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Inspection on 25/06/09 for Premier Court Nursing & Residential Home

Also see our care home review for Premier Court Nursing & Residential Home for more information

This inspection was carried out on 25th June 2009.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

Residents and their relatives expressed a good level of satisfaction with the service provided at Premier Court. Relatives told us, ‘Premier Court does well in all areas. It is a very comfortable home with very caring staff and is very much a home from home’. ‘There is always someone with time to talk to the residents’ and ‘I am very pleased with the care that my relative receives from all the staff. All requests from me are always dealt with immediately’. Two residents commenting on what it was like to live at Premier Court told us the ‘girls (staff) are very good’, the activities are good, ‘it is friendly’, it provides ‘company, friends and people to talk to’. People living in the home are positive about the activities and entertainment that is arranged for them. People tell us they enjoy their meals. People can be confident that staff are checked for their suitability to support vulnerable people and receive the training required to meet their needs and work safely. This includes training to support people with dementia.

What has improved since the last inspection?

People tell us they have confidence in the new manager and feel she is approachable and listens to them. Staffing levels have been increased and the reliance on agency staff has been reduced so that people are receiving support from staff who know them.

What the care home could do better:

People looking to use the dementia care service need to have access to information that tells them about the home’s approach to dementia care and the service they can expect. People living in the home need to be confident that staff are following the correct procedures for the safe use of equipment to prevent infections. People living in the home need to be confident that the risk assessments in place to keep them safe are being followed by staff and kept under review. People identified as loosing weight need to be confident that the nursing staff will carry out the planned intervention, they have assessed the person needs, such as weighing them more regularly. This is to make sure people receive the health care and support they need.Premier Court Nursing & Residential HomeDS0000019499.V376105.R01.S.doc Version 5.2 People need to be confident that the nursing staff will use medical devices safely to protect them from infection. People need to be confident that their medicines will be stored at the correct temperature to keep it safe and that their medicines will be given within the timescales prescribed. This is so it will be effective and there is no risk of overdose. People need to be confident that staff have clear guidelines about when to give medicines prescribed as “when required” and record the reason for their use. This is to protect people from harm and ensure medication is given appropriately. People living in the home need to be confident that details of the risks associated with the use of prescribed medical gases are recorded so they can be managed safely. The management and organisation of the dementia care unit needs to be reviewed so people’s individual wellbeing is promoted through a person centred approach to their lives that recognises their individual needs. Assessments of people’s capacity to make decisions for themselves and any restrictions on their freedom needs to clearly recorded. This is to protect the rights of people living in the home and to make sure decisions are being made in their best interests.

Key inspection report CARE HOMES FOR OLDER PEOPLE Premier Court Nursing & Residential Home Thorley Lane East Thorley Bishops Stortford Hertfordshire CM23 4BH Lead Inspector Sheila Knopp Key Unannounced Inspection 25th & 26th June 2009 10:00 DS0000019499.V376105.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Premier Court Nursing & Residential Home Address Thorley Lane East Thorley Bishops Stortford Hertfordshire CM23 4BH 01279 758585 01279 758586 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager. Type of registration No. of places registered (if applicable) www.bupa.co.uk BUPA Care Homes (CFC Homes) Ltd New manager in post 18/4/09 – application to register will be required. Care Home 59 Category(ies) of Dementia (22), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (1), Old age, not falling within any other category (59) Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate 1 named female service user in category MD(E) The Commission is to be informed if the named service user leaves the home permanently for any reason and the registration will be amended removing this category (25/6/09 remains applicable) 2/7/09 Date of last inspection Brief Description of the Service: Premier Court is a purpose-built care home providing nursing and personal care with accommodation for 59 older people. Twenty two people with a diagnosis of dementia may be accommodated within the overall capacity of the home. It is owned and operated by BUPA Care Homes Limited and is situated on the outskirts of Bishops Stortford in a pleasant semi-rural setting. The home is on one floor and is built around a courtyard garden to which a number of bedrooms have direct access. However the building has recently been split into two areas to accommodate a unit for people with dementia. All rooms are for single occupancy and have en-suite toilets and wash hand basins. There is a large dining room and lounge for the main group of people living at Premier Court. The dementia care unit has a small lounge and dining room. The home also has a hairdressing salon, kitchen and laundry that, together with aids such as assisted bathing and toilet facilities, ramps and wide corridors, provide for the needs of older people. There are several small garden areas around the outside of the building, including a newly developed sensory garden and secure garden at the side of the unit for people with dementia. Parking is available at the front of the building. The home has a range of documents providing details of its terms and conditions including a service user’s guide and statement of purpose. The report on the last inspection by the Care Quality Commission (CQC)is also available. Weekly fees range from £982.25 for nursing and dementia care and £866.70 for residential care (correct on 25/06/09). Variable rates per room are charged to funding authorities. Personal toiletries, newspapers, hairdressing, optician, chiropody and dentistry are subject to additional charges. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The information in this report is based on a visit to Premier Court over 2 days. On the first day a second inspector carried out a period of observation designed to give insight into the experiences of people with dementia who are not so able to express this for themselves. During the second day a pharmacist inspector was present to review the medication systems. A new manager came into post on 18/4/09. Together with support from the senior BUPA managers she is addressing the management and care issues that have been identified for improvement. These are all subject to an action plan being monitored by the company. Therefore at this stage we are confident that the issues identified as a result of this inspection are being responded to by management and this is reflected in the rating we have given. To make sure we include a range of views in this inspection we made survey forms available to residents, their relatives and health and social care professionals, who have regular contact with the people living at Premier Court. We sent surveys to 15 residents, 15 relatives and 10 staff. We made 14 survey forms available to local General Practitioners (GPs), Community Nurses and other health & social care professionals who have contact with the people who live at Premier Court. We received replies from 5 residents, 2 relatives, 1 member of staff and 2 health care professionals. Although the number of responses was not representative the range of views was consistent. We have reviewed the information received about Premier Court between our visits. This includes the Annual Quality Assurance Assessment (AQAA). Each year managers of care services are required to send us their Annual Quality Assurance Assessment (AQAA). This document tells us how well outcomes for people using the service are being met. It also provides us with some numerical data. We have also reviewed the notifications we receive about accidents and incidents in the home. Last year we carried out an annual service review because our assessment was that Premier Court was providing a good service. However recent information indicates concerns that standards may have changed. A specialist pharmacist inspection took place on 27/5/09 to assess arrangements for the safe handling, storage, administration and recording of medicines following recent incidents reported to the Commission. We needed to take further action following that visit to make sure medicines are managed safely. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 6 What the service does well: Residents and their relatives expressed a good level of satisfaction with the service provided at Premier Court. Relatives told us, ‘Premier Court does well in all areas. It is a very comfortable home with very caring staff and is very much a home from home’. ‘There is always someone with time to talk to the residents’ and ‘I am very pleased with the care that my relative receives from all the staff. All requests from me are always dealt with immediately’. Two residents commenting on what it was like to live at Premier Court told us the ‘girls (staff) are very good’, the activities are good, ‘it is friendly’, it provides ‘company, friends and people to talk to’. People living in the home are positive about the activities and entertainment that is arranged for them. People tell us they enjoy their meals. People can be confident that staff are checked for their suitability to support vulnerable people and receive the training required to meet their needs and work safely. This includes training to support people with dementia. What has improved since the last inspection? What they could do better: People looking to use the dementia care service need to have access to information that tells them about the home’s approach to dementia care and the service they can expect. People living in the home need to be confident that staff are following the correct procedures for the safe use of equipment to prevent infections. People living in the home need to be confident that the risk assessments in place to keep them safe are being followed by staff and kept under review. People identified as loosing weight need to be confident that the nursing staff will carry out the planned intervention, they have assessed the person needs, such as weighing them more regularly. This is to make sure people receive the health care and support they need. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 7 People need to be confident that the nursing staff will use medical devices safely to protect them from infection. People need to be confident that their medicines will be stored at the correct temperature to keep it safe and that their medicines will be given within the timescales prescribed. This is so it will be effective and there is no risk of overdose. People need to be confident that staff have clear guidelines about when to give medicines prescribed as “when required” and record the reason for their use. This is to protect people from harm and ensure medication is given appropriately. People living in the home need to be confident that details of the risks associated with the use of prescribed medical gases are recorded so they can be managed safely. The management and organisation of the dementia care unit needs to be reviewed so people’s individual wellbeing is promoted through a person centred approach to their lives that recognises their individual needs. Assessments of people’s capacity to make decisions for themselves and any restrictions on their freedom needs to clearly recorded. This is to protect the rights of people living in the home and to make sure decisions are being made in their best interests. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1, 2, 3 (standard 6 does not apply to this service) People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People looking to move into Premier Court will be involved in an assessment of their nursing and care needs to make sure that it is a suitable place for them to live and staff will be able to support them. EVIDENCE: BUPA have a mystery shopper system where callers telephone the home to make sure people making enquiries about the service are given the correct information. The information about the services does not currently reflect the details of the dementia care service offered. Details need to be available so that people looking to use this part of the service know what to expect and what type of Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 10 approach is taken to supporting people who have dementia. The manager is aware of this and reviewing the dementia care service so we do not need to take any further action at this stage. We looked at the experience of someone who had recently come to stay at Premier Court. They had been assessed before coming to stay. Information had been received from other specialist health professionals who knew the person concerned. This had led to a care plan being put in place describing their care needs and how they wish to be supported. A relative had been involved in providing information about their personal preferences. They had received a contract describing their terms and conditions and fee arrangements. People moving into Premier Court are able to add personal possessions to their rooms to make them feel more familiar. We checked the conditions detailed on the current registration certificate and confirmed they were still applicable. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have individual plans of care but cannot in all cases be confident they are up to date or reflect their individual needs. People have access to a range of community health care professionals to support their health needs but action by staff to address changes such as weight loss are not always followed up. People can be confident that the regular audits carried out on the medication systems, to make sure people receive their prescribed medicines, have been effective. However further work is needed to make sure there are suitable gaps between medicine rounds so people are not given doses too close together. People living in the home need staff to act for them where they are unable to maintain their dignity, by having suitable clothing or choosing to have their bedroom doors closed. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 12 EVIDENCE: The people we met in their rooms and those spending time in bed had all received good attention to their personal care and hygiene. People had access to drinks and their call bells. Where bedrails were in use there were detailed risk assessments in their care plans. Charts are in place for staff to record levels of fluid and food intake so that people who are not able to make choices for themselves are closely monitored. A specialist tissue viability nurse has been monitoring the management of pressure sores within the home and providing the nursing staff with support. There was evidence that wounds are healing from the detailed records of the nursing care provided. We looked at the care of diabetic residents and identified that staff were not following the company procedures to prevent the spread of infection from contaminated equipment. This was brought to the attention of the manager who removed the equipment from use and has confirmed the action taken to make staff aware of their responsibilities and the correct equipment for single patient use is in place. This meant we did not need to make an immediate requirement. Following an earlier incident, notified to us, we looked at risk assessments for people with swallowing difficulties. We found that the assessment which required the person concerned to have a soft diet did not match what they were having to eat or the level of supervision being provided by staff. The manager has taken action to minimise further risk until the residents current care needs have been assessed by a speech and language therapist. Speech and language therapist are able to check people’s swallowing reflex and provide guidance on the consistency of food to be offered. Because we could see that action had been taken we did not need to make an immediate requirement. People have very detailed care plans but these are not always kept up to date. Monthly reviews on the dementia care unit had not taken place according to company policy and several people identified from the nutritional assessments as losing weight, had not been weighed more regularly as detailed in their plan of care. For example one person identified as needing to be weighed every week had not had this done since April despite continuing to loose weight. We spent time observing staff interaction with people living on the dementia care unit. The contact we observed from care and activity staff was positive. Staff knew the residents and were able to add information about their lives into the conversation. There was relaxed easy communication with kindliness, warmth and lots of smiles. Visitors were included in conversations and interaction with the people present. However staff did raise concerns the Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 13 regarding levels of staff available to help them support residents who have times when they need one to one support and the role of the registered nurses in providing direction and guidance. On 27th May 2009 a pharmacist inspector visited the home to assess arrangements for the safe handling, storage, administration and recording of medicines following incidents reported to the Commission. Findings of that inspection resulted in requirements being made for accurate and complete medication records to be kept, for improved security of medicines and for controlled drugs to be stored in line with Regulations. At this inspection we also looked at medication storage and records. The requirements made at the inspection in May have been met. Medication is stored securely for the protection of residents but it is of concern that the temperature of the medication storage room has been recorded at or above the recommended maximum of 25 C several times during the previous month. The failure to store medicines at the correct temperature could result in people receiving medicines which are ineffective. This poor temperature control has been noted by the manager who is taking steps to ensure the temperature is better controlled and an air-cooling unit has been ordered. A requirement has therefore not been made on this occasion as we expect this to be managed by the home. We looked at the records made when medicines are received into the home, when they are given to people and when they are disposed of. In general these were in good order providing an audit trail of medicines in use. This demonstrates that people receive the medicines prescribed for them. Some people are prescribed medicines on a “when required” basis but there are no guidelines for staff on the circumstances these are used and when they are given there is no recorded justification for their use. Some people are prescribed a medical gas to help with their breathing but care plans do not contain details of its use or documented assessments of the risks involved to both themselves and other residents of the home. We watched medication being given to some people during the morning and this was done with due regard to people’s privacy and personal choice. The morning medication was not finished until 10:55am. This could result in people receiving doses of medicines too close to those needed at lunchtime. Although the manager was aware of this and taking steps to ensure there is a suitable time between medicines rounds we expect further improvements in this area to protect residents. A health professional who completed a survey told us ‘Things have begun to improve greatly under the new manager’ and ‘she is making it a priority to sort out the medication issues’. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 14 On arrival in the home and during the day we observed people in their rooms and beds where clothing and covers had become dislodged. Staff did not address this as they passed and leaving doors open appears to have become common practice. Staff did say that some residents in this position chose to have their doors open. However we also saw people who would not be able to make this choice for themselves left in a position where their dignity was reduced. The approach to these issues needs to be reviewed, for example looking at more suitable clothing during the day for people in this position. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who are able to make choices for themselves are offered the opportunity to take part in a range of activities and events that they are involved in planning, but can also decide how they spend their own time. However the support needed for people who have dementia or are very frail and spend their day in bed, may not be reflected in their care plans or resources available to them. People are able to maintain contact with their families and friends because there is a welcoming atmosphere. People are able to choose their meals from a varied menu so that they will have something they enjoy that will meet their dietary needs. However the meal time arrangements for people with dementia need to be reviewed to make this a more positive experience. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 16 EVIDENCE: Residents and relatives were positive about the range of entertainment and activities organised by the 2 activity organisers. Pictures of events are displayed. A resident commented on enjoying the recent theatrical production by ‘Tickled Pink’. Residents told us they are encouraged to join in but their personal choices are respected. We were told about themed events to celebrate specific days, trips out to garden centres and shops in a mini bus, afternoon tea using the new garden furniture in the courtyard and quizzes. A new resident told us they had enjoyed a painting session, which was a new experience for them. People are supported to keep control over their lives. One person told us about the support they get from staff so they can carry on with household tasks within their room and the shopping staff do so they can have their favourite toileteries and snacks. BUPA’s Personal Care Planning programme includes specific questions on resident choice. The activity organisers keep a record of their contact with residents, which is reviewed by the nurse in charge so they can add information to the daily records kept about each person. However we found from the care plans we reviewed for people who have dementia little use was made of this information to describe how people’s social life and level of occupation was effecting their sense of well-being. For example one person gets comfort from the soft toys around them but this is not mentioned in their plan of care. The daily notes for another person listed bowel care, positioning and personal care with very limited reference to comfort, how they were spending their time or what staff were doing to maintain their life skills. For another person the nursing staff had recorded as part of their monthly review that the individual ‘remains unable to participate in any of the activities of home due to their physical condition’. No reference was made to other areas of stimulation or comfort that could be provided. People are confident that they are able to keep in touch with their families and friends. Their involvement regarding key decisions is recorded as part of each individual’s plan of care where applicable. Visitors confirmed they were made to feel welcome and staff offered then drinks. A notice board keeps people informed about events and celebrations. People are offered a choice of freshly cooked meals that are prepared to meet their dietary needs. Residents are able to choose where they have their meals. We spoke with a group of residents who have their breakfast in the dining room while others are served in their rooms. One person said they had a small appetite and staff served them small portions, which they liked. Another person said they needed their meat cut up but sometimes had to remind staff. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 17 Staff were available to support residents who need help to eat their meal. On the day we visited some residents were enjoying a Pimms or sherry before their lunch. BUPA operate a ‘Nite Bites’ menu system which means staff are able to offer a variety of hot and cold food options throughout the night. Our observation of the lunch time arrangements on the unit supporting people with dementia indicates, this is an area that needs to be reviewed. The manager reported that she has been in contact with a BUPA catering manager to look at what can be done. Further reference has been made to this in the environment section of this report. Consideration needs to be given to how; meals are served, staffing resources to enable people to eat their meal within a reasonable period of time, consideration of pictorial menus and provision of specialist aids to feeding to maintain independence. We observed that one lady was left entirely alone to sleep throughout lunch, she was not given food at the time it was served to others and did not ask for it. Staff lacked the capacity to respond to each individual. They had to just respond to people who were noisier or more demanding. This means quieter people got left out. One option would be to allocate a member of staff to each table. The last person was served their lunch at 1.55 pm and people were being assisted for over an hour with their meals, which would mean the food had cooled down. Snacks and drinks were available for people to pick up during the day. A recent environmental health food hygiene inspection (11/3/09) has rated Premier Court as a 4 star service. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People feel they are able to express their concerns and are confident that the new manager will address them. People living in the home, their relatives and staff can be confident that the new manager is introducing a positive culture into the home. This will enable people to speak out if they have any concerns about the protection of vulnerable people and the care they are receiving. EVIDENCE: BUPA are in the process of introducing a new complaint procedure which includes forms for recording verbal complaints as well as formal complaints. From the information made available to us we have found that the manager is not receiving an undue number of complaints. Records of the action taken and response to the person concerned are recorded. The open door approach of the current manager has been welcomed by visitors and staff. A resident told us the manager was out and about in the home so knows what is going on and she visited them in their room every few days. A relative said ‘she is not just a name behind a door’. The manager’s self assessment states 8 complaints were received in the 12 months covered by the report and all were upheld. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 19 Three sources identified to us concerns regarding care practices at night which may mean people are not getting the skin care they need. The manager had been made aware of this and told us she is due to carry out unannounced night visits. It is clear from talking to relatives and staff that practices within the home related to management and staffing were not addressed. People did not speak out but are now very relieved to see the changes that are taking place. It is of concern that staff told us about omissions in care but did not speak out as they felt nothing would be done under the previous management. The information we have about investigations and reviews that have taken place under the Hertfordshire Safeguarding Adult procedure indicate that the new manager has worked with the outside agencies involved, in a positive way. Three of the investigations were instigated following notifications from the manager herself. Investigations into medication errors have concluded the necessary safeguards are now in place. Appropriate action was taken by a care agency following an incident reported by a resident, involving an agency care worker. The worker is no longer working in the home. The manager is aware of the need to obtain an updated copy of the Hertfordshire Safeguarding Adult procedure so staff have clear guidance to follow. We advise managers to attend training organised by the local authority, as well as company training programmes, so they are aware of what is expected of them. There are places within each person’s plan of care to record their capacity to make decisions for themselves and the involvement of relatives, advocates and appointees where this is the case. However there are no references to people’s freedom of movement, where they are living within a locked unit. This needs to be addressed. Also as referred to in the section covering medication the records of people being given medicines to manage their behaviour must clearly set out the rationale for use and why it has been given, to protect people’s rights. Training, understanding and recording of capacity needs developing within the service so staff are confident in this area. We have advised the manager to attend training being made available by Hertfordshire County Council on the Mental Capacity Act. It was reported that some staff had attended Mental Capacity Act training but the certificates confirming this were not available. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are living in a home that is designed to support older people and enables then to add their own personal possessions so their surroundings are familiar to them. However the manager has identified the need to review the organisation of the facilities, available to people with dementia, to support good dementia care practices that builds on people’s individual strengths. People need to be confident that all areas of the home will be kept free from odours. EVIDENCE: The main areas of Premier Court provide people with a comfortable environment to live in. The dining room and main lounge are spacious and assisted bathing and toilet facilities are provided around the home. People are Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 21 able to add their own belongings to their rooms to make them feel like their own. Since our last key inspection Premier Court has been registered to admit people with a diagnosis of dementia. The company took the decision to separate part of the home into a specialist area for people with dementia by making one corridor, of the square footprint of the home, into a closed unit with its own lounge, dining room and garden access. Access to and from the unit is by key pad entry. The current dining room is too small to accommodate the number of people with wheelchairs, specialist seating and mobility aids. This meant people could not move freely about. One person got their zimmer frame caught up with the flex of the hot trolley and an accident was averted by staff. The manager has identified the need to look at how the unit is functioning so it creates a positive environment for the people who live there. Bedrooms directly off a straight corridor with a dining room or lounge at either end don’t give people opportunities to recognise what the different areas are for or to walk towards points of interest. As described in other areas of this report previous management arrangements do not appear to have addressed issues within the service. There has been considerable wear and tear in some areas, with stained carpets and damaged walls.The manager reports that approval has been given for redecoration, refurbishment and replacement of flooring in 11 bedrooms, corridors, day areas and 4 bathrooms. It is anticipated work will be completed within the next 3 months. The central courtyard garden and gardens around the side of the building are well maintained. Seating areas and shade are provided. Residents are able to watch squirrels, birds and ducks from the windows. Overall the cleaning in the main part of the home was good and there was a fresh atmosphere. This was in contrast to the odours on the dementia care unit. Additional domestic staff were working in this area on the second day of our visit and things had improved. As detailed above the planned refurbishment should address odour problems where these have become ingrained. There is a large industrial scale laundry that caters for the needs of people living within the home. Staff are provided with the personal protective equipment they need to carry out their jobs and promote good infection control practices and hand hygiene. The manager reported an action plan was in place to address any outbreaks of infection. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that they will be supported by staff who have been checked to make sure they are suitable to work with vulnerable people. People can be confident that checks are carried out on the registered nurses to make sure their registration to practice, is up to date. EVIDENCE: Staff tell us that the staffing levels have been increased and unexpected gaps in shifts are now being covered where this was not previously happening. This was described by a member of staff as ‘working short’. Relatives told us that previously the staffing levels and atmosphere at the weekends and bank holidays were different and more staff were needed. The manager reported plans to increase management cover at the weekends to monitor the service. The new manager has been actively recruiting new staff and told us they now have a full compliment of care staff but still need to recruit 2 more nurses. A relative commented that there is now a better ratio of male and female staff that provides more choice for male residents who would prefer to receive their care from a male carer. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 23 The managers self assessment tells us that staff complete the Skills for care induction. Approximately 50 of care staff have NVQ qualifications at level 2 in care. which meets the target set by these standards. On the day we visited new staff were shadowing experienced staff as part of their introduction to the home. We looked at the recruitment records of 4 staff. We were able to confirm that the checks on their integrity, employment history, health status and criminal records history had all been completed before they started work. This is to make sure only suitable people are employed. The manager has checked the personal identity numbers of the registered nurses to make sure they are registered to practice, with the nursing and midwifery council (NMC). The manager told us that she has requested a full audit of the personnel record by BUPA’s human resources department to make sure everything is in order. The manager is currently reviewing the training programme and booking courses and updates for staff to make sure they have the skills needed according to their jobs within the home. This includes moving and handling training. Each member of staff has their own training and development portfolio. Staff who work with people who have dementia have been on training courses. BUPA have recently developed further clinical training opportunities for the registered nurses to make sure they keep up to date. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be reassured that BUPA are supporting the new manager and providing resources to improve the quality of the service provided at Premier Court. People can be confident that any money they deposit for safekeeping will be managed according to company procedures and that regular checks on balances are carried out. People can be confident that there are good systems in place to make sure the safety of people living and working in the home is supported. EVIDENCE: Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 25 It is clear that there has been a failure of management in this service that is now being addressed by BUPA under a new manager. A relative told us ‘I have noticed a huge improvement. She is genuine and kind and got to know my relative in that short time where as the other manager before her did not know much about her needs or seem to care. Staff appear happier and more efficient’. The Relatives and health professionals we spoke to and who completed surveys confirm that the new manager is making a difference and improving standards. Residents, relatives and staff are positive about the support they are receiving from her. People told us that the new manager is out and about in the home, knows what is going on and has an ‘open door where this was previously shut’. A relative told us the new manager was ‘like a breath of fresh air’. BUPA will need to forward an application to us (CQC) to register the manager under the Care Standards Act. We extended the timescale given for completion of the Annual Quality Assessment (AQAA) as the new manager had only just come into post. The AQAA and action plan seen by the pharmacy inspector on our visit on 27/5/09 confirmed that the manager is aware of what needs to be done to improve the service and provide stability. The manager reported that ‘BUPA has developed a national Quality and Compliance team which has links to local areas and can be accessed to provide additional expertise and advice’. Plans for improvement include the completion of a ‘Diagnostic Review to monitor improvements made and provide advice on future improvements’. Annual customer satisfaction surveys are used to gather the views of people using the service and feedback is given in an annual report. As the new manager is aware there have been concerns she has recently sent out her own surveys and received a good response. BUPA are monitoring the quality of the service closely through their quality and compliance reporting systems, which identify the level of risk according to scores given for each area reviewed. Recent reviews include medicines and wound care. The area manager is providing us with regular updates of the company action plan to keep us informed of the progress being made. People are able to deposit personal money with the administrator so they can have access to it. There are clear systems in place to track all transactions. BUPA auditors carry out financial checks. Independent financial advice is available to residents who need help in this area. The manager reported she is taking steps to reinstate the company supervision procedures so staff receive the monitoring and support they need. There are clear well organised systems in place to make sure health and safety systems within the home are monitored and equipment is regularly checked and serviced. Staff receive training in safe working practices as part of Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 26 their induction and regular updates. The BUPA care records include a section on bedroom safety that covers the use of specialist equipment such as recliner chairs and electrically adjustable beds. The manager is aware that not all of these are up to date and the risk assessments need to be reviewed. Accidents and incidents are recorded and monitored. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 17 Requirement The registered provider must make sure that the registered nurses provide the care people need according to the assessments and evaluations they have carried out (Nursing and Midwifery Council Code of Conduct (1/5/08). In this instance assessments to weigh people more frequently had not been followed up and a risk assessment to minimise the risk of choking did not reflect the care being provided. This is to make sure people receive the care they need to maintain their health and protect them. When people are prescribed medication on a “when required” basis there must be clear guidelines for their use and the reason they are used must be recorded. This will protect people from harm and ensure medication is not given inappropriately. Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 29 Timescale for action 31/08/09 2. OP9 15 13(2) 31/08/09 3. OP9 13(4) Where medical gases are stored and used, the risks posed to people must be assessed, managed and documented. This will protect people from harm. The reason individual people are living within a locked area of the home needs to be recorded together with an assessment of their capacity to agree to this decision and any safeguards that need to be in place. This is so people have their rights protected and all action taken can be shown to be in their in their best interest. 31/08/09 4. OP18 13(7)(8) 30/09/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Premier Court Nursing & Residential Home DS0000019499.V376105.R01.S.doc Version 5.2 Page 30 Care Quality Commission Eastern Region Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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