weight noted on the form. We went into this persons bedroom and we saw a beaker of fortisip (a prescribed food supplement) drink on the table dated 30th November at 15:00hrs and the beaker was full. This person is receiving poor nutritional care. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the 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 who use the service are receiving a poor quality of health and personal care which places them at risk of harm due to neglect of care. EVIDENCE: We looked at the homes complaints records and saw 16 complaints had been recorded since August 2009. The outcome for all of the complaints was available and they had all been substantiated. We looked at the accident records and saw a number of entries dated November 2009 where people who use the service had been found with skin tears on their leg, a big bruise on a persons right hip, a wound on their left shin consistent with a bump. The accident records were poorly completed and there was no information to show the home had investigation how these injuries had been sustained. The home had not referred any of these people to safeguarding. This is not protecting the people who use the service. There have been 18 safeguarding referrals to Worcestershire County Council since the last key inspection in July 2009. The majority of the referrals have been about incidents that have happened on Rednal unit. We carried out a Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 21 random inspection on 7th October 2009 and due to the outcomes of care we found for the people whose care we tracked, we referred four people who use the service into safeguarding due to neglect of care. In December we received three notifications about medication incidents that had happened in November 2009. The notifications told us that eight people who use the service had not received the medication as prescribed but staff who were from a recruitment agency had signed to say they had given it. Four people had not received their medication as there was none in stock in the home and one person had two missing tablets. The home is not protecting people from harm due to neglect of care. We have shared this information with Worcestershire County Council who is the lead agency for coordinating safeguarding investigations. Please also refer to the health and personal care section of this report. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Parts of the home are in need of refurbishment to make it a more pleasant and a safer environment for the staff and people who use the service. EVIDENCE: The quality improvement plan which we received on 15th November told us they had undertaken a health and safety audit of the home. The manager (designate) is to review the audit report and implement an action plan. The manager sent us a copy of the action plan after the inspection. The general audit has 42 action points and it stated five had been completed. The second audit report was for catering; this had 17 action points and three had been completed according to the action plan. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 23 The improvement plan also states commencing 1st November, the manager (designate) will monitor and review the air ambience temperature. We asked to see these records. We were told they have not started yet. The manager (designate) sent us a copy of the most recent water tests for Legionella and these were negative. We were told the plans for refurbishment of the home will soon be put to the board of directors for the company. We were told the board are supporting the refurbishment of the home. Since the last inspection a new floor has been laid in parts of Rednal unit which has made some improvement, but there remains a bad odour in the unit and the carpets are stained and badly worn in parts. Communal bathrooms, toilets and sluice areas throughout the home are still in need of refurbishment as referred to in the inspection report dated 20th July 2009. We asked to see the window restrictor checks and were told they are done monthly and were last checked during the health and safety audit in November. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are not enough staff provided to meet the health and social care needs of the people who use the service which places them at risk of harm through neglect. Recruitment practices need to be more thorough to ensure people can be confident staff are suitable to care for them. EVIDENCE: The inspection found poor outcomes of care for the people who use the service (refer to health and personal care and daily life and social activities sections). On the morning of the inspection on Rednal there were two trained nurses (one was an agency nurse) and eight care staff and an extra carer from 07.00 to 11.30 to help with breakfasts. One carer had a healthcare appointment and left the unit for two hours. On Cofton there was one trained nurse and nine care staff (three of which were agency staff). The agency trained nurse due on duty did not arrive that morning but was replaced by another agency nurse at 10.00hrs. We spoke to staff who told us they feel that the level of care needed is impossible with the staffing levels. Staff told us the agency carers did not finish getting the residents into bed until 03.00hrs on the Sunday prior to the inspection. At 12.30hrs we saw there were still people in bed on Rednal unit who had not been washed. Staff confirmed there were eight people to Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 25 wash and get up. Staff appeared very stressed and were tearful when we spoke to them. We spoke to the manager (designate), area manager and the responsible person for the organisation and asked for evidence of dependency assessments. We were shown documents which were not dated but we were told they were completed shortly after the manager (designate) arrived at the home at the end of August; three months ago. They told us no formal criteria is used to work out the numbers of staff depending on ratio of high, medium or low dependency levels. We were told the staffing levels are the same on both units; two trained nurses and eight care staff. Despite the outcome of the last dependency assessment which showed for Rednal 10 high and 37 medium dependency people and Cofton eight, 32 medium and eight low dependency people using the service. The home are providing the same staffing levels for a unit which has higher dependency people using the service and it is a unit offering specialist dementia care as a unit offering general care for older people with lower dependency levels. The responsible person agreed there were not enough staff on duty and agreed to rectify this immediately. We looked at the recruitment for two staff. The home are following the recruitment procedures but we recommend that all applicants provide the actual month and year for employment so gaps in employment can be monitored. This recommendation was made at the last key inspection in July 2009. Staff told us they do lots of training and had dementia care yesterday, but again due to the staffing levels they are unable to put into practise what they have learnt. We spoke to two trained nurses from the agency and they told us they had not received any formal induction training when they commenced working at the home. One nurse told us she was not asked to come in for induction formally, but she came in her own time prior to starting her first shift at the home. We looked at the training matrix which shows the training for staff at the home. There are some gaps particularly for the manager (designate). The manager (designate) told us she had not received her mandatory training since she was employed at the home. There is no information on the training matrix to show if staff have received any training about the Mental Capacity Act and Deprivation of Liberty safeguards. The manager (designate) told us she did this training last year before she started work at this service. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home needs significant improvement to ensure it is run safely and in the best interests of the people who use the service. EVIDENCE: The manager (designate) started work at the home at the end of August 2009. She is a registered nurse and has a post graduate certificate in dementia care from Worcester University. We spoke to trained nurse and care staff and they told us the new manager was supportive and approachable. This visit was also to check compliance with three Statutory Requirement Notices (SRNs) which were served by us in relation to health and welfare of Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 27 the people who use the service, the management of medication and the quality of the care records. The findings are the SRNs have not been complied with. There have been no changes to the homes management of peoples monies since the last inspection. We saw the monthly provider visits were being carried out and recorded. We looked at the quality assurance monitoring returns completed by a representative of the company for October and they stated the following:• Care plans in place however on examination some plans contradict and actions not always current. • Need ongoing evidence of service user/ advocate involvement with the care plans. • Concerns about lack of daily notes. • Weekly baths not always happening. • Position change charts were not always completed as per plan. • Poor dementia care awareness environment. • Standard 27 it appears that staffing levels have been less than adequate to meet the needs of service users on several occasions recently. • Standard 30.13 not evident if staff have training in prevention of pressure damage. • Standard 35.3 request by CQC to set up accounts for service users with high levels of funding not yet addressed. We looked at the accident records and saw a number of entries dated November 2009 where people who use the service had been found with skin tears on their leg, a big bruise on a persons right hip, a wound on their left shin consistent with a bump. The accident records were poorly completed and there was no information to show the home had investigation how these injuries had been sustained. The home had not referred any of these people to safeguarding. We asked the manager (designate) about the high incidence of injuries to people who use the service and she told us they are seeing small injuries such as bruises due to the moving and handling equipment. She told us they have provided more moving and handling training. In December we received three notifications from the area manager about medication incidents that had happened in November 2009. The home is not sending these notifications to us without delay in accordance with the regulation. We received two notifications three weeks after the incident and one two weeks after the incident. We looked at the fire records and we saw the daily checks were not being consistently recorded as there were seven gaps between 14th November and 1st December 2009. Water tests have been carried out for the management of Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 28 Legionella. A recent health and safety audit has been carried out by the company. Please refer to the environment section of this report. Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 1 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 2 X 1 2 Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 30 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1)(2) Requirement Timescale for action 01/12/09 2. OP8 12 (1) 3. OP12 12 (1) Care plans must be in place and sufficiently detailed and care needs reviewed as peoples needs change to ensure staff understand what is required and people can be sure their needs will be met. Timescale for action 31/08/09. Requirement not met. The date given is the date of the inspection. The health and social care needs 01/12/09 of the people who use the service must be promoted and provided to ensure they are not placed at risk of harm through neglect of care. Timescale for action 31/08/09. Requirement not met. The date given is the date of the inspection. The health and social care needs 01/12/09 of the people who use the service must be promoted and provided to ensure they are not placed at risk of harm through neglect of care. Timescale for action 31/08/09. Requirement not met. The date given is the date of the DS0000004122.V378587.R01.S.doc Version 5.3 Lickey Hills Nursing Home (2 Units) Page 31 4. OP9 13(2) 5. OP9 13(2) 6. OP27 12(1) inspection. To make arrangements to ensure 01/12/09 that care plans include detailed information and instructions for staff in respect of the administration and management of medicines, including the reasons to give medicines on a when required basis and what constitutes needed for a named person. Timescale for action 31/08/09. Requirement not met. The date given is the date of the inspection. To make arrangements to ensure 01/12/09 that medication is stored securely and at the correct temperature recommended by the manufacture to ensure medication does not deteriorate which can make the medication ineffective and possibly harmful to people living in the home. Timescale for action 30/09/09. Requirement not met. The date given is the date of the inspection. 01/12/09 You must ensure that the numbers and skill mix of qualified/unqualified staff are appropriate to the assessed needs of people living at the home, taking into account the size, layout and purpose of the home, at all times. This is so that people can be confident that their needs will be met in a timely manner. Timescale for action 31/08/09. Requirement not met. The date given is the date of the inspection. Notifications of death, illness and 31/12/09 other events must be submitted without delay to demonstrate the home are taking appropriate and DS0000004122.V378587.R01.S.doc Version 5.3 Page 32 7. OP37 37(1)(2) Lickey Hills Nursing Home (2 Units) prompt action for all incidents in the home to ensure the health and welfare of the people who use the service is promoted and they are protected from harm. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP29 Good Practice Recommendations It is strongly recommended that the home review the laundry provision with particular regard to its location and size. Thorough and robust recruitment records should be kept in the staff file to demonstrate that any employment gaps or issues that arise through the recruitment process are explored at interview to ensure that people are fully protected. Staff should receive training about the Mental Capacity Act and the Deprivation of Liberty safeguards to ensure they have a clear understanding of how this impacts on the care of people who live in the home who lack mental capacity. Large sums of peoples monies held in the joint client account should be moved to individual high interest bearing accounts to ensure the home is acting in their best interest with regard to their savings. 3. OP30 4. OP35 Lickey Hills Nursing Home (2 Units) DS0000004122.V378587.R01.S.doc Version 5.3 Page 33 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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