Inspection on 06/11/07 for Regents Court Care Home

This inspection was carried out on 6th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Regents Court Care Home 31/01/09

Regents Court Care Home 16/06/08

Regents Court Care Home 23/11/06

Regents Court Care Home 20/10/04

Regents Court Care Home 30/04/04

Regents Court Care Home 12/01/04

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

CARE HOMES FOR OLDER PEOPLE Regents Court Care Home 128 Stourbridge Road Bromsgrove Worcestershire B61 0AN Lead Inspector Deborah Stuart-Angus Unannounced Inspection 08:10 6 November 2007 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 Regents Court Care Home DS0000004151.V344314.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. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Regents Court Care Home Address 128 Stourbridge Road Bromsgrove Worcestershire B61 0AN 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) 01527 879119 01527 872631 c.wood@alphacarehomes.com www.alphacarehomes.com Alpha Health Care Limited Mrs Pauline Vernon Care Home 37 Category(ies) of Dementia - over 65 years of age (37) registration, with number of places Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2006 Brief Description of the Service: Regents Court was established as a care home in 1984, and is set in the heart of Bromsgrove. When first registered only personal care was provided, then the home was registered to provide both personal and nursing care for a maximum of 30 older people. It was then temporarily closed and completely refurbished, and is now registered to provide personal and social care to a maximum of 37 older people with dementia. The home has been refurbished to a good standard, with accommodation provided on two floors. Access is provided to both floors by way of either stairs or a central passenger lift. The home is part of a group of homes owned by Alpha Health Care limited. The charges for this home identified at the time of Inspection ranged from £346- £495 a week. Additional costs include hairdressing, private chiropody, aromatherapy and alternative therapies. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an inspection undertaken by one Inspector without prior notice. It included a tour of the building, talking to staff, 3 managers, and a review of records including information forwarded by the Manager. Care records were reviewed as part of the ‘case- tracking’ of four people who live at the home, and three staff files were reviewed. A random selection of people and their relatives and friends were talked to during the Inspection, and they were asked about life at the home and the care they receive. There were 2 requirements from the last inspection that had not been addressed; a further 12 requirements have been made as a result of this inspection. What the service does well: What has improved since the last inspection? What they could do better: To enable this home to go forward and provide care for individuals who face substantial levels of risk, there is a need for effective management and leadership. Care records and risk assessments must be able to be relied on for accuracy and individualised preferences. Appropriate actions must be taken to safeguard individuals to maintain their health and well being and managers Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 6 must ensure that staff understand the implications of failing to adequately protect residents. Competence in care practice needs to improve and take into account the client group’s physical, mental health and communication needs and staffing needs to increase. The team should pro-actively solicit and follow advice from other professionals to assist in meeting high dependency needs, challenging behaviour and physical frailty so that residents are not placed at risk of harm, lack of supervision or institutionalised practices. The Home must develop a greater awareness of concerns about unexplained injuries and the high rate of accidents. Appropriate procedures must be followed in relation to any allegation about actual or suspected abuse /abusive practice, or neglect, so that residents are protected from harm. Any complaints received must be fully investigated, and taken seriously and consequent improvements must be actioned. Safe systems and monitoring must be in place for risk management and policies about restraint must be supported by practice which ensures that resident’s freedoms and liberties are maintained. This needs to be supported by effective training and appropriate supervision systems. Suitable arrangements must be in place for infection control, satisfactory standards of hygiene and safe access within the home. Equipment must be in good working order and in adequate supply. A suitable environment should be developed which meets the client group’s needs. Laundry and cleaning services need to improve and service users must be consulted about their social interests so that there is more engagement with the local community. 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. Regents Court Care Home DS0000004151.V344314.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 Regents Court Care Home DS0000004151.V344314.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): 1,2,3,4 (6 is not applicable) Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some prospective people are not being adequately assessed prior to admission. The lack of detailed assessments of residents needs and unavailability of terms and conditions of residency does not give total assurance of the completeness of information provided and as a dementia home, provision of dementia care is not based on current good practice guidance. EVIDENCE: The service has developed a Statement of Purpose which sets out aims and objectives of the home. There is a service user guide available in standard written format, which is placed in the drawer of each resident’s room. Residents have an assessment of needs made prior to coming to live at the Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 9 home but this appears to be process rather than needs driven. Information gathered could be scant and varied according to extent and depth and did not always reflect individual’s needs, particularly in relation to dementia care. Preassessment did not reflect the range of illness for example from mild to severe memory loss, and consequently did not reflect individualised descriptions of behavioural needs. The information did not give reassurance that the home was able to meet a wide range of challenging need and high levels of dependency. Staff were observed interacting with residents and and it appeared evident that they were not familiar with person centred communication in relation to meeting the needs of people with behaviour that can challenge. A member of staff was observed with a resident with little memory loss and marked independence. The staff member failed to interact at an appropriate level with the resident and did not promote the person’s independence, insisting on doing unecessary tasks that the resident was very able to do for themselves. Staff were also observed trying to make a resident with challenging behaviour sit down when the resident wanted to be involved in preparation. The manager said that either the resident or a family member are provided with a contract of residency and that a copy is held on file. When a copy of the contract was requested the manager said: ’ They are not kept here, they are kept at HQ, but I have asked for them to be here’, consequently no contracts were available for inspection on the day. (The home does not accommodate people who need Intermediate Care and the Commission For Social Care Inspection has not been made aware of any plans to do so). Regents Court Care Home DS0000004151.V344314.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): 7,8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health, personal care, privacy and dignity of residents fails to be accurately, consistently or safely promoted, managed or maintained by either staff, care planning or management systems in the home. EVIDENCE: Care plans exist but instructions and content are poor and frequently inaccurate and can fail to highlight high levels of individualised risk. This can impact on residents’ needs not being fully met, resulting in ineffective care and consequent high levels of poor risk management. One case tracked resident lacked fluids contrary to district nurse advice and care staff were not aware of the resident’s hydration needs. One staff member was asked about the resident’s needs for regular fluids and the person said: ‘I Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 11 am not a doctor’. A resident’s care plan failed to accurately indicate that she had experienced a fracture, skin problems, swelling in both feet and had a leg ulcer. A member of care staff was observed failing to follow care plan advice and did not properly cleanse ulcerated skin and applied aqueous cream on top of encrusted skin plasma. On one resident’s records it said the individual had ‘good hearing’ yet 3 weeks earlier in the file the person was noted as being ‘hearing impaired’. Manual handling instructions were not always clear. One resident was observed being hoisted by one carer and there were no instructions in the care plan about hoisting. On one resident’s care record it was noted stated that their mobility had worsened owing to surgical problems yet an entry three months later stated that there was no change to the original moving and handling assessment. Care plans were not formally agreed with and counter-signed by the resident and/or their next-of-kin or representative. One resident who was fully able to communicate well said they had not been given the opportunity to discuss their care plan, and said ‘ I have never seen a care plan or signed anything’. Care plans were reviewed but this was inconsistent and not always done on a regular basis and reviews did not always contain accurate or up to date information. One resident had a ‘Waterlow Assessment’ for pressure sores which was inaccurate and was assessed at low to medium risk, yet the assessment failed to refer to a variety of risk factors which if they had been noted would have increased the score to very high risk for pressure sore development. Another resident experienced a high number of falls, and 11 incidents were recorded but this number was different to that recorded in both the accident records, and the accident audit system. Two residents had been identified as frequent fallers with associated moving and handling risks, but both care plans failed to propose a form of risk management. Resident’s personal dignity was not always promoted or maintained by all staff. Personal care was observed being provided by a male member of staff to a female resident. When the resident was asked if this was their preference they said that they would prefer a female carer but had not been asked. A staff member was observed singularly hoisting the same resident into a wheelchair in a manner that seriously compromised her dignity and personal privacy, failing to cover the resident’s lower body. Residents do not always wear their own clothes. A resident’s daughter was visiting and she stated that it was frustrating when things went missing from her mother’s room and that twice she had seen two people wearing her mother’s clothes. Supervision of residents who need assistance with eating is inconsistent, which can mean that resident’s do not eat what is in front of them. For example staff were very busy supervising in the dining room where there were more people with challenging behaviour which meant that staff were not available to assist other residents in of the 3 rooms where residents were eating. Residents who need supervision to eat are at risk of not eating properly owing to a lack of Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 12 staff in dining rooms. One resident was observed at breakfast where she spent 40 minutes with her head in a cup or in a bowl trying to eat without any assistance. When staff were asked about this they said she ate independently, yet the care plan said she needed assistance. Most staff were seen to be respectful to residents and polite. Resident’s appearance was noted to look tidy and clean and some men were shaven. Some staff knocked on bedroom doors before entering. Medication was observed to be managed in accordance with previous inspection advice. Entries to medication administration records were countersigned by two care staff which confirmed the authenticity and accuracy of any amendments, and records appeared to illustrate actual doses of medication administered if a variable dose had been prescribed. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 13 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): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are not always helped to exercise choice and control over their lives and are not always consulted about their social interests. Arrangements do not always exist to enable residents to engage in local social or religious activities. Lifestyle in the home would not appear to always match the expectations and preferences of the more mentally able residents and the nature and circumstances of that invoke deprivation of personal liberty are not always recorded. Residents receive a balanced diet of wholesome and nutritious food. EVIDENCE: Residents expectations and preferences are not always met in relation to social, cultural, religious and recreational needs and there was little specialist activity based on good practice recommendations. For example resident’s were not seen engaging in any meaningful participation, or sensory activity and they appeared over compliant with home routines. One resident was observed Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 14 having sat in a chair for 5 hours where he ate lunch and dinner and said to his neighbour: ‘I have sat in this chair all day’. On asking another resident if he enjoyed life in the home he said: ’I am very lonely, this is only existing, not living’. During the Inspection a visitor stated that she had been a friend to some residents for 20 years and she knew them from church where they had been frequent attenders prior to their move to the home but said since living in Regent’s Court ‘they have never been to the Church’. On discussion with one of the residents about his religious preferences he said he very much wanted to return to the Church. An activities organiser is employed and there is a contracted complimentary therapist. When asked about the prospects of an activities programme the organiser said: ‘no activities programme as such existed as most activities are on a one to one basis,’ and more dependent residents are offered aromatherapy and hand massage but this can be charged for. An annual trip to the theatre, some pub trips and occasional visits from the local Church also take place. A local group had been involved in a decorating project. Birthdays are celebrated on a small scale. The Activities Organiser said last year there were plans for a snoozelem room which had not moved forward. Plans were described for a multi sensory garden, and a newsletter exists for those who can read it. One more physically able resident attended a local computer training course. However when asked if she went out to other local facilities, she said ‘I am not allowed out on my own, except to the garden, because I have had a stroke’. She added that she did not know any of the keypad codes to leave the building and said ‘ I would love to be able to go to the shop or for a walk.’ On a resident’s care record it said she was independent in oral care but on observation she was not offered the choice to brush her teeth during her morning care, or asked if she would like to brush her own hair, nor was she offered a mirror and not all residents were asked if they would like to go to a dining room to eat. An appealing balanced diet was available, and the cook was aware of individuals various food requirements. One resident commented that the food ‘was good’, and it appeared wholesome and nutritious. Breakfast consisted of toast and a cereal, with two hot choices for lunch. Pieces of fresh fruit were offered during the day, however fluids need to be more freely available. In a 12 hour period drinks were only seen to be offered at meal times and at 3pm. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 15 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): 16, 17 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health, personal care, privacy and dignity of residents fails to be accurately, consistently or safely promoted, managed or maintained by either staff, care planning or management systems in the home. People are not, therefore, adequately protected neither are they confident that their complaints will be properly addressed. EVIDENCE: A complaints procedure was displayed on the wall, but it is unlikely that this had meaning to many resident’s owing to their severe mental health conditions. From observations some more able residents were not confident that their complaints would be listened to. One resident said she had complained several times of the loss of two pairs of shoes but staff did not take any notice. On discussion with staff they proceeded to advise the resident that she was wrong, but then realised that shoes were missing. Another resident was in bed and complained of a sore throat but this was ignored by the care staff on duty. Six complaints have been received by the home in the last 6 months about neglect of different residents. These have come from social workers, doctors and family and have been referred for investigation under the local ‘adult Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 16 protection’ procedures. At the time of the inspection, the outcomes of these investigations were still awaited. From inspection some residents would appear to have been exposed to high levels of risk. In some of these cases, although some health interventions were made, the adult protection procedure was not always followed and recording was not accurate or kept up to date. One resident was observed as having unexplained bruising to his left hand between his thumb and forefinger. The person could not recall how the injury occurred and there was no entry in the accident record sheets, or in the accident audit records, or in his daily record. On discussion with the manager she was not aware of the bruising and said ‘if this had been done deliberately I think he would have said something’. The manager said that if she thought this was abusive she would have referred it to the local authority. Another resident was observed with a large facial bruise on their right cheek but the person was unable to say how this happened. On inspection of the resident’s care record file the bruise was marked on a body chart, but there was no entry in the accident records or the accident audit. On discussion with staff no explanation of the bruising could be offered and they said ‘she may have fallen out of bed’. Another resident was observed with unexplained injuries that were several weeks old to both right and left shins. On a record called ‘Monthly Assessment of Change’ for August, an entry stated that the staff had found the resident in her room with cuts to the front of both of her legs, but were not aware of how this happened. Again although there was also a reference to the injury in ‘daily progress sheets’, there was no entry in the accident record or accident audit. The manager was aware of both situations but was not aware of the variance in recording. Assessments are inaccurate which causes a failure to adequately protect residents. For example there was a letter of concern from a relative about a resident who had a consistently high number of falls. The falls assessment was assessed as medium risk yet the information was outdated and inaccurate. Had accurate information been assessed it would have increased the score to very high risk. On inspection of the care records there was no risk management structure in place, nor had any advice or guidance been sought from falls assessment specialists. Another resident’s care records showed inaccurate assessments which fail tro recognise the level of high risk for individuals. A resident was assessed as ‘medium dependency’, and ‘medium risk’ for falls, yet the dependency assessment stated there was ‘no history of falls,’ when at the time of its completion the person had experienced 11 falls in 6 months. On scrutiny of the falls assessment, seven key assessment areas had been ignored. If they had not been ignored the falls score would have increased from 14 to 22, which is very high risk. On discussion with the manager she stated her own level of Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 17 concerns about this resident’s frequent falling, but she did not seem aware of the problems with inaccurate risk assessment and inaccurate recording. She assured that an Adult Protection Policy and Procedure is in place and that if she suspected abuse or abusive practice she would alert the local authority, however the local authority had not been alerted by the manager in any of the aforesaid situations. The manager was also aware that accident auditing, risk assessment and risk management needed to be improved. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 18 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): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users who live in this home are not adequately protected by suitable arrangements to prevent infection and its possible spread. Satisfactory standards of hygiene are not maintained. The home is not free from offensive odours and residents using this service are accessing areas which are hazardous, and their safety is compromised. Not all parts of this home are kept clean or tidy and equipment is not always in good working order or in adequate supply. EVIDENCE: A programme of routine maintenance appeared to be in place, but records were not thorough or up to date. Various Gas Safety checks had been carried out. A year ago there was a periodic inspection for electrical installations but Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 19 this excluded the installations in the extension. 12 electrical safety recommendations were made but it is not clear whether these have been completed. The soiled waste disposal system showed no written evidence of safety inspection. At the site all resident’s rooms, communal toilets, the sluice room, 3 lounges, 2 annexed dining rooms, the kitchen, laundry and patio were inspected. Communal space included three dining rooms, two annexed with two television lounges. There is a well kept garden and patio area. Lighting was sufficient. Communal toilets were near both downstairs lounges, and were marked with a toilet picture. Some rooms were en-suite and there are two communal bathrooms. Some rooms were shared but screening was present. Some residents’ rooms had doorways which appeared narrow for wheelchair use and could only be accessed by careful negotiation. There were not many grab rails visible in rooms and bathrooms. Two hoists were available, and two bath hoists, but there were no visible high toilet seats, or toilet frames for those who may have needed them. Three wheelchairs were available for use one of which had difficulties in its operation remarked upon by the staff trying to use it who said: ‘this wheelchair is like one of those supermarket trolleys that has a mind of its own’. One walking frame was being shared in one of the main lounges between 4 people, but 19 frames are reported to be in the home. The home had few signs and communication aids for residents with dementia needs for example some rooms had no signs, pictures or numbers on the doors. Call systems in rooms seemed to work but one call system in an upstairs room was not plugged in and was placed away from the resident’s bed. Not all rooms were very warm but were quite well decorated. In the attic extension one room was cool in temperature and some radiators did not appear to be working fully. The resident who was in bed said ‘I am cold’. Communal bathrooms in the attic extension were also cool, but water temperature was acceptable. A policy for Infection Control was in place, but this was contravened by the evidence seen during the inspection. For example in one resident’s room there was an offensive smell of urine and a very wet carpet. In another resident’s room there was an extremely offensive smell and heavily urine soaked fabric chair and a urine soaked bed. The chair had several layers of previous staining and was exceptionally dirty and had coatings of dirt on the arms. The floor was in need of cleaning and hoovering. In another resident’s room there was urine soaked into the carpet and urine on the hard surfaced bathroom floor, whilst in another resident’s bathroom there were hardened faeces on the floor. In another room there were old faeces splashed up the wall by the toilet and new faeces on the bathroom floor by Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 20 sink. One resident was eating breakfast in their room beside an open and full commode and another resident was eating breakfast in her room with two tissues on floor with faeces in them. An ambulant resident was in the downstairs communal toilet that was covered in urine on the hard surface floor. The external patio had two urine soaked chairs drying outside. The Kitchen sluice sink was dirty and although laundry facilities existed it was untidy with resident’s clothes scattered on the floor. There were no domestic staff available to interview about the unclean state of the home. On discussion with the manager she said she knew there were problems in the laundry and the kitchen. She said she also knew there were problems with domestic staff hours. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users who use this service are not safe as a result of how the service is delivered and this has exposed them to a high degree of personal risk with some very serious consequences. Increased occupancy rates, dependency levels and cognitive disabilities of some residents has placed an ill equipped staff group under increased pressure to meet a range of additional complex needs, and a diminished and deteriorating service quality has resulted. The service has not promoted or encouraged the need for a competent staff team and staff do not individually or collectively have the skills or experience to deliver the specialist services which the home offers to provide. EVIDENCE: Since the last inspection there have been 5 adult protection issues raised by various professionals regarding resident’s care at this home within a period of 4 months - from April to August 2007. These involve allegations of neglect, isolation, soiling, high rates of falls, unexplained bruising, lack of resident supervision, over sedation, malnourishment, dehydration, pressure sores, poor Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 22 manual handling, poor practice and problems over security of the resident’s belongings. Staff are not assessing or recording the correct levels of risk for individuals with high levels of physical frailty and care plans are not completed properly in relation to the level of risk that individuals face. Resident files and recording systems seem to be huge and unwieldy and are frequently missing key information and clear risk management strategies which appears to be causing confusion in what staff are exactly supposed to be doing. One resident had a recorded nutritional assessment score of 9 as low to medium risk which failed to reflect additional information which was available on the resident’s file. If the assessment had included the accurate and up to date information the nutritional assessment score would have been increased to at least 21 - which is very high risk. Supervision of staff in relation to care planning or provision is not filling this gap. Poor staffing levels, consequent poor supervision of residents and staff inexperience in dealing with high need residents - are posing risk to the people who are using this service. For example one resident waited two and half hours for personal care. When the care staff were asked why this was the case one responded with ‘I have done 4 since 8’ o’clock’. When the manager was asked why this was the case she was concerned about the staff’s response. The home has clearly increased its occupancy rates and staff do appear to be under increased pressure to meet additional complex needs of residents. The staff complement therefore would not seem adequate in relation to assessed needs of the resident group and domestic staff do not appear to be employed in sufficient numbers, or hours. Staff complement needs improving as this is affecting resident’s care needs being met for example one non-ambulant resident was observed having waited half an hour to get assistance to use the toilet. Another two resident’s care plans referred to them both requiring assistance to eat but both were observed at breakfast with no staff supervising or assisting. Another resident waited two hours for breakfast and her first morning drink when her care plan indicated that she needed plenty of regular fluids. One resident was observed at breakfast asleep with his head on the table and did not eat anything nor was he encourage to eat. A recruitment procedure exists and CRB checks are in place and two references were in place for the three staff records that were checked. Staff training warrants improvement as they do not appear skilled enough to meet the emotional and physical needs of residents in a care home with a dementia registration, which means they may not recognise the importance of individualised person centred support. For example some residents were seen to be rushed ; their dignity was compromised; corners were cut and the home was not always clean and posed a high risk of infection. When the managers Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 23 were asked about staff training they assured that Induction was in place and said it followed national requirements. They stated that an Induction pack was available but it was evident that staff were not trained in the mandatory requirements necessary. For example a comprehensive training plan is not in place and training records lack accuracy and detail. Training provided appeared to be weak, with areas not being identified or targeted for individuals. For example in 2006 and 2007 targets for basic requirements such as Health and Safety, First Aid, Infection Control, Adult Protection, and Manual Handling were not being met within the first 6 months of employment. Over the last year only some staff had availed some training and little has been achieved in the areas of Food Hygiene; Health & Safety, First Aid or Dementia training. One record said that all staff had received Adult Protection training, whilst another conflicted and said that only 4 staff had received it. Training in falls prevention or person centred care was not evident. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use this service are not safe as a result of how the service delivers its management and administration. Quality assurance systems are not effective and risks are not always highlighted or managed effectively. EVIDENCE: The home has nearly doubled occupancy since its new registration. It has admitted residents with both profound levels of dementia and those who have mild memory loss. Many residents also have high levels of physical frailty. One younger resident has a generic mental health problem. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 25 It would appear that staffing levels, and a lack of staff skills are not guaranteeing quality outcomes in safe care and health practice. When the manager was asked about this she said she had been working under undue pressure owing to staff shortages, staff leaving, and a lack of administrative support from her employer. When asked about her own training she said she needed to learn more about dementia and that although there had been some dementia training provided by the employer it was not enough. However plans were in place to provide more dementia training for staff with an external provider. She had received some Infection Control training from her employer. In relation to the lack of staff skills it was noted that the in house training programme which the manager and staff access do not offer courses on pressure sore management, tissue viability, health conditions and diseases of old age and person centred care. Recent concerns regarding the poor physical health of residents and allegations of neglect, are supported by the fact that both manager and staff would not seem adept in risk managing the severe complexities that physical frailty can bring within the resident group. There is a lack of team knowledge in relation to tissue viability, falls management, incontinence management, manual handling, promoting independence, first aid, health and safety, adult protection and the communication skills for person centred approach in dementia care. It would appear that the implementation of policy and procedure is not adequately protecting residents at Regent’s Court. Many written policies and procedures exist (with some exceptions) but staff do not always perform in accordance to policy. The Infection Control Policy is in place but from many observations this policy was directly contravened on numerous occasions. The home is not maintained in a clean manner and domestic staff ratios or hours are inadequate. An adult Protection Policy is also in place but there seems to be a possible reluctance to refer residents to Social Services, and there is evidence of a high rate of unexplained bruising, accidents and unexplained injury. On some occasions family, GP or district nurse has been informed of these events but on others there are inaccurate records, inaccurate risk assessments and ineffective risk management. There are a high rate of falls, accidents and injuries but a lack of external specialist advice, other than local GP and district nurse involvement. The application of quality assurance systems particularly in relation to the recent allegations of neglect of residents from social workers and GP’s are not robust or effective and direct supervision warrants improvement. Accident Audit systems are not accurate, and are unlikely to be whilst they are based on inaccurate staff recording in care records. Direct supervision and leadership ethos needs to be more prominent. For example on 4 days in one month there Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 26 were no managers present on duty in the home, which under the present circumstances would not seem to encourage a strong ethos of leadership or direct access to immediate supervision. Some staff supervision records existed but they were not dated and they lacked detail. The last inspection commented on problems with care planning and the home’s self assessment says that that this has improved, when all previously stated evidence herein would say that care plans are not up to date nor are assessments accurate in relation to the level of risk documented in the plan of care. Senior Care staff are not always aware of other professionals’ advice. The advice in one resident’s care record from a district nurse said that owing to a resident’s present poor health fluids were to be ‘pushed’. On discussion with the Senior Care staff they were not aware of any issue relating to hydration for the resident and thought it unnecessary for the resident to be monitored for fluid intake on a chart. There was no evidence of any service user surveys being undertaken but, with regard to the views of family, friends and community stakeholders, there was extreme variance in the nature of the comments being made, as reflected elsewhere in this report. Two social workers and two doctors have made allegations about neglect of care. One relative has written a letter of serious concern, one visiting relative has said ‘the care is OK, but it is frustrating when clothes go missing and other people are wearing them’. A visiting friend has said: ‘They don’t seem to do anything with residents. They sit here all day. They hardly ever go out.’ Security seemed inconsistent in the home. The internal premises seemed highly secure to the point for some residents of depriving certain freedoms and liberties, yet the door to entrance hall to the car park was left open. Safe storage of medicines was observed, and lockable cabinets were in place. Gas Safety checks were in place, but were due for review. Water temperature appeared to be regulated and external areas appeared well maintained. Décor appears new in many areas but the environment lacks stimulus or colour. Financial accounting procedures appeared to be in place and records of transactions were kept and written transactions of the management of service user’s money were recorded with separate accounts kept for aromatherapy bills, all of which were sent to families. Records and receipts were available. The manager was aware of the strategic direction of the Company and the desire to make Regents Court a dementia care home, and was aware of the Company’s financial procedures. The manager appeared to work in close partnership with the provider and maintained regular contact. Training and development of staff was poor and staff lacked effective supervision. Policies were reviewed but staff are not always implementing policy. Quality assurance mechanisms are in place but they do not function as a core management tool. The philosophy of the home would appear to be discussed in supervision in Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 27 relation to resident’s personal rights but then these can be ignored and person centred care is not always evident in practice. There is a high number of accidents and staff can cut corners and ignore basic safe practices. The home has direction but lacks the skills and competencies to fulfil it. There would appear to have been a lack of support from the parent organisation and a serious lack of monitoring of the running of the home from directors and senior members of that organisation. Resources are at an unacceptable level and people who use this service are not adequately protected by its management or systems. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 28 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 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 2 18 1 2 3 3 2 x 2 2 1 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 x 3 1 1 1 Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 15(1) Requirement Timescale for action 06/11/07 2. OP7 15(2) 3. OP10 12(4) Care plans must be developed to include the care required to meet the assessed needs of people using the service. Care plans must be formally agreed either with the people, or with their representatives if they are unable to provide informed agreement. This is to ensure that staff understand the care to be provided to people, and are able to provide this care in a consistent manner. Remains outstanding from the previous inspection – timescale for action 31/12/06 Care plans must be reviewed 06/11/07 regularly by a care staff in order to identify people’s changing needs. Remains outstanding from the previous inspection – timescale for action 31/12/06 All people using the service must 31/01/08 be treated in a manner which respects their privacy and dignity. DS0000004151.V344314.R01.S.doc Version 5.2 Regents Court Care Home Page 30 4. OP30 13(6) 5. 6. OP38 OP38 13(5) 18(1) 7. OP26 13(3) 8. OP26 16(2)(k) 9. 10. OP26 OP22 23(2)(d) 23(2)(c) 11. OP13 13(7) and 13(8) Arrangements must be put in place, including the training of staff, to prevent people using the service being placed at risk of harm or abuse. A safe system must be in place for moving and handling people who use the service. Staff must receive training appropriate to the work they are to perform. In particular, a staff training and development programme which meets Skills For Care requirements must be in place. This is to ensure that staff are able to meet people’s needs in a holistic manner and provide care in a safe way. Suitable arrangements must be in place to prevent infection and the possible spread of infection, and to maintain satisfactory standards of hygiene. This is to safeguard people’s health and safety. The home must be free from offensive odours, and suitable arrangements should be in place for the regular emptying of commodes. This is to safeguard people’s health and comfort. All parts of the home must be kept clean. This is to safeguard people’s health and comfort. Any equipment at the home must be maintained in good working order and in adequate supply. This is to ensure that people’s needs can be met in a safe and effective way. Issues around deprivation of a person’s liberty must be identified and addressed through care planning and staff training. If, on any occasion, a service user is subject to physical restraint, the circumstances and nature of the restraint must be DS0000004151.V344314.R01.S.doc 31/03/08 31/03/08 31/03/08 31/03/08 31/03/08 31/03/08 31/03/08 31/03/08 Regents Court Care Home Version 5.2 Page 31 12. OP26 16(2)(f) 13. OP12 16(2)(m) and (n) 14. OP17 22(2) and 22(3) recorded. This is to ensure that no service user is subject to physical restraint (e.g. denied access to leaving the premises) unless it is the only practicable means of securing the welfare of that or any other service user and there are exceptional circumstances. Adequate facilities must be 31/03/08 provided for people to have their laundry sorted and kept separately. This is to ensure that the dignity and comfort of people is respected. People must be consulted about 31/03/08 their social interests, and arrangements must be in place to enable them to engage in local, social and community activities. This is to ensure that people’s social needs and expectations are met. The complaints procedure must 31/03/08 reflect the needs of people using the service. Staff must be aware of the procedure and ensure that any complaint made is fully investigated and feedback is given to the complainant in an appropriate format. This is to ensure that people’s concerns are addressed promptly and effectively. 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. Refer to Standard OP27 Good Practice Recommendations Staffing levels should be reviewed to ensure that the home is staffed in accordance with the needs of the residents DS0000004151.V344314.R01.S.doc Version 5.2 Page 32 Regents Court Care Home within the home. Regents Court Care Home DS0000004151.V344314.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Regents Court Care Home DS0000004151.V344314.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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