Inspection on 06/02/08 for Queens Court Nursing Home

This inspection was carried out on 6th February 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Queens Court Nursing Home 15/01/08

Queens Court Nursing Home 23/05/07

Queens Court Nursing Home 05/12/06

Queens Court Nursing Home 26/06/06

Queens Court Nursing Home 24/01/06

Queens Court Nursing Home 17/01/05

Queens Court Nursing Home 28/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Queens Court Nursing Home 52 - 74 Lower Queens Road Buckhurst Hill Essex IG9 6DS Lead Inspector Gaynor Elvin Unannounced Inspection 6th February 2008 10:00 X10015.doc Version 1.40 Page 1 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 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queens Court Nursing Home Address 52 - 74 Lower Queens Road Buckhurst Hill Essex IG9 6DS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 559 0620 0208 559 0315 queenscourt@hotmail.com Ranc Care Homes Ltd Mrs Rosemary Mathias Care Home 90 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (22), Physical disability of places over 65 years of age (27) Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 40 years and over, who require nursing care by reason of a physical disability (not to exceed 22 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 27 persons) Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 41 persons) The total number of service users accommodated in the home must not exceed 90 persons 23rd May 2007 Date of last inspection Brief Description of the Service: Queens Court is a purpose built two-storey care home for up to 90 residents over the age of 65 years. The home is also registered to provide nursing care for persons aged 40 years and over, who require care by reason of a physical disability. It is located in a residential area in Buckhurst Hill near Ilford in Essex, close to local amenities, shops and public transport systems. The home is divided into two units: a residential care unit located on the ground floor and residential care with nursing unit located on the first floor. Personal accommodation comprises of single rooms with en-suite toilet and wash hand basin facilities, with the exception of a double room on each unit, also with en-suite facilities for married couples or those who wish to share. The home has a garden to the rear, a patio area to the front and ample parking. The fees are calculated according to the assessed needs of the resident and at the time of this inspection were informed that they ranged from £425.00 to £1073.00. The fees are broken down into basic board and lodging fee and other costs relate to the care support and nursing provided to each individual. Additional costs include private chiropody, toiletries, newspapers, hairdressing, dial-a-ride and some activities. Queens Court Nursing Home DS0000015397.V359437.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. This unannounced inspection took place over two days, 6th and 15th February, over a period of fifteen hours. All of the Key National Minimum Standards (NMS) for Older People, and the intended outcomes, were assessed in relation to this service during the inspection. The inspection process included reviewing documents required under the Care Home Regulations. A number of records were looked at relating to the residents, staff recruitment, training, staff rosters and policies and procedures. During the visits to the service time was spent talking to Mr Rai, the Responsible Person for the company, Ms Mathias, the Registered Manager, Mr Greaves, the Director of Nursing Services, Ms Chibanda, Clinical Nurse Manager, a registered nurse, care staff, residents and relatives. This report has been written using accumulated evidence gathered prior to and during the inspection. Comment cards from 4 residents, 2 relatives of residents, 1 care manager and 4 members of staff were completed and returned to the Commission and views expressed are included within the contents of this report. The Commission is currently considering an application for the condition of registration category of the residential unit, provided by the service, to include dementia care. What the service does well: What has improved since the last inspection? Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 6 The provision of activities has steadily improved since the commencement of the activity coordinator to develop the social aspect of care provision for residents. The Clinical Nurse Manager has demonstrated a commitment to the development of the staff training programme to improve the competence and skills of the staff workforce. Repair and refurbishment to the physical environment of the home has progressed. These aspects are contributing towards the process for improving outcomes for the residents since the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 7 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 Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based on standards 1, 2, 3 and 5. People wanting to use the service can be confident that their basic needs are assessed prior to admission to ensure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Written information about the homes services and facilities is not readily accessible to prospective residents or their representatives prior to their admission. New residents and their relatives spoken with confirmed that they had a trial visit to the home and moved into the room that they were shown. They also confirmed that they were given a lot of information verbally throughout the visit and were asked after moving in if they had any concerns that they would like to raise. The manager advised us that the homes’ Statement of Purpose’ was currently being revised and that she would ensure that this information would be provided to all prospective residents in the future to inform them about the Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 9 services and facilities provided at Queens Court. This will be given in conjunction with the new colour photographic brochure being produced by Ranc Care Homes. The manager or clinical senior nurse usually undertakes pre-admission assessments to ensure that the service provided can meet the needs of the prospective resident. An assessment undertaken for a recently admitted resident was examined and mainly focused on immediate presenting dependency/nursing needs. The assessment could be developed further to ensure a more person centred approach. Areas of need identified could be explored further and more detail recorded to inform care planning tailored more towards the individual. For example the assessment stated that the individual was able to perform most activities of daily living with minimal assistance and has a small degree of short-term memory loss. Identified strengths and abilities would determine the level and type of support the individual required. This would guide staff in the delivery of a consistent and appropriate level of support tailored to the individuals’ needs promoting optimal independence and self worth. In addition to their own assessment, where available, the home uses social service and health assessment information as well. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based on standards 7, 8, 9, 10 and 11. People who use this service can expect to have access to healthcare professionals but cannot be sure that the care and support they require will be delivered in a consistent and planned way that is tailored to their individual needs. Insufficient staffing numbers does not assure people that their dignity and diversity is always upheld or that support is always provided in a safe and timely manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst we were at the home, we observed and heard staff interacting well with residents. However feedback from discussion with residents, care reviews and questionnaires indicated that insufficient staffing levels and some staff attitudes, mainly agency, did not ensure that all care needs were met or that dignity and diversity was respected (See evidence in outcome area for staffing). Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 11 Overall the care planning system has developed since the last inspection but there are still areas that require further work and continued staff input. We looked at a sample of care plans, four from the nursing unit and four from the residential unit, and found that in general they were up to date and on the whole regularly reviewed. Some aspects of the care plans were good identifying assessed needs and expected outcomes, including risk management strategies that were linked into the care planning arrangements. The content of care plans were variable and focused mainly on nursing needs. There remained scope for developing a more person centred approach to care planning, with greater focus on identifying more preferences, maintaining strengths and abilities and detail on promoting independence and self worth. This would help the team evidence further that they appreciate the diversity of the residents in their care. There were aspects of the plans where advice and guidance for staff were too general/brief and did not provide a clear basis upon which to review care practice. For example some action plans simply instructed staff to liaise with family or other health professionals such as ‘liaise with family to understand gestures and verbal exchange’ and ‘physiotherapist for breathing techniques’ and ‘speech and tracheotomy specialist in relation to communication needs’. This basic level of guidance is not sufficient or practical in a busy working environment and does not guide staff, particularly new or agency staff, to meet needs in an effective or consistent manner, as and when required, and reduce residents’ anxiety. Assessment and care planning is an essential tool particularly in the larger home with a larger workforce. The initial assessment process could be improved to obtain useful and critical information, such as this, from the resident, relatives and healthcare professionals to inform care and support planning. Other aspects of action plans were not only brief but also nursing orientated and did not provide appropriate guidance for non nursing care staff, particularly care staff whose first language was not English. For example an action plan to meet the needs of an individual with diabetes was brief and simply stated ‘staff to be aware of signs of hypo and hyper’ and ‘to be given a diabetic diet’. The absence of clear-recorded guidance for staff to follow does not enable staff to be sufficiently confident to deliver appropriate and agreed care. Records show a proactive approach with regard to GP and specialist services being contacted in a proactive manner as and when necessary. Visits by healthcare professions and corresponding advice were recorded. The team need to ensure care plans are revised or generated according to the new information, including any changes or monitoring in the care to be provided, this will ensure continuity. We noted that changes required in the enteral Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 12 feeding regime for one resident was only recorded in the daily notes and not reflected in the care planning arrangements. Potentially this essential information could be lost and the resident could be put at risk. We also noted that historical information relating to enteral feeding regimes dating back to 2004 was held in the care records and could cause confusion to staff, or potential risk to the resident if the wrong information was read. Further attention needs to be given to ensure care plans are consistent and used as an active working document to inform all staff on current care needs and requirements. Issues of poor care practice and poor care outcomes for residents, such as pressure sores and injury sustained from poor moving and handling were raised through complaints from relatives, prior to this visit to the home. The outcome of care reviews undertaken by Social Services, information from residents and relatives and our visit to the home conclude that insufficient numbers of trained, competent and supported staff impact on safe and appropriate care delivery and the outcomes for people using the service. The management had recently undertaken an internal medication audit in November 2007. The audit was not completed in its entirety and a full and detailed audit was recommended to be undertaken and then bi-monthly. Shortfalls were identified in medication practice such as recording and following policy and procedure, mostly relating to the residential unit, and a recommendation for care staff to be trained/updated and working practice to be assessed was made as a matter of urgency. No further action had been taken in this area. We noted that only four care staff were identified on the training matrix as having received any form of training in the administration of medication between April and July 2007, and one in December 2007. The annual training plan did not show that additional medication training was planned for. Mr Rai, the responsible person for the company, during discussion, gave his assurances that a full external medication audit was planned and action would be taken to address shortfalls found. We will monitor this outcome area during the inspection process. We examined a sample of Medication Administration Records (MARs) and found they were accurately completed, signed and dated. Administration of medication was not observed. Increasingly, people admitted to the nursing unit at the home are entering the end stages of a disease process and the main focus for the nursing unit is changing towards the provision of a service that delivers quality care to individuals in their end stages of life. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 13 The staff are supported by the Community Specialist Home Care Support Nurse, who is GP based and works with nursing homes in the area of Buckhurst Hill. Following an identification of training needs, an intense training programme was being delivered to staff in some of the essential elements of palliative such as pain control, nausea and vomiting, syringe driver for continued medication administration, terminal agitation, recognising terminal phase and breathlessness. Discussion with the Community Specialist Nurse told us that care standards in this area had improved and that staff are recognising and dealing with residents pain better; less people are being admitted into hospital and more people are being supported appropriately to stay in the home at the end stages of life. The Community Specialist Nurse also told us that the management are keen for staff to be trained and are supportive, the training is delivered free and staff are very willing to learn, there was recently a 12 week course held and everyone attended, however there is a high staff turnover. The only concerns are the staffing levels in that they are not sufficient to meet dependency needs, and staffing levels need to be increased. Three registered nurses have completed additional training in palliative care. The staff team are working with the Gold Standard Framework, a positive initiative that provides a framework of clear, quality objectives in assessment and recording of end of life needs and the planning and provision of care. We noted, with concern that recorded within some care plans were serious decisions made by relatives on behalf of some residents in relation to in the event of serious illness or terminal illness to not initiate treatment. It was not clear as to what the individuals expressed wishes were or why they were unable to make the decision themselves. Records should show how and why this decision has been reached, and by who in accordance to the Mental Capacity Act Code of Practice. The home must familiarise itself and refer to the Mental Capacity Act 2006. We also noted that plans around death and dying for residents on the residential unit simply state for staff to discuss with family what needs to be done in event of dying, this practice is not tailored to individual wishes in relation to care in the last stages of their life. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based on standards 12, 13, 14 and 15. Not all the people who use the service find the lifestyle experienced in the home, and facilities provided, matches their expectations and preferences, and satisfies their social and recreational interests and needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information gained from residents and their relatives in care reviews undertaken by the reviewing officer, from Social Services were shared with the Commission. The reviews confirmed that whilst the provision of activities has steadily improved, particularly for those on the residential unit, further development of this aspect of care provision should be considered by the team to ensure the frailer resident with more complex support and nursing needs are also provided with opportunities that promotes their emotional and social well being. For example, the reviewer found that the health of one residents had been up and down emotionally and physically and was told by the resident that they were bored most of the time – every day was the same, they were frustrated Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 15 by their total dependence, spent most of the time in their room, laying on their bed as this helped to reduce their pain in their leg. They also found that when some residents were asked if they wanted to join in with an activity their immediate answer was taken, and if it was ‘no’ they were left, nobody actually finds out why the resident declines and if they could be supported for a short time etc. Care and support planning records did not demonstrate opportunities or reasons for declining or alternatives offered. . On the tour of the premises we found the activity room was well equipped and noted a bookcase with varied books also in large print and various films and CDs. It was disappointing to note that these items were not accessible to the residents throughout the home and radios were on stations that played music not suited to the residents. Three residents with higher needs and some degree of cognitive impairment were seated in the lounge/diner, all were dozing. When spoken to they told us that they were bored and would like something to do, music was playing but each said it was not to their choice. There were no drinks available to them and one requested a cup of tea. There was no available staff around to assist them. Another said that she would like to read. There were no books available in the lounge, the paper was out of date and a few old tatty magazines were available but in very small print. This was discussed with the manager and later that day we observed that the bookcase from the activity room containing various books including large print was placed in the lounge. The activity room contained various collections and displays of art and craft undertaken by some residents; and the activity taking place that day in one of the dining rooms was well attended by the more able residents, who all said afterwards that the activity was enjoyed. We noted from the complaints log that a relative had raised concerns with the management with regard to a need for the activity coordinator to have additional assistance to support those residents attending activities with personal needs. Action was taken to address this issue by ensuring care workers assisted throughout activity sessions. Being a very large home, with residents who have high dependency levels and care and support needs, consideration must be given when calculating the staffing levels to include the individual assessed social and emotional needs of residents to ensure that these can also be met appropriately and effectively. Group activities included church coffee morning, music quiz, exercise, reminiscence quiz, art, and bingo and group crossword. Residents told us that the activity programme was not provided on a regular basis; and that activities Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 16 such as bingo used to occur on the same day each week and you would always know when it was happening. The activity coordinator had undertaken individual social need assessments that identified likes and dislikes, spiritual needs, family tree, past experiences, pets, hobbies and leisure pursuits, interests, sports interests, reading and entertainment choices and preferred daily routines. The assessments were kept in the activity room and separate to the individuals support plan. This important and relevant work should inform social care planning, which overall was weak. Other records recorded the daily, organised group activity offered to a resident and whether they had either participated, observed or refused the activity. Whilst these records provide some indication of activity participation, they do not relate to the residents noted preferences, level of participation or benefit achieved; a more individualised approach in this aspect of care would bring the activity coordinators and the care teams’ work together to promote a team approach to improving outcomes for people in this area. During the inspection comments received from residents with regard to lifestyle and food was variable. One resident told us ‘‘no variation in food, it is dreadful, stews mostly – no taste, all taste the same. I go to bingo or anything that is going but not offered regularly’’. Another told us ‘it’s very boring, not enough to do, I don’t like being here, we have spelling, painting, exercise and an occasional quiz’. Another told us ‘‘food is ok, seems to be overcooked, I would like a bit more variation. I have all my meals in the dining room, I buy soups from time to time, and I am having soup today, as I don’t like the meal. Visitors are always made welcome, always tea and biscuits. I don’t join in the activities much, I can’t do a lot of the things they do, my daughter keeps me supplied with books’’. Another told us ‘‘I would love to go out of the home for a drive or a walk – I would like to go to Ilford shopping. We don’t get this opportunity and carers pick up some shopping for you such as stockings or tissues, …used to participate in activities put on by home but they are boring and I don’t now’’. Another told us ‘‘the food is improving, doesn’t like to mix or partake in any activities, keeps herself to herself in her room, no problems’’. The internal audit undertaken by management in November 2007 found considerable dissatisfaction with the quality of meal provision and this continues to be addressed. We found comments from residents during our visit to be variable in relation to the meals. In the main people thought that the Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 17 quality of meals were improving but issues with regard to the standard of cooking, choice and temperature of food when received indicated further monitoring and improvement. Queens Court Nursing Home DS0000015397.V359437.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based on standards 16 and 18. There is a satisfactory system in place to record and address complaints, and policy and procedure for safeguarding people. However there is a lack of action being taken to fully address emerging problems within the home. This does not assure people living in the home that it is being run in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has a complaints policy and procedure that is displayed in the reception area of the home and included in the Statement of Purpose. The policy is not up to date in that it advises ‘should lines of action not prove satisfactory to you, or you do not feel able to approach us directly, you have the right to make a formal complaint to the Commission of Social Care Inspection’. The CSCI in our regulatory role have no explicit statutory powers to investigate complaints, however we use our regulatory role and powers of inspection to review the way in which a service has dealt with complaints made. Complaints in respect of residential care homes should be made to Social Services Customer Care department to be considered through formal processes under their statutory powers. This information should be reflected within the complaints policy. Despite the managements assurance at the last inspection that communication and complaint management systems had been reviewed, evidence correlated Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 19 throughout the inspection process indicate that practice in this area has not improved. The Commission has continued to be advised by relatives of their dissatisfaction with the way in which their complaint, relating to poor care practice at Queens Court, has been managed or not managed as the case may be. In response to the concerns brought to the attention of the Commission, we requested the management of Queens Court to look into the matters raised and follow their complaints process more effectively and efficiently and that this would be reviewed at the next subsequent inspection visit. The home’s Statement of Purpose says that ‘all complaints are fully investigated and the complainant is informed of the outcome of the investigations: any corrective action necessary is taken to improve the quality of the service’. We found that there were a number of complaints about the same issues and that there was a lack of action being taken to address emerging themes. The homes complaints log was examined and we noted that action taken in response to, and outcomes of investigation of written formal complaints were vague. The management’s complaints investigation and review process does not openly and effectively examine current practice or underlying issues to initiate pro active action planning, risk assessment and monitoring to ensure incidents are not repeated. We also noted that the stance taken by management in concluding an outcome, in most cases, was to dismiss staff involved with no further action taken to improve care practice. For example in the case of a complaint relating to two separate incidents with regard to incorrect moving and handling of a resident, the complaint log records did not identify any actions that were taken in response to the complaint with regard to staff training and assessed competence in this area or the review of moving and handling risk assessments and management strategies to ensure such incidents were not repeated. A process that could be included within the homes quality monitoring and assurance audits. Since the last inspection the home has worked in partnership with the Local Authority and other multi professional agencies, within an agreed structured strategy, to address some safeguarding and care management issues in the home that have been raised by residents and relatives. Although management have followed the process, again a more responsive and pro-active approach is required to ensure such incidents were not repeated. Following an influx of complaints and safeguarding vulnerable adult referrals relating to poor care management; care reviews for all residents placed at Queens Court were undertaken by Social Services reviewing officer. Subsequent concerns highlighted during some reviews were shared with the Commission and mostly related to the high level of agency staff used, who Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 20 appear poorly trained and poorly prepared, and some have language difficulties. Regular staff appeared overstretched and unmotivated and in some cases disrespectful. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based on standards 19, 20, 21, 22, 23, 24, 25 and 26. People who use the service live in a home that is generally clean and aims to provide a safe and well-maintained environment that meets their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Manager informed us that there is an ongoing refurbishment programme being undertaken. Floorboard replacement was almost near completion to reduce noise. Re-carpeting of lounge and remainder of bedrooms was scheduled to commence 3rd March. New curtains and bedspreads for all rooms were on order. New furniture was planned for all lounges and dining rooms. The boiler had recently been replaced and installed. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 22 A tour of the premises was taken. An offensive smelling odour was noted in the first lounge/dining room. When this was brought to the managers’ attention she arranged for a domestic assistant to clean the carpet with an industrial cleaner. She later told us that plans were in place to refurbish the room including new carpet and chairs. Feedback from residents was positive regarding the cleanliness of the home and all expressed praise for the domestic assistants and their kind and happy approach to their work. There were grab rails, and aids in bathrooms, toilets and communal rooms. The home had assisted baths and shower rooms. We were informed by the manager that one bathroom had been out of action since November. Another bathroom was noted to be very cold and the screen in the level access shower room appeared to be collapsing. Hand washing facilities (liquid soap and paper towels) were provided throughout. The laundry room was well organised and fitted with three washing machines and two driers. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines; washing machines had the capacity to carry out sluice wash cycles. Call systems were provided throughout all individual rooms and in communal rooms with leads to enable residents to call for assistance. Pressure relieving equipment was available including mattresses, airwave mattresses and cushions. A good range of equipment to aid daily living was available e.g. perch stools, helping hands etc. and one resident’s room was fitted with an overhead hoist. Several hoists were available to assist staff in moving and handling/transferring residents. Individual residents’ rooms were fitted with locks and keys were provided to those who had made a choice. Lockable facilities were provided for residents’ personal use. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor based on standards 27, 28, 29 and 30. People who use this service cannot be assured that their needs will be met by staff in adequate numbers, that are suitably skilled and competent or supported in their role. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service has vacancies and is currently accommodating sixty-five residents, thirty-nine of which are accommodated on the nursing unit and have high and complex needs. The manager confirmed that the staffing levels for the residential unit consists of five care staff in the morning, four care staff in the afternoon/evening and three care staff at night. The staffing levels for the nursing unit consists of two registered nurses and six carers throughout the day and two registered nurses and two care staff at night. The previous inspection highlighted that staffing levels were insufficient at key periods during the day meaning residents have to wait to receive assistance. Feedback from residents prior to visiting the service, from questionnaires and from speaking with residents during this visit told us that staffing levels continue to be insufficient. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 24 One resident told us ‘‘ there is not enough staff, they are like a whirlwind and then disappear, they are very busy’’. Another told us ‘‘there is a high usage of agency staff now and some are quite rude. There is no longer many regular staff and this is very sad, those regular nurses employed by the home are very good and tolerant. On the whole I am well looked after’’. Another said ‘‘the staff are very good, they do the best they can but they are very short staffed but the staff’s general attitude is good’’. Another resident told us ‘‘…some night nurses are a bit awkward, when asked to do something they say they’ll be back in a minute. Once I am washed in a morning I don’t see anyone else ‘til lunchtime – I’ve asked him or her if I have a contagious disease. The male staff are very rough, I have said I don’t want to be cared for by them anymore’’. And another told us ‘‘the place has deteriorated due to shortage of staff, agency people do not know what they are doing, I only need help going to bed and getting up, haven’t kept me waiting too long but due to the staff shortages they can’t help me straight away’’. One resident with mobility needs, requiring a wheelchair and a hoist to assist in movement plus the assistance of two carers, told us that ‘‘this was usually managed well. The staff were ok, but very busy I sometimes have had to wait up to thirty minutes for my call bell to be answered’’. An internal audit undertaken in November 2007 by the homes management highlighted unacceptable time lapses experienced by residents for their basic needs to be met such as having a shower and assistance to go to the toilet; and call bells are not always answered promptly, or if they are, residents are told they must wait. We noted on more than one occasion during our visits to the home that call bells were ringing for up to ten minutes prior to being answered. Following an influx of complaints and safeguarding vulnerable adult referrals relating to poor care management; care reviews for all residents placed at Queens Court were undertaken by Social Services reviewing officer. Subsequent concerns highlighted during some reviews were shared with the Commission and mostly related to the high level of agency staff used, who appear poorly trained and poorly prepared, and some have language difficulties. Regular staff appeared overstretched, unmotivated and some were disrespectful. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 25 Comments from staff, received through questionnaires told us that only ‘sometimes’ was there enough staff to meet the individual needs of the service users. The calculation of staffing numbers must be in accordance to the assessed needs of the residents. Residents’ needs and dependency levels must be reviewed on a regular basis to ensure changing needs are identified in order for the residents’ needs to met effectively and efficiently. The manager acknowledged that there has been a recent high use of agency staff to cover a high level of sick leave and staff turnover and is currently recruiting. A sample of staff recruitment and training records were inspected. We noted in one file that references were not sought from the original referee details given on the application form. Two additional names and addresses of referees were given – there was no explanation recorded as to why originals were not used and the manager was not able to provide an explanation. The reference forms completed gave no indication as to what capacity the referees knew the applicant. The first reference was from a business centre and stated the applicant was known as a student, there was no reference to the applicant being a student on the application form. The second reference was from a private address and stated that the applicant was an employee – the reference did not state what capacity the applicant was employed in and this also did not link to the application form. Neither reference provided any specific or relevant information that would apply to the suitability of the applicant for a job in the caring industry. New staff are issued with a staff handbook that contains the homes policy on equal opportunities and grievance policy and procedures; the General Social Care Council Code of Conduct and a job description. New staff undergo an induction that is service specific and incorporates basic training in the subject areas moving and handling, health and safety and fire safety. The induction does not meet National Occupational Standards or include practical assessment of competence and understanding. The staff training list/matrix showed us that the staff team deployed across both units within the home is made up of: 9 registered nurses, 1 overseas nurse on adaptation training, 43 care staff, 3 senior care, an activity co coordinator, a housekeeper and a hotel services manager and 6 domestic assistants, a head of laundry and a laundry assistant, a cook, assistant cook and 2 kitchen assistants, a gardener and a maintenance person. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 26 The home had not yet successfully reached the recommended target of 50 of the care staff workforce having a National Vocational Qualification (NVQ) level 2 in care. The training matrix showed, and the manager confirmed that only twelve care staff had achieved an NVQ level 2 in care, nine had commenced and were half way through. The training matrix showed gaps in training received in first aid, with only sixteen staff members having received this training in the last 3 years, and registered nurses had not received training/update in this area at all. We also noted that training in other mandatory subjects such as infection control, health and safety, fire safety, safeguarding vulnerable adults and moving and handling are not undertaken with care staff on an annual refresher basis, and many had not received any further training in these areas since their induction. Only five care staff had received training in the administration of medication. Fifteen staff had received training in challenging behaviour between July 2005 and November 2006. Fourteen staff had received training in managing confusion in 2006. The annual training plan showed us that training in mandatory subjects and areas specific to residents needs was planned throughout the forthcoming year. The annual training plan needs to link with the training matrix to demonstrate that all staff members have the opportunity to attend planned workshops to enable them to bring their individual training, development and update requirements up to date. A report identifying the outcomes of an internal audit, undertaken in November 2007, by the homes management, suggests robust recruitment processes, increased monitoring during probationary periods, increased training and development opportunities, increased formal supervisions, and the attachment of mentors as actions that need to be implemented to improve the current level of care and service delivery. We will be reviewing the progress of actions taken during the inspection process. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 27 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate based on standards 31, 32, 33, 35, 36, 37 and 38. The home is not managed in an effective way. A lack of commitment to continuous improvement in quality services, support and outcomes does not ensure that the service is run in the best interests of the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is a registered nurse with a Diploma in Management and has been at the home for 10years. A middle management structure, the Director for Nursing Services, provides support to the registered manager of Queens Court, and other registered managers employed by Ranc Care Homes. Quality monitoring and internal audits were not structured and although they highlighted strengths and weaknesses in the service they did not provide a Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 28 pro-active action plan for implementation and future monitoring to improve standards and outcomes for residents. We noted from the records of minutes of meetings with staff, and heads of departments, that middle management took an authoritarian and condescending approach with a blame culture. This was also reflected in the high number of complaints and safeguarding vulnerable adult allegations received and concerns raised about how these were managed by the service. A responsive approach that scrutinises practice in a constructive and analytical way would identify where improvement is required and raise standards more effectively. Queens Court is a large home that caters for many residents with high complex needs and has a large workforce. Improvement in care delivery requires additional staffing levels and a stable workforce with greater supervision, support and additional training. Whilst staff training and support has progressed since the introduction of the Clinical Nurse Manager role, further development in this area remains restricted due to limited hours dedicated to the role. The Clinical Nurse Manager is also included in the staff rota providing care. Formal one to one supervision with individual care staff is undertaken approximately every 2 to 3 months. In view of the issues highlighted within this and previous reports and the homes internal audit process, more frequent and regular supervision would benefit staff by providing more opportunity for individualised discussion particularly in relation to areas of practice, residents needs and the aims and objectives of the service. Records showed us that although most elements of supervision were included and reflected, the tick box format followed does not provide for a mutually agreed agenda. The supervision process should encourage inclusion, partnership working and individual development. The minutes of a staff meeting told us that a satisfaction questionnaire was given out to staff, when a member of staff asked why they had to put their names to it they were told by middle management that ‘people should have the courage of their convictions’. This element of quality monitoring should be used as a method to gather information from staff, against set criteria and provide staff the opportunity to express their views and true feelings freely. Anonymity encourages equality by enabling those who normally lack confidence to participate and have a voice. Residents have their own arrangements in place for the management of their financial affairs. The manager supports residents in managing small amounts of money left by relatives for every day use such as hairdressing and personal items. The system for the safekeeping and management of this money was secure, Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 29 records identified transactions with corresponding receipts and a running balance was confirmed by signature. The balance was checked and correct The home had a new policies and procedures manual that included health and safety policy and procedures for staff guidance. The infection control policy contained a procedure to be followed in the event of an outbreak of infection. At the last visit to the home in May 2007 a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. gas, electricity certificates, lift, hoists, annual PAT testing etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). This area was not reviewed on this occasion. The maintenance person undertook internal maintenance audits regularly and issues highlighted were addressed. Feedback from residents in relation to the upkeep and cleanliness of the home and domestic staff was positive. Following this inspection we were informed that the Director of Nursing Services had left employment with Ranc Care Homes. Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 30 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 2 2 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 2 3 3 3 3 STAFFING Standard No Score 27 1 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 2 3 3 Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 31 Are there any outstanding requirements from the last inspection? Yes 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 OP16 OP32 Regulation 22 Requirement A more responsive and proactive approach is required to the way complaints are investigated and reviewed to ensure the process openly and effectively examines current practice or underlying issues to complaints are managed satisfactory and robust action planning, risk assessment and monitoring is initiated to ensure incidents are not repeated. Timescale for action 01/06/08 2. OP27 18(1)(a) Resident’s must be supported by 01/06/08 staff in sufficient numbers so that all their needs can be met in full when required. This is a repeat requirement not met within given timescales 01/03/07 and 30/08/07. 3. OP28 OP30 18 Staff must have access to training that is consistent with their roles and responsibilities in core subject areas with appropriate update in current practice to effectively do their job. DS0000015397.V359437.R01.S.doc 01/08/08 Queens Court Nursing Home Version 5.2 Page 32 4. OP33 24 The quality assurance and audit process must include an action plan to be implemented that will address the improvements required that would impact on outcomes for residents. 01/06/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. OP7 Refer to Standard Good Practice Recommendations There remains scope for developing a more person centred approach to care planning, with greater focus on identifying more preferences, maintaining strengths and abilities and detail on promoting independence and self worth. Consideration must be given to how the service users can receive a more individualised service tailored to meet all assessed needs. Social care aspects of care planning needs to develop in order to consider how best meaningful interaction can be provided according to individualised social needs to promote well being. The development of individual training and development profiles that use information gathered from supervision and residents needs assessments would further enhance the skills base of the service. A staff group who receive training that continues to develop their understanding, knowledge and skills would support residents further. 2. OP12 3. OP30 4. OP30 Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Queens Court Nursing Home DS0000015397.V359437.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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