Inspection on 08/08/06 for Limetree Care Centre

This inspection was carried out on 8th August 2006.

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

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

Other inspections for this house

Limetree Care Centre 26/11/07

Limetree Care Centre 05/12/06

Limetree Care Centre 09/05/06

Limetree Care Centre 16/11/05

Limetree Care Centre 01/06/05

Limetree Care Centre 25/01/05

Limetree Care Centre 03/06/04

Limetree Care Centre 01/03/04

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

CARE HOMES FOR OLDER PEOPLE Limetree Care Centre 8 Limetree Close London SW2 3EN Lead Inspector Lisa Wilde Random Unannounced Inspection 10:00 8 , 9 , 10th & 15th August 2006 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000043119.V307517.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000043119.V307517.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Limetree Care Centre Address 8 Limetree Close London SW2 3EN 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) 0208 674 3437 0208 674 3949 mohamed.madarbux@excelcareholdings.com Limetree Healthcare Ltd Care Home 92 Category(ies) of Dementia - over 65 years of age (28), Mental registration, with number disorder, excluding learning disability or of places dementia (6), Old age, not falling within any other category (64) DS0000043119.V307517.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2006 Brief Description of the Service: Limetree Care Centre is a modern, purpose built home. It is located just off the South Circular Road between Tulse Hill and Streatham Hill. The home is not very close to any tube or train stations and the local shops and other facilities are a fifteen-minute walk away. It is owned and managed by Excelcare Holdings. Limetree offers residential and nursing care for older people with dementia; there is one residential floor and two nursing floors. There are 92 rooms all with full en-suite facilities. The current fees are charged from £350 per week. Additional charges are made for things such as hairdressing and newspapers. The home makes copies of the Commission’s reports following the inspections, available in the reception area of the home. At the time of this inspection there were 18 vacancies but the Commission has placed an embargo on this home and is not allowing to the home to take any admissions at present. DS0000043119.V307517.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place in August 2006. The inspector spent three days at the home talking to service users, managers and staff, going through records and checking medication stocks. The inspector then spent a further day telephoning twelve service users’ relatives. Comments from relatives on individual issues are mentioned throughout the report but in general relatives talked about different satisfaction levels, ranging from some relatives who said they were very happy to some who said that they were very worried about care at the home. For the sake of protecting relatives’ identities, the floors on which they visit have not been identified in this report. The inspector was concerned that while there had been improvements in some areas, most of the requirements made at the last inspection were not met. Sixteen standards were assessed at this inspection, only two of those were met and following this inspection there are now forty-five requirements in place. One immediate requirement had to be left because of a particular concern about how someone was being moved by staff and an enforcement notice was issued following the inspection to make sure that the home improves its practice on the nursing floors with regard to record keeping around service users’ health care needs. Although much of the report has, by necessity, to talk about the home as a whole, the inspector found that most of the problems related to the nursing floors in this home and that standards on the residential ground floor have shown greater improvement. What the service does well: What has improved since the last inspection? The home has improved how it consults with relatives by sending out more information by email and by holding more Relative’s Meetings. DS0000043119.V307517.R01.S.doc Version 5.2 Page 6 Comments from service users’ relatives and the minutes of the Relatives Meetings show that relatives feel that things are generally improving at this home. One relative said that the cleanliness in the home has improved and two said that the way staff care for service users has improved. Staff at the home have worked hard to contact relatives and talk though service user care plans with them. What they could do better: The standards assessed at this inspection showed that the home must do more work: • • • • • • • • • • • • • • • • all service users must have a signed contract or terms and conditions. staff must read, understand and follow care plans. external professionals’ guidance must be followed. care plans and risk assessments must be changed whenever a service user’s needs change. service users and their families must be supported to think about and write useful care plans around how they want to die. accurate records must be kept of all health care monitoring and staff must react whenever monitoring shows that a different response is needed. medication procedures must be followed. the home must do more to find out what individual service users and their relatives think about the food at the home. records must be maintained of all investigations into complaints. records must be maintained of all investigations of allegations of abuse. all staff must have training in protection of vulnerable adults, dementia care and working with challenging behaviour. the organisation must conduct ongoing checks into why the missing criminal records bureau checks have not been received and make sure that those staff without those checks in place are adequately supervised. staff must have their own training and development plans in place and these must be brought together into an annual training plan for the home. staff must be supervised regularly enough and must have an at least annual appraisal of their work. People who are offering supervision must be trained to do so and have been judged as competent to do so. record keeping throughout the home must be clear, comprehensive and effective. the fire protection systems and the floor cleaning systems must be improved. DS0000043119.V307517.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000043119.V307517.R01.S.doc Version 5.2 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 DS0000043119.V307517.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some service users do not yet have a signed contract or terms and conditions which means that some service users and their relatives are not being given information about their legal rights and responsibilities. Because the home has not been allowed to admit any service users in the past few months, they have not been able to assess any new service users so it is not possible to judge how they identify a new service user’s needs and decide whether they can meet those needs. Standard 6 is not applicable as this home does not provide intermediate care. EVIDENCE: There is new legislation in place now that will come into force on 01/09/06 and 01/10/06 which will require services to state exactly what fees each service DS0000043119.V307517.R01.S.doc Version 5.2 Page 10 user is paying and how it breaks down into different areas, in the service user guide. (Recommendation 1) A senior manager told the inspector that at their last audit of the home not all service users have a signed contract in place yet. (See Requirement 1) There was a previous requirement that the registered person must ensure that the home meets the special needs of service users suffering from dementia. This is a wide reaching requirement and although much of the evidence of this report shows that the home does not meet this requirement, it has been removed as all the issues are now addressed with more specific, targeted requirements. There was a previous requirement that the registered person must ensure that service users have a comprehensive needs assessment completed in consultation with them and /or their representative, having regard to the service user’s needs in respect of health and welfare. This assessment must be kept under review. The Commission has placed an embargo on this home and has not allowed any service users to move to this home since the last inspection. The home therefore has not been able to assess any new service users and it is not possible to assess this requirement. This issue will be assessed at the next inspection. (See Requirement 2) DS0000043119.V307517.R01.S.doc Version 5.2 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 11 Quality in this outcome area overall is poor although standards on the residential ground floor are higher than the other two nursing floors. This judgement has been made using available evidence including a visit to this service. There are now detailed written care plans in place for all service users that describe how staff will make sure service users’ needs are met. These plans are reviewed monthly and relatives have been contacted to try and make sure that the service user or next of kin has agreed every care plan. However, evidence showed that often staff do not know what is in the care plans and are not offering care in accordance with the care plans or external professionals’ guidance. Records are not effectively maintained of all the care and monitoring required by the care plans. Sometimes when staff are monitoring a health condition they do not react properly when that monitoring shows an unusual result. This means that the care plans are not meaningful and service users and relatives have been asked to agree to something that is not, in fact, occurring. Service users’ health care and other support needs are not being fully met. DS0000043119.V307517.R01.S.doc Version 5.2 Page 12 No one at this home has been judged as capable of being responsible for their own medication so staff at the home are responsible for all service users’ medication. Evidence showed that staff are not always following procedures and the home is not administering medication as required which means that the service users may be being put at risk of harm from medication not being given as it is prescribed by the doctor. Although staff at the home acknowledged the difficulties involved when discussing with relatives how service users want to die, the home is not doing enough to write useful care plans around end of life issues which means that this very important area of care is not being addressed and service users may not be being allowed to die as they would wish. EVIDENCE: The inspector examined eleven files over the three floors. The majority of the following evidence was found on the nursing floors. The inspector found that detailed care plans are now in place for all areas of a service user’s care on all the files examined. A senior member of staff is now reviewing these plans every month. However, on further examination of how the care plans were being used several issues were noted. Some of these issues related to staff not doing what was required by care plans, some issues related to staff not knowing what was in the care plans and some issues related to staff not recording information properly. Two service users had ulcers and had a wound care plan in place written by the nurses in the home. These plans said that the wound must be cleaned and the dressing changed every 2/3 days. The wound records showed that on some occasions the wounds were being cleaned every 2/3 days but on some occasions the wounds were being cleaned and dressings changed at different frequencies with the longest interval between cleaning being nine days. One of these service users had to attend the foot clinic every two weeks and had a care plan stipulating that this must not be missed and they had missed one of their last four appointments. Two service users had care plans that said they needed specific amounts of fluid every day. The records showed records of individual drinks were being recorded but totals of daily amount were not being recorded, that on no day did they receive the stipulated amount of fluid and no action had been noted in the files or on the plans to address the issue. One service user had a care plan saying that the doctor had restricted their fluid intake to 1000mls per day. No records were being maintained of how much fluid this service user was taking. Staff thought that this care plan had DS0000043119.V307517.R01.S.doc Version 5.2 Page 13 been stopped yet staff had been signing the care plan every month stating that it should continue. One risk assessment was in place for one service user because another service user was aggressive towards them. The aggressive service user had moved out of the home over a month previously and staff had reviewed the risk assessment since then but had not changed or removed it. One risk assessment stated that one service user should be monitored every quarter of an hour. No records were being maintained of this and when asked, staff did not know that this was in the risk assessment and said that this plan would be unrealistic anyway. There was a previous requirement that the registered person must ensure that risk assessments are reviewed to reflect any changes in the risk management of the service user. This was not met. (See Requirement 3) Five service users had a care plan that said they needed to be taken to the toilet every 2/3 hours. There was a toileting chart on all the files that was not completed for anyone. Two service users had care plans that said they needed to be turned in bed every 2/3 hours but no records of any turning were being maintained. All service users are supposed to be weighed monthly and on most occasions they are. Two service users had care plans that said they had to be weighed weekly. One of these was only being weighed monthly and one had three weekly weights recorded in the last three months, in addition to their monthly weights. Hourly checks were being recorded of all service users on two floors but the third floor used a different record and some of these records had no date on them. These night records showed that sometimes night staff were checking some service users more often than hourly but when asked, staff could not find any records that indicated why the checks had been increased. One waterlow (assessment of health risks) record had not been completed in June. Monthly blood pressure charts are not needed for all service users but of the seven that were being used, three had not been completed for every month. One service user had a bowel chart in place but there were no entries for the months of July or August. One service user had a care plan that stated staff had to spend twenty minutes of every shift with them to assist them with confusion and managing their aggressive behaviour. The records in the daily log only made comments such DS0000043119.V307517.R01.S.doc Version 5.2 Page 14 as “calm” against the entry for that care plan and no records were being maintained of whether twenty minutes was being spent every shift or what effect that was having i.e. whether the care plan was working or needed to be changed. (See Requirement 4) Pain assessments were only being completed if someone was in pain however there was a section on the form that should be completed if the service user is in no pain. None of the pain assessments were dated and there was no evidence of them being reviewed regularly. Risk assessments around nutrition were not consistent in that some service users had care plans in place around additional nutrition needs with a very low risk number on their risk assessment but one service user who had a very high risk number on their risk assessment had no additional nutrition needs identified in their care plan. The home uses a tool called the MUST form to record and assess nutritional needs. Senior staff said they have only recently introduced this but the details were not being completed these forms consistently. The home does not keep records of the food that service users eat even if they are diabetic. Staff said they would record food if there was a problem identified. The records of one service user who had been having their food recorded showed that staff were just writing what the food was, not how much was being eaten and the records were not being kept every day. (See Requirement 5) This service user had to have their food pureed and of the thirty-one daily records that were available twenty-eight recorded mashed potatoes and vegetables, on two days chicken was added and on one day meat was added. (See Recommendation 5) One service user had a care plan that said they had to have exercise because they were at very high risk of developing pressure sores but there was no recording tool to show how often they were getting exercise. Only one service user had their wishes after death care plan completed. Staff said that this is a difficult area, as many relatives do not want to talk about it and some files did include records that staff had spoken with relatives about the issue. Staff talked about how difficult it was to know when a service user should become very ill but remain in the home and be allowed to die there, as opposed to being sent to hospital. The Regional Manager said that staff are due to start training in End of Life issues soon. (See Requirement 6 & Recommendation 2) Only four of the eleven service users had had a review in the past year and only one service user had the home’s placement review form completed. (Social services have a duty to review care every year but if they do not do this the home must review the care themselves) (See Requirement 7) DS0000043119.V307517.R01.S.doc Version 5.2 Page 15 None of the files had the benefits/power of attorney section of their file completed and none had the complete details of service users’ dentist, chiropodist and optician. (See Requirement 8) Eight of the service users did not have a dated inventory of their belongings on file. Four relatives reported clothes, toiletries and other possessions going missing and them having to replace them. (Requirement 9 & 10) A visiting professional told the inspector that staff were not following instructions that had been left regarding the use of a hoist for one service user who had a fractured arm. An immediate requirement was left and this issue was referred to the borough’s adult protection team for investigation. (See Requirement 11) There were five requirements relating to records and monitoring in the last report all of which have not been met. Following review of all the above evidence that relates to monitoring and recording of issues, the previous requirements have been brought together and one requirement has been made and an enforcement notice has been issued. (See Requirement 12) There was a previous requirement that the registered person must ensure that care plans are drawn up with service users and/or their relatives and risk assessments for the use of bed rails where appropriate. Some relatives have read through and signed the care plans but some still have not. Staff have been working hard to improve their consultation with relatives in many ways and there was evidence that the home is continuing to try to persuade relatives to come to the home and sign the plans. While the home must continue with its efforts to contact relatives, this requirement can now be removed. Risk assessments for the use of bed rails are now in place. Two relatives said that their service users used to sit in the lounge whereas now they are always in their room when they visit. One relative said that recently they had visited at 3.30pm and the service user’s bed had not been made and they were sitting alone on a chair in their room in their pyjamas. There was a previous requirement that the registered person must ensure that the home is conducted in such a manner that makes proper provision for the health and welfare of service users. Care must be delivered in accordance with agreed care plans and guidance. A record of care and support given to service users must be accurately recorded on all relevant documents. This is a wide reaching requirement that is to some extent overtaken in this report by more specific, targeted requirements. This requirement is not met but part of it has been removed. (See Requirement 13) DS0000043119.V307517.R01.S.doc Version 5.2 Page 16 There was a previous requirement that the registered person must ensure that copies of accidents and incidents relating to the service user are kept in their files. This is not yet being done. (See Requirement 14) The inspector examined the medication records for July and August on all floors and checked the stocks of medication held. There was a previous requirement that the registered person must ensure that all service users are given the opportunity and support to self-administer their medication unless they have been risk-assessed as not being able to. All files now had a medication risk assessment on them with some saying that the service user did not want to administer their medication and some saying that they were unable to administer their medication. After talking with staff the inspector was not entirely confident that staff at the home were not just assuming that service users couldn’t administer medication but the risk assessments were in place as previously required. There was a previous requirement that the registered person must ensure that an individualised procedure is available on the handling of covert administration of medication. Staff on the second floor said that no one was having their medication administered covertly but they correctly described the procedure they would follow if they believed someone needed this i.e. by gaining written consent from the GP and the next of kin and by putting in place a written procedure for that service user. There was a previous requirement that the registered person must ensure that all instructions on MAR charts are written in English (not Latin). This is now being done. There was a previous requirement that the registered person must ensure that the system on the handling of refusals of medication is implemented however the timescale for the meeting of this previous requirement had not elapsed by the time of this inspection. There is now a written procedure in place and a form that staff must complete when someone refuses medication for the period of time identified in the procedure. When asked, staff on the ground floor could not describe this procedure. One service user had an enema prescribed for three days in a row but the service user had refused the third treatment for around ten days. Staff said they were waiting to give the third enema but did not understand that after this period of time the third enema may now not be effective, the initial course was incomplete and the GP’s advice should have been sought after the third enema had been refused. (See Requirement 15) There was a previous requirement that the registered person must ensure that the list of staff authorised to administer medication is up-to-date. The three lists have been updated but only the list on the ground floor is signed by the home manager. Only the list on the ground floor included samples of the DS0000043119.V307517.R01.S.doc Version 5.2 Page 17 initials that staff would use to sign the medication administration record. (See Requirement 16) There was a previous requirement that the registered person must ensure that the use of all prescribed items is documented, in particular external products. The records showed that all prescribed items are now on the medication administration charts. There was a previous recommendation that the registered person should ensure that the frequency of all blood monitoring is indicated on the bloodmonitoring sheet, including the action to be taken for high/low readings, or refusals to have monitoring carried out. The blood monitoring sheets are in place but do not indicate procedures for high/low readings or refusals. Staff on the first floor could describe what they would expect if a high blood pressure reading was taken i.e. they would take another reading in four hours. However, on one occasion a high reading had been recorded and the next test had not been taken for approximately sixteen hours. (See Requirement 17 & Recommendation 3) There was a previous recommendation that the registered person should ensure that the Homely Remedies list is authorised by the GP annually and that any residents who cannot be given one or more Homely Remedies are identified. On the second floor the list had been updated and signed but was kept in the homely remedies file while the old list was still on the wall of the medication room. (See Recommendation 4) On the ground floor staff are administering enemas to service users but have not received specific training from the District Nurse on how to do this safely. Staff said that some of them have been trained as nurses but staff on a residential unit are not allowed to undertake tasks that a nurse should undertake. This is a borderline procedure but to ensure that staff are operating appropriately, the District Nurse should be called in to assess the situation and offer advice and training. (See Requirement 18) There were gaps in the administration records on the first and second floor both for oral medication and external products. (See Requirement 19) On the first floor the letter F was being used on the medication administration chart to denote an “Other” reason why medication was not given but the reason was not being defined as required. (See Requirement 20) Blood pressures were being taken for one service user weekly but two readings had been missed in June. Requirement 12 addresses this issue. Some medication was only to be given when the service users required it and some staff were signing when they had not taken it. (See Requirement 21) DS0000043119.V307517.R01.S.doc Version 5.2 Page 18 All stock checks on the ground and first floor tallied with the records. On the second floor one of the stock checks did not tally with the records. (See Requirement 22) On the second floor two checks had been missed in February and March for one service user’s blood monitoring. Requirement 12 addresses this issue. X was being used instead of the stipulated letter A or E to denote medication being refused and sometimes medication was being recorded as refused and destroyed when in fact it was only refused. Staff on the ground floor had been using ticks to record the use of liquid paraffin instead of signing the record as they would for any other prescribed item. (See Requirement 23) DS0000043119.V307517.R01.S.doc Version 5.2 Page 19 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X Quality in this outcome area was not assessed. EVIDENCE: There was a previous requirement that the registered person must ensure that service users or their representatives are consulted about their interests and favoured lifestyles, these must be recorded and appropriate opportunities are given to service users in relation to meeting these needs. (See Requirement 24) The inspector decided that given the concerns outlined throughout this report and the number of requirements about standards of care, the home should focus on those areas in the next few months and activities will be assessed at the next inspection. In addition, the current activity co-ordinator is returning to being a care worker and the home has just recruited two new part-time co-ordinators. Three relatives said that the food was ok or alright. One relative was very unhappy with the food and said that they had mentioned this many times to the home, both in the surveys that are sent out and directly to a manager but that things had not improved. They said that the quality was poor and the food DS0000043119.V307517.R01.S.doc Version 5.2 Page 20 appeared cheap. They were concerned about the “stodginess” of the food. Another relative said that the service user gets given as an example, pear and custard but they have no teeth so cannot eat the pear. (See Requirement 25) The home has recently introduced a snacking policy whereby chocolate, crisps and fruit are available all day for service users to eat. Sandwiches are also available in the fridges to allow service users to eat during the night or before breakfast if they are hungry. The Regional Manager said that this policy has increased service users’ appetites generally. The inspector saw service users on the floors during the three days and all of them chose crisps or chocolate when offered the snacks, no one chose fruit. One member of staff said that one service user takes all the snacks to their room sometimes and the inspector saw one member of staff have to take chocolate off a service user as they had chosen this but were diabetic so were not supposed to eat sugary foods. One relative said that they were concerned that their service user had put on a lot of weight recently and another relative sad that they did not think that this policy was a good idea because they felt that enough “proper” food should be provided at mealtimes. The inspector was concerned about the long-term implications of this policy that introduces a lot of salt and sugar into these older people’s diets. (See Requirement 26) DS0000043119.V307517.R01.S.doc Version 5.2 Page 21 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records are not being maintained of all investigations into complaints, which means that the home cannot show that it is listening to and responding effectively to service users and their relatives’ concerns. Records are not being maintained of all investigations of allegations, which means that the home cannot show that it responding effectively to issues of potential abuse. All staff have not had recent training in protection of vulnerable adults and this along with other issues of concern raised throughout the report means that service users may be being placed at risk of harm. EVIDENCE: There is a complaints policy that states that the complainant will receive a response within twenty-eight days but there are no target timescales in the policy for completion of any investigation. (See Recommendation 6) There is a complaints file, which includes a list of all complaints received but the forms used to record how the complaint is investigated are not complete. Details of the investigation, outcome, action and whether the complainant was satisfied were not in place. (See Requirement 27) DS0000043119.V307517.R01.S.doc Version 5.2 Page 22 There is a separate file for issues that are dealt with as allegations or adult protection issues but there was only one letter in this file that had been sent to the home by a social worker after investigating one recent allegation. The home is not keeping records of all the issues that have been investigated. (See Requirement 28) The manager’s training records showed that only half the staff have had recent training in adult protection. The borough’s adult protection team has offered some of that training. (See Requirement 29) DS0000043119.V307517.R01.S.doc Version 5.2 Page 23 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X Quality in this outcome area was not assessed. EVIDENCE: Although these standards weren’t assessed, two issues were raised during relatives’ feedback about the environment. Although generally relatives were happy with service users’ rooms, six relatives reported that the home had been extremely hot over the summer, most of the concerns being on the second floor. While it appeared that the home had been following guidance around what to do in hot weather, the lack of air conditioning and fans appeared to have made the environment uncomfortable regardless of what staff were doing to ease the situation. This issue had been raised in the recent Relatives’ Meeting and managers had felt that they had resolved the problem but relatives said that they had not noticed a difference. One relative said that they had been told that they could not alter the radiator temperature in the service user’s room when having individual controls is a requirement of the DS0000043119.V307517.R01.S.doc Version 5.2 Page 24 standards and a senior manager had told the inspector that all rooms had individual controls. (See Requirement 30) One relative said that often when things need fixing in the rooms it takes a long time for them to get fixed. They said that as an example they visited one week and the light bulb wasn’t working and when they visited the week later it still had not been replaced. The home should address this but the issue of maintenance will be fully assessed at the next inspection. DS0000043119.V307517.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Over 50 of care staff either hold or are undertaking the required NVQ Level 2/3 in Care which means that the staff are becoming qualified to offer the standards of care required to meet service users’ needs. There are still some staff at this home who do not have the required criminal records check on file and the home has not been doing all it can to make sure that those checks are in place. Although the risk may be small, this could mean that some staff have criminal records that the organisation is not aware of that would mean that they would not be suitable to work with vulnerable people. Senior managers were not aware of the additional supervision requirements that have to be in place when someone is working without the required criminal record check, which means the managers are not doing all they can to keep themselves up to date with procedures that are in place to protect service users from harm. Staff do not have their own training and development plans in place and these have not been brought together into an annual training plan for the home which means that the home cannot be sure that they are offering the necessary training to make sure that staff can meet the needs of service users and the aims of the home. EVIDENCE: DS0000043119.V307517.R01.S.doc Version 5.2 Page 26 The numbers of staff on duty was not fully assessed because the duty roster for staff was not complete. When the inspector asked for the last four weeks rosters the manager had to ask another member of staff and use other documents to fill in the roster as they believed it had been worked. (See Requirement 31) There have been staff recruited since the last inspection but they have not started work yet so their personnel files have not been sent to the home from head office yet. There are still some staff working at the home who do not have any criminal records bureau check in place or who have a standard check instead of an enhanced check. The manager was not aware of the additional requirements that are in place should a member of staff be working with only a POVAFirst check in place and no criminal bureau check i.e. these staff cannot escort service users and have to be supervised by an identified member of staff. The manager was able to check and verify that these staff had not escorted service users out of the home but was not sure if they had been supervised as some staff at this home have not been supervised for a considerable time. The manager and other senior staff in the organisation were not aware if further recent attempts have been made to find out why the checks have not been received yet. (See Requirement 32) The organisation’s last audit of the personnel records showed that there are historical problems with getting two verified references on file. However, one person had been employed as late as May 06 with only one reference being gained. (See Requirement 33) The organisation has introduced an Induction and Foundation record for new staff that is in line with the Skills For Care national requirements but this record has not been used for any staff yet. (See Requirement 34) The managers training records were not complete so it was not possible to fully assess what training staff had undertaken. A senior manager reported that over 50 of staff either hold or are undertaking the NVQ Level 2 or 3 in Care and the records appeared to verify that. Appraisals have not been conducted so individual training and development plans are not in place for staff and these have not been brought together into one overall training and development plan for the home which identifies all the training necessary to ensure the home is meeting the needs of the service users and when the home intends to offer that training to staff. (See Requirement 35) There was a previous requirement that the registered person must ensure that all staff receive training in dementia care and challenging behaviour. Work has DS0000043119.V307517.R01.S.doc Version 5.2 Page 27 been done in this area and many staff have started a ten module course around understanding dementia but it has only just started and not all staff are undertaking it. Four of the twelve relatives said that they had had to talk to staff about the way that they spoke to service users, that they did not spend enough time coaxing service users and that they didn’t seem to understand what they needed. Eight of the twelve relatives said that staff were nice, or seemed ok pr seemed caring. The Regional Manager said that the challenging behaviour modules are towards the end of this course. Staff reported that they feel some staff are uncertain about how to manage aggression. (See Requirement 36) The inspector received information from one relative about how staff treat service users that was of such concern that they referred the relative’s case to the borough’s adult protection team for investigation. DS0000043119.V307517.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36, 37 & 38 Quality in this outcome overall is poor although standards on the residential ground floor are higher than the other two nursing floors.. This judgement has been made using available evidence including a visit to this service. The manager has made an application to be registered with the Commission and has the required qualifications and experience to run the home. He has now submitted an application to be registered with the Commission. Staff are not supervised regularly enough and the people who are offering supervision have not been trained to do so. Staff have not had annual appraisals of their work and training needs. This means that service users are being cared for by staff who are not receiving effective support, advice and guidance from senior workers. Record keeping throughout the home is not clear, comprehensive or effective which has an impact in many ways. Service users are not being given the required information about their rights and responsibilities, service users’ care is not being offered properly, medication records are not maintained as they DS0000043119.V307517.R01.S.doc Version 5.2 Page 29 should be, the manager cannot show that the home responds well to complaints and allegations, the manager cannot know that the training on offer is adequate and improving staff performance, the roster doesn’t show which staff are on duty and whether the numbers of staff on duty reflect the number of staff that are supposed to be on duty and fire test records are not fully effective in showing that the fire detection system is working. Most of the health and safety procedures are being followed properly, which means that service users are being protected from harm. However the fire protection systems and the floor cleaning systems are putting service users at some risk. EVIDENCE: There was a previous requirement that the registered person must ensure the manager has the skills for managing a care home. The manager has put in an application to be registered with the Commission and his interview is on 17/08/06. He holds a nursing qualification and has completed the NVQ Level 4 Registered Managers Award. He holds a Masters in Business Administration and additional qualifications in, among other things health promotion, care for older people and teaching and assessing. He has been a nurse since 1991 and has been a manager since 1994. He has been at this home for nearly a year. Staff described the manager as “supportive” and “good at getting things done”. One relative said that he had been “ a brick”. During this inspection he evidenced his awareness of the needs of the service user group and how staff should meet those needs. This was the first time the inspector has visited this home so could not conduct a full assessment of the manager’s abilities but given the number of unmet requirements from the last report and the additional requirements that are now being put in place, it is clear that there remain significant challenges. While quality assurance systems were not assessed during this inspection they were generally discussed with the manager. Only two relatives knew about the inspections and the reports that are written following inspections although more were aware of the embargo that is in place at the moment. Although the inspector saw the report of the last inspection in the reception area to the home relatives said that they do not look at the documents in the reception area because they go straight on to the floor they are visiting. (See Requirement 37) The managers’ records of supervision showed that twenty-seven out of sixtysix care staff have not been supervised since April 2006 (the manager only had supervision records dating from April). Staff have not had annual appraisals of their performance. Only the home manager has had training in supervision, no other staff who offer supervision have had training in how to offer supervision DS0000043119.V307517.R01.S.doc Version 5.2 Page 30 and conduct appraisals and a senior manager said that they had concerns about the quality of some of the supervision records that they have audited. The manager said that senior staff are aiming to conduct twelve supervision sessions per month to address this issue. (See Requirements 38 - 40) Evidence throughout this inspection shows that the home is not keeping records as required. The previously mentioned enforcement notice that has been issued relates in part, to record keeping. The inspector examined all health and safety records and documentation. All the required records were in place and up-to-date apart from the weekly fire tests. Only the ground floor fire call point has been tested, as the key does not fit the call points on the other floors. The manager said he has requested a new key. (See Requirement 41) Two records of the weekly fire tests were missing. The manager felt that this was because fire drills had occurred on those days but he could not find records of drills on those days. (See Requirement 42) A fire door leading to the garden is regularly propped open with a box to allow service users to go out. (See Requirement 43) Staff reported that some staff are wedging paper in the door alarm to stop the alarm sounding when the outside door is open. Senior staff said they were aware of this. (See Requirement 44) During the three days at the home the inspector slipped on the first floor twice and saw a member of staff slip once. When the Facilities Manager investigated this a day later she said that the floor had been sticky when she checked. The cleaner on the second floor mopped the hallway and placed a caution sign on the wet area but the area that was wet was approximately five metres long and covered the whole width of the hallway so there was no way to walk around the wet area. The caution sign was placed at one end of this large area and it is possible that some service users would not recognise the purpose of that sign anyway given how their dementia has affected their understanding. (See Requirement 45) DS0000043119.V307517.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 X 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 1 1 2 DS0000043119.V307517.R01.S.doc Version 5.2 Page 32 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 OP2 Regulatio n 5 Requirement Timescale for action 30/11/06 2. OP3 14 (1) 3. OP7 OP8 13(4)(c) 4. OP7 12 (1) (a) & 15 The Registered Individuals must ensure that all service users have comprehensive, signed terms and conditions (or a contract if they are paying privately) in place and that new service users receive these documents at the point of moving to the home. 30/11/06 The registered person must ensure that service users have a comprehensive needs assessment completed in consultation with them and /or their representative, having regard to the service user’s needs in respect of health and welfare. This assessment must be kept under review. This previous requirement was not assessed during this inspection. The Registered Manager must 30/09/06 ensure that risk assessments are reviewed to reflect any changes in the risk management of the service user. Previous requirement: Unmet timescale 01/08/06 The Registered Manager must 30/09/06 ensure that all staff read and DS0000043119.V307517.R01.S.doc Version 5.2 Page 33 5. OP7 OP8 12 (1) (a) 6. OP7 OP8 12 (1) (a) & 15 7. OP7 OP8 12 (1) (a) & 15 8. OP7 OP8 17 9. OP7 OP8 17 10. OP7 OP8 12 (1) (a) & (4) (b) 12 (1) (a) 11. OP8 12. OP7 12 (1) understand the care plans that are in place. The Registered Manager must ensure that advice is sought on an individual basis from a diabetes specialist as to whether accurate records of food eaten need to be maintained for all the service users with diabetes. The Registered Manager must ensure that staff sensitively gather the views of service users and their relatives with regard to end of life issues. In the interim, if relatives do not wish to discuss the matter, this should be recorded on the care plan. The Registered Manager must ensure that all service users have an annual review of their care involving service users and their representatives should they choose. The Registered Manager must ensure that all service users have on file details of their dentist, optician and chiropodist (plus district nurse if they are on the residential floor) and who has power of attorney for them. The Registered Manager must ensure that all service users have on file an up-to-date inventory of their possessions that is altered when new possessions are bought or replaced. The Registered Manager must ensure that service users’ possessions are not taken, misplaced or lost by staff or other service users. The Registered Manager must ensure that staff use the hoist as directed by the community physiotherapist when moving and transferring the identified service user. The registered person must DS0000043119.V307517.R01.S.doc 31/10/06 30/11/06 30/10/06 31/08/06 30/09/06 30/09/06 10/08/06 14/09/06 Page 34 Version 5.2 OP8 OP37 (a) & 17 ensure that the information in care plans relating to the following and recording of bowel charts is followed by the staff at all times. And The registered person must ensure that the information in care plans relating to the recording of weight loss is followed by the staff at all times. And The registered person must ensure that the information in care plans relating to the following and recording of waterlow scores is followed by the staff at all times. And The responsible person must ensure that night staff follow the written guidance in the care plans and record the actions taken. All previous requirements: Unmet timescale 01/08/06 Now brought together into the following requirement and enforcement notice: The Registered Manager must ensure that all fluid, nutrition, weight, wound and other health care records relating to all relevant service users, are kept contemporaneously, in sufficient detail and are accurate. The Registered Manager must ensure care is delivered in accordance with agreed care plans and guidance. Part of a previous requirement: Unmet DS0000043119.V307517.R01.S.doc 13. OP7 OP8 12 (1) (a) & (b) 14/09/06 Version 5.2 Page 35 timescale 01/08/06 Now extended to The Registered Manager must ensure care is delivered in accordance with agreed care plans and guidance and that external professionals advice is followed at all times. The Registered Manager must ensure that copies of accidents and incidents relating to the service user are kept in their files. Previous requirement: Unmet timescale 01/08/06 The Registered Manager must ensure that the system on the handling of refusals of medication is implemented. Previous requirement but the timescale for completion had not elapsed by the time of this inspection. The Registered Manager must ensure that he signs the lists of staff authorised to administer medication and that they include samples of the initials staff use to sign the medication charts. The Registered Manager must ensure that staff appropriately and effectively react to results of blood tests or other tests that are not within acceptable levels. The Registered Manager must ensure that the District Nurse is brought in to offer training to staff on the ground flour in the administration of enemas and rectal medications. The Registered Manager must ensure that all medications including external products, are signed for at the point of administration. The Registered Manager must ensure that any time F is used to denote an “other” reason for DS0000043119.V307517.R01.S.doc 14. OP8 17 & Sch3 3 (j) 14/09/06 15. OP9 13 (2) 31/08/06 16. OP9 13(2) 31/08/06 17. OP9 13(2) 31/08/06 18. OP9 13(2) 31/08/06 19. OP9 13(2) 31/08/06 20. OP9 13(2) 31/08/06 Version 5.2 Page 36 21. OP9 13(2) 22. 23. OP9 OP9 13(2) 13(2) 24. OP12 16 (2) (m) & (n) 25. OP15 OP33 16 (i) & 24 26. OP15 12 (1) (a) & 16 (i) 27. OP16 22 medication being refused, that this reason is defined on the chart. The Registered Manager must ensure that any medication that is only to be taken when the service user requires it, is not recorded as refused when it is not taken. The Registered Manager must ensure that the medication stock checking systems are effective. The Registered Manager must ensure that the correct key letters are used on the medication administration charts at all times. The Registered Manager must ensure that service users or their representatives are consulted about their interests and favoured lifestyles, these must be recorded and appropriate opportunities are given to service users in relation to meeting these needs. Previous requirement not assessed at this inspection. Previous timescale 01/08/06 The Registered Manager must ensure that service users and their relatives are consulted about their satisfaction with the food on offer and that action is taken to improve satisfaction for individual service users. The Registered Manager must ensure that advice is sought from the dietician for all service users as to the effects of the home’s “snacking” policy and what appropriate snacks should be available. The Registered Manager must ensure that details of complaints investigations, outcomes, action taken, timescales and whether the complainant was satisfied with the outcome are recorded DS0000043119.V307517.R01.S.doc 31/08/06 31/08/06 31/08/06 30/11/06 30/11/06 30/09/06 31/08/06 Version 5.2 Page 37 28. OP18 29. 30. OP18 OP27 OP37 31. OP25 32. OP29 33. OP29 34. OP30 35. OP30 accurately and held in the home. The Registered Manager must ensure that record of all allegations and adult protection issues is maintained in a confidential manner in the home. 13 (6) & The Registered Individuals must 18 (1) (c) ensure that all staff attend adult (i) protection training. 17 The Registered Manager must ensure that an accurate roster is maintained of staff, as they worked at the home. 13 (4) The Registered Manager must (a) & (c) ensure that the temperature in the home is comfortable at all times and that service user’s relatives are aware of how to turn down the radiators in service users’ rooms. 18 (2) & The Registered Manager must 19 (1) & ensure that all care staff who do (4) not have current enhanced Criminal Records Bureau check on file are appropriately supervised and do not escort service users from the building. Ongoing efforts must be made to find out when the missing checks will be received. 18 (2) & The Registered Individuals must 19 (1) & ensure that no staff begin work at (4) the home without having received back two adequate references. 18 (1) (c) The Registered Manager must (i) ensure that all staff receive induction and foundation training that is in line with Skills For Care national requirements. 18 (1) (c) The Registered Individuals must (i) & (2) ensure that following an at least annual appraisal, all staff have in place an individual training and development plan. These individual plans must then be brought together into an overall annual training and development plan for the home that identifies 13 (6) DS0000043119.V307517.R01.S.doc 31/08/06 30/11/06 31/08/06 31/08/06 31/08/06 14/08/06 31/08/06 30/11/06 Version 5.2 Page 38 36. OP30 37. OP33 38. 39. OP36 OP36 40. OP36 41. OP38 42. OP38 43. OP38 44. OP38 45. OP38 what training is required for all staff to ensure the needs of service users and aims of the home are met. 18 (1) (c) The Registered Individuals must (i) & (ii) ensure that all staff receive training in dementia care and managing challenging behaviour. Previous requirement: Unmet timescales 31/03/06 & 01/08/06 24 The Registered Manager must ensure that relatives are aware of when the Commission’s inspections occur and when a new report is available for them to read in the home. 18 (2) The Registered Manager must ensure that all staff receive effective supervision regularly. 18 (1) (c) The Registered Manager must (i) & (2) ensure that all staff have an at least annual appraisal of their performance and training needs. 18 (1) (c) The Registered Individuals must (i) ensure that all staff who offer supervision and undertake appraisals have received training in how to do so and have been judged as competent to do so. 13 (4) The Registered Manager must (a) & (c) ensure that all fire call points are tested on a regular basis. & 23 (4) (c) 13 (4) The Registered Manager must (a) & (c) ensure that tests of the fire & 23 (4) system occur weekly and records (c) are kept of these tests. 13 (4) The Registered Manager must (a) & (c) ensure that fire doors are not & 23 (4) propped open inappropriately. (c) 13 (4) The Registered Manager must (a) & (c) ensure that staff do not inappropriately prevent door alarms from sounding. 13 (4) The Registered Manager must (a) & (c) ensure that cleaning procedures and products do not place service DS0000043119.V307517.R01.S.doc 30/11/06 30/09/06 31/10/06 30/11/06 30/11/06 31/08/06 14/08/06 14/08/06 14/08/06 14/08/06 Version 5.2 Page 39 users at risk of 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. Refer to Standard OP1 Good Practice Recommendations The Registered Individuals should begin work on establishing exactly how each service users’ fees break down and put these in their service user guide. (This will become a legal requirement on 01/09/06 for current service users and 01/10/06 for new service users). The Registered Manager should consult with other managers in the organisation to establish a clear set of guidelines and procedures so that staff can be confident of how to draw up palliative care plans to prevent service users having to be unnecessarily sent to hospital when they wish to die in the home. The Registered Manager should ensure that the frequency of all blood monitoring is indicated on the bloodmonitoring sheet, including the action to be taken for high/low readings, or refusals to have monitoring carried out. The blood monitoring sheets are in place but do not indicate procedures for high/low readings or refusals. Previous recommendation. The Registered Manager should ensure that as updated Homely Remedy lists (and any other records) are brought into the home, the old lists are files away to avoid any confusion. The Registered Manager should ensure that service users who are on pureed food have as varied and nutritious a diet as possible. The Registered Individuals should review the Complaint Procedure to insert a target timescale for the completion of a complaint investigation. 2. OP7 3. OP9 4. OP9 5. 6. OP15 OP16 DS0000043119.V307517.R01.S.doc Version 5.2 Page 40 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000043119.V307517.R01.S.doc Version 5.2 Page 41 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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