Inspection on 26/04/10 for Loose Court

This inspection was carried out on 26th April 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Loose Court 23/02/10

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 17/07/2010.

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 6 0 4 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 www.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 2 3 0 2 2 0 1 0 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 26 service users living in the home. Following the inspection in November 2009, the registered person agreed to 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: This inspection was undertaken by three inspectors on the 26th of April 2010. We were in the home from 9.30am until 8.20pm. We gathered evidence by looking at individual service user files, assessing policies and procedures, and speaking with service users, staff, management and relatives. This focussed inspection was undertaken to assess compliance with outstanding requirements from the key inspection in November 2009, and the random inspection in February 2010. We specifically looked at evidence around meeting service users needs, management of the home, and staff competencies. We found significant shortfalls in all areas assessed, with evidence demonstrating that service users were not being appropriately cared for. We found that only one of the outstanding 15 requirements had been met. We also found evidence of further breaches of Regulation, and new requirements have been issued. In addition we served Code B notices which informed the Responsible Individual that the Commission believes offences have been committed by failing to ensure service users individual needs are met in respect of care planning, risk assessments, medication, assessments, and competencies of staff. HEALTH AND PERSONAL CARE. This outcome area looks at care planning, risk assessment, medication and upholding service users privacy and dignity. We have assessed all these areas, and our findings are as follows: Care planning and Risk assessment. We had informed the provider in November 2009 and in February 2010 that service users care plans were inadequate, and requirements were made. The provider informed the Commission after each inspection that they were addressing shortfalls in care planning, and have submitted action plans outlining improvements. At this inspection it was evidenced that the provider has failed to implement their action plan. This places service users at risk of harm. Four care plans were assessed. All had significant shortfalls. Our analysis of the care plans evidenced a lack of detail so significant that it may be detrimental to the health, safety and welfare of the service user, and places service users at risk of harm. We also found conflicting risk assessments around the management of falls, and the required support needs of the service user. The care plans have been written without consultation with the service user, even though it states in the inclusion support plan I would like to be included in any decision making regarding my care. The care plans are not signed, dated or authorised by the service user, the home manager, or the service users representative. One care plan did not have a current falls risk assessment or mobility assessment in place. This is despite the service user having a fall in February 2010. The mobility risk assessment had not been updated since November 2009. This stated no difficulties with mobility. We asked the manager about the fall in February. She had no knowledge of it Care Homes for Older People Page 4 of 27 and had not reviewed the accident file. This service users current care plan with regard to mobility and associated risks is out of date and contains information which is wrong and misleading. The manager agreed that this service user is at risk of falls, and is vulnerable to falls when alone in his room. Yet the home has failed to make his environment safe, and has failed to adequately address his changing needs with regard to mobility. Another care plan assessed had three conflicting risk assessments around the management of falls, and the required support needs of the service user. (This service user has had three recent falls). The manual handling support plan states I sometimes need one carer to help me stand from the chair and sit. The mobility support plan states I use my zimmer frame to mobilise independently. And the accidents support plan states I have a history of falls I need staff to assist me to sit down because I cannot see properly. The accident form from the most recent fall (three days before the support plan was written) stated that staff are to monitor in public areas. This has not been reflected on the support plan. The current support plans contain conflicting information, do not supply staff with clear guidance of support needs, and do not reflect the outcome of the most recent fall. Furthermore, the manager has stated on the accident form of the 7th March 2010 that staff are to put in place a falls monitoring chart. This has not been done. A care plan stated I am incontinent and wear a pad. Then it goes on to say I can use the toilet every two hours. There is no further information regarding supporting this service user with remaining continent and providing support to use a toilet. This care plan also says staff to monitor my urine for offensive smells colour etc. There is no explanation of what is meant by etc. There is no support plan in place to guide staff about how to monitor. The brief personal profile on a support plan has been left blank. Beside each support plan are three further columns, these are titled risk management plan in place, review number, and review dates. None of the support plans have a review date or a review number. There is no clarity for staff, and, as stated, information contained in support plans is often conflicting. For example, in an accident support plan it states I havent had a fall recently so staff need to be proactive to ensure this does not happen, they need to check me regularly during the day and night. This is not sufficient detail about the level of support required. Staff are not guided as to what pro active steps to take. There is conflicting information in the mobility and manual handling support plans. In the mobility support plan the service users use of a zimmer frame is recorded. In the manual handling support plan it does not mention the zimmer frame. Additionally, the mobility support plan states I am able to walk safely and to keep my independence at all times, yet the manual handling support plan states I would love to have one carer to supervise and guide me where to go as I am mobile and independent. It then further states staff ensure there is no under shoulder lift and palm to palm hold only. This suggests the service user requires assistance and guidance when mobilising, and the mobility support plan suggests no assistance is required. A support plan we looked at said the service user can hear clearly. When we looked at the recent hearing examination record this recorded both ears to be completely blocked with wax. There was no record of any action being taken. Care Homes for Older People Page 5 of 27 Another example of support plans containing conflicting information was found on the cognitive ability support plan for a service user. It stated: I have the ability to deal with my personal hygiene. Yet on the personal hygiene support plan for the same service user it stated: I am unable to attend to my own personal hygiene. We looked in detail at a health care plan, and found there was no support plan in place for the health needs of the service user, and a complete absence of any information on file regarding the illness, how it presents, the signs and symptoms, when to use the stand by medication (when the health needs exacerbated), or what to do in terms of support and management. We saw some brief information about the health condition on the pain support plan. However, this information did not contain sufficient detail, and may lead the staff to give the service user medicines either too late or unnecessarily. For example, it states I am asthmatic so there are times that I have shortness of breath, staff to observe me at all times. Staff need to take immediate action if I am breathless. There is no further information. There is no explanation of what immediate action to take. It then goes on to say I have my nebuliser and ventolin evohaler for faster relief. Again, no further information is supplied. Staff have no guidelines in place to determine how to support this service user with their acute physical health need. Inspection of daily notes evidenced poor recording and a significant failure in either following the support plans or taking action. Furthermore, the records are not completed fully, and handwritten entries are poorly written and do not always make sense. When staff do record a problem such as declining medicine or refusing to eat there is no record of any action being taken and the support plan has not been reviewed or amended to cover these aspects of care. When we looked at a medication support plan, there was no support plan in place. It simply listed the medications the service user was prescribed. There was no explanation of what the medications were, why they were prescribed, how the service user prefers to take them, what times they are administered, or whether they were PRN (when required) medications. Listing medications does not constitute a support plan. Again, this is an example of where the support needs of the service user have not been identified, and staff have no guidance, clarity or direction around how to provide appropriate support. On one file we saw a letter from a community respiratory nurse dated the 23rd February 2010. This letter included a pamphlet on breathing exercises and offers help and advice on managing the breathing. There is no support plan regarding this health need, and the breathing exercises are not on the care plan. When we looked at a medication prescribed to a service user we saw that on the 19th of April 2010 she was prescribed a specialist drug. We asked a senior carer what side effects the medication may have. (This senior carer is an overseas trained nurse, and also wrote the care plan for this service user). She could not answer. We informed the senior carer that this drug is a diuretic. The senior carer told us that this would make the service user urinate more frequently. The drug was prescribed due to acute health problems with the service users legs. There are no support plans or any records in place to monitor the condition of this service users legs, nor any support plans in place to reflect the increase in support needs. Furthermore, no acknowledgment has been made regarding the impact on continence needs or possible changes to behaviour. Daily reports from when the tablets began indicate aggressive behaviour. This has not been reflected in a support plan. Care Homes for Older People Page 6 of 27 Risk assessments were poor, and again contained insufficient and conflicting information. A risk assessment for pressure ulcers gave a score of 5 (with no explanation of what this score meant) and the recommended action was a specialist propad mattress was needed. This has not been done, and there is no mention of this in the support plan for pressure areas. The support plan stated at the moment I am pressure free so staff need to work hard to prevent them. There is no further information supplied either in terms of using pressure relieving as a means of prevention, or guidance any other pro active measures to ensure this service user is kept free from pressure sores. A fracture risk assessment gives a high score of 8, indicating this service user is at high risk of falls and subsequent fractures. Yet the falls risk assessment gives a low score of 3. Both of these assessments were undertaken on the same date (10th April 2010). The recorded actions on both risk assessments are the same: staff should ensure a safe environment and ensure uses zimmer frame and monitor activities. This is not person centred, and contains insufficient information to be considered a robust support plan in respect of providing adequate support to minimise the assessed risk. We looked at a nutritional risk assessment. It recorded the service user has lost 0.8kg. The assessment does not cover all aspects of nutrition, nor does it give any information regarding the impact of this weight loss. There are no follow up actions recorded on this assessment, and staff have no guidance regarding how to monitor or support this service user. We looked at the weight record for this service user. This evidenced weight loss. There was no evidence on file that the home is recording what the service user is eating. Three of the four care plans had been recently reviewed and updated. Although the language used on these updated care plans was in a person centred style, we found that many of the phrases used in one care plan were repeated in the other two, and we question whether the care plans are a true reflection of individual needs, or a repeat of stock phrases. An example of this is all three care plans stated: I am a Christian of Church of England. I do believe in God. At my age now I forgot about my religion and how to respect religious holidays like Christmas and Easter Sunday. I hope staff will remind me about these. Medication. Our inspections in November 2009 and February 2010 evidenced medication practices were poor at the home, and put service users at risk. We required the home to ensure their medication practices and protocols were safe, and that they put into place robust systems for the management of medicines in the home. We observed the lunchtime medication round and inspected the homes storage of medicines. Our findings evidenced continued poor and unsafe practices. A senior carer was responsible for administering medication. There was a list of service users names on the medication trolley. We saw the senior carer repeatedly looking at this list of names, instead of checking the individual Medication Administration Records (MAR charts). When asked, she told us this list contained names of service users who had creams applied, and that these creams were now in their bedrooms. We observed her taking a strip of tablets from the trolley. She did not remove the box of tablets and therefore did not check the dispensing label. Furthermore, she did not read the back of Care Homes for Older People Page 7 of 27 the strip of tablets to check it was the correct medication. She then proceeded to administer two tablets from the strip. She did not sign the MAR chart, but put a dot in the box where it was to be signed. We looked at the MAR chart for this service user. The medication which has just been administered to her was PRN medication. This means they are only administered if required (for pain relief). She was administered these tablets without the senior carer asking her if she needed them at this time. When asked by us why she had not consulted the service user, the senior carer replied she is always complaining of pain in her legs, and offered no further explaination as to why she did not consult the service user. We accompanied the senior staff member to the medication room. We inspected the medication trolley and noted that the home has a combination of blister packs and original boxed medication. The tablets in boxes have had the initial of the service user written on the top of them by care staff. This is poor and unsafe practice as (witnessed during the medication round) it means the likelihood of staff not checking the administration instructions on the box is high, and may lead to errors being made. We saw that the home has purchased a new controlled drugs cupboard. However, they have lost the key and it cannot be accessed. Furthermore, it is not fixed to the wall and therefore does not comply with Regulations. Although the home did not have any controlled drugs on the premises on the day of inspection, this could change and at present the home are unable to store controlled drugs correctly. Another medication cupboard was not secured to the wall and again this does not comply with Regulations. Similarly, the medication trolley is left free standing when stored in the medication room and is not secured to the wall. This does not comply with Regulation. As discussed in our assessment of the environment, we found medications stored inappropriately and unsafely in service users bedrooms. Not only was the storage of this medication not secure, but the labelling of the medication had been tampered with by staff, and we found dispensing instructions written in capital letters by marker pen across the dispensing label. When we raised this with the manager she told us we shouldnt do it but we need to. Daily Life and Social Activities. We spoke with some service users who told us their experiences of life at the home. One service user told us Ive got nothing to look forward to when I get up. None of the staff talk to you. Youre left so much on your own. The radio is on from morning to night with the same awful music. We asked if anyone had asked her what music she liked. She told us no. We asked if activities were offered. She replied we havent got any. Some relatives told us that when they visit there never appears to be any staff around. They said that service users are alone in the lounges, and there have been several occasions where they have had to find a member of staff to assist a service user. This has included times where service users have fallen. During our eleven hours in the home we observed no activities apart from one member of staff playing a game of connect four with a service user. Meals and Mealtimes. Care Homes for Older People Page 8 of 27 We observed lunch and teatime at the home. Both were chaotic and rushed events, and service users were seen to be distressed and to not have the assistance they required. We also noted at both sittings that food was removed from service users before they had finished. It is our assessment there is a correlation between the weights of service users and how they are assisted with their nutrition at mealtimes. At lunchtime, service users were assisted to the dining room by staff. There was then a long wait for lunch to arrive (approximately 20 minutes). Service users became agitated. One service user threw her zimmer frame across the floor, many service users were shouting out why they were waiting so long. None of the four staff in the dining room acknowledged or responded to the service users. One of the care staff began to bring around jugs of orange and blackcurrant juice. She was observed several times pouring the orange juice without offering a choice. The meals were plated up by the kitchen staff. The choice of meal was either meat pie or salmon with cheese sauce. Before giving them out to service users, care staff poured gravy over the meat pie and cheese sauce over the salmon without offering a choice. We observed a service user putting her meal in the middle of the table. Another service user takes it and begins to eat it. None of the care staff notice this. The kitchen assistant does, and accuses the care staff of giving out the wrong meal. We observed another service user trying to eat rice pudding with the handle of a fork. None of the staff noticed. We brought it to a carers attention and a spoon was provided. Plates were cleared very quickly, and in some cases before the service user had finished eating. There was a lot of food waste. One service user was being assisted to eat by a carer. Although the carer was sitting beside the service user, she was not looking at her and kept putting spoonfuls of food in the service users mouth whilst there remained food in it. The service user kept coughing, but the carer continued to feed her. The carer then removed the plate although there was still food on it. Our observations at teatime evidenced that service users were agitated, and staff did not provide appropriate assistance. We also observed instances in which service users were not treated with respect, and their dignity was not upheld. Service users were given either a bowl of soup or a finger of pizza. We observed one service user who was agitated and required assistance with her meal. This service user kept trying to leave the dining room. A senior carer came up to this service user and stood very close to her. She then instructed her to sit down sit down, sit down, sit down, sit down. Her face was right in the service users face. The service user sat down and the carer (still standing) put a spoon of soup in her mouth and then walked off. The service user then stood up. The carer walked back to her and told her to sit down. The carer put another spoon of soup in her mouth and stayed for 45 seconds. She then walked off and returned with sandwiches and took the soup away. She did not return and the sandwiches were not eaten. Another service user was given a bowl of soup. Ten minutes went by and she had not touched it. We asked the service user if she was going to eat the soup. She said dont Care Homes for Older People Page 9 of 27 know. We passed her a spoon. She thanked us and began to eat. Another service user stood up. Across the dining room a carer shouted at her (also pointing her finger) to sit down. We saw at least two service users with a pizza slice in front of them that they could not cut. After 20 minutes a carer came over to cut it. By this time it was cold and the cheese had gone hard. COMPLAINTS AND PROTECTION. Evidence gathered at this inspection tells us that service users are not protected from harm, and staff do not have the necessary skills to ensure people are kept safe. These are the same conclusions we evidenced at both the key inspection in November 2009, and the random inspection in February 2010. This is not an environment conducive to ensuring service users are listened to, and their concerns taken seriously and acted upon. We looked at the complaints book and saw a number of recent complaints from relatives. The complaints ranged from offensive smells in service users rooms, to significant concerns over healthcare and personal care needs. Most of the complaints had been responded to, and those that had had been upheld. All responses included an apology and assurances that the service would improve. We saw a complaint that had not been responded to at all. This was dated January 2010, and was concerning missing items. The manager could not tell us why this has been left. We spoke with some relatives. Two relatives told us they felt the home responded well to complaints. Other relatives told us the home has ignored their complaints, and they have significant concerns over lack of receipts and paperwork in respect of money been given to the home. They have requested clarity on this issue but they have received no response. We asked service users about making complaints. A service user told us if we complain there will be trouble, there is something about this place I dont like. I think it is because you are left so much on your own. None of the staff talk to you. They dont ask us how we are. Our observations at mealtimes tell us that even when service users voice concerns (about how long it took for the meal to arrive), they are ignored. Service users told us they are not listened to, and relatives told us staff are never around. Loose Court has a high proportion of unwitnessed falls. We looked at accident forms to assess whether the prevention and subsequent actions were robust enough to keep people safe from harm. Our assessment of these forms, and subsequent conversations with staff and management at the home tells us that service users are at risk of harm from neglect. Of concern is that none of the accident forms we looked at had been completed fully. The current system in place is confusing. Some accident forms are given a reference number, some are not. Many of the forms had not been signed by the manager. Of the seven accident forms assessed, five were unwitnessed falls. As already stated in this report, one of these falls took place in a bedroom and involved a television being pulled to the floor. Care Homes for Older People Page 10 of 27 When questioned, the manager was unaware of this incident. It was clear from discussions with the manager that she had not reviewed the accident forms on file, and could not given robust information about how the home was keeping people safe. We noted that for all the falls, first aid or immediate referral to a healthcare professional was not actioned. This is despite service users suffering injuries such as immediate bruising to the nose and forehead, pain in sacral area, pain in a finger and swelling of hip area. When we asked why none of these service users were referred to the GP, or to hospital via the emergency services, the manager told us the home was observing them. We asked her what training staff had been given to assess head injuries or broken bones. She told us they would be able to tell. The actions on these forms did not adequately address prevention of further falls. Many stated that the light in service users bedrooms would be left on at night. This is potentially disruptive and could possibly disturb sleep. Other forms stated ensure zimmer frame is with service user at all times. There is no explanation as to how this will be achieved. We spoke with staff about how they ensure service users are kept safe. We also asked them about their knowledge of safeguarding protocols. Staff told us they didnt know the individual needs of service users, and they did not read care plans. Their knowledge of safeguarding was poor, and only consisted of saying they would report abuse. They did not recognise that abuse could consist of failing to listen to service users, speaking harshly to them, not addressing their healthcare needs, failing to call for medical assistance following falls, not ensuring service users have enough to eat and drink, and not ensuring all safety measures possible have been taken in respect of accidents and falls. When we asked staff how they prevented falls, they told us they made sure people had their zimmer frames. We asked what other practices they used, and they could not give any further information. ENVIRONMENT. We assessed all communal areas and the majority of service users bedrooms. Our assessment of the environment evidenced shortfalls and hazards. Our inspection of the environment in November 2009 and February 2010 identified significant concerns around management of continence resulting in overwhelming odours in some bedrooms and communal areas. We inspected 18 bedrooms. All bedroom windows were open. Seven of these bedrooms were found to have offensive and strong odours. All of these bedrooms were cold. When we asked the manager why the bedrooms were so cold, she told us staff might have opened all the windows because you are here. In one bedroom we noted the flooring was vinyl. We asked the manager how the home supported this service user with her continence needs. She told us that much of the incontinence was due to the service user not being able to get to the toilet in time. She added that they were assisting the service user with incontinence pads. We asked why the service user had not been moved to a room which suited her needs better (a room with ensuite facilities). The manager stated this was a good idea, and she would progress this. We asked if this service user had been assessed by the specialist Care Homes for Older People Page 11 of 27 continence nurse team. We were informed by the manager she has not, and that at present, the home is giving this service user incontinence pads from previous residents who are now deceased. None of the bedrooms had suitable curtains to ensure the privacy and dignity of service users was upheld. Some rooms had no net curtains at all, and the rooms that did, these net curtains did not cover the whole window and overlooked other houses and gardens. The manager agreed that the curtains were unsuitable, and told us she would ensure all windows had full net curtains. A number of bedrooms had prescription medication stored in the bathroom cabinets. This medication was not being stored appropriately, as the bathroom cabinets do not conform to medication cupboard requirements. The manager was not aware of the Regulations around correct storage of medication, and told us it was her who introduced the policy of keeping these creams in service users rooms. In addition to this, we also found medications in service users bathroom cabinets which were prescribed for other service users, and medication which was no longer in use and out of date. We noted in one bedroom that wallpaper was peeling off the wall. This room also had an odour of urine, was very cold, and was very small. The room belonged to one of the service users whos file we were assessing. We could see the size and the condition of the room were poor, and could be detrimental to the service user (registered blind, frail, and has poor mobility). We asked the manager how the service user managed in the room with her zimmer frame. The manager told us that the room was not appropriate to meet the needs of the service user. We questioned why the service user remained in that room when it had been identified as inappropriate to meet her needs. The manager said it was because she (the manager) needs to be given time to get to know the service users. We pointed out that she had already told us the room was inappropriate. The manager told us she would consult with the service user and her representatives, with a view to ensuring a more appropriate room was identified and allocated. We noted several shortfalls and hazards in a double room we inspected. The room contained only one chair. This was covered in soft toys. There was nowhere for either service user to sit. The large bay window had no net curtain. There was a mobile radiator with sharp edges. The carpet was threadbare and stained. One bedspread was dirty and had a lot of staining. The manager told us that one of the service users in this room was very frail, and should be moved to a more suitable room nearer to staff (this room was upstairs) and nearer to the communal areas. We asked why this had not been done. The manager told us we dont want to approach the service user or her family about it. We questioned again why a move had not been facilitated given it had been identified by the home that the service users needs had changed, and she required moving downstairs and closer to facilities. The manager was unable to provide an answer. In a further bedroom we saw another portable radiator. This too had sharp fins. There was nothing to safeguard the service user from burning themselves on the radiator apart from a note stating do not touch. In another bedroom, the headboard cover was torn. Care Homes for Older People Page 12 of 27 We looked at how the beds were made. A number of the bottom sheets had creases in and still had the impression of having been slept in. We discussed the importance of beds being made without creases to assist in the prevention of pressure areas. We saw evidence of poor infection control. A number of wardrobes contained pads. There were no clinical waste bins in the bedrooms to put soiled items. Neither were there any bins. We saw buckets in two of the bedrooms lined with a bin liner. We looked in the shower room, a bathroom, and the sluice room. The clinical waste bins do not comply with infection control protocols. There was no facility for clinical waste in the sluice room. We noted that there was no handwashing facilities in the sluice room, nor was there a sink or any hand gel. The sluice was not working. Further evidence of poor infection control was noted in the homes management of laundry. Two bins are stored in the corridor by the staff room. Both are for dirty laundry. One bin contained bagged soiled clothes, the other contained used towels. Neither bins had locks on and were accessible to service users. There was evidence of institutionalised care. Although not all service users at the home are incontinent, they all have plastic duvets especially designed for individuals with continence needs. We also observed that taped to the inside of each wardrobe door is a list of individuals personal needs. The manager told us that many of the personal needs listed on these notes were out of date as needs had changed (one stated that the service user used an airflow mattress, but there was not one on her bed. Another stated that the service user could not stand, yet she uses a standing hoist). She also agreed they were inappropriate, should not be taped to wardrobes, and that staff should be aware of all current needs of service users. We saw photographs fixed to walls around the building which directed service users to toilets, lounges and dining rooms. None of the pictures corresponded with the facilities in the home. When we pointed this out to the manager, she agreed that the pictures were wrong, and could be confusing to service users who may look for what is in the photographs, but will never find those rooms in Loose Court. A number of other hazards were identified: bath panels were cracked and broken. A fire extinguisher in the main lounge was behind the television and was not accessible. Storage cupboards in all areas of the home containing hazardous materials, gloves, cleaning materials, and the gas shutdown valve were all easily accessible either by having the key hanging by the door, or by having a sliding lock. A service user who had recently moved rooms told us she had fallen out of bed three times since the move and had a bump on her head. This was confirmed by the service users relatives. They told us that in the previous room her bed had been against the wall. In the new room, it was in the middle of the room. This has disorientated the service user. STAFFING. Our inspections in November 2009 and February 2010 evidenced that staff competencies were poor. At our inspection today we observed staff working with service users, assessed staff training, looked at staff files, and spoke with care staff. Care Homes for Older People Page 13 of 27 Our findings tell us that staff competencies remain poor. Despite evidence of staff undertaking training this is not put into practice. There is limited understanding of service users needs by staff, and this is hindered by a language barrier. There was an absence of management support to implement new practices. When we interviewed staff some told us that they did not read the care plans. However, the deputy manager named these same staff as having read the care plans the day of the inspection. We did see some examples of staff interacting positively with service users. However, staff did not have much time to spend with service users, and we observed many times where service users were alone. Our observations in the dining room evidenced that staff speak to service users harshly, and ignore their requests or questions. When we asked a care worker to tell us about an individual service user, and to describe her needs and her care plan, she told us she had not read the care plan and was not sure of her needs but you can tell what she needs by looking at her. Staff files were inspected and found to contain sufficient information including references and evidence of criminal record bureau checks. MANAGEMENT AND ADMINISTRATION. Outcomes for service users at Loose Court remain poor. Our inspection evidenced significant failings across all areas assessed. Evidence gathered at this inspection continues to demonstrate that the provider is failing to ensure that the service is managed appropriately. This failure by the provider is putting service users at risk as evidenced throughout this report. There have been 3 managers at this home in a six month period. Since our inspection we have learnt that the current manager has left without notice, and the home is without a manager. The manager was present throughout the inspection. The registered provider was present for most of the inspection. Both the manager and registered provider were involved in the feedback meeting at the close of the inspection. The registered provider told us he was confident the home had made great improvements. When we pointed out examples of care plans, risk assessments and accident records in which we assessed were poor and continued to place service users at risk, he told us that it would take more time. We informed him that it had been more than five months, and that service users continued to receive a poor service and were at daily risk of harm. Neither the registered provider nor the manager were able to give evidenced assurances of improvements. Although the manager had been at the service seven weeks, she did not know the service users by sight, did not know details in care plans, and had not reviewed accident forms and was unaware of known risks to service users. During the inspection the inspectors looked at the records in respect of Provider visits required by Regulation 26. (These are called Regulation 26 visits and should be undertaken monthly). The records showed that visits to the Home were undertaken on 9 April 2010, 11 January 2010, 7 December 2009, 12 October 2009, 21 May 2009, 2 March 2009, 19 February 2009 and 23 October 2008. Care Homes for Older People Page 14 of 27 The contents of the reports varied, some of them had very little information in them, and where issues had been identified no subsequent actions had been recorded. The records showed that sections of the early reports had not been completed at all. The reports for 12 October 2009, 7 December 2009 and 11 January 2010 were not signed or dated and as such there is no evidence to indicate that the visits were undertaken by an appropriate person. Whilst it is acknowledged that the reports dated 12 October 2009, 7 December 2009 and 9 April 2010 are more detailed in content, they are not robust and do not include a detailed action plan as to how any identified shortfalls are to be addressed, nor do they include dates by which the issues should be addressed. The dates recorded on the documents clearly show that the Registered Provider has failed to undertake the monthly visits to the Home and in fact the evidence shows that the Provider has only undertaken and produced a report for nine Regulation 26 visits to the home since October 2008. As such the quality of care provided at the Home has not been properly monitored, and consequently service users have been placed at risk of harm to their health safety and welfare. What the care home does well: What they could do better: Evidence gathered at this inspection tells us that service users remain at significant risk of harm and are not safe. None of the requirements made at the previous inspection have been met, and evidence of breaches in Regulations were found in all outcome areas assessed. We issued the registered provider with a Code B notice informing him of the breaches in Regulation, and of his failure to ensure service users individual needs are met through care planning, risk assessments, medication, and competencies of staff. The registered provider must ensure, without delay, that the following is addressed: 1. Care plans do not contain sufficient information about the service user to enable staff to provide necessary support. Care plans must be updated to include detailed information about support needs. 2. There is no evidence that service users or their representatives have been involved in formulating their care plans. The home must ensure service users are consulted and involved in care planning. 3. Care plans and risk assessments contain conflicting information. This means that staff are unable to determine which information is correct. The home must ensure that care plans give clear information. Care Homes for Older People Page 15 of 27 4. Care plans are not person centred. We found that phrases were repeated in other care plans. 5. Health needs are not appropriately recorded. This leaves service users at risk and vulnerable. 6. There is a lack of response to significant healthcare concerns, particularly falls. Service users are not supported to access health professionals and this places them at increased risk of harm. 7. Medication practices continue to be poor. This is exacerbated by the absence of medication support plans. This places service users at high risk of significant harm. 8. There is a lack of activities at the home and service users are left on there own. Service users lives lack choice and opportunity. 9. Service users are not treated with dignity and respect. There are occasions when they are spoken with harshly or ignored. 10. Service users are at high risk of malnutrition. Their meals are hurried and are taken away before they are finished, and records for tracking nutrition are poor. 11. The environment is not safe, and service users are at risk of harm. 12. Infection control is poor. 13. Care staff do not have sufficient competencies or skills and as a consequence service users are not adequately supported. 14. Management (including quality assurance) is poor. Service users health, safety and welfare is not met, and the entire management team has failed to ensure service users are protected from harm. The Commission are minded to take enforcement action against this 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 16 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 17 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 18 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 19 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 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 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 21 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. 29/01/2010 Care Homes for Older People Page 22 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 1 9 13 The registered person must ensure all medicines at the home are stored so that it complies with current Regulation and Legislation. To ensure medicines are stored correctly. 02/07/2010 2 9 13 The registered person must 02/07/2010 ensure that medicines are administered to service users in accordance with the prescription and that medication protocols and procedures are adhered to by all staff. Systems must be in place to ensure medicines are given to the correct service user. This includes ensuring that medication packaging and dispensing labels are not altered or written over by staff at the home. To ensure the health, safety and welfare of service users. 3 10 12 The registered person must 02/07/2010 ensure that service users are Page 23 of 27 Care Homes for Older People 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 treated with respect and their dignity is upheld by all staff working at the care home. To ensure service users feel valued and respected. 4 15 16 The registered person must 02/07/2010 ensure that they have a system in place that monitors service users nutritional status and that appropriate action is taken when changes occur. Where needed, service user dietary intake is monitored and recorded, in relation to what was eaten not what was offered. This must include ensuring service users receive a suitable nutritious diet in adequate quantities, and that all service users who require assistance to eat their meals are provided with appropriate support whilst maintaining their dignity. This includes making sure that meal times are not rushed and food is not removed before service users have finished eating. To ensure the health, safety and welfare of service users. 5 21 23 The registered person must ensure that bathrooms are suitable to the needs of service users and are maintained so to prevent injury or harm to a service user. this includes the 02/07/2010 Care Homes for Older People Page 24 of 27 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 replacement of broken bath panels. To ensure the health, welfare and safety of service users. 6 24 13 The registered person must 02/07/2010 have systems in place that ensure all potential environmental hazards are assessed and action taken to reduce or eliminate the risk. This includes the portable heaters and radiators situated in service users bedrooms. To ensure the safety of service users is met. 7 24 23 The registered person must 02/07/2010 have a system in place that ensures broken equipment in the home is removed and replaced. This includes items such as headboard covers. To ensure service users are comfortable and safe. 8 24 12 The registered person must 02/07/2010 ensure service users dignity is maintained through the provision of suitable curtains in service users bedrooms. To ensure the privacy and dignity of service users is met. 9 26 13 The registered person must ensure there are robust systems in place to control the spread of infection. 02/07/2010 Care Homes for Older People Page 25 of 27 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 To ensure the health, safety and welfare of service users and staff. 10 33 26 The registered person must 02/07/2010 ensure there are effective quality assurance and quality monitoring systems in place at the home. This includes monthly Regulation 26 visits. to ensure the health, welfare and safety of service users. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 It is recommended that the registered person ensures the controlled drugs cupboard is mounted to the wall and is fitted with a lock, ensuring that both comply with current regulations and legislation. It is further recommended that the registered person have a system in place relating to the management, responsibilities and holding of medication and controlled drugs cupboard keys, therefore ensuring the security of the medications. 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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