Inspection on 23/02/10 for Loose Court

This inspection was carried out on 23rd February 2010.

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

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

Loose Court 26/04/10

Loose Court 19/11/09

Loose Court 18/03/08

Loose Court 03/04/07

Loose Court 27/10/05

Loose Court 03/05/05

Loose Court 15/12/04

Loose Court 18/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 25/04/2010.

Random inspection report Care homes for older people Name: Address: Loose Court Rushmead Drive Maidstone Kent ME15 9UD zero star poor service 19/11/2009 The quality rating for this care home is: The rating was made on: A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection. This is a report of a random inspection of this care home. A random inspection is a short, focussed review of the service. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sarah Montgomery Date: 2 3 0 2 2 0 1 0 Information about the care home Name of care home: Address: Loose Court Rushmead Drive Maidstone Kent ME15 9UD 01622747406 01622749948 managerloosecourt@regalcarehomes.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Regal Care Homes (Maidstone) Ltd Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 46 Number of places (if applicable): Under 65 Over 65 0 46 dementia old age, not falling within any other category Conditions of registration: 46 0 The maximum number of service users to be accommodated is 46. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP). Date of last inspection 1 9 1 1 2 0 0 9 Care Homes for Older People Page 2 of 27 Brief description of the care home Loose Court was a domestic house until 1982, when it changed to a care home for the elderly. The house has had purpose built extensions. The accommodation comprises of three lounges and integral conservatory, and two dining areas. There are 35 bedrooms of which 4 are double rooms, 16 single rooms, and 15 single en-suite rooms. There is a lift to access the (15) first floor bedrooms, as well as stairs for those more ambulant. Some internal/external doors have keypad locks for the security and safety of residents. The home has a small-enclosed garden. The care home is currently registered as a residential care home for 46 older people (over 65 years) with a diagnosis of dementia. At present there are 36 service users living in the home. Following the inspection in November 2009, the registered person agreed to voluntarily cease admitting new service users. Loose Court is approximately 50 yards from the main Loose Road where local bus services are available to the town centre of Maidstone approximately 4 miles away, where there are two main line railway stations. Please contact the home for information regarding current fees. A copy of the most recent inspection report can be seen in the main hallway of the home. Care Homes for Older People Page 3 of 27 What we found: Choice of Home. Standards 1 and 3. We required the registered person (by 22/1/10) to review and update the statement of purpose, ensuring that prospective residents and their representatives have correct information about all services and facilities at the home. We also required the registered person (by 31/12/09) to ensure that prospective service users are competently and thoroughly assessed prior to admission to the home, including demonstrating appropriate consultation with the service user and their representative. We also told the registered person that their current pre admission assessment document was not person centred and gave an example of the personal care section of the form being a tick box system. This meant there was no room on the form to adequately describe the amount of support needed, or to record the personal preferences and wishes of the service user. The homes action plan stated that they would revamp the statement of purpose and service user guide to better reflect the home for its service users. We inspected the revised statement of purpose. Several shortfalls were identified, and we found the requirement to be unmet. Regulation 4 and Schedule 1 of the Care Standards Act requires the registered person to ensure certain information is included in the statement of purpose. Our assessment of the statement of purpose evidenced that the registered person had failed to include the qualifications and experience of staff. Instead, the information presented told the reader what qualifications in the future staff hoped to gain. Aside from giving information about the experience of the manager and responsible individual, the reader was given no information about the experience of the staff team. The registered person has also failed to provide sufficient information in the statement of purpose with regard to the criteria for admission to the home. The document goes some way to describing the process of admission, and the admission policy, but fails to mention what criteria prospective service users will be assessed by. The registered person is required to state the fire precautions and emergency procedures in the statement of purpose. This has not been done. Instead, the registered person has stated that all residents are made aware of the action to be taken in the event of a fire or other emergency, and copies of the homes fire safety policies and procedures are available on request. The document goes on to state that the home conforms to all relevant government guidance on protecting the health, safety and welfare of service users and staff. We could find no evidence in either individual files or in health and safety files that told us the home had made residents aware of fire safety policies. We did note that a recommendation from a recent fire safety inspection regarding problems with opening the front door had not been addressed. The registered person is required to include in the statement of purpose arrangements for service users to attend religious services of their choice. We noted in one care plan assessed by us that the home had asked the service user about their religious beliefs. The service user had informed the home they were a regular church goer. There was no care plan developed to meet the religious needs of this service user. Nor was there any evidence that the home had arranged for the service user to receive any visits from a Care Homes for Older People Page 4 of 27 vicar or a priest. The registered person is required to provide information in the statement of purpose regarding arrangements made for dealing with complaints. We found the information provided about complaints was lacking in key aspects of a recognised complaints procedure, and was not suitable or accessible to service users with dementia. The registered person has set out in the statement of purpose arrangements for dealing with reviews of service users plans. They say once a month, we review each service users plan together, setting out whatever changes have occurred and need to occur in the future. We assessed six care plans. For all these service users significant changes had occurred, and in order to sufficiently support the service user, the care plans should have been regularly reviewed and updated. None had. The registered person is required to include the number and size of rooms in the care home. The statement of purpose does not include any information regarding the size of rooms. The registered person is required to include information regarding arrangements for respecting the privacy and dignity of service users. The statement of purpose tells prospective service users this is carried out. During this inspection we observed a serious breach of confidentiality. At least eight individual service users daily logs were spread over tables in the lounge. (So much so that food and drink for service users were put on the floor). We asked the responsible individual to remove these confidential records and store them appropriately. The statement of purpose also tells prospective service users and their representatives that they will treat each resident as a special and valued individual. Lack of appropriate care planning, risk assessments, maintenance of health records, failure to respond to health concerns, and poor medication administration practices tells us that service users are not valued. Furthermore, we witnessed two incidents in which service users were not treated with respect or dignity: A frail service user was struggling to sit down and having difficulty. She was trying to ask for help. The carer interrupted her and harshly instructed her to sit down. We spoke with the manager and the responsible individual about this incident and asked them to address it with the carer straight away. The second incident witnessed involved a service user who had been sick. The sick bowl was left by his feet where he was sitting in the lounge. We spoke with the manager and the responsible individual and requested they ensure the dignity of the service user was upheld. Twenty minutes later we returned to the lounge to find the sick bowl still in place. We also saw a pair of false teeth in another sick bowl. We spoke to the carer ourselves, asking him to remove the sick bowl. He told us he is still using it, he is not finished. We asked him again to remove it. He refused. We immediately went to the responsible individual and required him to address the situation forthwith. The registered person told the home in its action plan sent to the Commission that they had devised a new pre admission assessment template. We asked to see this template and was told it had not been done. The home has a level 3 adult protection flag on the home from Kent Social Services. This means that no referrals from Kent Social Services are being made to the home. The Commission wrote to the responsible individual and requested they voluntarily agreed to Care Homes for Older People Page 5 of 27 cease admissions. The responsible individual informed the Commission they agreed to voluntarily cease any admissions (for example from other local authorities or from privately funded individuals). We confirmed with the responsible individual during the inspection that the home had not admitted any new service users since our inspection in November 2009. Given that the home had not admitted any new service users, we did not have enough information to adequately assess the requirement made in relation to assessment prior to admission. Therefore, we could not determine at this inspection whether the requirement was met. We have recommended to the responsible individual that a new pre admission template is developed as stated in their action plan. Health and Personal Care. Standards 7, 8, 9 and 10. We required the registered person (by 29/1/10) to develop comprehensive care plans which detail support needs of individuals, and to demonstrate that they have consulted with service users, and have taken into account their wishes and feelings. The homes action plan stated that they had devised a new care planning format and convert existing plans to the new format. We assessed six care plans. We chose the six individuals by determining the most vulnerable service users, and those service users whose support needs had undergone significant changes. We had also been made aware of these individuals from the safeguarding team who had told us about concerns they had in terms of the lack of care and support being offered to the individuals by the home. We had also had several concerns passed to us from a number of relatives. We felt that the home would have ensured these care plans were reviewed and updated, and reflected the changing needs of individuals, including detailed support plans, in depth risk assessments, and guidance for staff in every area of assessed need. None of the care plans had been reviewed, updated or changed in any way. We asked to see the new format. It had not been done. We asked to see an example of a care plan which had been updated, reviewed and converted to the new format. We were told none had been done. Many care plans said reviewed, no change. We challenged the manager about the no change statement as it was clear for all the service users we were case tracking significant changes had occurred. The manager was unable to tell us why the management team had not updated care plans. We looked at what information the home had on file for these service users. On one file there were three separate admission forms, with three different dates of admission. We saw that some areas of a service users life history had been filled in. This form was not dated. Done correctly, life history information can be invaluable in informing care planning, particularly care planning regarding choices and daily activities. We saw that the service user had told the home who his named favourite singer was, and that he was a church goer. We looked for evidence in the care plan that the home had integrated this information and ensured his spiritual wishes had been considered and care planned for (perhaps organising a visiting vicar/priest or enabling the service user to attend church). No further mention of the service users spiritual needs was made in the care plan. We spoke with staff and asked them if they knew who the service users favourite singer was. Care Homes for Older People Page 6 of 27 They did not. We asked if the service user was supported with his religious needs. They did not know what we were talking about. We looked at the statement of purpose which told prospective service users service users who wish to practice their religion will be given every possible support and facility. Another aspect of this service users notes under what I dislike, stated night time. We saw on the personal details form it had been written restless at night. We know from Regulation 37 notifications there have been incidents at night with this service user. The home had not care planned for a night time routine or had put in place any guidelines for staff in respect of this service user, even though they had knowledge that night time was a time of difficulty. When looking at care plans in November 2009 we found they were not person centred. the care plans assessed today further evidenced this finding. In every care plan we looked at during this visit there was an emergency care plan (for use should the service user require hospital admission). Every care plan was the same. It did not relate to the assessed care and support needs of the individual. For example: activity - personal hygiene; problems, possibly unable to maintain own personal hygiene. This would be no use as either a care plan or emergency care plan. It gave no indication of the assessed support needs of the individual, or noted how these needs could be met. We are concerned about how the home stores important information and confidential records of service users. The care plans were very full of documentation. They are badly organised. There are section dividers but these were not labelled. Some documents are duplicated several times. We found many entries in the care plans which were not properly dated, without the year noted, and in one care plan, with no date at all. We found confidential notes regarding a service user in another service users file. These notes contained important information about the service users recent changes in behaviour. Equally concerning was that these notes were found in a plastic wallet behind an old social services assessment, and written on the back of an old staffing roster. We required the registered person (by 8/1/10) to develop robust risk assessments which supported service users to have safe but fulfilling lives. We further required the registered person to ensure that no service user us subject to physical restraint. The registered person sent the Commission an action plan. This stated that the home had devised a new risk assessment template, and were reassessing risks for every service user, taking into account Deprivation of Liberty safeguards. Service users at the home continue to be physically restrained. Risk assessments giving staff permission to use physical restraint were still on files. We observed staff at the home continuing to remove service users mobility aids from them when they were in the dining room or sitting in a lounge. We observed one service user standing in the dining room holding onto the back of a chair. She was distressed and asked us to help her. She told us she could not walk. There was no staff around. We looked for her mobility aid and could not find it. The home has reported a number of falls to the Commission. We are concerned that some of these falls might have occurred when the service user did not have use of their mobility aid. We noted at the inspection in November that risk assessments pertaining to falls were poor. None of the service users had had a moving and handling assessment, Care Homes for Older People Page 7 of 27 and risk assessments simply stated high risk of falls, but no guidance in supporting or preventing falls was in place. We looked at falls risk assessments to ascertain if improvements had been made. None of the assessments had been updated. Some stated reviewed, no change. We found further evidence of poor risk assessments on all files. Some examples are: no risk assessments in place for service users requiring use of a hoist; one risk assessment stating risk assessment in bedroom due to hearing loss, but no further explaination was given. Most notable was the complete absence of any risk assessment with regard to robust management of the recent and current behaviours of service users. We know from receiving Regulation 37 notifications from the home, that five out of the six service users we were case tracking had been involved in violent and aggressive incidents either as the perpetrator, victim, or sometimes both. We knew that injuries had been sustained, and in one instance, an allegation had been made against a member of staff. Evidence from our assessment of these files told us that the registered person had failed to ensure service users changing needs were assessed and support plans put in place, and a complete failure and disregard to keeping these and other residents safe from harm and abuse. We spoke at length with the manager about how she was managing these incidents, and how, as the manager she was providing support and guidance to the staff team. The manager told us the home could not cope, and she could not guarantee any service users safety in the home. She informed us she had told the safeguarding team the same. We asked her about her knowledge of dementia and the different stages individuals can go through. We discussed a recognised fact that some people with a diagnosis of dementia can be challenging, and there are documented methods of supporting people through this. We reminded the manager that the home was registered for and actively sought admissions from service users with a diagnosis of dementia. The manager told us again that the home cannot cope at this present time. The manager told us she had completed one draft risk assessment in respect of aggressive behaviour. One of the titles on this assessment is existing controls. This language is inappropriate. The manager has told staff to make sure the service user is safe, but does not give any guidance as to how. In the next sentence staff are advised to walk away. This does not ensure that other service users are kept safe, nor does it ensure the safety of staff. The manager showed us another example which said staff MUST tell (service user) that this kind of behaviour will NOT be tolerated and if (service user) physically, verbally attacks anyone including staff the police will be called. The language used in this risk assessment suggests the manager does not have an understanding of how to support individuals with dementia who can present challenges. It is also guiding staff to be very confrontational, challenging and threatening with a service user. Both of the above examples are for the same service user. In one the staff are told to walk away, in another they are told to be threatening. We spoke to staff. None were aware of any service users care plan or risk assessments. We never read them. We dont get time, but were not told to read them anyway. They Care Homes for Older People Page 8 of 27 told us they had received no guidance from the management team and that staff did not know what to do when service users become challenging. We required the registered person (by 31/12/09) to ensure the health needs of service users are met, and to keep accurate health care and nutrition records. Furthermore, the registered person was required to ensure they responded, without delay, to health concerns, and that service users are given access to health care professionals for medical treatment. The registered person sent the Commission an action plan. This stated put in place systems to document and follow up on health care and nutritional needs and staff to be made aware and reminded at handovers of the need to involve health care professionals depending on established triggers. We looked at the health care plans of service users. None had been updated. They too had reviewed, no change written on them. Some service users have significant and on going health concerns. We found evidence in all files inspected that nutritional monitoring remains inconsistent and difficult to track. We saw that one service user is regularly weighed. We know that relatives of this service user have insisted this is done. At one stage the home had told the relative they were unable to guarantee to weigh the service user, and told relatives they must bring their own scales to the home and do it themselves. None of the other service users had been weighed regularly. One weight chart showed a service user had significant weight loss. No action had been taken. Some service users have food intake monitoring charts. However, the risk assessments for nutrition are poor, and do not tell staff what they should be doing to ensure the nutritional needs of the individual are met. One nutrition assessment stated food is to be liquidised to soup consistency and the kitchen staff is aware of needs. The needs were not stated on the assessment. At our inspection in November 2009 it was evidenced that staff at the home were not responding timely or appropriately to the health care needs of service users. It was also evidenced that management and staff at the home were poor at communication with health professionals and did not pass on concerns sometimes at all, or with an unacceptable delay. Evidence gathered at this inspection demonstrated that competencies in this key area have not improved, and there are significant delays to service users receiving appropriate medical treatment. An example of this is an incident reported to us in January 2010 regarding a service user sustaining a fall: this fall was sustained early in the morning. The service user was found on the floor of her bedroom before 8am. Eventually an ambulance was called and once at hospital (approximately fourteen hours after being found on the floor) it was determined the service user had a fractured hip and required an operation. Another example is also regarding a fall: an incident occurred at the home on 19th February 2010 in which a service user was found on the floor of her bathroom between the sink and toilet. The Regulation 37 notification states: no pain reported, bit her lip. Carer aided her to rise. Able to weight bare, walked fine. Complained of pain in right groin area when she sat down. Checked for bruising, none found. Red mark to back. The GP visited the home the following day and suggested an x ray. It was determined at the hospital that this service user had suffered a bleed on the brain and either had a cyst or brain tumour. Care Homes for Older People Page 9 of 27 We saw on one service users file the following entry: noticed that both legs are oedematous and shiny. Put on clean socks and slippers. Had a nice cup of tea. No concerns. We looked for further entries in the file to see if any action had been taken with regard to contacting a health care professional for medical attention. No action was taken. We required the registered person (by 31/12/09) to ensure they have safe and robust systems in place for managing medicines in the home, and that all medicines administered are signed for. We further required the registered person to ensure safe systems were in place to return spoilt items to the pharmacy. The registered person sent the Commission an action plan. This stated that two people do medication and, all staff administering medication are aware of medication policy and assessed on knowledge of same. On the 11th February 2010 we received a Regulation 37 notification from the home informing us of a serious medication error. A member of the management team left the medication trolley to answer the phone, and then after taking the phone call, gave a service user medication intended for someone else. This same member of the management team has overall responsibility for medication including audits, ordering, disposal and returns of medication. We phoned the home to discuss this with the manager, and wanted to know how, after their action plan stated that safeguards were in place in respect of two staff members doing medication, how the other staff member failed to keep the medication safe, and failed to notice that the medication was not given to the right service user. We also wanted to determine why, contrary to protocols, the member of staff abandoned the medication trolley and answered the phone. The manager informed us that two staff do not do the medication round together - as indicated and understood by the action plan. She informed us that two staff do the medication round, but separately. She did not know why the member of staff had left the trolley, but agreed it was a serious error. We asked what action the manager was taking in response to the error and in line with the homes own policies. The manager told us she was getting medication tabards for staff to wear when on medication rounds so they would remember they were doing medication. We asked if the manager had considered taking any other action and was told I dont want to beat my staff with a stick. We are not confident the manager has sufficient skills and knowledge to effectively manage staff performance issues and clear non compliance with medication protocols. We question whether the manager understands or is responsive to the needs of the vulnerable service users who put their trust in staff to care for them appropriately and give them the correct medication. The home has only one medication trolley. We were told that one member of staff has the trolley, while the other runs back and forth between the trolley giving service users their medication. Staff told us it is very stressful, and stated it is easy to make a mistake. Throughout the day there are four rounds of medication: 8am, 1pm, 5pm and 9pm. The staff rota showed there are a maximum of 5 care staff on duty for 36 service users. From 8pm there are just 3 staff on duty. We were told that the 8am medication round takes at least one and a half hours, and the 9pm round takes approximately an hour, sometimes longer. The 1pm and 5pm rounds take approximately three quarters of an hour each. means, that for the nine hour period between 8am and 5pm, there are three and a Care Homes for Older People Page 10 of 27 quarter hours where just 3 members of staff are available to support 36 service users. And for an hour during the 9pm medication round, there is one member of staff to support 36 service users. We inspected the medication administration folder. This contained information about how the home audits medication. We were told a designated member of the management team audits all medication weekly. Records showed there had only been five audits between the 6th of August 2009 and the 29th January 2010. There should have been 25 audits during this timescale. There were no records of any audits prior to the 6th August 2009. For four consecutive audits it was noted that the same service users photograph was not in place on the medication file. We asked why this was not rectified when it was noticed at the first audit. The manager and registered person could not say why and accepted that it should have been. The audit has a code which either we, the home manager or the registered person could decipher. None of the senior management at the home could offer any explanation or understanding of this auditing code. There was no explanation of the code (or of any outcome or follow up action) on any audit, yet boxes within the codes had been ticked. We saw on a number of medication administration charts PRN (when required) medications. Some of these medications were for pain relief, and some were creams for dry skins. We asked to see guidelines issued to staff in relation to administering PRN, particularly with regard to pain relief. There are no guidelines in place for any service user with PRN medication. We asked a member of staff how they would assess an individuals pain, and noted that the individual in question had advanced dementia. The staff member told us she kicks off if we dont give them to her. We dont know if shes in pain or not. This service user is on a high dosage of pain relief and the home do not know how to assess her pain, and have provided no guidance to staff regarding administration of PRN. We were told that the home audits PRN medication daily. We looked at the records. They revealed several errors, and indicated that large amounts of medication had gone missing. On the 16th of February, the audit for a tablet medicine goes from 51 to 58, then from 56 to 59. It then drops down to 52. None of the management team, including the person conducting the audit had taken any action at all. On another audit, numbers looked like letters, and it was unclear as to whether the count is correct. We were told that audits are only every done by one person. We looked at a diabetes recording chart. The dosage of medicine is determined by the blood reading. The dosage record had not been filled in, nor had the column for comments. The records in the destroyed and returned medication book were not complete. They were also not dated or signed. It is not clear where the medication has gone. The home does not have a robust system for ordering medication. We asked to see how the home orders medication and was handed a A4 envelope stuffed with papers. The papers were blank medication administration records, on which numbers had been written. Care Homes for Older People Page 11 of 27 The manager told us that the system would improve as she was changing the medication system to blister packs. The home already uses a blister pack system. We are concerned that service users are at risk of significant harm with regard to medicine administration at the home, and are further concerned that the home manager is relying on changing to a system which is already in place. The action plan stated that staff administering medication have been assessed on their knowledge. We asked to see copies of the assessments. None have been done. Daily Life and Social Activities. Standard 12. We required the registered person (by 29/1/10) to consult service users about a programme of activities, taking into account hobbies and interest, and to make suitable arrangements and provide sufficient support for service users to participate in regular activities of their choice. The action plan stated that service users interests and preferences to be assessed and, activities meeting their needs planned out on a weekly basis, and increased involvement of third party professionals with experience in dementia settings in delivering activities. The manager told us about the current activities offered to service users: once a week for an hour a therapy cat comes to the home. A music man visits weekly for an hour and a half, and a company specialising in motivation activities visits in total for 3 hours over a period of two weeks. This means that the weekly programme of activities for 36 service users totals 4 hours. Most of the service users are up and in communal areas between 10am and 8pm. This is ten hours a day, seventy hours per week. For at least 66 of these hours, service users are not offered any activities, and as our inspection findings demonstrate, staff do not engage or interact with them. The home does not have an activities coordinator and is planning to recruit into this post. During the inspection we observed very poor interaction from staff towards service users: in one lounge where several service users were sitting, a staff member was sitting watching the television, another carer was reading. In another lounge, again, with several service users in, the carer was standing staring at the ceiling, and in another lounge (where service users seemed quite poorly, distressed and were asking for help), the carer was watching television. In all of these situations observed the carers were completely oblivious to the service users, ignoring any communication or plea for assistance. When we raised this with the manager she told us: I know. The carers dont interact with the residents. I cant get them to. They dont know how to relate to them. Ive told them to watch the motivation people. Shall I sack them all? When we raised the point that it must be impossible for all 36 residents to benefit from the activities provided by the external contractors, the manager agreed and said that just a few per week benefited. The action plan stated that service users interests and preferences had been assessed. We asked to look at these assessments and any other information which would evidence such consultation. The manager informed us that none of the service users had been consulted or assessed with regard to their interests and preferences. Care Homes for Older People Page 12 of 27 When we were looking at service users files, we found some entries in respect of activities. These entries appear to have been written on the same day, in the same handwriting and ink, although different dates were entered. We shared this document with the manager who told us: it cant be true because none of the staff do any activities. It is not right and I will look into it. Complaints and Protection. Standards 16 and 18. We required the registered person (by 29/1/10) to develop a complaints procedure which is accessible and suitable for service users with dementia and to ensure service users are able to communicate concerns and complaints. The registered person sent the Commission an action plan. This stated devise clear procedure and make it available in every service users room and communal area. The new manager had made some attempt to make the complaints procedure accessible to service users by illustrating the document. However the information and some of the illustrations were confusing. It did not tell people how to complain in a logical and simple way. In addition, the flow of the procedure was wrong. It directed people to contact the manager but if not satisfied to contact the CQC or Social Services. The procedure did not include the Companys address and contact numbers or direct people to contact the responsible individual if not satisfied with the way the manager dealt with their complaint. There was no flow chart to make the description of this process easier to understand. When assessed, we found the information provided about complaints was lacking in key aspects of a recognised complaints procedure as stated in Regulation 22 of the Care Standards Act. Most notably, the procedure in the statement of purpose included information which is misleading and incorrect, and demonstrates the registered persons inability to understand safeguarding with relation to complaints. This is evidenced in the following sentence taken from the statement of purpose the person who is handling the complaint will interview the complainant. This may not be appropriate, and service users and their representatives need to know that the process will not necessarily include this. Furthermore, the entire complaints policy in the statement of purpose does not indicate any key people within the home or organisation. It refers to the person. The complaints policy states that: the written record of the complaint must be signed by the complainant. This may be difficult for some service users. The home must ensure that the complaints policy is suitable and accessible to the service users. We required the registered person (by 29/1/10) to ensure all staff receive accredited sufficient and effective training in adult protection (recognising and responding to signs of abuse) and that they are competent to use this knowledge. We also required the registered person (by 31/12/09) to ensure they inform the Commission without delay, of all significant events at the home. The registered person sent the Commission an action plan. This stated all staff to be trained in adult protection, staff supervision to cover same and, senior staff made aware of need to initiate notifications and, notifiable events and notification policy and procedure in place. Training records evidenced that not all staff had received training in adult protection. The registered person has not supplied details to the Commission with regard to how the Care Homes for Older People Page 13 of 27 training was carried out and if it was accredited. Information gathered from discussion with the responsible individual, the home manager, staff at the home, and the safeguarding team evidences that there is an overall failure by all staff at the home to safeguard the vulnerable service users living there. Our findings from this inspection match those of the November 2009 inspection which were that the management team had very limited understanding of adult protection issues or even recognising and responding to signs of abuse. The staff team had no skills or competencies in adult protection at all. Service users living at Loose Court are not kept safe from harm, and are at daily risk of detriment to their health safety and welfare. The manager has informed the Commission and safeguarding that she cannot keep people safe. As well as the risk of physical assault, service users are at high risk of falls (with no risk assessment), are restrained and their liberty denied on a daily basis (by not having mobility aids), are spoken to harshly by staff, do not have their dignity upheld, are at risk of malnutrition due to poor nutritional assessments, sporadic weighing, and no action being taken even if significant weight loss occurred., are at risk of being given the wrong medication or none at all, and are at risk becoming seriously ill by having their health care needs unknown, unmet and ignored. The registered person has demonstrated that he is unable to ensure the health, welfare and safety of service users in this home. Environment. Standards 24 and 26. We required the registered person (by 29/1/10) to ensure that service users are able to have privacy in their own rooms, and have lockable storage facilities available to them in their rooms, unless the reason for not fitting and supplying locked facilities is explained and supported by a comprehensive best interests assessment within the individuals care plan. Doors to the service users private accomodation must be fitted with locks suited to service users capabilities and accessible to staff in emergencies. The registered person sent the Commission an action plan. This stated that all bedrooms fitted with privacy door handles, all bedrooms to be fitted with lockable storage cabinets, and risk assessments completed. We looked at the newly fitted door locks and lockable storage facilities. We could see that all bedrooms had been fitted with these locks, and with lockable storage facilities. However, when we tested the door locks, we found them difficult to work. We questioned staff about how the service users were getting on with the locks. We were told that none of the service users can use them, and we are worried that they may lock themselves in and not be able to get out. We asked to see the individual risk assessments pertaining to the bedroom door locks and lockable storage facilities. None had been done. None of the service users had been assessed prior to the locks being fitted. We asked how the home and residents were managing with so many keys to so many rooms and lockable storage facilities. We were told that the same door key fits every bedroom door. This means, even if a service user had chosen to lock a room, believing it to be safe and locked, all other service users had access to the room (any room), as there was no difference between any key. The same situation applied with the lockable storage facilities. Rather than ensuring service users had privacy and a lockable storage for valuables, the system in place puts service users at risk of harm, and does not afford them or their valuables Care Homes for Older People Page 14 of 27 any privacy whatsoever. We required the registered person (by 29/1/10) to ensure the home is odour free and to ensure that service users live in a clean and hygienic environment. The registered person sent the Commission an action plan. This stated that procure new carpet cleaning equipment for use as when required, and weekly programme for problem areas. We looked at the communal area which had been presenting with foul odours in November 2009. We could see that the carpet had been removed and replaced by linoleum. Although the odour had gone, the linoleum was not a complete piece and had been made to fit together. This meant there is a large join from one side to the other, and could potentially be a trip hazard to service users. We assessed some bedrooms. Two bedrooms had overwhelming odours, and it was clear that continence issues of the service users had not been effectively managed. One bedroom was so offensive in terms of odour the member of staff felt unable to enter it. This was raised with both the manager and responsible individual. The manager was aware of the bedroom and of the odour, and told us it was unacceptable for anyone to sleep in or use the room, adding that the service user would be moved to a clean and hygienic room. We questioned that if this was the case (the problem had clearly nor arisen just on the day we were there), then why hadnt action been taken prior to today? The manager and the registered person were unable to answer the question. Staffing. Standards 27 and 29. We required the registered person (by 29/1/10) to ensure that the home employs staff who are competent to carry out their duties. Additionally, staff must be skilled and qualified. This includes achieving 50 of the staff team being NVQ qualified, and includes all staff receiving suitable training. We further required the registered person to supply to the Commission a rolling programme of training which demonstrates accredited training has been organised and booked in a timely fashion, and that all staff must have an individual training profile. The registered person sent the Commission an action plan. This stated all mandatory training completed and NVQ 2 & 3. We looked at the recent training records for all staff. The registered person has failed to meet either our requirement or his own action plan. We found that all mandatory training had not been completed, with significant gaps in first aid, health and safety, infection control, manual handling, fire, medication and adult protection. We required the registered person to supply to the Commission a rolling programme of training which demonstrates accredited training has been organised and booked. This was never sent to us. When we asked staff about the recent adult protection training we were told it was two hours. We watched a video and answered some questions. We asked if they felt competent and confident in how to respond to any safeguarding concerns. They told us they did not. As stated previously in this report, we found the staff at the home to be disrespectful to service users, ignoring their needs and mainly watching television. Information from Care Homes for Older People Page 15 of 27 Regulation 37 notifications and feedback from the safeguarding team tells us that staff are not competent or skilled in working with this service user group. Staff are not supervised, have not received adequate training, and have little skill in completing daily records. Service users were observed being ignored by staff, with the manager telling us that the staff are not very good; we are going to have a cull. We required the registered person (by 29/1/10) to ensure they operate a thorough recruitment process ensuring the protection of service users, and that documents supplied by prospective staff members are authenticated and validated by the employer. The registered person sent the Commission an action plan. This stated that there is a clear recruitment policy and procedure in place and adherence checked. We looked at staff files and found evidence that appropriate checks had been carried out. The registered provider is also undertaking an audit of all staff files to ensure all vetting processes have been undertaken. Management and Administration. Standards 31, 33, 36, 37 and 38. We required the registered person (by 29/1/10) to appoint a qualified and competent person to manage the home, to ensure staff are appropriately supervised by senior staff trained to do so, to ensure they sought the views of service users and other stakeholders by developing robust quality assurance systems, and to ensure that the home keeps and maintains appropriate records. And those records required by Regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. The registered person has appointed a manager. They took up the post on the 21st of January 2010. This requirement to appoint a manager was met, and therefore a Code B was not issued. However, information gathered at this inspection evidences that the home continues to be poorly managed, and service users remain at risk of harm through receiving poor care and support. The registered person sent the Commission an action plan and told us how it was addressing shortfalls in quality assurance. This stated that new formats devised, and all stakeholders are covered and results assessed and fed back with action plans instituted. Discussion with the manager and the responsible individual evidenced that the home had begun to develop quality assurance systems with regard to consulting with service users and their representatives. Regular relatives meetings are held where open discussions about the home take place. The home has also sent questionnaires to all relatives. We are encouraged by this initial attempt to improve quality assurance in the home. However, in discussion with the manager we ascertained that systems for seeking the views of service users were not developed. The home must ensure that they find effective ways of communicating with service users and recording their views about the home. The registered person told us in their action plan that supervision plan to be in place and implemented and training on supervision for deputy manager. Care Homes for Older People Page 16 of 27 We looked at supervision records. Evidence from these records demonstrated that the registered person had failed to meet either our requirement or their own action plan. Since our key inspection in November 2009, just six staff had received supervision. We looked at notes for one of these. They were very brief, and did not properly identify learning and performance needs and issues. Furthermore, neither the deputy manager nor senior carers had received any training in supervision. We had evidenced throughout our compliance visit significant shortfalls in staff competencies. Onging lack of staff supervision demonstrates the registered persons failure to understand how to meet support needs of service users through ensuring staff are appropriately guided and monitored through the process of supervision. When we looked at the action plan with regard to meeting the requirement of maintaining and keeping appropriate records, it was clear that the registered person had failed to understand the requirement requrement 17(1)(a) and Schedule 3), as the stated action by the registered provider on the action plan said service inspection files in single file in managers office and followed up as required. Evidence gathered throughout this compliance visit (and detailed within this report) demonstrates the registered persons failure to ensure correct records are kept. There are significant shortfalls of record keeping in care planning, risk assessment, records and actions regarding healthcare needs, nutritional assessments, falls assessments, medication records and use of hoists. The key inspection on 11th November 2009 evidenced that the registered person had failed to ensure safe working practices at the home. This included evidence that staff were not trained in moving and handling, fire safety, first aid, infection control, adult protection, care planning or risk assessment. Furthermore, it was evidenced that the registered person had failed to ensure regular servicing or testing of equipment such as gas appliances, soiled waste disposal, hoists and fire detection equipment. We required the registered person (by 29/1/10) to ensure that the health, safety and welfare of service users and staff were promoted and protected, and to ensure that equipment provided at the care home was maintained and in good working order. The registered person sent the Commission an action plan which stated, daily maintenance issued entered in communication book to be dealt with as soon as possible and policies relating to maintenance and job description for maintenance person to be in place. We inspected the file which contained the service inspection certificates. Evidence from this file demonstrated that the registered person had failed to meet either our requirement or their own action plan. We saw that although some equipment had been serviced, many had not. This included the nurse call system and emergency lighting. We saw a report from the fire safety check which required the home to make safe the lock on the front door as it was difficult to open. We saw two members of staff during the inspection struggle to open the door. This is a significant fire hazard, yet the registered person has failed to address this. Further documentation in this file evidenced that the registered person has failed to ensure maintenance checks are up to date. Some examples of this are: Hot water checks on Care Homes for Older People Page 17 of 27 individual bedrooms are not dated. It is impossible to tell the frequency or even year of these checks. Of concern is that many entries regarding the hot water checks state hot water poor. There is no evidence that this has ever been addressed. The cold water tank was last tested in July 2009. This tank should be tested every three months. The weekly cot side inspection was last undertaken in July 2009. The equipment in the laundry was last tested in February 2009. We noted from the in house maintenance log that the nurse call system is checked monthly. We asked how this frequency was risk assessed as we were concerned that one entry stated that the buzzer was missing. The manager agreed that this buzzer could have been missing for a month, potentially leaving a vulnerable service user unable to call for help. What the care home does well: What they could do better: This was a random inspection visit to assess compliance with requirements made at the key inspection in November 2009. Evidence gathered at this inspection tells us that service users living at Loose Court continue to experience poor quality outcomes. Their health needs, social needs and welfare needs are not being met. The registered person must ensure the home addresses the following: Care planning and risk assessment continue to be poor. This means that service users are at risk as their needs are not assessed, recorded or known. Recording of health care needs and concerns continue to be poor, and there was no evidence to suggest the home is meeting the healthcare needs of service users. There is a lack of appropriate response to significant healthcare concerns, including response to falls. This places service users at increased risk of harm. Medication administration practices in the home are poor, and service users cannot be sure they are receiving the correct medication. Service users are not offered regular activities, and their daily lives lack choice and opportunity. Staff do not interact with service users, and do not have sufficient skills or training to work effectively with the service users. The management team does not have sufficient skills or competence to ensure service Care Homes for Older People Page 18 of 27 users are kept safe or that they lead valued and fulfilling lives. The home continues to restrain service users by removing their mobility aids. Safe working practices continue to be poor as the home has failed to ensure all equipment is tested. Management of continence continues to be poor. Some service users are living in rooms with unacceptable odours. The dignity of service users is not upheld. Staff do not speak to service users with respect. The management team has failed to ensure staff are appropriately trained or supervised. The home has failed to produce a complaints procedure suitable to the needs of service users. The home has failed to ensure service users are protected from harm. The registered person sent the Commission an action plan. This was received late evening on the 28th January (the final date for draft report comments) by email from the new manager. The email stated: I tried to look through the report but time was short, so I decided it was better to work on the action plan. This tells us that the registered person had no input into the action plan at all, and the new manager was responding to the requirements in the report without reading it. We are not confident that either the registered person or the home manager has given consideration to the report or requirements, and have failed to understand the impact on service users of the poor care and support provided at this home. We are not confident that the registered person or staff working at the home have the skills and competencies to ensure service users needs are met and they are kept safe from harm. The Commission has significant concerns about this home and is taking enforcement action. Statutory requirement notices are being served to the registered provider on all 14 breaches of Regulation. Failure to meet these notices will result in further enforcement action being taken and may include proposing to cancel registration of the home. 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 set out on page 2. Care Homes for Older People Page 19 of 27 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 1 4 The registered person must produce a statement of purpose and service user guide which tells service users and their representatives about the home. The registered person must ensure that prospective residents and their representatives have correct information about all services and facilities at the home. 22/01/2010 2 3 14 In order to meet individuals 31/12/2009 particular support needs, the registered person must ensure that prospective service users are competently and thoroughly assessed prior to admission to the home. This includes demonstrating appropriate consultation with the service user and their representative has taken place. Prospective service users are currently not competently assessed prior to being offered a place at the home; therefore support needs are not being met. 3 7 13 The registered person must 08/01/2010 Page 20 of 27 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action develop robust risk assessments that support people to have a safe but fulfilling life. Current risk assessments are inadequate and do not safeguard service users. Risk assessments must ensure that no service user is subject to physical restraint unless this is authorized intervention that has been pre-approved using the Deprivation of Liberties safeguards assessment process and is kept under strict and documented review. 4 7 12 The registered person must develop comprehensive care plans which detail support needs of individuals. The home must demonstrate they have consulted with service users, and have taken into account their wishes and feeling. Current care plans are inadequate and do not contain support needs of individuals. The home has not consulted with service users or their representatives regarding care plans. 5 8 12 The registered person must 31/12/2009 ensure that the health needs of service users are met and keep and maintain accurate health care and nutrition records. Page 21 of 27 29/01/2010 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action The registered person must ensure that they respond, without delay, to health concerns, and that service users are given access to health care professionals for medical treatment. This includes seeking advice from specialist continence nurses and nutritional specialists to make sure the right support is given and that specialist advice is sought and followed when conditions change. Current systems do not promote or maintain proper provision for the health and welfare of service users. 6 9 13 The registered person must 31/12/2009 ensure they have there are safe and robust systems for managing medicines in the home. The home must ensure that that all medicines administered are signed for and there are safe systems to return spoilt items to the pharmacy. Current systems are vulnerable to error putting service users and staff members at risk 7 12 16 The registered person must 29/01/2010 consult service users about a programme of activities, taking into account hobbies and interests. The home must then make suitable arrangements and provide sufficient support for service Page 22 of 27 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action users to participate regularly in activities of their choice. To ensure service users social needs are met. 8 16 22 The registered person must 29/01/2010 develop a complaints procedure which is accessible and suitable for service users with dementia. To ensure service users are able to communicate concerns and complaints. 9 18 13 The registered person must 29/01/2010 ensure that all staff receive accredited sufficient and effective training in adult protection (recognizing and responding to signs of abuse) and that they are competent to use this knowledge. To ensure the health, safety and welfare of service users is met. 10 24 12 The registered person must 29/01/2010 ensure that service users are able to have privacy in their own rooms, and have lockable storage faculties available to them in their rooms. Unless the reason for not fitting and supplying locked faculties is explained in the supported by a comprehensive best interests assessment within individuals care plans; Doors to service users private accommodation must be Page 23 of 27 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action fitted with locks suited to service users capabilities and accessible to staff in emergencies. The registered person must ensure that each service user has a lockable storage space made available to them and is provided with the key to this storage. 11 26 16 The registered person must ensure the home is odour free. To ensure that service users live ion a clean and hygienic environment. 12 27 18 The registered person must ensure that the home employs staff who are competent to carry out their duties Staff must be skilled, qualified and competent. This includes achieving 50 of the staff team being NVQ qualified, and includes all staff receiving suitable training. The registered person must supply to the Commission a rolling programme of training which demonstrates accredited training has been organised and booked in a timely fashion. Furthermore, all staff must have an individual training profile. 13 36 18 Staff working at the care 29/01/2010 Page 24 of 27 29/01/2010 29/01/2010 Care Homes for Older People Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action home must be appropriately supervised. The registered person must ensure that all staff receive regular supervision which is carried out by senior staff who have received Have the necessary skills, training and experience appropriate to this role. 14 37 17 The home must keep and maintain appropriate records. The registered person must ensure that records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 15 38 23 Equipment provided at the 29/01/2010 care home for use by service users or by staff must be maintained in good working order. The registered person must ensure the health, safety and welfare of service users and staff are promoted and protected. 29/01/2010 Care Homes for Older People Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 26 of 27 Reader Information Document Purpose: Author: Audience: Further copies from: Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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