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Inspection on 28/07/09 for Tower Bridge Care Centre

Also see our care home review for Tower Bridge Care Centre for more information

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

What the care home does well

This is a large care home of simple design and layout with ample space for residents to wander around. Many residents experience good care and told us everything was “alright here”. ‘Alright’ was a frequently used phrase by residents and visitors. Some added to this by telling us Tower Bridge is, “Quite nice and everything is okay”. We saw, and the expert confirmed in her observations, that some carers were good, kind and caring in their manner towards residents. We received a survey form, completed anonymously, that told us, “The home is providing the correct support to achieve comfort and health for the elderly”.

What has improved since the last inspection?

The requirements we made in our report in 2008 have been addressed or are in progress. So, for example, the home is following the correct procedures for dealing with allegation of abuse or neglect; water temperatures are being regularly monitored to ensure residents’ safety; fire doors are being checked to ensure they function properly; faulty equipment has been replaced or repaired such as the washing machine. In summary the out-going manager had addressed these matters before leaving the employment of Southern Cross earlier in the year.

What the care home could do better:

The Commission is concerned about the absence of a registered manager, a new manager has been appointed but the turnover of managers means Tower Bridge still does not have consistent and enduring leadership and this may explain why we found variable care practices and some poor environmental standards. We found for example that some staff did not demonstrate theTower Bridge Care CentreDS0000007047.V376776.R01.S.doc Version 5.2 level of respect and dignity towards residents that they should expect. The expert saw some staff were ‘snappy’ towards residents, such that when a resident asked for help to move out of the dining room the staff response was rather unkind and brusque, “We’re still serving dinner”. Equally undignified was the reference to a male resident that he should try to “keep his dress clean”, this seemed to reflect a poor understanding of English and gender issues. Staff had failed to notice, or failed to act upon, the fact that a bedroom door was left open and the resident was in a state of undress. We also noted an inappropriate radio channel was playing loudly in one lounge area indicating that staff had little understanding of what might be appropriate for, or chosen by, the group of residents in that area. We have noted that the poor attitude of some staff did not apply to all staff but for those residents who experience this sort of poor care it must be most unpleasant and does not reflect the quality of care offered in the home’s brochure and charter of rights. We observed how little social engagement there was between staff and residents; contact with residents seemed limited to specific ‘care’ tasks otherwise residents sat quietly and in a somnolent state waiting for something to happen. Our expert noted that when she sat with the residents, who were initially rather sleepy, some became quite animated and were very responsive and seemed pleased to be with someone who shared, or had a good understanding of, their language and cultural background. Some visitors intimated their concerns about the care provided in Tower Bridge. They offered no specific evidence of poor care practices but they indicated that they lacked confidence in the home and thought it necessary to visit quite often to monitor the well being of their relative – “to keep an eye on things here”. The new manager will therefore need to gain the confidence of residents and their visitors over the coming months. We also felt that staff should be alert to the way families are communicating with residents since the expert noted tensions between residents and their visitors that would have benefited by staff intervention but it didn’t happen. Possibly the nuances of language, both spoken and the ‘body language’ , were missed by staff. Other specific examples where improvement is indicated is in the provision of meals. Whilst many residents said the food in this care home was ‘alright’ some commented on how tough the meat was sometimes. We thought the provision of sliced, fresh fruit during the day was commendable but the jugs of fruit juices arrived without cups to drink from. In another area we noted that the cups were chipped. Staff were very busy such that some medication and morning coffee were both delivered rather late in the morning. This may indicate that there were insufficient numbers of staff on duty at busy times of the day. We also noted that if agency staff were needed, to supplement staff numbers, authorisation had to come from a regional director and not the home or local area manager; we would expect the registered manager to have a degree of autonomy and delegated authority, with suitable budget controls, to make such day to day decisions. At present many residents think Tower Bridge is no better than “Alright” which is reflected in our assessment of a home that is providing poor outcomes for residents and warrants a nil star rating. We shall require the service to send us an action plan as to how they will meet standards.Tower Bridge Care CentreDS0000007047.V376776.R01.S.doc Version 5.2 Page 8

Key inspection report CARE HOMES FOR OLDER PEOPLE Tower Bridge Care Centre Tower Bridge Care Centre 1 Tower Bridge Road Southwark London SE1 4TR Lead Inspector Michael Williams Key Unannounced Inspection 28th July 2009 10:00 DS0000007047.V376776.R01.S.do c Version 5.2 Page 1 DS0000007047.V376776.R01.S.do c Version 5.2 Page 2 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 3 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Name of service Tower Bridge Care Centre Address Tower Bridge Care Centre 1 Tower Bridge Road Southwark London SE1 4TR 020 7394 6840 020 7394 7198 towerbridge@schealthcare.co.uk 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) Southern Cross Healthcare Services Limited Mrs Virginia Cheytan Care Home 128 Category(ies) of Dementia (128), Mental disorder, excluding registration, with number learning disability or dementia (128), Old age, of places not falling within any other category (128) Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 5 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, (not falling within any other category) – Code OP Dementia 2. Mental Disorder The maximum number of service users who can be accommodated is: 19th August 2008 Code DE Code MD 128 Date of last inspection Brief Description of the Service: Tower Bridge Care Centre is owned by Southern Cross Healthcare Group PLC and the manager confirmed that the certificate gives the correct details of ownership. Tower BCC is a large purpose-built home, with four floors, providing care for up to 128 older people, the majority of whom have single rooms with en-suite toilet and basin. As its name indicates, this home is just to the South of Tower Bridge, London, and so it is close to a wide range of services and facilities. The home provides care, including care for people with dementia to varying degrees on each floor so that on two floors nursing care is provided and on others floors care is at ‘residential’, non-nursing level. The Commission has recently reviewed the registration conditions to ensure they are within the correct legal framework and the revised conditions are listed in the preceding section of this report. There is ample communal space, lounge and dining rooms, on each floor and there is a small courtyard garden to the front of the premises; there is also car parking space in front of the building. The fees for the home range from £503 to £866 a week as at July 2009 and additional charges will be made for personal items and further charges will negotiated with the purchasing authority if the need for extra arises. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The inspection visit for this key inspection was unannounced and took place on the 28th July 2009. Mr Williams was the lead inspector and he was accompanied by two other inspectors, R Blenkinsopp and A Ford; in addition an ‘expert by experience’ (who is referred to in this report as the ‘expert’) assisted the Commission on this occasion. During our visit we spoke to residents, their visitors, to staff and management and we noted any written feedback in the surveys we circulated. We also took into account information we have accrued since the last visit in 2008. What the service does well: This is a large care home of simple design and layout with ample space for residents to wander around. Many residents experience good care and told us everything was “alright here”. ‘Alright’ was a frequently used phrase by residents and visitors. Some added to this by telling us Tower Bridge is, “Quite nice and everything is okay”. We saw, and the expert confirmed in her observations, that some carers were good, kind and caring in their manner towards residents. We received a survey form, completed anonymously, that told us, “The home is providing the correct support to achieve comfort and health for the elderly”. What has improved since the last inspection? What they could do better: The Commission is concerned about the absence of a registered manager, a new manager has been appointed but the turnover of managers means Tower Bridge still does not have consistent and enduring leadership and this may explain why we found variable care practices and some poor environmental standards. We found for example that some staff did not demonstrate the Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 7 level of respect and dignity towards residents that they should expect. The expert saw some staff were ‘snappy’ towards residents, such that when a resident asked for help to move out of the dining room the staff response was rather unkind and brusque, “We’re still serving dinner”. Equally undignified was the reference to a male resident that he should try to “keep his dress clean”, this seemed to reflect a poor understanding of English and gender issues. Staff had failed to notice, or failed to act upon, the fact that a bedroom door was left open and the resident was in a state of undress. We also noted an inappropriate radio channel was playing loudly in one lounge area indicating that staff had little understanding of what might be appropriate for, or chosen by, the group of residents in that area. We have noted that the poor attitude of some staff did not apply to all staff but for those residents who experience this sort of poor care it must be most unpleasant and does not reflect the quality of care offered in the home’s brochure and charter of rights. We observed how little social engagement there was between staff and residents; contact with residents seemed limited to specific ‘care’ tasks otherwise residents sat quietly and in a somnolent state waiting for something to happen. Our expert noted that when she sat with the residents, who were initially rather sleepy, some became quite animated and were very responsive and seemed pleased to be with someone who shared, or had a good understanding of, their language and cultural background. Some visitors intimated their concerns about the care provided in Tower Bridge. They offered no specific evidence of poor care practices but they indicated that they lacked confidence in the home and thought it necessary to visit quite often to monitor the well being of their relative – “to keep an eye on things here”. The new manager will therefore need to gain the confidence of residents and their visitors over the coming months. We also felt that staff should be alert to the way families are communicating with residents since the expert noted tensions between residents and their visitors that would have benefited by staff intervention but it didn’t happen. Possibly the nuances of language, both spoken and the ‘body language’ , were missed by staff. Other specific examples where improvement is indicated is in the provision of meals. Whilst many residents said the food in this care home was ‘alright’ some commented on how tough the meat was sometimes. We thought the provision of sliced, fresh fruit during the day was commendable but the jugs of fruit juices arrived without cups to drink from. In another area we noted that the cups were chipped. Staff were very busy such that some medication and morning coffee were both delivered rather late in the morning. This may indicate that there were insufficient numbers of staff on duty at busy times of the day. We also noted that if agency staff were needed, to supplement staff numbers, authorisation had to come from a regional director and not the home or local area manager; we would expect the registered manager to have a degree of autonomy and delegated authority, with suitable budget controls, to make such day to day decisions. At present many residents think Tower Bridge is no better than “Alright” which is reflected in our assessment of a home that is providing poor outcomes for residents and warrants a nil star rating. We shall require the service to send us an action plan as to how they will meet standards. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 9 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 Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1 and 3: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is providing important information about their service and is ensuring residents are appropriately assessed - so prospective residents can make a judgement about the home and whether or not it can meet their needs. EVIDENCE: We checked a number of care plan files and spoke to residents, their visitors and to staff including team leaders. There was assessment information in the files we checked. The Southern Cross paper work in one was well completed giving good information about the resident; this had been conducted but the previous floor manager. There is also a Dementia Assessment tool used for all those on Westminster floor this was also well completed. We were unable to locate the Community Care Assessment documentation in the files we inspected; this may be because in each care file holds only the Southern Cross forms and not the background information provided by other agencies such as Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 11 care managers. We understand that assessments are provided by social services when they are involved with any placements. Other information included information about advocacy, personal details and a property list. An initial care plan is set up when residents are first admitted. It was difficult to establish what information residents or relatives had been provided with prior to admission on whether a trial visit had been undertaken. Contracts were not inspected. Details of resident’s past history is something we have commented upon in the past and this has now been improved by including a ’Map of Life’ in the documentation so in some instances we found staff very well informed about the people they are caring for and so were better able to understand the behaviour of residents. The service has developed a residents’ guide, which sets out the aims and objectives of the home, and this folder also includes the more detailed statement of purpose - which provides basic information about the service and the specialist care the home offers. Both documents will need to be revised to take account of changes to the home’s manager and to the Commission’s details (because the Commission’s contact centre is now based in Newcastle and not London). The home’s guide is made available to individuals in a standard format. We were advised that each resident is given a copy and each has a contract, usually the local authority contract, but this is not kept in the main resident care folder as this is already very bulky. We previously found that not all case files contained an assessment by a suitably trained person such as a Local Authority Care Manager but the home now undertakes to ensure that in each case such an assessment is sought from placing authorities. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7 to 11: People using this service experience adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be advised that the home prepares detailed care plans but the care is inconsistent and varies from good in many cases to poor in too many instances. EVIDENCE: Whilst documentation in this home is very good the outcomes, that is, the quality of care experienced by some residents seemed less than good. Most significantly we found that the privacy and dignity of residents was repeatedly compromised by poor practice. Examples noted by inspectors and our expert include the brusque manner of some staff; the undignified manner in which some residents were left in their bedrooms with the door open; referring to male attire as a dress and some female residents looked bedraggled and unkempt in appearance. This person was sleeping in a lounge and she looked dishevelled with her hair scraped back, vest showing under her dress and no tights. We saw that several residents did not look very well cared for. In some instances their clothes were not very clean. One resident had poor dental health. For this person we did see a care plan but it just said ‘offer tooth Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 13 brush and paste’. With no further indication of how carers should support residents towards better dental hygiene nor did we see any indication that a dentist had visited. In another case file we saw a curious entry. Where a resident had been losing weight, the concern was and written as, “Relatives will be unhappy and staff will be upset”. This gave the impression that the response of relatives and of other staff was of more concern than the well being of the resident since no mention was made of the impact this weight loss would have on the resident losing weight. We find labelling of clothes undignified, with the use of black marker pens to inscribe a number on each garment. This method is still in use but we accept it will be some time before all clothing is appropriately marked with more dignified labelling. Whilst the processes and procedures for handling medicines were mostly satisfactory we did identify some points needing improvement. One photograph of a resident was missing; allergies were recorded on some charts but not all of them; abbreviations were sometimes used and the use of acronyms is open to misinterpretation and should be avoided. The drug reference manual was dated 2007 and needs to be updated. Other aspects of the control of medicines were satisfactory including administration charts, storage of medication, labelling of drugs and so on. In bedroom 9, we found a topical cream in an ensuite bathroom with the name label torn off and when we looked at the medicine administration chart for this person we found that it had not been prescribed anyway. We were advised that staff in the home are being and are being give guidance in end of life care; we note for example that an Occupational Therapist from a local Hospice is visiting the home to give advice on the ‘Gold Standard’ approach to end of life care. Information was clearer and ‘last wishes’ and other details about resuscitation were being recorded and kept in a readily identifiable location in each file. The former manager had acknowledged that this area of work is becoming increasingly important as residents make use of the new Mental Capacity Act to make known their expectations long before they become too unwell to express their final wishes. Documentation is now in place to record and review this very sensitive sort of information. We anticipate that the new manager will maintain this level of recording to ensure end of life care is well managed. Tower Bridge Care Centre DS0000007047.V376776.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12 to 15: People using this service experience poor quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are advised that this home has the facilities to offer a lifestyle might meet their needs and provide wholesome food in congenial settings but this is not always the case. EVIDENCE: A “Map of Life” provides good information in the case files about each resident’s past life and the reviews conducted by the local authority care managers also provided information about the resident, their family and relevant history. So staff now have the information needed to provide a good level of care and service but we found this was not always happening. As we have indicated in the summary of this report numerous lapses in care were noted by the inspectors. We have also received information directly from relatives and visitors about some poor aspects of care. Care staff should know that it is disrespectful to speak about a resident in their presence without including them to some extent in the conversation or at least acknowledge their presence whilst commenting. We observed one member of staff talking about a resident with no direct contact with that resident. We also found that residents were seen to be left unoccupied for considerable lengths of time. Staff were seen to be busy themselves but this left residents unengaged. It Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 15 was not unusual to find residents just dozing in their chairs or wheelchairs all day. We found as example that in one of the sitting rooms, eight residents were all dozing. A ‘D.I.Y.’ (home maintenance) programme was showing on the television and seemed to be of no interest to any of the residents present. No staff were present for some time. In another lounge four residents were in armchairs facing the window and all were asleep. In another lounge the planned activity was ‘music therapy’. However, the radio was playing a heavy rock-music channel; this was completely inappropriate. We asked if this was the music therapy listed on the activity programme for the day and were told that the C.D. (Compact Disc player) was broken and this was the only radio channel they could get on the radio used instead of the C.D. Despite this assertion about a faulty system the music was later changed to another more relaxing music channel. We are concerned that staff were showing little initiative or concern for residents. The loud and inappropriate music in this lounge indicated a want of sensitivity and awareness of the lifestyle and preferences of these aged residents. Until prompted to do so the staff made no real effort to change to a more suitable radio channel. The home employs an activities person and staff appear to see the ‘activity person’ as responsible for social engagement and therefore we saw only social engagement with residents. The cultural differences between staff and residents may also play a part here since staff who were not born in this country may not pick up on the clues and nuances of expression as well as someone sharing the same background as the residents. Our expert tended to confirm this finding. Secondly, there did not seem enough hours allocated to the role of activity coordinator. This is a very large home, spread over four floors and with up to 128 residents so the owners might consider increasing the hours required for this role. We were able to observe morning coffee beak and lunchtime. The dining areas were tastefully presented and are congenial settings in which to eat. Midmorning we noted on one floor that there were two bottles of orange and blackcurrant juice but no glasses and no one having a drink. When we queried this we were told the single member of staff could not leave the floor to go and get the glasses; the glasses were obtained some time later although throughout the whole morning period no one had a cold drink. When the mid morning drink arrived it was nicely presented with biscuits and a large platter of fresh, sliced fruit. These snacks plus tea and coffee were offered but it was 12:10 midday before the last mid morning drink was served. When lunch was served, two hot choices were available. The tables were nicely set up with cutlery, flowers, serviettes, menus and condiments. The qualified nursing staff served the lunch whilst care staff handed it out. The serving took some time and at the end of its service we tasted a small sample of the meal to see if it was still hot; although meals are served from a heated trolley, the mince was hot but the turkey meatballs were tepid and the vegetables cold. Twelve residents remained seated in their wheelchairs to have their lunch. They did not appear to have been given the opportunity to move to an ordinary dining chair to take their lunch at the dining tables. In respect of the food, we have received several comments about the quality and edibility of Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 16 food; one commentator said the meat was sometimes a bit tough, not tender enough and another told us that the roast potatoes (when served) can be difficult for residents to manage. Some residents say the food is alright and some said they enjoy the meals and the food is always very good. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18: People using this service experience adequate quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents cannot be assured of their safety at all times but procedures are in place to alert the appropriate authorities when complaints and incidents occur. EVIDENCE: To check the standards in this section we spoke to residents, relatives and staff; we checked the record of complaints and took note of the various notifications we received since the last inspection and this includes notification about safeguarding residents from abuse (where abuse or neglect may be suspected). We also received a small number of written comments that we took account of. Information on how to make a complaint was located in the bedrooms and was on display in the main lobby. During our previous visit in 2008 we made the following observations; residents we met gave the impression they were happy to report their concerns to the manager (this manager has since left the service). But in 2008 a resident gave a clear account of how things were being managed when she told us, “I did make a complaint about a member of staff and I know that it was addressed”. The resident was confident that, “The manager (at that time) would always sort any issues out when they arose”. We were also told by the same resident that she had, “Never seen staff member act unprofessionally and believes people are cared for very well”. So we concluded in 2008 that the procedures for addressing complaints were in order. Because the home has a new and unregistered manager we cannot confirm that residents and relatives will have the same level of confidence but the Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 18 processes and procedures for dealing with concerns and complaints remain in place and should be as effective as they were before. However, the fact that some visitors told us they felt the need to visit almost daily indicates a lack of confidence in the management of the home – not helped by the turnover of managers in recent years. We have been informed of far fewer incidents than last year but those that have been drawn to our attention caused great concern to those involved. In some instances we required the care home to investigate and resolve issues – such as the assertion that cold water taps were running too hot. Other issues about the care of residents were investigated by the local authority since they are the lead agency for dealing with alleged lapses in the quality of care. We noted some hazards that suggest not enough attention is being given to safeguarding residents such as creams in bedrooms not labelled nor prescribed for the person, razors and other washing items left unattended. In another bathroom the area was untidy and with aprons left on floor generally hazardous for infirm residents. Other issues such as the complaints about food, staff attitudes, the environment and so forth indicate that although there is ample scope for residents to complain there is all too often a need to complain. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 22, 24, 26: People using this service experience poor quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements have been made, residents have a safer and more comfortable environment in which to live but there are still shortcomings so residents will not always be entirely comfortable and safe. EVIDENCE: The home is a purpose built four-storey building close to public transport, shops, cafés and pubs. The home and grounds are fully accessible. There is a large car park with a small front garden and a side garden adjoining it. The floors are large with over 30 rooms. Each floor has two lounges and a dining room. We toured the whole premises including residents’ areas, the laundry, offices, clinic rooms and other facilities. It is very commendable that on one of the floors there is a fully equipped ‘Snoezelen’, which is a multi-sensory room for people with disabilities; regrettably no one was seen to be using this during the day of our site visit. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 20 The very dim lighting whilst comforting and pacifying for anyone already in the room may put people off entering the room in the first place. There was no domestic on one of the floors when we started our visit and a cleaner was only provided when the domestic had finished her work on another floor. The environment was in need of attention including repairs to equipment, redecoration and general upgrading. Several of the waste paper bins including those in the toilets, bathrooms and resident bedrooms were over flowing. Those in the toilets were of particular concern as these were full of used paper towels, spilling onto the floor and could pose an infection control risk. Some paper hand towel dispensers were empty. Only two swing bins had lids attached. In the lounge where there were reminiscence items this area was pleasant with an old piano, photographs and other items from the past. However there was portable television on a broken cabinet and the two clocks were wrong – these were put right during course of the day although others in the bedrooms and communal areas remained incorrect. Very few calendars were seen and apart from the reality orientation board few other orientation aids were in use. Some bedrooms were nicely personalised with family photographs, ornaments, pictures and items of furniture but other bedrooms were less attractive and indicated that the staff in particular their key workers were not giving enough attention to the environment, the bedrooms, of those residents to whom they were key worker. Several pressure relieving mattress were in use. The units for these, which sit on the end of the bed, were, in all those instances we checked, on the floor of the bedroom and so the wires and pipes trailing were causing potential hazards. Wear and tear especially to the walls was evident in both lounges with marks and staining to the walls. In one ensuite bathroom there were gloves and an apron on the floor - possibly used items - and this area was generally untidy and hazardous. Some bathrooms were congested with items such as hoists, trolleys and so forth. One bathroom was out of service and had been for three months we were told. In the shower room (No.2) there was a hole in the wall and three wall tiles missing; and it appeared the shower head attachment was detached. In this situation it would be difficult to shower a resident as the hole in the wall would allow water to penetrate the wall and cause water damage on this and possibly other floors. Also in this area were toiletries and razors although no staff were in the vicinity. Our concerns here is that such items should stay with the resident and be returned to the correct bedroom (so that they are not used for more than one resident), equally important is that items such as razors that may case harm to confused person are not left unattended. Other maintenance and décor problems we saw include Bedroom 3 which had a hole in the door. The pine drawers in the dining area had handles missing – and was over-filled with items and so likely to lead to further damage to the drawers. The other piece of furniture in this area was also worn. The dining room curtains were torn and frayed and too short for some windows; there were no other curtains to these windows. In the dining room several light bulbs were not working and the light shades missing this was both for the ceiling Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 21 lights and the side wall lights. In the staff office the drawers were without handles. A corridor cupboard was marked “Fire door – keep shut” but the door was ajar and accessible; when we checked inside we found there were pipes in this cupboard. In Bedroom 4 the carpet had two unsightly footprints on it, which appeared to be imprinted into the carpet and were not just dust marks. The dining room floor was dirty and had bits of food and crumbs on it, this was before the lunch was served so probably this debris had not been cleaned after breakfast. The fridge in the dining room needed cleaning. The carpet in the ground floor lounge remains in very poor condition because it is considerably damaged by cigarette burns. Stair carpets also remain in poor and unsightly condition. Generally door handles and walls were dirty and sticky and many areas of the home need a deep clean. We were advised there was four hoists, which was not working, one bathroom and one shower out of order. In many parts there was an odour, which was more pronounced in some areas for example where it seems some milk might have been spilt in or near a ‘fridge. People who have contacted us have also complained about unpleasant odours in the home. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27 to 30: People using this service experience poor quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has good recruitment practices in place and a well managed training and supervision programme but residents cannot be assured there are always enough staff, with the necessary skills, so as to provide a consistently good quality of care they need. EVIDENCE: We found many residents throughout the day somnolent and unoccupied. Several reasons may account for this - staffing levels may leave staff too busy to engage residents (as some staff say is the case); staff may not be motivated to provide social contact, we noted for example that some staff had a ‘snappy’ or rather bossy attitude towards residents and some staff treated residents in a less that dignified manner giving the very poor impression they had no interest in the wellbeing the people they support; some staff may feel it is the role of the activity coordinator to arrange activities and do not follow her lead. We also found that many staff do not share the same language and culture as residents this may inhibit communication between them - by contrast our expert did share a British/European background with residents and found residents quite eager to share their experiences. Regrettably staff did not seem to understand this point, and when asked, they thought their (spoken) English was good and that they did not need ‘English as a Second Language’ (ESL) classes. We found their communication was indeed limited to Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 23 basic conversation because many staff do not know about the history of their residents and cannot help by prompting residents to fill the gap as their memories fade. It is also noted that many residents in this care home are very frail and this will account for a degree of lassitude. We checked staffing levels and as an example of the staffing in this service we noted that on the second floor, accommodating 33 highly dependent residents with dementia and nursing care needs, there were two qualified nurses and five care staff but no domestic staff for some considerable time. On the first floor there were 33 residents and another was one temporally in hospital. 2 Trained nurses and 5 care staff, 1 domestic; this was the usual staffing levels we noted when we looked at staff rota. A carer and the activities person both said that the floor is very ‘heavy’, that is, twenty of the residents are very dependant such that 16 residents need to be moved using a hoist and this in turn will require at least two carers in attendance for each manoeuvre. Only one working hoist (standing type) on the floor, there were 4 broken ones in the bathroom. If sling type hoist is needed it has to be borrowed from the floor above. Carer said that staff tend to lift manually as it is quicker! (But we note not always as safe and not in accordance with the care plan and ‘moving and handling’ assessment). Whilst the home assures us that this ratio of care staff to residents is sufficient to met residents’ needs we found various lapses in the quality of the care offered. We conclude that staffing levels should be reviewed even though this level of staffing is ordinarily sufficient. This may not always be the case and an increase staffing ratios must be kept under active and constant review. More domestic staff seem to be needed, more activity input seems needed and possibly more care staff are needed if residents are not to be left poorly groomed and unattended as we have described passim. For example, a care staff member talked about a resident, who appeared to be very sleepy, as though she were not there. This member of staff’s name badge was upside down. She was defensive when asked about the activities and why so many resident were sleepy. Her interactions with residents were not appropriate and appeared to be quite ‘bossy’. There were few signs of residents’ well-being, engagement or interaction either between residents themselves or between staff and residents. In some areas such as the ground floor we saw and heard a more joyful atmosphere in the lounge. By contrast some residents say of staff “they are kind and helpful”. Even so, some staff told us that they find that they, “Do not have the time to do things as they would like to, no time to talk to people or do their nails”. We checked a sample of staff files to confirm that recruitment, induction, training and supervision is well managed and this appeared to be the case judging by the samples we checked. Staff confirmed that they receive supervision and the training records show that a lot of raining opportunities are available for staff. Staff themselves couldn’t always recall just what training they had received but the records show that the range of training that we would expect for this type of care home is available to staff and staff are receiving such training as ‘diversity and cultural awareness’; care of wounds; customer care; care planning; supporting residents with challenging behaviour; Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 24 dementia awareness; dealing with medicines, plus safety training including first aid, food hygiene, infection control and fire safety. It is regrettable that when the organisation, Southern Cross, is investing in such a broad range of training that staff are not always seen to be as kind, caring and competent as residents and relatives would expect of this nursing home. This is particularly unfortunate since we met a staff nurse who was the “Dignity Champion” (leading in disseminating information about the Rights of Residents) and she tells us that the programme of training is twelve weeks long and is being rolled out to all staff. Residents can expect an improvement in staff attitudes and attention if the training has any impact on those attending the course. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 33, 37 and 38: People using this service experience poor quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. We are told that the new manager has the skills to manage this service but we cannot assure residents that all standards are being met to an acceptable level and so the outcome for individual residents, their experience of the quality of care, varies from good to poor. EVIDENCE: We know, from the anonymous correspondence we receive from time to time that it can be very disturbing for residents and relatives to hear about any lapses in the care being provided to a very vulnerable group of residents and we share that concern. However unwelcome these incidents are the home has been cooperating fully with the Social Service Care Managers, to address and Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 26 remedy matters when fault is identified – and it is not always the case that the home is at fault, some complaints are not substantiated and others partly so. We conclude that for some residents their experience in Tower Bridge is quite positive; they get on well with the staff; some staff are described as kind and caring and the environment is mostly safe and secure. However this is not the experience of all residents and their visitors. Whilst we have not received the large number of notifications about untoward incidents we did in 2007 to 2008 we have nevertheless been notified of some matters that required investigation under the local authority safeguarding procedures. The numerous shortcomings outlined throughout this report point to an urgent need for clear leadership and effective management of Tower Bridge Care Centre. To this end we are told that a new manager has been appointed and that a new management structure is to be introduced to this very large care home. The plan is to have a manager with two deputies who will be in charge of the two nursing and two residential floors. The first step is therefore for Southern Cross to satisfy themselves that they have appointed a person with the qualities and competences needed and then apply for the registration of the manager to lead this new structure without delay. We do not overlook the many positive aspects of this home. Administration and record keeping is for the most part satisfactory; many staff have been complimented for their caring attitudes and some areas of the home are very pleasant and comfortable including the front lobby which is a popular meeting place for residents and staff. However, this is a home with a history of care that varies in the quality of outcomes for residents from year to year and so some consistency is needed to raise and maintain standards in all aspects of the home, environment, administration, staffing, residents’ health care and their social life. At present many residents think Tower Bridge is “Alright” which is reflected in our assessment of a home that warrants a nil star rating. Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 1 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 1 X X 2 X 2 X 2 STAFFING Standard No Score 27 1 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X 3 2 Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 28 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 OP10 Regulation 4 (a) and 5(b) Timescale for action Privacy and Dignity of residents: The 30/11/09 home must respect the privacy and dignity of residents. This is to ensure residents do not experience a loss of dignity when undressed. 4 (a) Privacy and Dignity of residents: The 30/11/09 and home must encourage staff to 5(b) maintain good personal and professional relationships with residents. This is so that residents do not experience poor attitudes by staff at any time. 12(4)b Activities: The home must review its 30/11/09 and provision of social, recreational and 16(2)n educational opportunities for all residents with due regard to their cultural and linguistic background. This is so that residents are given the opportunity to have a meaningful social life in the home. 15 Care Plans: Care plans must be 30/11/09 reviewed to ensure they include sufficient detail and guidance for staff to follow when delivering care such as dental hygiene. This is so that more specific detail is provided in care plans about how any care goals are to be met by nursing and care staff. DS0000007047.V376776.R01.S.doc Version 5.2 Page 29 Requirement 2 OP10 3 OP12 4 OP8 Tower Bridge Care Centre 5 OP9 6 OP9 7 OP9 8 OP15 9 OP19 10 OP26 Medication: all medication records must be kept up to date include a photograph of each resident with the administration chart. This is so that staff giving medication can ensure the correct medications is given. 13 Medicines: The home must ensure that all medicinal products including creams and ointments are only administered to those residents for whom it is prescribed. 13 Medicines: the home must avoid the use of acronyms, initials, when recording medicines. This is so as to avoid misinterpretation. 16(2)i Meals: The home must ensure it is providing food that is well prepared and suitable for the residents and in particular that the meat and other foods are tender. This is so that residents will not experience difficulty eating the food provided. 23(2) Environment: The home must b,c,d ensure that all areas of the home in particular residents’ bedrooms are well maintained. Dirty, damaged or broken furniture must be dealt with promptly. This is so that residents live in a safe and comfortable environment. 23(2)d Environment: the home must be kept free of malodour. This is so that residents live in a clean smell free and comfortable environment. 13 30/11/09 30/11/09 30/11/09 30/11/09 30/11/09 30/11/09 11 OP19 16(2) Environment: The home must 30/11/09 and ensure that communal facilities such 23(2)b as toilets, bathrooms and shower rooms and kept clean, tidy and well maintained including tiling and storage. This is for the safety and well being of residents. 16(2)g Environment: The home must 30/11/09 and ensure that the crockery it provides 23(2)b for residents is not damaged or chipped. This is to avoid hazards such as contamination and injury. DS0000007047.V376776.R01.S.doc Version 5.2 Page 30 12 OP19 Tower Bridge Care Centre 13 OP27 14 OP27 OP28 OP30 15 OP31 Staff numbers: The home must 30/11/09 review staffing levels. This is to ensure that home continues to provide staff in such numbers as are appropriate for the health and welfare of residents. This may include varying the numbers of staff on duty at different times of the day or days of the week. This is so residents know there are sufficient staff on duty at any one time to meet their needs promptly and in a timely manner. 18 and Staff skills: staff must have, or be 30/11/09 12(4)b trained to acquire, the communication skills and a better understanding of cultural background of residents so as to be able to communicate with residents at a level of understanding that will enable pro-active support of residents. We note this is underway but the requirement is restated from the previous date 30/10/08. 8 Manager: The service providers 30/11/09 must arrange for a manager to be registered without delay. 18 Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 31 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 OP1 Good Practice Recommendations Statement of Purpose: The home is recommended to update its statements of purpose so that it reflects the agreed changes to the manager and the Commission’s Contact Centre in Newcastle. The home is requested to supply the Commission with a revised version; this is so residents and others will have up date information about the service. Relatives Meetings: It is recommended that relatives meetings are held to promote their understanding of dementia. This is so relatives of residents with dementia can have a better understanding of the course and prognosis of dementia and therefore improve the quality of their time with residents. 2. OP13 Tower Bridge Care Centre DS0000007047.V376776.R01.S.doc Version 5.2 Page 32 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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