Inspection on 24/02/09 for Priory Manor [formerly Trebursye Manor]

This inspection was carried out on 24th February 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 21 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Priory Manor [formerly Trebursye... 02/04/08

Priory Manor [formerly Trebursye... 25/07/07

Priory Manor [formerly Trebursye... 10/01/07

Priory Manor [formerly Trebursye... 04/07/06

Priory Manor [formerly Trebursye... 01/12/05

Priory Manor [formerly Trebursye... 27/06/05

Priory Manor [formerly Trebursye... 12/10/04

Priory Manor [formerly Trebursye... 07/06/04

Priory Manor [formerly Trebursye... 01/10/03

Priory Manor [formerly Trebursye... 26/06/03

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Priory Manor [formerly Trebursye Manor] Trebursye Launceston Cornwall PL15 7ES     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: Helen Tworkowski     Date: 2 5 0 2 2 0 0 9 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. that people have said are important to them: They reflect the things 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 41 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 41 Information about the care home Name of care home: Address: Priory Manor [formerly Trebursye Manor] Trebursye Launceston Cornwall PL15 7ES 01566774752 01566775559 yvonne.osborne@amhc.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : HealthCare Trust Limited care home 54 Number of places (if applicable): Under 65 Over 65 29 29 29 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: 0 0 0 Service users in the category of MD may be admitted at age 55 years and over. Service users to include one named individual under the age of 65 years in Lakeside. Service users to include three named individuals under the age of 55 years in Lansye. Total number of service users not to exceed a maximum of 54 Date of last inspection Brief description of the care home Priory Manor is a care home registered to provide personal care and accommodation for up to fifty-four people, over the age of 55, who may have dementia or mental health needs. Occasionally the home also accommodates some younger people with mental health needs. The home does not provide intermediate care. The Registered Provider for this home HealthCare Trust Ltd. The fee levels are available from Healthcare Trust Ltd. Information about the home and copies of inspection reports can Care Homes for Older People Page 4 of 41 Brief description of the care home be obtained from the home. Priory Manor is in a rural location, approximately two miles from the centre of Launceston. It consists of a large detached three-storey building, with a connecting two-storey annex, which is currently derelict pending renovation. At the time of inspection there were 27 single bedrooms, one double room and a small flat available for residents. These are situated on the ground, first and second floor of the house. Many of the bedrooms have en suite toilets with some having en suite baths/showers. Bathing/showering and toilet facilities are available on each floor, close to bedrooms and communal rooms. There is a shaft lift house connecting the ground, first and second floors. There is a large lounge and a dining room on the ground floor and a further lounge on the first floor. Smoking is not permitted within the home but a covered outside shelter is provided at the rear of the building. The home stands in its own grounds and is approached by a long drive off a side road from the main A30. The only public transport is taxis; therefore the home has its own car for service users. Care Homes for Older People Page 5 of 41 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 peterchart Environment Staffing Management and administration Poor Adequate Good Excellent How we did our inspection: This inspection included an unannounced site visit on the 24th and 25th February 09. The site inspection was carried out by John McEachern (Regulation Manager), Brian Brown (Pharmacist Inspector) and Helen Tworkowski (Regulatory Inspector) on the 24th February. Jane Gurnell (Regulatory Inspector) and Helen Tworkowski (Regulatory Inspector) carried out the inspection on the second day. Through out this report the term we is used, this is because the inspection was carried out on behalf of the Commission. There is currently no Registered Manager or Responsible Individual for Priory Manor. The term Acting Manager is used to refer to an individual who we were informed was going to take over the Management of the home in April 09. We were told that Mr Patel will be the Manager until that point. Mr Patel and the Acting Manager were present in the home throughout the two days of this inspection. Care Homes for Older People Page 6 of 41 Over the two days of the inspection we looked around the building, and saw all rooms, apart from those who that were occupied. We looked at the plans of care for six people and how their care was provided. We also looked at how people were kept safe. We talked with some of the people who live at Priory Manor. We also spoke with six of the staff. We looked at the systems in place for recruiting staff, and at the induction and training records. We sat and observed a meal and spoke with the cook about the meals in the home. The medication system was examined, and we looked at other systems for keeping the home safe. We sent surveys to all of the 20 of the people who live at Priory Maor and to15 of the staff. In addition we sent surveys to care professionals (Health and Social Care) who have had contact with the home, we also spoke to a District Nurse by telephone. What the care home does well: What has improved since the last inspection? What they could do better: There needs to be consistent leadership and managment to improve this service. The service fails to meet all of the needs of the vulnerable people it accommodates. Over the previous 18 months there have been 6 different managers. During this period serious concerns have been raised regarding the safety and well being of people who live at the home. During this 18 month period there appears to have been short periods of improvement when a new manager has been appointed however these improvements have not been maintained. We found that the information that the home provides in documents such as the Statement of Purpose and Service User Guide does not accurately reflect the service provided. Also, information on the homes website and information provided to us in the form of the Annual Quality Assurance Assessment (AQAA) did not reflect the service provided. The current group of service users have complex and sometimes conflicting needs, and given the size and nature of the building, the low levels of staffing, poor recruitment and the lack of any coherent management, it is difficult to see how people can be kept safe. Over the last few months incidents have occurred where people at Priory Manor have been harmed. Information in Care Plans lacked sufficient detail to ensures that peoples needs are met. Managers and staff are not always aware of peoples historys, of their care needs and of any risks. Visiting care professionals have told us that they given this information repeatedly to the home, to find at the next visit that it has been lost. We found that staffing levels in the home were insufficient to meet the needs of people who use the service. There was evidence that people were at risk and we were concerned that the social, educational and leisure needs were not being met. There was no evidence of any rehabilitative work or work to promote or maintain independence. The recruitment, selection and vetting of staff needs to be improved. All staff must be provided with induction training. Staff were receiving basic training whilst the inspection was being carried out, however this was a a very basic level. An Immediate Requirement was left at the end of the site visiting, requiring an immediate improvement in staffing levels as these were too low to keep people safe. We found that medicines were not stored securely in the the medicine room keys were seen not to be secure and one of the cupboards was not fitted in accordance with the current regulations. We found that people could not be confident that they would receive their medicines as prescribed, that the actual dose given was not always Care Homes for Older People Page 8 of 41 recorded and that when required medicines were recorded as administered although there was no guidance available to staff on how to administer these. 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.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 41 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 41 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. Information about the services and facilities provided at the home is misleading. The home does not have the capacity to meet the needs of people currently accommodated. Evidence: As part of our site visit we asked for a copy of the Service User Guide and Statement of Purpose, these two documents provide people who are thinking about moving to the home and other professionals with information about the service. Priory Manor has a combined document containing both the Statement of Propose and Service User Guide. This document does not contain all the information that is required by the regulations. We found that the document, which had been reviewed in December 2008, was misleading. The document said that the home provides slow stream rehabilitation through to long term care. We were unable to evidence that any rehabilitation was being provided. Care Homes for Older People Page 11 of 41 Evidence: The document also states, The integrated activities program is delivered by both activities coordinator and support staff which means it can be flexible and responsive to an individuals abilities. We saw staff playing board games with people, but could not evidence and integrated activities program. When we looked at peoples Care Plans, we saw no evidence of an integrated activity program. We also noted that the document states that one of Priory Manors objectives is To ensure freedom from fear and anxiety, providing a caring environment where risk to the individual has been reduced to the minimum. We found that this was not the case, risks to individuals were not being properly managed and people have been harmed in recent months because of this. We looked at the website for this home. We found that the information included a statement that, The therapeutic rehabilitation program is founded in a broad conceptual approach which includes: restoration and maintain current skills, self care with an aim for independent living, socialization and community integrated (if applicable), development of new age appropriate skills, prevention of relapses, recreation and access to education courses. We found the home lacks the facilities and services to make such a statement a reality. One visiting health care professional commented in a survey, Due to the diversity of individual clients needs within the home, it is questionable as to whether these can be met within the same setting. We found that the core documents and information maintained by the home did not accurately reflect the facilities, services and care arrangements. The comments of some staff, and health and social care professionals evidence that their experience of the service is different to that which is said to be provided. This was of particular concern as we found that people were not protected from potential risk of harm. Prior to this inspection visit we asked for information regarding who was funding the contracts of care for people at Priory Manor. We were told that this was not known for 15 of the 20 people. Homes are required to keep a record of who has made arrangements for admission, and of any contractual arrangements. We were told that no new people have been admitted to Priory Manor since the last inspection. We therefore were unable to inspect this area of the service. Care Homes for Older People Page 12 of 41 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. Care Plans do not detail the needs of the individuals who live at Priory Manor. The people who live at Priory Manor are at risk of being harmed or of harming others because their needs are not met or they are not kept safe. Some aspects of the managment of medication are unsafe. Evidence: As part of this visit we looked at the Care Plans for six people who live at Priory Manor. We found that these documents noted the needs of people, though some of the information was written in a general rather than a specific way.This means that Care Plans do not always direct and inform staff. Many of the documents that form part of the Care Plan were neither signed nor dated so that it was unclear who had written them or if they were current documents. Further to this we noted that there were no signatures or Service Users or their representatives. It was therefore unclear if they had been actually involved in the care planning process and whether their consent had been sought. We found that some Care Plan documents were duplicated or incomplete so it was difficult to know which was the current document. Some of the care plans Care Homes for Older People Page 13 of 41 Evidence: noted that people were at risk, for example because they might harm themselves or others. However, other did not contain sufficient information about risk or risk assessment. We found that relapse or crisis plans were incomplete or contained insufficient details to be of help to staff. When we looked at actually what happened in practice there were discrepancies. We asked three staff if they had read the Care Plans. These staff had worked at the home for a few months. All three people told us that they had not fully read the Care Plans. Reasons given for not reading the plans included lack of time. One person thought it best not to, during his/her probationary period. We were not confident that these staff would be able to assist people in a manner that was informed by the Care Plans. When we looked at Care Plans and care arrangements we found that these peoples needs were not always being met and they were not always being kept safe. For example we found that one individual had needs that would indicate that he/she should be provided with support to manage his/her diet. However when we observed a meal we found that no such support or guidance was offered. We looked at the accommodation that was provided for this person, but we found that it did not reflect the needs described in the care plan or the identified risks. A further example was in relation to diabetes. There was no guidance for staff on how this condition is to be managed. We asked care staff about the use of pressure relieving equipment used by one person. They were unable to give an explanation about how this equipment relates to assessed needs. We were given feedback by some of the Health and Social Care professionals. One person commented in relation to meeting individual needs, that this never happened. The person told us that Documentation remains of great concern. This has been reviewed and changed by various managers or by the company. However there is now documentation missing with was supplied by the CMHT (Community Mental Health Team), this is care reviews and risk assessments. These were in the clients files on previous reviews, but latterly have become lost. The last manager to leave was horrified to learn of some of the clients previous history as this was not available in any documentation and due to the changes in care staff there was limited knowledge, and Subsequently 3 care reviews and risk assessments were hand delivered by myself, which on review on 11/2/09 were again found to be lost. Information in the Annual Quality Assurance Assessment, (AQAA), stated that one of the things that is done well at Priory Manor is that We implement service user focused comprehensive individual Care Plans, including management and risk assessment with emphasis to positive planned interventions. We found this statement to be Care Homes for Older People Page 14 of 41 Evidence: inconsistent with the comments to other health and social care professionals and from the evidence in the Care Plan records. One care professional told us that when he/she had visited the home to review the needs of an individual, a member of the staff who he/she believed knew the person best was not allowed to attend the meeting. We were told that a senior member of staff attended, but he/she had little if any knowledge of the individual and therefore was unable to contribute to the review. The person also told us about a situation that compromised the safety of a person who uses the service. We were told that the person had been assaulted, but had been observed to have been left alone unsupervised, with the person had perpetrated the assault. We were told by staff that checks had to be made in relation to three individuals to ensure their safety and that of other people. These checks were to be made ever 5 minutes, 15 minutes and 30 minutes. However, we believe that this placed an unreasonable burden on an already stretched staff team. We spoke with a District Nurse about a recent contact with the care home and who expressed a lack of confidence in the homes staff in being able to meet the needs of some of the people. The Nurse gave an example where staff from Priory Manor had requested a visit but they had failed to ensure that they had the correct equipment, she was therefore unable to carry out the procedure. She felt that staff did not know what was going on. On the first day of the inspection we were told that the person rostered to cook had taken an individual for a routine X-ray, as no one else could drive or be available. During the visit we noted that staff spoke with consideration to the people who live at Priory Manor. Staff, in spite of being extremely busy, took the time to speak to people whenever possible. We also observed that staff managed episodes of conflict well. We found that whilst the home had secure storage for medicines that one of the cupboards was not fitted in accordance with the regulations. The key to the medicines cupboards were not always kept secure and that items other than medicines are stored in the medicines cupboards. This reduces the security of medicines and increases the risk of medicines going missing and not being available for people to take as prescribed. We found that the home uses printed Medication Administration Record (MAR) charts which give the administration times as M,N,T and B. When we asked a member of staff they were able to tell us that these related to M - 07:30, N - 12:00, T - 17:00 and B - 22:00, however there is no documentation within the medicines policy to support this. Care Homes for Older People Page 15 of 41 Evidence: We found that some people are prescribed to have medicines administered either weekly or fortnightly by a visiting healthcare professional. However there were no records in the home when they had last had these medicines administered or when the next administration was due to take place. This means that the people could not be confident that they would have their medicines administered as prescribed. We also found that when medicines were prescribed to be administered with a variable dose that although a record was made that something had been administered the actual dose administered had not been recorded. This means that the staff would not be able to feedback to the prescriber the individuals response to the medicine and this may compromise their care. We also found that the dose administered for some people had been changed from that on the label but we could find no supporting evidence in the persons notes for this. For people prescribed medicines to be taken when required we could find no evidence to say how the decision to administer was to be made, or when the medicine had been given how the decision had been made. This means that people cannot be confident that they will have their medicines administered to meet their needs. When we spoke to a member of staff administering medicines he told us that he had been at the home for a short period and had previously worked at another home for a month. He had had no assessment of his competence to administer medicines at the home, and the training records did not show that he had received any medication training. Care Homes for Older People Page 16 of 41 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Priory Manor do not have the opportunity to take part in meaningful activities or to develop or maintain any skills. People do not have the opportunity to participate or be present in the local community. Peoples ability to make choices and freedoms are restricted, without any recourse to the Mental Capacity Act. People generally enjoy the food at Priory Manor however the dining room is poorly furnished and people lack appropriate support to manage their diets. Evidence: On the second day on the inspection we talked to one of the people who lives at Priory Manor about how they spent their time. We were told that the individual enjoys gardening and attends a horticultural course, however on that day he was unable to attend as there was no one to take him. The individual explained that he would be able to go if a taxi was arranged, however this did not happen, and this was a disappointment. We saw staff trying to make time to play board games with people. However, given the level of staffing and the needs of the individuals it was difficult to see how any level of meaningful activity could be carried out. The Acting Manager told us in the Care Homes for Older People Page 17 of 41 Evidence: Annual Quality Assurance Assessment (information supplied to the Commission) that one of the things that they do well is All our activities are designed to create a fulfilling and stimulating environment to live in, whilst supporting life skills and enhancing feelings of worth, purpose and value. Popular activities include, cooking, bowling, trips and visits within the local region in the homes designated transport. During this inspection we saw no evidence to support this statement. One person helped staff to clear plates etc, but we saw no evidence of any support to develop or maintain life skills. The laundry is down a steep set of steps, and would be impossible to access for most of the people who live at Priory Manor. The main kitchen is also not accessible. One of the areas of concern identified in feedback from health and social care professionals was the lack of activities and opportunity to follow personal interests. We observed that the majority of people spent their time sitting in the lounge, dozing or watching TV. When we were shown around the home on the morning of the first day of inspection we were told that many of the individuals were asleep in bed, and that they spent a portion of their day asleep in their rooms. We observed that the main occupation for many of the people at Priory Manor was having a cigarette. At certain times residents queued to be given a lit cigarette and to go out to a smoking area. This area was not a pleasant place to sit. On being shown around Priory Manor we observed that there were a number of key pads in operation, this meant that no one was able to leave the building without staff first entering a code. For one person it also meant he was unable to go to his own bedroom without the assistance of staff. Whilst we are aware that there are concerns regarding the risks posed by some individual, when they moved around unsupervised it was of concern that these restrictions had not been properly agreed, risk assessed and documented in the care plans, as is required by the Mental Capacity Act. We were told that people were given keys and therefore had the opportunity to lock their bedroom doors, though not everyone chose to do this. Priory Manor is in a rural location a couple of miles from Launceston, the house is situated at the end of a long drive. There are no near neighbours and there is no public transport. When homes are in such locations it is the Commissions expectation that opportunities are developed so that the people can have the support they need to be present and participate in the local community. There was no evidence of this happening at Priory Manor. One the first day of the inspection we observed the main meal (lunchtime) in the dining room. We had seen on the menu that there was apparently a choice, however no record of who had chosen what could be found when we asked. The meal was Care Homes for Older People Page 18 of 41 Evidence: lasagna, with mash potatoes and peas. Individuals were served by staff, and at the end of the meal seconds were offered. We knew that some of the people at the home had health issues because of obesity and diabetes, however we saw that these individuals were given very large portions, and in one case then offered a further and equally large second helping. There appeared to be no consideration as to whether this was appropriate. The dining room is a large room, the carpet was dirty and stained, the tables worn. Tables were laid with a minimum of cutlery, there were no napkins or serviettes, some people clearly had difficulties keeping their clothes clean. We were told in surveys completed by the people at Priory Manor that they most people always or usually enjoyed their meals. There was a notice board in the dining room which should have provided people with information about the meal options, however this was not completed on either of the days we visited. There appears to be a lack of recognition of different needs relating to race, ethnicity, age, disability and gender. One health and social care professional commented that, ... there is a range of ages within the home, with no change in service delivery,..., thus some more physically fail vulnerable clients are in the same area as the younger clientel. Care Homes for Older People Page 19 of 41 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. The people who live a Priory Manor are not always protected from abuse and neglect. Evidence: There have been ongoing serious concerns regarding the safety and well being of the people who live at Priory Manor since early in 2008. These concerns have resulted in Safeguarding Meetingschaired by Social Services. Concerns raised at these meetings have not been resolved. We have has been advised that a number of the things that should have been done to make the home safe have not been completed. We were provided with information by the home that indicated that some of the people who lived at the home posed a risk to other people who live there. We found that the arrangements in place to protect people from harm were unsatisfactory and people were at risk. There were two incidents, one at the end of December 08 and one at the beginning of January 09, where individuals who lived at Priory Manor harmed other individuals in the home. It was of concern that only three care staff were available at this inspection to support twenty people in this large building. As previously stated we were told be a health and social care professional about a situation that compromised the safety of a person who uses the service. We were told that a person had been assaulted, but had since been observed to have been left alone unsupervised, with the person had perpetrated the assault. Care Homes for Older People Page 20 of 41 Evidence: We found that peoples freedoms were being curtailed, for example through the locking of external doors, without these measures being considered in relation to the Mental Capacity Act. It is important that people are not only protected from harm, but that this is done within a framework to ensure that it is both legal, and in their best interests. Information provided by the home as part of the AQAA stated that there is comprehensive in house training in relation to Mental Capacity Act issues. However when we discussed issues relating to the Deprivation of Liberty with the the Acting Manager, he appeared to have little understanding of how the Mental Capacity Act operated in practice and the implications. We were also told through the AQAA that, Breakaway training is offered as mandatory training, this training is used to help people avoid conflict situations and to get out of such situations with a minimum of harm. We were also provided with information about the training staff have received. This showed that none of the staff had received Breakaway training. Any form of restraint or restriction may be considered as a form of assault if not appropriately assessed. We were told that the home had received no complaints in the previous 12 months. Nine of the ten staff responding to a survey said that they knew what to do in relation to a concern. Eleven of the people who live at Priory Manor said that they knew how to make a complaint, whilst eight people said that they did not. We received concerns raised by an ex-manager and member of staff prior to this inspection. The concerns related to a range of issues including concerns about the building, concerns about the competence of staff, the lack of staffing and concerns about the high level of risk in the service. In looking at these issues we found that there are short falls in relation to these areas, although not necessarily as specifically raised by the complainants. Care Homes for Older People Page 21 of 41 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. Priory Manor generally provides a good standard of accommodation however it is not suited to the needs of the group of people accommodated and this means that people are at risk. Evidence: Priory Manor is a large house that has been considerably extended in the past. Some of these additions are now semi derelict and are awaiting demolition or refurbishment. The house is in a rural area, at the end of a long drive. We talked with the Manager about a letter received by the Commission in 2007 about the phased redevelopment of the home. The original time scales have not been met and the Commission must be provided with information that clarifies these plans. We toured the building on the first day of this site visit, and looked in most of the rooms. We did not enter rooms that were occupied by residents or in use for training. The bedrooms that are currently in use are on three floors. They have recently been renovated and generally provide a good standard of accommodation. The majority have an en-suite toilet and shower. There is a shaft lift between the ground, first and second floor. There is a shower room on the second floor, at the time of the visit this room was being used to store the cleaners trolley. There is a large bathroom on the Care Homes for Older People Page 22 of 41 Evidence: second floor. This room has a corner bath which we were told was not in use. The bath itself is not suitable for people who may have difficulties getting in and out of the bath. We asked what bathing facilities would be used by someone on the first floor, and was told that they would need to use the shower room on the floor below. Given the number of people accommodated and concerns about the complex needs of people living at the home, this bathing facility must be reviewed and improved. There is a large lounge area on the ground floor, this room is labeled as the mens lounge, though was in use by men and women. The lounge was adequately furnished but lacked items that would make it more homely.This room has a small kitchenette and is used by staff serving drinks. There is a second lounge on the first floor that was labeled as the ladies lounge, we did not see this room as it was being used for training. There is an outdoor smoking area, that is enclosed, and can only be entered and exited from the house. This area has some benches and large ashtrays and bins. The corridor to this area is dirty and unpleasant. The laundry area is in the basement, down a steep flight of stairs. We were told that this area is not used by the people who live in the home. There were washing and drying machines. Staff told us that they could use red bags for foul laundry, which should reduce the risk of infections. However whilst we were walking around the home we noticed a member of staff carrying soiled linen, whilst the staff was wearing gloves to protect herself from infection, this would not have protected anyone else or anything she touched. We found that most of the home was clean, however a few of the bedrooms smelt of urine. We were told that these bedrooms were not in use and were awaiting new carpets. The house is set in considerable grounds, however there is very limited out door seating, and given the lack of staffing and the need for supervision there appears to be little access to the garden. Some of the area around the house is derelict and unsightly. The kitchen area is not accessible to most of the people who live in the house. The flooring and cupboards were worn and damaged. Near the kitchen there is an area of the home that is no longer in use. We found that it was possible to gain access to this semi-derelict area from the outside. We also found that there were a few confidential documents lying in one of the rooms, and the processions of someone who had lived at the home. There is a small flat adjacent to this area, occupied by one person. We found that to get to the flat the individual needed to ask staff to allow him/her through a locked door. However, once in the flat the individual could, if they chose, gain access Care Homes for Older People Page 23 of 41 Evidence: to the kitchen and to the semi derelict part of the building. We found that there was no reference to these risks or restrictions in the persons care plan. We spoke to staff about how they contacted each other when on duty, and was told that there was a walky-talky system. However on the first day of our visit this was not in use. There was no call system in use in the home, for anyone to call for help. Given the size of the building over 4 floors, the potential risks and needs of people living in the home, and the low levels of staffing (3 care staff) we were concerned that staff and the people who live in the home could be unable to call for help when needed. We found that there were key code pads on some of the stair ways, though not all were in use. We asked staff about these but they did not know there purpose. One of the pads that was in use was on a stair case from the ground to the upper floors, however there was a lift next to this stair case that could easily be used. Concerns regarding the appropriateness of the building for the people accommodated has already been considered earlier in this report. Care Homes for Older People Page 24 of 41 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. There are insufficient staff to ensure that people are kept safe or have regular meaningful activities. There are some poor staff recruitment practices and there is no evidence of proper checks being made to ensure that suitable staff are employed. New staff are not always given the training or skills to carry out their work. Evidence: We given information in the AQAA about what the home does well in relation to recruitment. We were told that there are, Robust effective recruitment process adhering to all requirements and guidelines. Also that there is a, Strong established care staff group who have completed induction training and acknowledge codes of conduct. The evidence we gathered shows that this is not the case. On the first day of the inspection we found that there were three care staff on duty during the day (7am to 7pm). In addition to this there were senior staff, but from our discussions and observations they were not providing care to the people in the home. They had not attended the staff handover in the morning. We were told that over the previous weekend there had been three care staff on duty and no additional senior staff. We observed that in addition to caring for the residents the care staff duties included cleaning, doing all the laundry, washing and clearing the dishes from all meals, serving meals prepared by the cook, making teas and coffees, providing Care Homes for Older People Page 25 of 41 Evidence: activities, taking people to appointments outside the home, and in addition answering the door and dealing with phone calls when none of the administrative staff are around (weekends and evenings). As has already been noted earlier in this report, we were told that the three staff are also responsible for carrying out checks on the whereabouts and safety of three individuals who might be a risk to themselves or others. This involves checks every 5 minutes, 15 minutes and 30 minutes. These individuals may be in different parts of the house including their bedrooms. Staff told us that they currently work 12 hours shifts (7am to 7pm and 7pm to 7am), and therefore would mean they would be entitled to an hours break each during that 12 hour period. This means that for three of the twelve hours during the day there are in effect two staff on duty to carry out these tasks. Information provided by the home in the AQAA indicates that 19 of the 20 people need help with dressing/undressing and washing/bathing. The information also states that 10 of the 20 people need help going to the toilet. We were also told in the AQAA that one person needs two or more care staff to help them with their care by day and by night. We sent surveys to 15 of the staff, ten were returned. Six of the ten staff said that there were usually enough staff, however in comments about what the service could do better comments included that the number of staff needed to be improved, and that there needed to be an improvement in the activities for residents. It was evident that 3 care staff were unable to meet the needs of all people using the service. Because of the concerns we issued for the safety and well being of people at Priory Manor due tot he low levels of staffing we issued an immediate requirement notice, requiring an immediate improvement in staffing. We asked for a copy of the rota or off duty sheet and was shown a document that we were told was not accurate. Homes are required to keep a record of the hours staff work in the home, this is not only for planning but ensure that there is accountability for the service provided. We were told in the AQAA that one of the ways that home evidences the things it does well is through the staff off duty sheets. We looked at the recruitment files of three staff who had recently started work in the home. We found that there was no Criminal Records Bureau check or check of people who are proscribed from working in a care home for two of these individuals. We found that one person had two references on file, however these related to a different home, and different employer. Such documents are not transferable. The other individual had no references on file. We could find no contract of employment. We did find information that implied that two of the individuals were only to work limited hours Care Homes for Older People Page 26 of 41 Evidence: and to undergo training. We checked the number of hours these individuals were working, and it was double the number that was in the information. We asked to see evidence of training, as this was part of the agreement for the individuals to work. There was no evidence of any training being arranged in relation to this agreement, and the Manager could not provide any explanation for this situation. We asked one of the people, whose recruitment we looked at, if they had received an induction. They told us that they had not. We were subsequently sent information (training matrix) by the Manager showing that no induction had taken place for these people. We were then told in separate correspondence that an induction had taken place. Six of the staff responding to the survey said that their induction had mostly covered what they needed to know to do their job, three people said that it partly covered what they needed to know, and one person said not at all. One person commented I was given an induction pack and told to complete what I could and to ask for help if/when needed- at the time no training days were set up to help me to gain some of the information that I needed and although the (previous) manager said that I was welcome to come to him for help he was always too busy to set time aside for this. Another member of staff commented that They give me only the induction checklist nobody orientated me. Concerns were raised by the previous manager that some of the staff had difficulties with understanding English sufficiently well to be able to carry out their role. When we visited we found that a number of the staff did speak English as a second language, and although they spoke it very well, they had some difficulties initially understanding what we were saying. We were told by the previous Manager that he had concerns that whilst some of the staff appeared to understand what was being asked of them, in reality they did not understand, and were therefore unable to follow instructions. The previous Manager said that this had been confirmed by a senior Manager representing the Healthcare Trust Ltd, when he interviewed staff. During this inspection we were told that there was training being held in the home, and were shown a plan of the training day that staff were to attend. This showed that a number of topics were to be covered on a day. We discussed this with the Acting Manager, who explained that this training was initial training, and further training would be provided. We have been sent a training matrix showing that training has been provided in a number of areas. We would acknowledge the importance of giving all staff a basic knowledge of aspects of care however, it is essential to ensure that staff more than basic training. The information in the AQAA told us that 56 or 12 of the staff group of 22 have NVQ 2 or above in care. However when we compared this with the training matrix that we Care Homes for Older People Page 27 of 41 Evidence: had been sent, we found that fewer of the staff could be considered to have this qualification, or an equivalent qualification. We asked the Registered Provider, prior to this inspection, to provide us with information as to the details of staff who have worked in the home since April 2008, this includes staff who have left. We were provided with some of the information, however this was insufficient to make a judgment on staff turnover. Care Homes for Older People Page 28 of 41 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. People who use the service cannot have confidence that the service is well led or managed appropriately, resulting in a poor quality of service, where people have suffered harm. Evidence: There has been no Registered Manager, this is a person who has been confirmed as fit to run a care home by the Commission, for more than a year. When we arrived to start the inspection we were introduced to the person who we have described in this report as the Acting Manager, he said he was the Manager, and we confirmed that he was in overall day to day charge of the running of the home. However when his Manager, Mr Patel, arrived we were told that this was not the case, and in fact that Mr Patel was the Manager, and the Acting Manager would not take over the responsibility for the running of the home until April 2009. We asked one of the staff who had worked at the home for four years to tell us about Care Homes for Older People Page 29 of 41 Evidence: the previous managers at Priory Manor. He told us that the current Acting Manager had been there for a few weeks, the manager before that had worked for about 3 months, the one before that 5 months, the one before that about 4 months, the one before that 3 months and the one before that had been there 4 to 5 years. This confirmed the view expressed by visiting professionals that there have been frequent changes of manager, this has had a negative impact on the quality of service. Throughout this report there have been significant concerns which affect the health and welfare of the people who live at Priory Manor. It is evident that some of the care arrangements, services and facilities place people at risk. People who use the service cannot be confident that they will get the right care because there is not and has not been for 18 months, consistent managment and leadership. The Safeguarding Issues being dealt with by relevant authorities and the concerns expressed by Health and Social Care Professionals are evidence of the negative impact the lack of proper managment has had on peoples lives. One Health/Social care professional commented The service could improve if firstly a solid and consistent care management structure could be maintained. We asked to see the homes quality assurance system, this should include feedback from people who use the service. We were told that no such information was available for the past year. We asked to copies of monthly visits made on behalf of Healthcare Trust Ltd, to check that on the running of the home. We were given copies of reports of these visits relating to 29/1/09, 30/10/08, 24/7/08 and 19/2/08. No other reports could be found at the time, though we have been told that other reports have since been found, however we have not seen these documents. We noted comments in the report of January 09 that one of the staff felt that she had been thrown in at the deep end, whilst in October 08 another staff commented in this report that they felt forgotten, isolated and unsupported. In relation to safety, a fire risk assessment had been completed and was available in the fire logbook. The weekly tests for the fire alarms, and also regular drills were recorded. The monthly visual checks of the emergency lighting had been completed however the monthly visual checks for the fire extinguishers had not been done. The fire alarm system had been serviced on 4th February 2009 and the records indicated that a further visit was necessary for some repairs. A document dated January 09 identified a list of staff who had expressed a need for updated fire safety training. When we asked we were told that this had been addressed, but the updated information had not been added to the training records. Care Homes for Older People Page 30 of 41 Evidence: We found that COSHH Data sheets, sheets that explained the dangers posed by chemicals were available for a number of cleaning products. However, when we walked around the home on the first day of inspection we found that the cleaning trolley with a range of products had been left in a shower room, rather than stored in a locked cupboard. We looked at the records of monies held belonging to people who live at Priory Manor. We saw that there was a record of cash held and income and expenditure. We were told that for most individuals cigarettes were purchased for them, and that receipts were sent to the person who controlled their finances for reimbursement. We also found on leaving the building on the first day of inspection that anyone entering the building could access confidential information, relating to individuals who live in the home, in the main entrance. It was also possible to access the keys to various parts of the building. All records relating to people who live at Priory Manor should be kept secure. We saw that a staff communication book was used to record information relating to what had happened at Priory Manor, on a daily basis. This style of communal recording is not good practice and should cease. Records should be kept on an individual basis, so that if an individual wishes to see their records. Care Homes for Older People Page 31 of 41 Are there any outstanding requirements from the last inspection? Yes £ No R 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 Care Homes for Older People Page 32 of 41 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 1 27 18 There must be sufficient staff 27/02/2009 on duty to meet the physical and emotional needs of people at Priory Manor, to ensure their safety, to provide activities and stimulation and develop their skills where appropriate. People need to be safe and to be provided with the service that has been contracted. 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 1 17 A record must be kept in the 01/06/2009 Care Home in respect of each Service User that details the placing authority/organisation which arranged the admission to the care home. This will ensure that people who use the service will have the information about the placement arrangments and funding. 2 1 4 The Registered Provider must compile a written statement, a Statement of 01/06/2009 Care Homes for Older People Page 33 of 41 Purpose, which accurately details the facilities and services provided for people who use the service. The Statement of Purpose must include all matters listed in Schedule 1 of the Care Home Regulations. A copy must be provided to the Commission. There must be clear information, explaining to the Commission and other interested parties what and how the service is to be provided. 3 1 5 The Registered Provider 01/06/2009 must produce a written guide, the Service User Guide, which accurately details information about the services provided. A copy of the Service User Guide must be provide to each Service User and to the Commission. This will ensure that accurate information is available to people who use or may wish to use the service. 4 7 12 The Registered Provider must make proper provision for people who use the service. This must include the health and social care needs of people are known about, recorded and met. This is to ensure that the people who use this service can be confident that they 01/06/2009 Care Homes for Older People Page 34 of 41 will be safe and that their needs will be met. 5 7 15 The Registered Provider must maintain detailed and up to date care plans that are kept under review. This is to ensure that the people who use this service can be confident that will be safe and that their needs will be met. 6 9 13 Arrangements must be made to ensure that medicines prescribed to be administered when required are used in accordance with a clear protocol. This is so that people can be confident that they will receive their medicines in the same manner from any person administering medicines 7 9 13 Arrangements must be made to ensure that people receive their medicines as prescribed, and that records show what has been administered and when this has been done. This is to ensure that people prescribed medicines receive them at the intervals indicated by the prescriber 8 9 13 Arrangements must be 01/05/2009 made to store Controlled Drugs in a cupboard fitted in accordance with the current regulations. 30/04/2009 30/04/2009 01/06/2009 Care Homes for Older People Page 35 of 41 This is to ensure that these medicines are not at risk of any diversion 9 12 16 The Registered Provider 01/06/2009 must consult with people who use the service about their social, educational, leisure, and activities, and make arrangements to enable people to follow these interests within the home and in the community. People who use the service need to be supported to follow their interests. 10 14 12 The Registered Provider must ensure that any restrictions placed on an individual are must be informed by the Mental Capacity Act. Peoples rights must not be arbitarily or unlawfully restricted. 11 15 12 The Registered Provider 01/06/2009 must ensure that advice and support is provided to those people who have been assessed as having dietary needs. People who use the service must be supported to eat well and stay healthy. 12 18 13 The people who live at Priory 15/04/2009 Manor must not have their liberties restricted, other than as described in the Mental Capacity Act. 01/06/2009 Care Homes for Older People Page 36 of 41 Peoples freedoms must be respected. 13 19 23 The Registered Provider 01/06/2009 must inform the Commission in writing of any planned changes to the accommodation and how the building will be kept safe for the people who live there. The Commission must be in agreement with any substantial changes to the building. 14 19 12 The Registered Provider must undertake to review the building regarding its suitability to meet aims and objectives set out in the Statement of Purpose. People need to be confident that the building is suited to their needs. 15 27 12 The Registered Provider 01/06/2009 must make proper provision for the health and well being of people at Priory Manor, by making sure that their are adequate number so staff on duty. This is to ensure that peoples needs are met and they are kept safe. 16 29 19 The Registered Provider must ensure that there are robust recruitment procedures that must include taking two suitable written references, and a POVA check prior to an 01/06/2009 01/06/2009 Care Homes for Older People Page 37 of 41 individual starting work in a supervised capacity. No one may work unsupervised unless a CRB check has been completed. This is to ensure that only people suited to the work may be employed 17 30 18 Staff must have the training 01/07/2009 (including induction training) they need to ensure that they have the skills to carry out their role. This is to ensure that staff are competent in providing support to the people who live at Priory Manor. 18 31 12 The registered Provider must ensure that there is suitable, competent and consistent management of the home. Consistent and competent management of the home helps to ensure that people are kept safe. 19 32 26 The Registered Provider must ensure that monthly unannounced visits are conducted on behalf of the company. Reports of these visits must be available in the home and sent to the Commission. The Registered Provider (Healthcare Trust Ltd) must be and be seen to be aware and responsible for the conduct of the home. 01/06/2009 01/06/2009 Care Homes for Older People Page 38 of 41 20 33 24 The Registered Provider 01/06/2009 must ensure that there is a quality assurance system to review and improve the quality of the care provided. This system must include consultation with the people who live at Priory Manor and their representatives. A report must be produced and made available to the residents. A copy must be supplied to the Commission. This is so that the managment of the home can measure how well the home is achieving goals for people who live in the home. 21 38 13 The Registered Provider 01/06/2009 must ensure that arrangements must be made to ensure that the people who live at Priory Manor are safe from unreasonable risks. This means that derelict areas of the building must be secured. Staff and residents must have the facility to call for help in an emergency, and that all staff have regular fire training. This is to ensure that that the people who live at Priory Manor are safe. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 39 of 41 1 2 The Registered Provider should provide to each person who has moved to Priory Manor information regarding their fees and payment arrangements. Meals must be provided in clean and well furnished rooms. The people at Priory Manor should be given clear information as to how they may complain about the service, if they should need to. Appropriate bathing facilities must be provided on the first floor. At least 50 of the care staff should have a care qualification to at least a level 2 National Vocational Qualification (NVQ). This is so that staff are trained and competent to care for people who live in the home. Care staff must deal with foul laundry in a manner that avoids the risk of infection. The dining room carpet and other areas for the home that smell should be cleaned. 2 3 15 16 4 5 21 28 6 7 26 26 Care Homes for Older People Page 40 of 41 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@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) 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. 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