Inspection on 30/01/08 for Tower Bridge Care Centre

This inspection was carried out on 30th January 2008.

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

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

Other inspections for this house

Tower Bridge Care Centre 27/11/09

Tower Bridge Care Centre 28/07/09

Tower Bridge Care Centre 19/08/08

Tower Bridge Care Centre 27/06/07

Tower Bridge Care Centre 22/01/07

Tower Bridge Care Centre 27/06/06

Tower Bridge Care Centre 22/11/05

Tower Bridge Care Centre 09/05/05

Tower Bridge Care Centre 06/10/04

Tower Bridge Care Centre 23/08/04

Tower Bridge Care Centre 21/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

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

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 30th January 2008 09:15 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 DS0000007047.V356924.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. DS0000007047.V356924.R01.S.doc Version 5.2 Page 3 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 Position Vacant Care Home 128 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (0), Mental disorder, excluding learning of places disability or dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (0), Old age, not falling within any other category (0), Physical disability (0), Physical disability over 65 years of age (0) DS0000007047.V356924.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. on the first floor, 34 patients, frail elderly persons aged 60 years and above (female) and 65 years and above (male) to include one female resident aged 46 years and above on the ground floor, 29 residents aged 65 years and above with dementia on the second floor, 33 patients, elderly persons aged 60 years and above (female) and 65 years and above (male) with mental health disorders and/or dementia on the third floor, 31 residents with dementia, and/or persons with mental health disorders on the second floor, 1 patient, 54 years and above (female) with dementia As agreed on 19/06/2006 one Service user, 57 years and over, with a mental disorder can be accommodated on the second floor Two (2) service users under the age of 65, with dementia, can be accommodated. 27th June 2007 Date of last inspection Brief Description of the Service: Tower Bridge Care Centre 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 very near 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 in some areas nursing care is provided and in other areas care is at ‘residential’, non-nursing level. The Commission is reviewing the registration conditions to ensure they are within the correct legal framework and so the registration of this home may be adjusted after that review. 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 at the front of the building. The fees for the home range from £360 to £850 a week as at January 2008. DS0000007047.V356924.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection included a visit to the home on 3oth January 2008. The lead inspector Michael Williams was accompanied by two other inspectors, Alison Ford and Rosemary Blenkinsopp. In addition to the inspection visit, which latest approximately nine hours, a number of questionnaires were distributed to interested parties and we received back ten from residents, nine from visitors, two from professional agencies and one from a member of staff. In compiling this inspection report the Commission also noted information we received - including details of any complaints, untoward incidents and general correspondence. During the course of the inspection visit we spoke to many of the residents, to visitors and to the staff team. We toured the premises and checked a wide range of documentation, including care records, staff records and other statutory records, particularly those relating to safety such as fire records and the record of accidents. This enabled us to cross-check and verify information. What the service does well: Tower Bridge Care Centre is a very large, spacious care home with wide corridors and large bedrooms that have ensuite facilities. The entrance lobby is a pleasant, welcoming area and visitors comment on the friendly atmosphere of the home. In respect of the admission process some, but not all, resident’s files were well managed with the detailed information a resident might expect to be provided. In respect of health and personal care again we saw good practice in some areas with detailed assessments and care planning in place. Residents, and/or their relatives, are in most cases involved in the planning of their care. The owners, Southern Cross use standardised formats for the care-planning and these are very detailed – but a little cumbersome for everyday use by staff. In respect of daily life in the home some residents were keen to tell us how much they “enjoyed the dinners”. Activities and entertainment is regularly provided and the home has provided a range of posters and objet d’art including posters of bygone film stars. This home is divided into floors with each floor providing a different level of care. The spacious corridors and lounges on each floor give ample space for resident to wonder and to choose where and with whom to spend the day. The small enclosed garden towards the front of the premises is available, especially in the summer months, for residents to enjoy some fresh air each day. DS0000007047.V356924.R01.S.doc Version 5.2 Page 6 In respect of staffing, the staff we spoke to were impressed with the induction training they had received and they confirmed that have been receiving training in key areas of their work. The new manager is confident she can improve this home from its previous poor rating to at least a good, two star, rating within a reasonable timescale. What has improved since the last inspection? What they could do better: We identified shortcomings in each of the seven sections of this report; details of our observations are given under each subject heading in the main report. In respect of the first section, about choice, we note that staff are not always completing all the important sections of their own documentation and in some instances these documents are not being signed and dated. In respect of health and social care, the documentation is complex and detailed but not always completed very effectively, for example not signed or dated; some detail is not relevant to the form, for example details of hair-dressing are not relevant in the form about mobility. Some detail, for example about ‘Last Wishes’, is missing; this is now particularly important with the introduction of the Mental Capacity Act because residents may have made known their wishes before they came dependent and entered the care home, it may for example influence what treatment they wish to receive. In respect of daily life in the home we were concerned about the support residents get, or do not get at meal times. Staff did not know what food they were serving, residents were not always being supported in a dignified manner; (disability) aids to eating were not made available to residents and DS0000007047.V356924.R01.S.doc Version 5.2 Page 7 we observed a lack of support and encouragement for a resident who was rejecting her meals. Some problems relating to the management of medication were also noted such as the lack of detail abut medication which is to be given only ‘as needed’, (such as the maximum dose at any one time and how many doses in one day). Although three activity coordinators are employed we saw that when for example old time music was being played for residents, staff did not take this as an opportunity to engage with residents – it was a somewhat passive activity with little obvious impact. This may be because the staff do not share the same language, background and life experience of residents. It may be that the music being played has now become repetitive and uninspiring for staff and residents. The environment is clearly improving but some areas, particularly above the ground floor, were still very poor (but we note work is underway). Staffing matters are also improving but one over-arching concern for the Commission is the turnover of staff in particular the number of managers that have been employed in this care home. This home needs a period of stability if it is to achieve and sustain good standards throughout. 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. DS0000007047.V356924.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000007047.V356924.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1 and 3: Quality in this outcome area is as adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured they will be provided with detailed information about the service and their needs will be assured though not as fully as they might expect. EVIDENCE: We checked a number of care plan files on three of the four floors and spoke to residents, their visitors and to staff including team leaders. The admission of new people to this service appeared ‘process driven’ and not particularly personalised so in some instances there was minimal consideration of the individual needs such as details of a resident’s past history and the checklist which their own processes require to be completed within 24 hours. The service has developed a statement of purpose, which sets out the aims and objectives of the home, and includes a service user’s guide, which provides basic information about the service and the specialist care the home offers. The 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 DS0000007047.V356924.R01.S.doc Version 5.2 Page 10 this is already very bulky. Not all case files contained an assessment by a suitably trained person such as the care manager making the placement. Areas of strength include the statement of purpose and resident guide but matters requiring improvement include the need to ensure a full an accurate assessment, made without delay including history and current needs of each resident and an assessment by a suitably trained person such as the care manager from the placing authority. This section, about choice, is assessed as adequate. DS0000007047.V356924.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7 to 11; Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Residents have care plans but they are not as comprehensive as residents might expect; health care needs are being addressed but again not as comprehensibly as residents might expect; medicines are mostly well managed with some deficiencies identified whilst death and dying is being handled sensitively there are still gaps in the information held by the home. EVIDENCE: We received a number of comments from relatives summarising their concerns about staffing levels, support and supervision of residents, “No-one really comes and checks her (my relative)”. Another commented that “Staff don’t seem to want to engage with residents”; and another said “Staff need to be reminded this is the residents’ HOME – it can be frightening when (staff) raise their voices”. Other visitors tell us that there do not seem to be enough staff on duty and some that are on duty do not have a good grasp of English. One comment referred to a wish for staff providing personal care to reflect the ethnicity and gender of their relative. Another told us “…cleanliness could be better, (my relative) sometimes smells of urine”. In our questionnaires we DS0000007047.V356924.R01.S.doc Version 5.2 Page 12 asked residents and relatives about meeting care needs; 3 replied “always”; 6 say “usually”; 1 said “sometimes” and 1 reported “never”. Southern Cross provide very detailed and extensive care planning formats for their care homes and these include documentation for various assessments, skin care, food, falls and so forth. Care Plan formats are very detailed and comprehensive. However, staff are not always completing them as fully as residents might expect for example some lack details about end of life care and any last wishes; some lack details about residents’ life history, important if staff are to understand residents’ needs as they become increasingly dependent; many of these document lack signatures and dates so the source of the information and its relevance is lost. Good practice was noted in respect of health care support with specialist being called in when the need arose, for example chiropodist and dentists and skin specialists. We did note however that the pumps on supportive, air-flow mattresses were left on floor and not fixed to the end of the bed and in one instance an inspector drew attention to a pump that was malfunctioning. As part of their delivery of care staff are provided with specialist information for example in respect of infection control; information is sited in bedrooms where the information is needed. We find labelling of clothes undignified, with use of black marker pen. Although the procedures and practice for dealing with residents’ medication was mainly satisfactory we identified some problems. Ointments were found in bedrooms that did not belong to the resident, were out of date and in one instance belonged to a deceased resident. Staff are not always verifying prescriptions with two signatures when transcribing onto medication administration charts; in some instances there was a lack of detail about when how much and how often ‘as needed’ medication was to be administered. 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. It was therefore disappointing to note that in some instances there was little or no information about this final aspect of care. This area of work will become 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; this must be checked, and recorded more thoroughly at the time of admission and regularly at reviews thereafter. Areas of strength include the detailed documentation and good assessment and care planning in many areas. Matters requiring improvement include the need to sign and date documents and to include relevant life histories. As documents are not being signed in all cases the home must confirm that regular reviews of care are taking place. The handling of medication needs improvement in some areas such as the use of two signatures where necessary; the correct disposal of medicines and ointments and staff should not be using any prescribed medicine or creams for other residents. End of life information needs to be strengthened. This section, about health and personal care, is assessed as adequate. DS0000007047.V356924.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): NMS 12 to 15: Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. As each residents’ life history is not always recorded they cannot be assured their preferences will be known and acted upon; contact with the community is being maintained and encouraged and resident can exercise some control over their lives when they have the capacity to do so. Residents cannot be assured that their nutritional needs will always be met in full. EVIDENCE: In the various comments we received many referred to the need for more staff. One suggested that, “there should be more staff so residents can be taken out even if it’s in wheelchair”, and “They have entertainers but do not go on any trips or days out – to sing or enjoy entertainment”. The employment of a full time activity coordinator and two assistants is commendable; some activities were seen to be underway whilst we were visiting. However staff did not seem very skilled in engaging residents, they music old time music on but did not engage very effectively with residents to stimulate conversation and memories – it was very passive, possible staff and residents were not stimulated by repetition of a limited rang and style of music and songs from one specific era. We met with several residents who were quite happy with the care their relatives were getting in Tower Bridge Care Centre and had no complaints. Visiting Nurses confirmed that the home seems to provide a satisfactory level of care and they found staff to be very caring – but DS0000007047.V356924.R01.S.doc Version 5.2 Page 14 language was often a point of contention, not all staff have a good grasp of English and few share the South London, ‘Cockney’ background of many residents we were advised. The manager told us about regular community contacts that include local churches and schools coming into the home as well as resident making local excursions to pubs and places of interest – however in some of our questionnaires people were asking for more outings and activities – more stimulating activities is suggested. Autonomy and choice is inevitably limited by age and frailty and so it is in this care home; residents have some choice about their daily lives such as when to retire to bed or to rise, what to wear, what meal to select and when and where to wander around the home. It seems unlikely this limited range of choices will be extended if staff can only deliver basic care because of their limited grasp of the residents’ first language (which is usually, but not always, English in this care home) and have only limited understanding of their personal history and life in the UK over last 70 to 90 years. The nuances of conversation and opportunity to reflect on shared past events and experiences are lost on them. For example, I mentioned that the number ‘1945’, which came up in conversation, would be an easy number for everyone to remember (end World War 2) and the staff member had no idea what I was referring to. Visiting nurses have notice difference of background. Mealtimes were of particular concern to all three inspectors. There was a lack of suitable equipment such as bedside or over-bed tables; a lack suitable eating aids such as adapted cutlery, staff were limited in their skills at meals times, either not supporting residents to eat, not encouraging residents to eat or not offering alternatives and standing when feeding residents. A choice of just two main courses in a home of 128 residents is far too limited. The dining tables lacked suitable table accoutrements such as salt and pepper, staff say this because residents will pour it away. This suggests a lack of respect and dignity for residents and suggests there is insufficient support for residents at meal times – condiments can be offered and withdrawn if not needed; this would give another opportunity for staff to engage and communicate with residents if they had the skills to do so. We received a number of written comments reflecting our own observations such as “Staff show little interest in engaging with residents” and “Staff from other cultures have limited understanding of the food served”, “Staff need more training in feeding residents unable to fed themselves”, “(my relative) needs more care, i.e. supervised when eating”. The menu was on the table in small print – a large print pictorial menu would have benefited some of the residents. The inspector sampled tea from the trolley that was being given out to residents. It was cold and very strong – once again attention to detail by staff, the quality of the service they offer, could easily remedy such matters. Areas of strength include the activity leaders, the involvement of the community and the generally relaxed and pleasant atmosphere of the home. Matters requiring improvement include the need to improve service to residents at meal times and the equipment to support that. This section, about daily life, is assessed as poor. DS0000007047.V356924.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): NMS 16 18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents will know that their concerns will be listened to and that suitable procedures are in place to safeguard them from harm. EVIDENCE: We spoke to residents, relatives and staff; we checked the record of complaints and took note of any relevant notification we received since the last inspection. W also received 22 written feed comments that we took account of Information on how to make a complaint was located in the bedrooms. The statement of purpose and the resident guide provide information about how to whom to complain. Information about how to complain in place including statement of purpose and residents’ guide and in bedrooms. 18 people told us they know to whom and how to complain and 2 did not. The home’s record of complaints was in place and we checked this to ensure complaints and concerns are being recorded and acted upon so residents, and their representatives, know they are listened to. We also noted that a record is kept of missing items of clothing and other residents’ property so that these items can be returned to their owners in due course. The manager is well informed about the procedures for referring allegations of abuse or poor practice to the local Social Service Department (before initiating a full investigation) – as well as referring to the placing authorities and of course the Commission. All staff with whom the inspectors met were aware of what to do in the event that abuse was suspected or witnessed. There is a vulnerable adult’s policy and an ongoing training programme for staff on safeguarding adults, and it was DS0000007047.V356924.R01.S.doc Version 5.2 Page 16 noted that new staff have this training. Staff told us that they would report it on although they had limited knowledge of the external avenues for reporting such matters because their knowledge in respect of whistle-blowing procedures was uncertain. So it is recommended staff are given clearer advice about referring concerns to senior managers within the organisation and to relevant external bodies such the Commission and the local Social Service Department, if they have concerns about the safety of residents and staff that are not being addressed effectively. During the course of the last inspection issues of restraint were identified by the inspector – we are advised that no restraint now takes place. The home is reminded that any form of physical restraint must be recorded in accordance with regulations 13(8) and 17 (Schedule 4:o) and must be dealt with in accordance with the revised Mental Capacity Act. Areas of strength include the information provided to resident and others; the recording and actions taken to deal with complaints; the procedures in place to deal with allegation of abuse or neglect. Matters recommended for improvement include the advice to remind staff of the correct whistle-blowing procedures both internal and external and their rights to disclose information if the safety of residents is being compromised. Whilst a number of concerns are raised about the running of this home, such as the quality of staff, this section is about how such concerns are managed and so this section, about complaints and protection, is assessed as good. DS0000007047.V356924.R01.S.doc Version 5.2 Page 17 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): NMS 19 to 26: Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. Residents cannot be assured they are living an entirely clean, safe and well maintained environment. 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. Rooms are spacious and all have en-suite facilities. People have been able to personalise them with items from home. It was noted that some items of furniture need repairing and some of the woodwork is chipped and battered. Bathrooms are functional and not aesthetically pleasing and would not help to make bathing an enjoyable experience. Many toilet bowls are stained and equipment is being stored in the bathrooms. Bathroom number 2 on the first floor needs the ceiling repairing. The second floor was in parts in a poor DS0000007047.V356924.R01.S.doc Version 5.2 Page 18 condition. One area, which was pleasant, was the reminiscence lounge. This was decorated with old pictures and memorabilia from past times. The pictorial aids used to identify bathrooms and other areas, were beneficial and domestic in style therefore not allowing a clinical feel to prevail. There were many areas, which required redecoration, and several items requiring repair. Many of the draw fronts were detached; lids to swing bins missing and several clocks were wrong including that one on the reminiscence lounge. In areas where there are high levels of confusion clocks and calendars and domestic style orientation aids should be available and visible to maximise orientation. Paintwork in several areas needed addressing particularly in corridors. In the dining area one window curtain was missing and one window had no curtain. One bedroom we visited was particularly bare and several bedrooms had very limited personal effects and were without pictures. In one bedroom the cushion to the armchair was missing and mouth pastilles were found on the floor. In another bedroom of a resident, whom we ‘case-tracked’, the Christmas cards were still up. When we asked staff about this the staff member started to take them down; the inspector pointed out that it was an enquiry not a request to remove them – once again is was indicative of poor communication skills and possibly a lack of understanding of English traditions (12th Day of Christmas is the day for removing decorations - if tradition is followed by the resident). If it was the resident’s choice to leave cards on display a little longer then this was not made known to the inspector. The home was in most areas reasonably clean and tidy on the day of the inspection although the 3rd floor was somewhat malodorous, especially the sitting room. Redecoration has started on this floor. On the first floor it was noted that the sluice room was locked although the code to open it was written on the door and there was a key hanging beside it. It is therefore possible that people who live in the home could open this hazardous room. We checked the laundry and arrangements for washing clothes. The general arrangements are acceptable but the labelling of clothes was not – the use of a black marker looked unsightly and undignified. We recommend a system for purchasing named labels for each reside – as most residents book their places in advance this could be available upon arrival. Areas of strength include those areas that have been upgraded and refurbished and this includes the small, enclosed garden to the front of the property; those areas inside that have been improved, such as part of the ground floor, look very smart and homely and gives a good impression. There are however many matters requiring improvement, décor in may areas needs attention; some areas are not entirely clean and there was malodour in at least one location; damaged furniture and fittings need to be attended to. Care and nursing staff might be reminded that they have a responsibility to notice areas of damage and report for maintenance – and follow up to ensure residents they care for are living in a clean, safe and well maintained home. This section, about the environment, is assessed as adequate. A requirement will be made for the home to be surveyed inside and out and a timescale for the ongoing refurbishment sent to the Commission. DS0000007047.V356924.R01.S.doc Version 5.2 Page 19 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): NMS 27 to 30: Quality in this outcome area poor. This judgement has been made using available evidence including a visit to this service. The home has good recruitment practices in place but residents cannot be assured there are enough staff, with the necessary skills, to provide the care and support they need. EVIDENCE: Of the 22 written comments we received many refer to a need for more staff and many comment on the poor communication skills of some staff. These are some of the things we were told about:- ‘Some staff have a poor command of English’; ‘Some staff show little interest in engaging with residents’; ‘Some staff have little understanding of the food they are serving at meal times’; ‘Staff need to be reminded this is the residents’ HOME, at times staff raise their voices which can be frightening’. Six people specifically stated, “There should be more staff on duty”, whist others inferred more staff, with the necessary skills, were needed to meet the needs of residents; thus, “I would like (my relative) to be cared for by staff from the same ethnic background and same gender”. We observed for ourselves instances where communication was difficult; for example, one member of the care staff on an upper floor had limited English – but she was extremely pleasant, smiling and very willing. Few, if any, staff seem to share the South London, Cockney background of many of the residents. The manager is aware of this problem and has strategies in mind to address it, such as training in cultural norms in England. DS0000007047.V356924.R01.S.doc Version 5.2 Page 20 Staffing levels were adequate on the day of the inspection although apparently bank staff had been brought in at the last minute to replace staff who failed to attend for their shift. Even though minimal levels of staffing may be in place the organisation does need to consider residents’ and visitors’ comments about staff levels. The outcome for residents when staff are present in sufficient numbers and lack the necessary skills was very obvious during our observation of meal times. All three inspectors saw poor practice; for example a lack of suitable aids for residents with physical problems grasping cutlery; a lack adequate supervision whilst residents were eating – or failing to eat, limited verbal communication with residents during the meal, slow service with many staff rushing around delivering plated meals and few sitting quietly with residents, worse still some staff were seen standing whilst feeding residents, a very undignified method. Staff agreed that they were able to access training to help them fulfil their roles. One new member of staff described the induction programme that she was undertaking and said how good it was. She was also able to confirm that appropriate pre-employment checks had been completed prior to her starting work. Comments received by staff relate to the difficulty of managing the rotas with staff shortages occurring at short notice. Some bank staff were said to be not satisfactory. All staff we spoke to confirmed updates in statutory topics including abuse. Those staff interviewed demonstrated a working knowledge of infection control procedures and dealing with Dementia. In respect of recruitment of staff we checked that all the necessary checks are being made including police [CRB], references, health and qualification checks. Staff training is in place and the staff we spoke to confirmed this. The staff files are well managed and indexed so as to be able to check correct procedures are being followed for each appointment. Staff induction is arranged for and staff are receiving supervision. Areas of strength include the safe recruitment of staff, their induction, training and supervision. Matters requiring improvement include the need to ensure staff have the skills to communicate with residents and that they are being deployed in sufficient numbers to meet the needs of residents. Since the outcome for residents at the moment is that they feel that communication with staff is poor and their needs are not being fully met because there are not enough staff on duty this section about staffing is assessed as poor. DS0000007047.V356924.R01.S.doc Version 5.2 Page 21 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): NMS 31, to 33, 35 to 38: Quality in this outcome adequate. This judgement has been made using available evidence including a visit to this service. The person managing the home is well qualified and experienced but this home still needs to improve the outcomes for residents if they are to feel Tower Bridge Care Centre is run in their best interests and is providing the care and support the pay for. EVIDENCE: Not all aspects of this home are poor or adequate. We received a very positive comment from one person who stated, “The home is excellent in all respects, they are exceedingly fortunate in the standard of staff…”. It is therefore clear that whatever shortcomings remain - in a home that has had many problems in the past - it is moving towards better standards and this was the impression we formed when we visited the home. Many people we spoke to talked about the improvements they see. Nevertheless there are still critical shortcomings that need the manager’s, or owners’, attention. DS0000007047.V356924.R01.S.doc Version 5.2 Page 22 The new manager has been in post since January 2007. She has a nursing background and has the Registered Manager’s Award. She has worked in, and managed, services for older people since 1982. She is keeping her skills upto-date through the internet, professional publications and attendance at local providers forums run by the Care Homes Support Team. It is clear from the evidence seen during the inspection, that she is a competent manager. The home’s newsletter stands out as nice example of quality of service and the ‘editors’ are commended. The Department of Health does not provide specific guidance on the ratio of staff to residents; this home has a typical number of staff deployed. Nevertheless, residents do not feel they always get the support they need and this may because of the way staff are deployed or the skills staff have or do not have. One questionnaire we received summarised the concern of visitors thus, “My family are always on top of this” – suggesting they need to visit regularly to ensure care is being provided. It is for the managers in the home to provide adequate day to day supervision and guidance and to monitor how residents’ needs are being identified and addressed. To this end we acknowledge the deployment of a ‘floor manager’ on each of the four floors of the home – this will provide leadership in each area of what is a very large service. When we asked people, ‘Do residents receive the ‘care and support needed?’ only 3 people said always; 6 say usually; 1 said sometimes and 1 never. This indicates a not very high level of satisfaction. The manager has instigated a formal supervision process and staff files showed that supervision, of a good level, is happening two monthly – this is in addition to the day to day supervision mentioned above. As we did in 2007 we again confirmed that satisfactory procedures are in place to enable residents to have access to their personal allowances, whilst ensuring that their monies are kept safe. The owners have put in place bank account that will identify the deposits for each residents and this is highly commendable. Local computerised accounts are in place so each resident can be provided with a regular statement of their savings. Neither the home, nor the owners, are appointees for the purposes of collecting and holding residents’ benefits or pensions; this is usually a relative or a local authority. A specialist firm has been consulted about new legislation to do with fire safety and their requirements have been put into place. Record keeping is proficient; we checked a range of records to confirm this including fire safety, accidents, complaints, incidents, residents’ money records, care records staff records and so forth. In respect of health and safety we identified a number of potential hazards, some critical and other less, so but all needing to be addressed or as minimum ‘risk assessed’ with safeguards put in place. Hazards include: Hot radiator, at 57oC, in lounge ground floor and very near a chair; hot water to a bath was a little high at 45.5oC; rubbish and other items stored in fire exit corridor; door lock to bathroom faulty; door handle to bedroom loose; damaged and broken furniture in various location around the home may pose a hazard; sluice room locked but still accessible to vulnerable residents; a malfunctioning pressureDS0000007047.V356924.R01.S.doc Version 5.2 Page 23 relieving mattress may harm or at least not protect the resident as needed; calls bells detached or out of reach as were drinks; we also noted the poor arrangements for eating in bed or in chair (lack suitable bedside or over-bed table) – there is both a physical hazard of spilling food and drinks and a health/neglect hazard if residents are unable to eat in a comfortable position. Those medicines that are to be administered “as required” need to have full instructions including maximum dose, duration and reasons for administering the drug. Those medications that are hand-transcribed need two staff signatures in place to confirm the accuracy of the information recorded. We have judged outstanding requirements to have been addressed to the extent that they no longer need to be restated in this report but new requirements will be made where new or similar issues arose during our inspection in January 2008. Areas of strength include the new manager who is highly regarded by the residents and the staff team; the clear progress towards higher standards is also acknowledged; much of the management in this home is good, including record keeping, and there a general sense of well being in this home. Nevertheless there are various matters requiring improvement including health and safety and the deployment of suitably competent staff in adequate numbers to meet residents’ needs at all times. This section, about management and administration, is assessed as adequate. DS0000007047.V356924.R01.S.doc Version 5.2 Page 24 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 3 2 3 2 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 3 1 DS0000007047.V356924.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 14(1)a Requirement Assessments: The home shall not provide accommodation unless an assessment has been undertake by a suitably qualified person such as care manager prior; this is so that residents can judge whether or not their needs can be met. Care Plans: Care plans must completed in sufficient detail that residents will know their needs and preferences can be taken into account. Records: all documents, including statutory ones, such as those in a resident’s case file, must be signed and dated so residents will know who drafted them and when. Aids and Adaptations: The home must supply and maintain suitable aids and adaptations including suitable mattresses so residents’ skin is not put at risk of breaking down. Aids and Adaptations: The home must supply and maintain suitable aids and adaptations including suitable eating aids so DS0000007047.V356924.R01.S.doc Timescale for action 30/04/08 2 OP7 15 30/04/08 3 OP37 17 30/04/08 4 OP10 OP22 23(2)n 30/04/08 5 OP10 OP22 23(2)n 30/04/08 Version 5.2 Page 26 6 OP9 13(2) 7 OP11 15 8 OP15 16(2)i 9 OP19 16 and 23 10 OP26 16(2)j & k 11 OP27 18 and 12(4)b that residents can be supported to maintaining their eating abilities in a dignified manner. Medication: the home must ensure that suitable procedures are in place for the safety and well being of residents. This shall include disposal of medicines and double signatures for prescriptions transcribed by nurses and not the pharmacist. End of Life care: The assessments and care plans of residents must include reference to end of life care and any advance decisions under the Mental Capacity Act so residents will know they wishes will be respected. Meals and Menus: The home must provide a wider range of choices than just two main choices and must make the menus available in a size and style to suite residents. Maintenance: The owners must provide the Commission with a detailed schedule of works that covers refurbishment of the inside of the premises, for each floor, and outside of the building - where work has not already been completed. This is so residents can be assured the building is being maintained properly. Smells: Smells that arise as a result of poor hygiene must be eliminated by maintaining good hygiene practices in all parts of the home so residents and their visitors do not suffer the unpleasant effects of malodour. Staff skills: staff must have or be trained to have the communication and understanding of cultural background skills so as to be DS0000007047.V356924.R01.S.doc 30/04/08 30/04/08 30/04/08 30/04/08 30/04/08 30/06/08 Version 5.2 Page 27 12 13 OP38 OP38 13(4)a 13(4)a able to communicate with residents at a level that will ensure their well being. Health and safety: Residents must be protected hazards such as hot water and hot radiators. Health and safety: residents must be protected from harm by having equipment in place and well maintained such as call bells, bedroom and toilet door locks and door handles. 30/04/08 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP12 OP10 OP27 Good Practice Recommendations Activities: residents and their families are requesting more outings and this passed on as a recommendation. Laundry and labelling clothes: clothes must be labelled in discreet and dignified manner. Staffing Levels: it is recommended that staff levels and the deployment of staff at different times of the day be reviewed to evaluate whether or not residents’ needs are being met with the current staff to residents ratios. Mental Capacity Act: it is recommended that the residents’ care plans include references to the new Mental Capacity Act (as revised) so as to ensure matters such as restraint and restrictions of liberty as well as any advance decisions are recorded and addressed lawfully and correctly. 4 OP17 DS0000007047.V356924.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000007047.V356924.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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