Inspection on 14/12/08 for Lucas Court Nursing Home

This inspection was carried out on 14th December 2008.

CSCI 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lucas Court Nursing Home 06/01/09

Lucas Court Nursing Home 07/11/08

Lucas Court Nursing Home 21/10/08

Lucas Court Nursing Home 01/07/08

Lucas Court Nursing Home 29/06/07

Lucas Court Nursing Home 12/06/06

Lucas Court Nursing Home 18/10/05

Lucas Court Nursing Home 26/04/05

Lucas Court Nursing Home 30/09/04

Lucas Court Nursing Home 28/04/04

Lucas Court Nursing Home 07/01/04

Lucas Court Nursing Home 18/08/03

Lucas Court Nursing Home 15/05/03

Extracts from inspection reports are licensed from CQC, this page was updated on 20/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Lucas Court Nursing Home Northampton Lane North Moulton Northampton NN3 7RQ     The quality rating for this care home is:   zero star poor service 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 assessment of the service. We call this a ‘key’ inspection. Lead inspector: Kathy Jones     Date: 1 7 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 36 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 36 Information about the care home Name of care home: Address: Lucas Court Nursing Home Northampton Lane North Moulton Northampton NN3 7RQ (01604)493233 01604493234 lucascourt@schealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Lynda Miller Type of registration: Number of places registered: Southern Cross Healthcare Services Limited care home 60 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: All service users in the category of DE(E) must be accommodated on the first floor. No one falling in the category of DE(E) may be admitted into the home where there are 28 service users who fall within the category of DE(E) already accommodated in the home No one falling in the category of OP may be admitted in the home where there are 60 service users who fall within the category of OP already accommodated in the home. No one falling in the category of PD may be admitted into the home where there are 6 service users who fall within the category of PD already accommodated in the home No one falling in the category of PD(E) may be admitted into the home where there are Care Homes for Older People Page 4 of 36 0 0 0 6 Over 65 28 1 60 6 6 service users who fall within the category of PD(E) already accommodated in the home. To be able to admit the named person under 65 years of age named in Variation Application No. V000020533 dated 13th May 2005. To be able to admit the named person under 65 years of age named in variation application no V000029387 dated 7th February 2006 Two named female service users may be accommodated in the category of Mental Disorder, until such time as they leave the home. No further service users may be admitted in this category Date of last inspection Brief description of the care home Lucas Court is a care home providing personal and nursing care for up to 60 people. Currently Lucas Court provides care for older people, older people with dementia, older people with a mental disorder and people with a physical disability. Southern Cross Healthcare owns the home and it is located in the village of Moulton on the outskirts of Northampton. The village has some local shops and public houses and is on a bus route in to Northampton. The home is a two storey building with the first floor allocated for dementia care, and care for people with mental health needs. Fifty of the bedrooms are single rooms with forty-eight of these rooms having en-suite facilities. There are five double rooms in the home. The home has a passenger lift. There is an enclosed well-maintained garden to the rear of the home, which is accessible to wheelchair users, and a car park. A scale of charges confirmed as being current at the time of the inspection in July 2008 states that fees are from 650 pounds to 750 pounds perr week. The fees quoted are exclusive of any free nursing contribution, which is collected from the Primary Care Trust by Southern Cross Healthcare. Local Authorities who are funding people are charged at a set rate. These people will be asked for a top up fee, which varies according to their ability to pay. The fees include personal care and where applicable nursing care, meals and accommodation. Chiropody, hairdressing services, and newspapers can be arranged and are charged separately. Other costs would include clothing and toiletries. Information about the services provided including the complaints procedure is displayed in the foyer of the home. This includes the statement of purpose, a service user guide and a copy of the most recent Commission for Social Care inspection report. Care Homes for Older People Page 5 of 36 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: Standards identified as key standards and highlighted through the report were inspected. The key standards are those considered to have a particular impact on outcomes for people who use the service. Prior to the inspection visits we spent a day collating information and planning the inspection. This pre-inspection planning involved reviewing the service history which details all contact and correspondence with the home. We took into account the findings of the last key inspection which was carried out in July 2008 and four random inspections carried out in August, September, October and November 2008. As a result of evidence gathered during the random inspections we served statutory Care Homes for Older People Page 6 of 36 requirement (enforcement) notices on 5th December 2008. These notices required that improvements were made in the management of peoples health and welfare and their medication. The timescales for compliance which had been set had not been reached when we carried out this inspection, however as part of this inspection we looked at what progress was being made to address the concerns. There were two unannounced inspection visits, the first of which was carried out on a Sunday and involved one inspector looking primarily at staffing levels. The second day involved three inspectors and a regulation manager. On the second day an expert by experience accompanied us. An expert by experience is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The main focus of our inspection was to consider the care people were receiving and how they are safeguarded. We selected a sample of people and looked at the records in place to assess and support their care needs and where possible spoke with them and the staff caring for them. We also observed the routines of the home and the care provided, seeking views from people who use the service, staff and visitors. Due to the number of safeguarding referrals received by the local authority we looked at these records and cross checked the information against other records such as staff records to see what action had been taken. We provided verbal feedback on our findings to managers throughout the inspection. Requirements detailed in this report contain those made at previous inspections where compliance has not been achieved, requirements made in the statutory requirement notices where compliance has not yet been checked and some new requirements. What the care home does well: What has improved since the last inspection? What they could do better: Overall the service needs to be more proactive in identifying and acting on shortfalls to improve standards of care and better systems need to be in place to monitor and sustain improvements for all people who use the service. More clarity is required about the type of care people are being admitted for and who will be responsible for overseeing the care. Following admission people need to be able to rely on staff to monitor their health care needs, to provide the care that they need including nursing care and to make prompt referrals to medical professionals when required. Areas for improvement range from the provision of basic care such as ensuring that people are able to have regular baths or showers to making sure that people get the proper treatment for pressure ulcers. Arrangements need to be in place to ensure that peoples prescribed medication doesnt run out, is available at all times and given according to the frequency and instructions that have been prescribed. The quality of peoples lives could be improved by more interaction and more opportunities for stimulation between scheduled activities. Care Homes for Older People Page 8 of 36 Consideration needs to be given to how people can be better safeguarded. This would include better record keeping and coordination helping to ensure that investigations and any required actions are completed in a more timely way and ensuring that issues do not reoccur. Some improvements were needed to the decor in some parts of the home and action needs to be taken to address the unpleasant odour on the dementia unit. We have found that equipment to meet peoples particular needs has not always been readily available. This has included pressure relieving mattresses, pressure cushions and specialised equipment. When considering the adequacy of staffing levels it is important that instead of looking just at the numbers that systems are in place to check that people are getting the care they need at the time they need it. There also needs to be better management of the staff rota and staff team so that the nurse in charge knows exactly what staff should be and are on duty. There needs to be enough support staff such as cleaning staff at weekends as well as weekdays. Records need to be accurate and staff need to be adequately trained and sufficiently competent to meet the needs of people. 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 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 36 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 36 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed and determined prior to admission, however lack of clarity about whether people are admitted for residential or nursing care and who is responsible for their care leaves people at risk of their needs not being met. Evidence: Information is available to people considering using the service and their families in the form of a statement of purpose and service user guide. A copy of the documents and a copy of the most recent inspection report are also available in the foyer. Photographs of staff were on display, which is very useful in helping visitors to identify staff and their roles. At the time of the inspection some changes were required to reflect recent changes to the management and staff team. The statement of purpose and service user guide, are corporate documents with some information specific to Lucas Court. Advice has been given at previous inspections to Care Homes for Older People Page 11 of 36 Evidence: include more information about Lucas Court, for example the range of needs that can be met and the type of care provided. This is important in helping people who are considering using the service to make informed choices about their care. It was confirmed that the recommended changes have not yet been made but that they were due to be reviewed on 22nd December 2008. The statement of purpose identifies that an assessment of peoples needs is carried out prior to admission, which would involve visiting the person either at home or in hospital. This is important in helping to determine if peoples needs can be met. There have been no admissions to Lucas Court since an embargo on admissions agreed between commissioners of services and Southern Cross in September 2008. From the care files reviewed for people admitted prior to the embargo on admissions we found that pre-admission assessments had been carried out. Information gathered included medical history, consideration of any risks such as developing pressure ulcers or falls. Information is also gathered about peoples social interests, religion and friends and families. It is important that information is gathered from all sources to help ensure that the required care and support can be provided. We were however concerned that review of the minutes of disciplinary hearings held for four staff in relation to someone who used the service highlighted that all staff had been unsure as to whether this person had been admitted for residential or nursing care. This had significant implications as to who subsequently was responsible for the monitoring of the persons pressure area care, nurses at the home or district nurses. The minutes of the hearings did not contain any recommendations as to how this basic information should be recorded and transmitted to staff or who was to take responsibility for it. This would seem to be a basic requirement of the assessment process and these failures leave people at risk of their needs not being met. Intermediate care is not provided at Lucas Court; therefore standard six has not been assessed. Care Homes for Older People Page 12 of 36 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Ongoing failures in relation to the management of peoples health care needs and medication puts peoples health and well being at risk. Evidence: Since the last key inspection carried out on 1st July 2008 four random inspections have taken place as a result of concerns about the management of peoples health care needs. Concerns have been identified about the care planning process and the delivery of care according to peoples assessed needs. Some particular concerns have arisen about pressure area and wound care and monitoring of peoples health and well being in relation to things such as constipation and the management of their medication. There have also been delays in making referrals to health professionals for advice and treatment. Requirements have been made based on the concerns, and enforcement notices were served on the 5th December 2008 as a result of these breaches of regulations. As stated in the summary the timescales for compliance with the enforcement notices had Care Homes for Older People Page 13 of 36 Evidence: not been reached at the time of the inspection. We have also in instances where we have felt that people may be at risk made referrals to the local authority under the safeguarding vulnerable adults procedures. This has enabled them to review the care for individuals and put in place plans to safeguard people. Minutes of disciplinary hearings held for four staff in relation to lack of wound care for one service user identify that four staff had not received any training in care planning and that one staff member expressed their concern about writing a specific wound care plan as they did not feel sufficiently experienced. The minutes also indicate a lack of clarity about the relative responsibilities of staff for ensuring that care plans are in place and that information is passed on from one staff member to another to ensure continuity of care. Each staff member felt that it was another staff members responsibility to complete the care plan. This has led to peoples needs not being met. In the four care staff files reviewed all contained a memo from the previous manager stating that they had failed to audit the care plans allocated to them. The record of one staff member recently involved in another disciplinary hearing (who was actually in charge of the home for a period of time due to the registered manager being on sick leave) also identified that there were concerns about their ability to oversee the management of care plans and fluid management on the ground floor. Requirements have been made based on the concerns, and enforcement notices have been served as a result of these breaches in regulations. As stated in the summary the timescales for compliance with the enforcement notices had not been reached at the time of this inspection. During this inspection we reviewed a sample of care files for people and found that for the four people reviewed on the ground floor there had been an improvement in the management of their care. For example for someone with a pressure ulcer, there were appropriate care plans to guide the care and also records to show the treatment given and progress of the wound. There was also evidence that advice from the tissue viability nurse was being implemented. Given previous concerns raised regarding pressure area and wound care and the improvements made on the ground floor it was of particular concern to identify through a sample check of care records two people on the first floor (dementia unit) who were not receiving appropriate care. Records contained statements such as sore sacrum, with records for one person slight skin breakage on sacrum. Entries in daily records state that carers have reported this to the nurse but there is no evidence of the nurse reviewing the person, seeking advice from the tissue viability nurse or acting on the information. Care Homes for Older People Page 14 of 36 Evidence: A care plan for one of the people referred to above dated 5th August 2006 stated that he was at high risk of pressure ulcers and that he was being nursed on a spenco mattress but was to be transferred to a high grade mattress when available. We found that this person continued to be nursed on a spenco type mattress and had no pressure cushion. When asked a staff member advised that nine cushions were on order but that there was only one on the unit which was being used by someone else. As a result of our concerns we were assured by managers that the mattresses for both of these people would be changed and that their pressure area care would be reviewed by the project manager. There was an improvement in the completion of records, with care staff identifying within the records the care delivered and any concerns that they had about the individual, however this was not always being picked up and acted on. Delays were again identified in contacting the General Practitioner in respect of someone with dementia who was recorded as not having had a bowel movement for eight days. Personal hygiene records for eight people on the dementia unit were reviewed back to the begin inning of December 2008. There was no record of any of these people having a bath up to the time of the inspection. We talked to staff about how baths are planned and organised. Staff told us that that there is no particular plan for bathing, mornings are the busiest times, so people are washed in the mornings and bathing, they fit in when they can. Staff said that baths were usually done in the afternoons but that the increase in expectations on care staff for record keeping meant that they no longer had time. The management of peoples medication was identified as being of concern has been an ongoing area of concern and a pharmacist inspector has been involved in one of the random inspections. Concerns have included medication not being available. An enforcement notice has been served and compliance will be checked when the timescale for compliance has been reached. On our inspection visit of 14th December 2008 we did see some evidence that action was being taken to establish better stock control systems. The nurse on duty on the first floor (dementia unit) advised that all medication had been checked and any surplus stock was being returned for disposal. Advice was given to ensure that the full quantity of medication either returned or disposed of was recorded in the disposal record to maintain an accurate audit trail. We had noted that one record did not contain the full amount set aside for disposal. Staff were heard to speak respectfully to people who use the service. Peoples dignity Care Homes for Older People Page 15 of 36 Evidence: was preserved in that all personal care was provided within the privacy of peoples rooms. The expert by experience commented that people who use the service looked clean and tidy and that they had told her that they enjoyed having their hair done by the hairdresser who visits regularly. We were however concerned about the lack of baths and showers for people which has the potential to impact on their self image and dignity. Care Homes for Older People Page 16 of 36 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a programme of activities, however the quality of peoples daily lives is largely dependant on their ability to express their needs. Evidence: People at Lucas Court have a wide range of different needs, with some people more able to express those needs than others. During our inspection visits some of these people have told us that they are quite happy with their daily lives at Lucas Court which has been their home for a number of years. The focus of recent inspections has been mainly on those people who are less able to express their needs and who we have considered to be the most vulnerable and at risk, however we do acknowledge that some people are satisfied with their daily lives. The expert by experience spoke with people about their daily lives and observed the routines on both floors. People spoken with said that the routines are flexible in that they are able to choose when they go to bed. Observations on the morning of inspection identified that those people who require assistance can wait until quite late in the morning for help with washing and dressing. Care Homes for Older People Page 17 of 36 Evidence: There was a notice on a wall about a games corner being for people who use the service and visitors. There were draughts, dominos, cards and a type of connect four game available in the corner of the lounge on the ground floor. No activities organised or supported by staff were seen during the visit. People said that there is an activities lady who usually visits on weekdays but was not there on the day of inspection. People said that activities included playing skittles, excercise to music and sometimes quizzes. Those people who joined in with these activities said that they enjoyed them. The manager had advised that the day before the inspection could not recall the outing. Some people spoken with said that they enjoyed going out into the garden. On the ground floor people in the lounge were asleep or just generally sitting. One resident had a book by her side and another was knitting, indicating that some people have their own individual ways of spending their time. People also spoke about the local priest who regularly visits them and conducts a service at Lucas Court. This helps those people of that faith who are no longer able to go out to church. The expert by experience observed staff to be gentle and considerate when assisting people to transfer from wheelchairs to a chair in the lounge. However there was not much conversation (chit chat) between them and the person they were moving although they did tell the person what they were doing and why. On the first floor (dementia unit) a member of staff was in the lounge, but was sorting out prescriptions the whole time rather than interacting with people who use the service. There was music, Christmas songs, being played from a radio but again no activities. At one point the member of staff was heard to ask someone who uses the service to turn the music down. A member of staff who came to relief the first member of staff again didnt interact with people apart from helping one person who was trying to wrap a Christmas card in cloth. Feedback from the expert by experience, observations and discussions with managers indicates that while there are planned activities which people enjoy, more could be done to enhance the daily lives of some people. On the dementia unit, work and thought has gone into creating a cosy room, which is furnished to resemble a sitting room in a family home with items such as a pram, cot, books and photographs. There were also some wall displays containing items such as bolts and chains and soft toys. All of these provide opportunities for engagement with people, however we did not see this happen and noted that staff time was taken up with either completing paperwork Care Homes for Older People Page 18 of 36 Evidence: or attending to peoples physical care needs. Visiting arrangements are flexible and visitors are made welcome. Social events such as coffee mornings are organised to encourage friends and relatives to visit. People were offered a choice of main meal at lunch time which on the day of inspection was roast lamb, spaghetti bolognaise or salad. Desert was bread and butter pudding with custard. The food was hot and well presented. People were offered and given assistance with their meals where required. Care Homes for Older People Page 19 of 36 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are not adequately safeguarded. Evidence: There is a complaint procedure, which is detailed in the statement of purpose and available in the foyer. A sample of people spoken with told the expert by experience that they felt safe at Lucas Court and that they could go to the manager with any problems. Since the key inspection in July 2008 the local authority have received a high number of safeguarding referrals. There were some investigations ongoing at the time of the last inspection and taking these into account, referrals have related to twelve people. In some cases more than one referral was received for the same person. Some concerns have been raised about staff attitude and treatment of people who use the service, though the majority have been about lack of care and in particular nursing care which has led to poor outcomes for people. We have kept in touch with the local authority in respect of the progress of their investigations. They have raised some concerns about delays and difficulties in receiving information from Lucas Court about the actions that they have taken to safeguard people. Care Homes for Older People Page 20 of 36 Evidence: During this inspection we examined records relating to some of the safeguarding referrals and looked at the actions that have been taken. We also cross checked this information with staff records where there were allegations that people had not received the care that they needed. We looked at the investigations, which had taken place with regards to safeguarding incidents relating to two people who use the service and were able to establish that disciplinary action had been taken. Although there was evidence that that four staff members had been asked to provide information about another safeguarding incident by a certain date (19/09/08) we were unable to locate any documentary evidence that this had been provided and neither the current acting manager or the project manager could locate information with regards to any subsequent investigation into this incident. We were concerned about the delays in concluding investigations. In some cases staff were suspended from duty, however for one disciplinary investigation involving four members of staff, the investigation had started on 14th May 2008 and had not been concluded until the final hearing on 12th September 2008. This would seem to be an extended period for such an investigation where major concerns were identified in relation to assessment, care planning, delivery of nursing care and management. During our inspection in September 2008 we were concerned about a care plan for someone who uses the service which indicated that concerns or accusations may not reflect the truth. The care plan indicated a lack of understanding about safeguarding vulnerable people. The care plan has now been altered but it was of concern that it was necessary for us to raise the same issue in October 2008 and to refer it to the local authority under safeguarding procedures. It was very difficult to locate some of the information relating to safeguarding which was held in different places. We were told that some investigations had been carried out by managers of different homes who had different practices in relation to storage of records. A more coordinated system is required to ensure that there is a better overview of safeguarding issues to help ensure that investigations and any subsequent actions are properly followed through in a timely manner. A sample check of staff files confirmed that some training in safeguarding vulnerable adults has been provided. Care Homes for Older People Page 21 of 36 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Lucas Court provides a comfortable place for people to live, which is spoilt by the unpleasant odour in some parts of the home. Better arrangements are also needed to ensure that people requiring specialist equipment receive this promptly. Evidence: Shared areas of the home such as lounges and dining rooms and a sample of peoples bedrooms were seen during the inspection. People on the first floor, which is the dementia unit, are able to, where mobility allows wander freely. The home had been nicely decorated with Christmas decorations. However the general decor could be improved in some areas; the wallpaper was peeling off the walls in some places, especially at the corners of the walls. on one corridor the wooden handrail had been taped at the end and the tape was beginning to hang off. Some of the doors and walls especially on the first floor were badly scratched. Peoples names were on the doors, but quite often it was written on a scrappy piece of paper. The expert by experience spoke with someone on the ground floor and looked at their bedroom. They were very pleased with their room, which looked out onto the garden, had an en-suite facility and contained some furniture, which they had brought from home. There was a note on the wardrobe that this and the drawers should be tidied Care Homes for Older People Page 22 of 36 Evidence: once a week and a chart with the date and a signature to say when it had been done last. At our inspection in July 2008 we found that on entering the dementia unit there was a strong odour in the corridor, which appeared to be coming from the carpets. The carpets in the lounge were also quite stained. The registered manager at the time advised that quotes were being obtained to replace some of the carpets, which would include part of the corridor on the dementia unit. The strong odour continued to be present on both inspection days and was particularly offensive on our inspection on Sunday 14th December 2008. We spoke with cleaning staff and looked at cleaning records on 17th December 2008 (There were no cleaning staff on duty on 14th December 2008). Records showed that the carpets are washed regularly and staff told us that the odour appears to be coming back from the floor baordsand that the stains reappear when the carpet is dry. There is a pleasant enclosed garden at the rear of Lucas Court with patio and lawned areas and an aviary. The garden has level entry access, which enables wheelchair users who can mobilise independently to go in and out as they wish. There is a no smoking policy in the home. We noticed that there is an open shed in the garden where people who use the service and staff can smoke. We were told that this had been donated by an ex resident to provide some shelter. During our inspections since July 2008 we have identified some concerns about the availability and use of specialised equipment to meet peoples needs. We also observed that the condition and cleanliness of some equipment such as wheelchairs was poor. One of our concerns has been that it has been necessary in some instances to prompt the provision of equipment. This has included specialist seating and pressure relieving equipment. In respect of specialist seating managers have advised of difficulties with assessment and funding and in one case appropriate seating is not available four months after we raised the issue. Changes to the care of this person have reduced the safety risks but the lack of specialist seating has increased social isolation. This particular situation is being monitored through safeguarding adults procedures. The acting manager advised that he was chasing up a particular type of pressure cushion recommended by the tissue viability nurse for someone with pressure ulcers who spends a significant amount of time in their wheelchair. Having the correct equipment is an important part of meeting peoples needs. Care Homes for Older People Page 23 of 36 Evidence: Some measures were observed to be in place to reduce the risk of infection. For example disposable gloves and aprons were available and staff were observed to be using them. At the last inspection we identified that less than half of the staff had received training in infection control. A sample of staff files checked contained training certificates for infection control dated September 2008. Care Homes for Older People Page 24 of 36 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing arrangements, which include keeping under review staffing levels, staff training and competence do not adequately safeguard people who use the service. Evidence: Comments received from people who use the service and relatives at the inspection in July 2008 included concerns about staffing levels. We made a requirement that staffing levels must be reviewed and monitored in consultation with people who use the service that there are sufficient staff to meet their needs. Since then concerns have been raised with the local authority about staffing levels particularly at weekends. As a result we started this inspection on Sunday 14th December 2008 in order to look specifically at staffing. This highlighted that records relating to staffing such as rotas could not be relied on as a accurate reflection of staff on duty. We checked the staff rota, staff signing in record, spoke with the nurse in charge on each floor and staff actually on duty. We found that one carer recorded on the rota was not actually in the building. The nurse on the ground floor thought she was working on the first floor, however the nurse on the first floor didnt know she was expected to be on duty as she was not recorded on the upstairs rota. Another carer phoned in sick that morning, which staff Care Homes for Older People Page 25 of 36 Evidence: had said made it difficult to assist people with washing and dressing and to serve and supervise breakfast. The majority of people need some assistance washing and dressing with many needing two carers to assist. People also need assistance with meals, either feeding or support, prompting and monitoring. During the inspection on the 17th December 2008 we asked for various information, which included details of the actions taken to meet the requirements. An action plan dated 16th December 2008 was supplied on the day of inspection. In response to the requirements about staffing levels the action plan states weekly staffing review utilising residential dependency formula. This formula provides a guide for care homes, however is not sufficient in itself to ensure that peoples needs are met. Within the requirement made we included the need for consultation with people about the sufficiency of staff to meet peoples needs. This important aspect has not been included within the action plan. People who use the service have again told us that there are staff shortages and we observed that people had to wait until late morning to be assisted with washing and dressing indicating that this problem had not been fully resolved. Discussion with staff, cleaning records and observations identify that there are not always sufficient ancillary staff to support care staff. For example there are rarely any cleaning staff at weekends, which puts additional pressure on care staff and has the potential to increase the risk of infection. Review of staff records and in particular disciplinary records has highlighted concerns about the understanding of some staff in relation to their roles and responsibilities and also about their competence in meeting peoples needs. As a lot of the concerns identified during recent inspections and through safeguarding hae been about nursing care we have focused particularly on records for registered nurses. Minutes of disciplinary hearings held for four staff in relation to lack of wound care for one service user, state that none of the staff had received training in care planning when the person was admitted but were expected to take responsibility for writing the care plan. Each staff member felt that it was another staff members responsibility to complete the care plan. We are concerned that the four staff referred to, are registered nurses and as such would be expected to be competent in the planning of peoples care and able to take responsibility for the delivery of that care. Certificates of training were held on staff files indicating that staff were being provided with training to help address the shortfalls which had been identified through inspection. However other records appeared to contradict that the training had taken place. For example there was a certificate on one nurses file for nutrition awareness Care Homes for Older People Page 26 of 36 Evidence: training, which was said to have taken place at Lucas Court. There is no record either on the staff rota or the signing in record of the nurse being in the building on that day. In addition at a later disciplinary hearing she stated that she had not had the training, a statement that went unchallenged. A sample check of staff files confirmed that criminal record bureau clearances and references are obtained prior to staff starting work. The applications included a full employment history. These checks are important in helping to protect people who use the service. Care Homes for Older People Page 27 of 36 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and oversight of Lucas Court has not adequately protected people who use the service. Evidence: Standard 31 relates specifically to the role of registered manager. As there was no registered manager in post at the time of the inspection, this standard has not been assessed as such. However the management arrangements are considered critical in the quality of care and in safeguarding the health and welfare of people who use the service and are therefore reported on in that context. Since the inspection in July 2008 there have been some management changes. We have been informed at a meeting with the responsible individual that the then registered manager has retired. A registered manager from another care home was managing the home for a temporary period supported by a project manager. A new manager was appointed shortly before this inspection and was present on the second Care Homes for Older People Page 28 of 36 Evidence: day of inspection. It is too soon to comment on the ability of the current manager, however, the expert by experience spoke with people who use the service and they described the new manager as A nice man very friendly and helpful and they felt that they could go to him with problems. We were concerned in July that although the registered manager had some periods of sick leave the findings of the inspection indicated that the management arrangements and oversight by the organization had been insufficient to ensure that peoples needs were met and their health and welfare safeguarded. Records for a staff member who was in charge of the home for a period of time due to the registered manager being on sick leave identified that there were concerns about their ability to oversee the management of care plans and fluid management in the ground floor nursing unit. This raises questions about the adequacy of management arrangements at that time. The four random inspections carried out since that time have identified some efforts to make improvements, however we continue to be concerned that areas of risk to people who use the service have often been highlighted through our inspections and enforcement action has been necessary to achieve some level of improvement. We have found on this inspection improvements in relation to wound and pressure area care on the ground floor. We would have expected that given this has been highlighted as an area of concern on the ground floor, checks should have been made on staff practice on the first floor in relation to pressure care. We were told by the nurse in charge of the first floor that they were expected to review three care plans a day and revise where necessary in order to achieve the required improvements in care planning. We have made requirements and have served an enforcement notice as a result of shortfalls in care plans, which have led to risk to people, so fully support the need for these improvements which should be working tools to support peoples care. We were however concerned that there appeared to be a lack of understanding about the need to focus on peoples care needs and prioritise the care plans for people who may be at highest risk. Southern Cross Healthcare has a range of quality assurance tools and audit to measure the quality of care; for example Operations Managers carry out monthly unannounced visits to look at the quality of care provided. These unannounced visits are a requirement of the Care Homes Regulations 2001 as it is considered important that organisations are overseeing the quality of care provided to people using the service. Reports of visits in September, October, November, and December 2008 were seen and confirm that views have been sought from people who use the service , relatives and staff. Care Homes for Older People Page 29 of 36 Evidence: Various tools have been recently been put into place to aid the organisation in auditing and monitoring areas where risk has been identified. These include a tissue tracker for people with wounds, and a weight monitoring tool which provides some oversight of people who are at nutritional risk. Some people leave small amounts of money for safekeeping to assist with paying for services such as hairdressing and chiropody. This is kept in a central bank account, which accrues interest and is added to each individual account. During our inspection, in July 2008 we found that records were kept of all transactions and receipts kept to verify these which help to safeguard people. A report of an unannounced visit carried out by the Operations Manager in October 2008 identifies that she checked peoples finances and found that they were being managed in accordance with company policies and procedures. Poor record keeping has formed part of the concerns that we have had over recent inspections, These concerns are confirmed in a care audit report of an audit carried out by a Southern Cross Auditor on 1st and 2nd October 2008. They looked at eight service user files and eight personnel files and identified significant shortfalls in record keeping and staff training. During this inspection we have found that staff have a better understanding of the need to keep records up to date, however we are concerned that the completion of records is impacting on rather than supporting the quality of care and outcomes for people who use the service. Examples have been given in this report of people not receiving baths and of limited interactions between staff and people who use the service said to be as a result of increased expectations in relation to record keeping. There are also examples of care staff completing records and then nursing staff not acting on the information, putting people at risk. We also found that we could not rely on the accuracy of records such as the staff rota. Observations during the inspection were that staff were carrying out safe practice in relation to the movement and handling of people who needed assistance. Training records identify that staff do receive training in safe working practices, however some updates are now required to help ensure that staff have the necessary knowledge and skills to reduce the risk for people who use the service. Care Homes for Older People Page 30 of 36 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 8 12 (1) (a & Peoples health and well 11/09/2008 b), 13 (1) (b) being must be monitored with prompt action/referral to healthcare professionals as appropriate. This must include the risk of constipation for those people unable to express a problem. 2 8 12 (1) (a & b), Where it is assessed that it is 11/09/2008 necessary to monitor peoples fluid intakes, records must be checked daily and reasons for people receiving insufficient fluids investigated. 3 9 13 (2) Accurate, complete and up to 11/09/2008 date medication records must be kept to ensure that medication is administered correctly, safely and as intended by the prescriber to manage individual health needs. 4 19 23 (2) (d) Carpets must be kept clean 30/09/2008 and free from odour and replaced as required to ensure people have a pleasant environment to live in. Page 31 of 36 Care Homes for Older People 5 27 18 (1) (a) Staffing levels must be 30/09/2008 reviewed and monitored in consultation with people who use the service and sufficient staff provided to meet their needs. 6 30 18 (1) (c) (i) Staff training should be 30/10/2008 implemented to address gaps identified in the staff training matrix to ensure that all staff have up to date training to meet residents needs. 7 33 24 (1) (a & b) Quality assurance systems must be effective in improving and maintaining the quality of care provided to people who use the service. 30/09/2008 Care Homes for Older People Page 32 of 36 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 There must be clarity within 27/02/2009 the assessment and admission process as to whether people are admitted for residential and nursing care and which staff will be responsible for overseeing their care. To ensure that peoples needs are met. 2 7 15 Put in place suitable arrangements for ensuring that service users are notified of any revisions their care plans. To help ensure that people are kept informed about their care. 05/01/2009 3 7 15 Put in place suitable arrangements for ensuring that service users plans are reviewed. To help ensure that peoples changing needs are met. 05/01/2009 Care Homes for Older People Page 33 of 36 4 7 15 Put in place suitable arrangements for ensuring that service users have a written plan as to how their care needs are to be met To help ensure that people get the care they need. 05/01/2009 5 8 12 Put in place systems to ensure that arrangements for peoples health and welfare and treatment, are implemented and maintained. To safeguard peoples health and welfare. 18/12/2008 6 8 13 Put in place arrangements 18/12/2008 for service users to receive where necessary, treatment, advice and other services from any health care professional. To help ensure that people get approriate medical intervention. 7 9 13 Put in place effective 18/12/2008 arrangements to ensure that accurate records are maintained of medications received and administered. To ensure that there is a system to confirm what medication people have had. 8 9 13 Put in place effective 18/12/2008 arrangements at the home to ensure that all medication is administered to service users as prescribed Care Homes for Older People Page 34 of 36 To ensure people have the medication they need. 9 18 13 A more coordinated and consistent system for the management of safeguarding investigations and storage of records must be implemented to ensure these are dealt with in a thorough and timely manner. To safeguard people 10 22 23 Arrangements must be made to ensure that people have equipment appropriate to their needs. This would include any necessary specialist seating and pressure relieving equipment. To ensure peoples needs are met and quality of life maximised. 11 37 17 All records must be kept up to date and be accurate. This must include staff rotas. To enable proper planning and organisation to meet peoples needs. 28/02/2009 02/03/2009 16/02/2009 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 12 Improve the quality of peoples daily lives by looking at readily accessible activities and increased staff interactions in addition to the planned activity programme. Care Homes for Older People Page 35 of 36 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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