Care Home: Queens Court Nursing Home

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What the care home does well Queens Court is a purpose built care home and has a relaxed and inclusive atmosphere. Residents live in a clean and comfortable environment. There are ample communal areas for people to enjoy, including attractive garden areas with outside seating. Management are good at keeping us (CQC) informed about incidents occurring in the home. Visitors are always made welcome at Queens Court. What has improved since the last inspection? People have access to more information about the home in order to assist them in deciding if the home is right for them. The management of medication within the home has improved since the previous inspection, this has resulted in less medication errors. What the care home could do better: As with previous inspections the main theme highlighted throughout this report is a lack of adequate staffing, or poor staff deployment. In order for peoples` needs to be met management must review the levels of care staff provided. Pre-admission assessments, care plans and daily records need to include more detail about peoples` needs and preferences in their personal care and social activity. This is so that staff have clear instruction to follow. There needs to be detailed records to confirm that the care delivered is in accordance with peoples` preferred needs and choices. People want to be offered the opportunity of participating in their monthly care plan reviews. This would promote and encourage their independence and feelings of self worth. Care plans around death and dying should be completed so that people can be confident their wishes are recorded and will be respected. The management team need to review the arrangements for medication administration to ensure that people receive their medication at the right time and with an appropriate lapse of time between doses. There have been ongoing issues relating to the quality of the food service at Queens Court. Work needs to continue to ensure that people are offered a good variety of nutritionally balanced and well cooked food. The training programme needs to continue to provide the staff with the skills they need in relation to caring for older people and people living with dementia. The system for looking after peoples` personal monies is not robust and needs reviewing so that people can be confident their monies are looked after safely. Key inspection report Care homes for older people Name: Address: Queens Court Nursing Home 52 - 74 Lower Queens Road Buckhurst Hill Essex IG9 6DS     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Jane Greaves     Date: 1 1 0 1 2 0 1 0 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 39 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. 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 Care Homes for Older People Page 3 of 39 Information about the care home Name of care home: Address: Queens Court Nursing Home 52 - 74 Lower Queens Road Buckhurst Hill Essex IG9 6DS 02085590620 02085590315 queenscourt@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ranc Care Homes Ltd Name of registered manager (if applicable) Mrs Esther Enwezor Type of registration: Number of places registered: care home 90 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is 90. The registered person may provide the following categories of service: 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 into any other category - Code OP Dementia - Code DE Physical Disability - Code PD Date of last inspection Brief description of the care home Queens Court is a purpose built two-storey care home for up to 90 residents over the age of 65 years. The home is also registered to provide nursing care for persons aged 40 years and over, who require care by reason of a physical disability. It is located in a residential area in Buckhurst Hill near Ilford in Essex, close to local amenities, shops Care Homes for Older People Page 4 of 39 1 5 0 1 2 0 0 8 90 0 90 Over 65 0 90 90 Brief description of the care home and public transport systems. The home is divided into four units: Two on the ground floor providing a residential care unit and a dementia care unit. The first floor accommodates people who require nursing care. Personal accommodation comprises of single rooms with en-suite toilet and wash hand basin facilities, with the exception of a shared room on each floor, also with en-suite facilities for married couples or those who wish to share. The home has a garden to the rear, a patio area to the front and ample parking. The fees are calculated according to the assessed needs of the resident and at the time of this inspection were informed that they ranged from £525.00 to £874.00. The fees are broken down into basic board and lodging fee and other costs relate to the care support and nursing provided to each individual. Additional costs include private chiropody, toiletries, newspapers, hairdressing, dial-aride and some activities. A service Users Guide and Statement of Purpose were not readily available to people to provide information about the home. The last inspection report was freely available in the foyer area of the home. Care Homes for Older People Page 5 of 39 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key site visit undertaken by two inspectors totalling 17 hours. At this visit we considered how well the home meets the needs of the people living there and how staff and management support people. A tour of the premises was undertaken, care records, staff records, medication records and other documents were assessed. Time was spent talking to, observing and interacting with people living at the home, visitors and staff. Prior to the site visit the manager had completed and sent us the homes Annual Quality Assurance Assessment (AQAA). This is a self assessment document required by law and tells us how the service feels they are meeting the needs of the people living at the home and how they can evidence this. Before the site visit a selection of surveys had been sent to the home for distribution to residents and staff. Care Homes for Older People Page 6 of 39 Views expressed by visitors to the home during the site visit and in surveys responses have been incorporated into this report. Feedback on findings was provided to the manager throughout the inspection and the opportunity for discussion and clarification was given. We would like to thank the residents, the manager, the staff team and visitors for the help and co-operation throughout this inspection process. Care Homes for Older People Page 7 of 39 What the care home does well: What has improved since the last inspection? What they could do better: 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. Care Homes for Older People Page 8 of 39 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 39 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 39 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information gathered prior to people being admitted to the home was not always detailed enough for people to be assured their individual care and support needs would be met. Evidence: The managers AQAA stated: All service users have a full pre-admission assessment to enable us to establish the level of care required. We receive a summary of care management from social services for the majority of service users. We have reviewed and updated service user guide and statement of purpose, these are available for prospective service users. We also have new brochures and information packs which are available at the reception and are given at pre-admission assessment or sent in the post on request. We encourage prospective service users and family member to spend time at the home either for a full day or a morning so they can sample food, activities and the general feel of the home. Service users and families are encouraged to choose their rooms when they visit the home. Care Homes for Older People Page 11 of 39 Evidence: We obtained a copy of the Service User Guide and the Statement of Purpose to take away with us. Overall these documents contained the necessary information to help people make an informed decision as to whether Queens Court was the right home for them and whether provided the necessary care and support to meet their individual needs. As identified at the previous inspection of this service in 2009 the Service User Guide did not include details of fees and additional charges as is now required to help peoples planning. Of the 13 people responding via surveys prior to this inspection visit, 11 said they felt they had received enough information prior to entering the home, and one said they had not been provided with sufficient information. We looked at pre admission assessments for 4 people that had moved into the home since the previous inspection visit. There was a tick box format for the person making the needs assessment to complete relating to personal care and physical well being. This was to indicate yes or no to whether assistance with areas such as washing, dressing, bathing or using the toilet etc. was needed. The assessments did not include any specific detail about the individual, personalised needs and preferences of the person considering moving into the home. Some assessments showed that representatives from Queens Court had visited the person in their own home to undertake this assessment, others showed they were emergency admissions and the assessment had been undertaken on the day of admission. Some of the people living at Queens Court can exhibit some behaviours that may challenge staff and potentially cause anxiety among fellow residents. One pre admission assessment we looked at stated: (Persons name) can be quite moody and can display some aggressive behaviour and screams at staff There was no information gleaned at the point of admission about what triggered the persons aggressive outbursts or what strategies were needed to pacify the person in the first instance. Records showed, and staff confirmed, that they received a good level of basic core training to meet the needs of the people living at Queens Court, more detail in included in the staffing section of this report. The numbers of staff on duty, or the deployment of staff within the home, does not effectively meet peoples needs. Please see the staffing section of this report for more detail. Relatives told us: Very easy admission process, I had a chat with the manager who Care Homes for Older People Page 12 of 39 Evidence: explained the process and showed me around the home and another told us Getting (persons name) in was straight forward. Care Homes for Older People Page 13 of 39 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive good basic care, this may not always be in a timely manner or in accordance with their wishes and preferences. Evidence: We looked at 8 care files, including a sample from each of the four units at the home, to assess how well peoples care is planned and the detail available for staff to follow to deliver personalised care to meet peoples needs. It was clear that residents, or their representatives, had been involved with the initial development of their care plans. Information within the care plans showed that regular monthly reviews were undertaken to ensure that the care regime remained appropriate to meet peoples needs. People we spoke with told us they were not consulted as part the monthly reviews of their care plan and felt they would like to be involved. One person said after all, it as about me and my life isnt it? The homes Statement of Purpose stated that All care plans are reviewed every 28 days or before should the need arise. These will be done by the named nurse/key Care Homes for Older People Page 14 of 39 Evidence: worker in conjunction with the service user and/or their advocate. This does not concur with our findings at this inspection. Elements of individual risk were assessed as part of the care planning process. These included the basic core activities of daily living such as mobility, safety, falls, use of bed rails, self administration of medicines and risk of developing pressure sores. There was also a person centred approach to risk assessment relating to individual peoples choices, such as not being disturbed by staff doing routine checks on individuals during the night and storing food in their personal rooms. Overall, risk assessments included clear instruction for staff to follow to minimise areas of risk, for example, an assessment relating to the danger of a person choking included good detail for staff to follow about what food the person should have, how they needed to be positioned to eat safely and what to do in the event of a choking episode. Risk assessments were reviewed monthly alongside the care plans. In the files we looked at there were care plans in place for areas including: Maintaining a safe environment, Communicating, Breathing, Eating and drinking, Eliminating, Personal cleansing and dressing, Controlling body temperature, Mobilising, Working and playing, Expressing sexuality, Sleeping, Death and dying, Pain management and Psychological health. None of the care plans we looked at contained information within the plan for dying or death, whilst it is acknowledged this is a sensitive area it is also one of great importance for individuals. Care plans need to include more detail for staff to follow to be able to deliver consistent personal care and to meet the needs of people displaying specific needs such as behaviours that challenge or aggressive outbursts. For example one care plan we looked at relating to an individuals personal mental health support needs stated: (he/she) can be challenging and physically and verbally aggressive - staff to be patient, walk away, try again when settled down. There were no suggested alternative strategies and no identification of the triggers for these behaviours to enable staff to de-escalate aggressive behaviours or to distract people who were showing signs of becoming anxious or aggressive. The management told us that a routine system of auditing care plans was in place. we looked at a copy of the previous months audit, this showed that 14 care plans had been reviewed and, where issues were identified, the staff team were given a target date to address the shortfalls. We noted that one issue identified was that a person had moved into the home 5 days prior to the audit yet there was no care plan in Care Homes for Older People Page 15 of 39 Evidence: place. The pre admission assessment had been undertaken in excess of 2 weeks prior to the person entering the home. There was evidence in the care plans to show that external healthcare support was accessed on behalf of people living at the home. These included, GP, specialist nurses, Occupational Therapists and Tissue Viability nurses. The quality of daily recording varied greatly. Some examples clearly detailed the personal care and support provided and this showed that peoples preferences and choices were being met. Other examples included very little person centred information, indicating what tasks had been done unto people, for example got (persons name) up, washed and dressed, but little person centred information to confirm that the care and support had been provided in accordance with peoples wishes and preferences. People told us they felt their personal care needs were not always being met. For example one care plan for personal care clearly stated that the person wished to have a bath or shower at least once a week. Recording did not confirm that this need was being met and the person told us that, although things had improved of late, a bath or shower was being offered approximately every 10 days. Residents told us of waiting up to 45 minutes from initially ringing the call bell until their needs were met. The issue seemed to be that at busy times it could take up to 10 minutes for a carer to become free and answer the bell, then if a second member of staff was required to help with lifting a resident, or a hoist was required, then it could be another half an hour. A person told us of an instance where they had been in physical distress the day before this visit waiting for someone to come to help them onto the toilet. We saw visitors during our initial tour of the home. They told us there was a lack of staff that often resulted in a delay in call bells being answered. They said excellent staff In survey responses told us that 4 people felt they always received the care and support they needed, 9 said they usually received this and 2 said sometimes. 5 people said staff were always available when they needed them, 6 people said usually and 2 said sometimes. 4 people said they always received the medical care they needed, 7 said usually and 2 said sometimes. Comments we received via surveys included: Baths/showers are haphazard, in my Care Homes for Older People Page 16 of 39 Evidence: opinion not frequent enough. I would like one AT LEAST once a week; usually I have to ask repeatedly. Response times to the buzzer can be lengthy. Someone usually comes after about 10 minutes to ascertain the need, but then it can be a lengthy wait for the need to be met. If the need is for the toilet this can be very difficult. We looked at medication administration and storage in each unit at the home. There was an individual trolley and medical room on each unit. Senior carers administered the medications on the residential and dementia unit, with qualified nursing staff responsible for this on the nursing unit. All staff responsible for administering medications that we spoke with confirmed they had attended medication training within the past year, this was Pharmacy led training delivered in house. Peoples competency to administer medications was assessed by the manager through supervision, there was evidence on individual staff files to confirm this. We saw that some bottles and packets of medication were signed and dated to indicate when they had been opened. This is good practice as it provided an accurate audit trail of medications maintained within the home however this practice was not routinely followed throughout the home. The monthly medication audits undertaken in the home showed this issue had been identified regularly since October 2009. On the nursing unit staff told us the morning medication round started at approximately 08:20 after handover from night shift. They told us the round generally took around 2 hours to complete. We observed that the lunchtime medication round started at 12:45 and ended at around 13:30 hours. This meant there may not be sufficient lapse of time in between doses of peoples medication. On the residential unit staff told us that the medication round started around 09:00 hours because the senior on duty assisted with helping people to get up, washed and dressed first. They told us the round generally finished at 10:15 with the lunchtime medications being administered between 12:30 and 13:00hrs. We looked at controlled drug storage and administration. These were recorded and stored appropriately. The medication room and fridge temperatures were routinely recorded. Room temperatures varied from 20 - 25 degrees Celsius during the two week prior to this visit, this had been through a period of cold weather. We were concerned that the summer temperatures may mean that medications were not being stored within a safe range however the manager told us that air conditioning had been arranged to be Care Homes for Older People Page 17 of 39 Evidence: fitted. People were supported to manage their own medication if they were able and wished to do so. Risk assessments were in place to support this activity. We observed staff knocking on residents doors before they entered and we heard staff address residents courteously. Residents told us They do their best to preserve your dignity here but this hoisting business is awful. The managers AQAA stated: There has been a lot of emphasis on Person Centred Care. We have had training sessions regarding Dignity In Care and the quality of care people at their last days. We noted that none of the ladies in the dementia unit were wearing stockings or tights. In a bathroom on the nursing unit we saw a supply of net pants designed to keep incontinence pads in place. These were not individually named and staff confirmed that they were used where they were needed. The manager acknowledged that this practice did not serve to promote peoples dignity. As we walked around the nursing unit we saw urinary drainage bags, not discretely covered, sited on the side of the bed nearest the door. It is appreciated that in some instances it is the persons position in the bed that dictates which side of the bed the bag needs to be, however these could be covered in order to promote peoples dignity. On the nursing units we saw various records relating to the personal needs of residents located on a shelf easily accessible to anyone passing by. The homes Service User Guide stated: All residents medical notes and personal details are kept in a locked filing cabinet within the offices. Access to these are kept to a minimum, and goes on to say: Our confidentiality policy on personal information and confidentiality states that no details or information will be passed on to a third party without prior permission. Daily practice observed in the home at this visit did not support this statement. Care Homes for Older People Page 18 of 39 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot be sure they will lead a fulfilling lifestyle or that the routines of the day are always resident led. The meals service in the home is not generally acceptable to residents. Evidence: The managers AQAA stated under the section outlining identified areas for improvement: Getting the staff to improve their interaction with the residents within their work schedule and that the service had improved over the past 12 months by we have purchased more activity equipment. We celebrated St Georges Day and summer party with service users and families, it was a great turnout. We have more external entertainers outside visits. The homes Statement of Purpose informed residents about various social activities, hobbies and leisure interests that people could expect to engage in if they wished. these included movement to music, singalongs, games, bingo, craft and art groups and baking. We were provided with a copy of the programme of activities and outings arranged for the people living at Queens Court. This showed that there were monthly shopping trips Care Homes for Older People Page 19 of 39 Evidence: provided for the ladies living at the home whilst the gentlemen had a separate monthly outing. There was monthly entertainment arranged including singers, Owls R Us, The Farm, A summer garden party and various performers and acts. A monthly Residents Social Afternoon had been arranged for one afternoon per month so that people could get to know each other, this was arranged at residents request. Formal activity sessions provided people with the opportunity to take part in art sessions, beauty afternoons, movement to music, prize bingo, movie mornings and various games. We saw little evidence of meaningful daily occupation taking place such as real interaction between care staff and the residents, it appeared that activity was restricted to the two defined co-ordinators and the care staff were purely there to support people with their physical care needs. During lunch the activity co-ordinator came into the dining room and told people that a game of roulette had been arranged for a date in the future, this sent a buzz of excitement around the room. At various areas in the dementia unit we saw soft toys and items such as hats and scarves for residents to engage with, these were generally tidied up in hanging containers and not about the unit for people to access at will. Residents did not seem to be wandering freely around their home, rather sitting compliantly either in their rooms or in designated lounge areas. We saw 11 residents in the lounge on the Dementia unit, they appeared to be engaged with staff, talking, listening to music and singing. We observed one resident becoming anxious and saw a staff member interacting with this person very well and giving them a doll to cuddle and comfort. By the time we left the unit the person was singing to the baby and fully engaged with it displaying no further anxiety. In the afternoon we saw people had been playing dominoes in the lounge on the dementia unit. We saw that a number of people were in their rooms, many asleep after lunch. We saw one person who was distressed sitting alone in their room. The person was worried because they didnt know why they were there, where their money was, how they were paying for staying there. They had not drunk their cup of tea, saying they didnt want to because then they would need to spend a penny and theres no-one to help me. If you buzz to spend a penny they dont really like it so I dont drink all my tea and Ive been sleeping all day, what else is there to do when you cant walk Care Homes for Older People Page 20 of 39 Evidence: anymore? We asked the manager how often staff checked on people sitting in their rooms, especially on the dementia unit. She told us that staff were expected to check on people in their rooms every 30 minutes. Discussion took place whether this practice was acceptable on a dementia unit and how people could be encouraged to come out of their rooms and offered something meaningful to do. We saw staff meeting minutes of August 2009 that included the following: can we try as much as possible to engage residents? If you are at the nurses table writing a report you could do this in the lounge. Sometimes it makes them feel secure just to have you there. During the course of the inspection we noted there were just 2 people in the lounge on the residential unit, they were both snoozing. All other people had gone to their rooms, the manager told us that this was peoples daily routine on this unit and their choice. We spoke to three people in their rooms, they told us they did not sit out in the lounge unless they were participating in some kind of activity as they felt more relaxed in their rooms. Residents told us visitors were always made welcome and offered a cup of tea if they were at the home when the tea trolley came round. There were pilot kitchens on each unit where visitors could make a cup of tea if they wished. A relative told us they had No concerns at all. We discussed religious observance with people of 3 different faiths. They told us they were supported to practice their individual religious observance if they so wished. We obtained copies of 2 weeks menu to take away with us. These showed that people were offered a choice of main meals daily both lunch and supper time. The choices were not very imaginative. Of the 14 days menu we sampled there were 7 options of pasta, vegetable cheese style bakes and 7 options of pies. There were no choices of dessert and the vast majority of these were bought in, not home made, such as Arctic Roll, Jam sponge and custard, tinned apricots and tinned fruit cocktail. We saw meeting minutes for October and November 2009 that showed people living in the home had some real issues with the quality and quantity of food provided at the home. The manager and the Chef had attended this meeting. Issues raised by residents included the food being served was not that on the menu, the food was either undercooked or overcooked, the supper meal was insufficient, cutlery was not Care Homes for Older People Page 21 of 39 Evidence: clean, food sometimes served cold despite being kept in the hot trolley until serving and some residents felt the menu was not always nutritionally balanced. We saw a letter of complaint that a resident was about to pass to the manager saying that despite assurances at these meetings there had been no improvements in the quality of the food. There were laminated menus on the tables so that people would be reminded of the choices of the day. However, on one table the menu was for a different week, this indicated there was toad in the hole or tomato cheese, leek and onion bake whereas the actual choices on the day were steak pie, mash and veg or a pasta and cheese bake. Tables were nicely laid with cloths and fabric flowers, the dining rooms were clean, light and airy. During our tour of the home we saw staff offering sensitive support to help people eat, this included sitting next to the person at the same level and talking to them gently. We took lunch with the residents, people told us: I am never quite hungry at this time, breakfast is quite late. People told us Breakfast is from 9 onwards, with onwards being the operative word, lunch is at 12:30 and tea at 5pm. The Statement of Purpose stated that snacks and beverages were available outside normal mealtimes via a member of the nursing or care team. Residents spoken with told us they were not aware of this. A resident said they could not remember what they had ordered for lunch, the order had been taken the day before, residents told us that weekend meal orders were taken on a Friday. The Chef told us there were always options available on the day if people did not fancy the daily option. However observation showed that peoples meals were dished up from the hot trolley by care staff and delivered to the person at their table. There was no dialogue to confirm that the person was still content to have the meal ordered. We noted that one person had hardly eaten any of their meal, they were struggling to chew the meat in the steak pie. A carer came to take the plate away, the person said they didnt fancy it, the carer replied oh didnt you and took the plate away. No further dialogue took place to explore why the person hadnt enjoyed the meal or offering any alternatives. We visited the chef in the kitchen to discuss the fact that people were not always happy with the quality of food at the home. The response was that there were 90 Care Homes for Older People Page 22 of 39 Evidence: peoples tastes to satisfy and that it wasnt possible to always achieve this. We asked what food was available for night staff to provide snacks if anyone wanted something between tea at 5.30pm and breakfast the following day. We were told that the sandwiches left over from tea were always left on the side for staff to give to people and that bread, butter and marmalade was available on the individual units so that people were able to have a cup of tea and toast if they became hungry during the night. Seeing as the chef was preparing the sandwiches for afternoon tea at 2.45pm it would probably not be appropriate to give them to residents during the night as they would not have been stored in the fridge in the interim and there could be a risk of food poisoning. The chef told us that the store cupboard and fridge were locked overnight from 6 pm. Care Homes for Older People Page 23 of 39 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that any concerns they have would be listened to and dealt with properly and that, as far as possible, they would be protected in the home. Evidence: The managers AQAA stated Our current complaints procedure allows complaints to be dealt in a robust fashion. We display our complaints procedure throughout the home to make it available to all. Our complaints procedure is also within the new service user guide and statement of purpose. Procedures are in place to deal with POVA issues and allegations of abuse are followed up promptly. We saw that the home had a clear complaints process in place. This was on display for people throughout the home including in each individual bedroom. The format of these was discussed as the print used was quite small and might be difficult for people to read. On surveys most people said that they knew who to talk to if they were unhappy about anything and knew how to make a formal complaint. People were encouraged to raise any concerns. We saw that comments and suggestion sheets were readily available in the lobby area for people to use. A residential services manager had discussions with residents and took any concerns to the manager. Regular residents meetings provided another forum for any issues to be raised. One person on a survey said, The home manager is always available to speak, listen and make amendments as necessary. Care Homes for Older People Page 24 of 39 Evidence: The AQAA stated that five complaints had been made about the home in the previous 12 months. When we looked at complaints records we saw that seven had been recorded. One of these was not related to anything at the home. Complaints had been well managed and recorded. From information viewed people can feel confident that if they raise any concerns they will be listened to, and their concerns will be investigated and responded to appropriately. In the past year a high level of safeguarding alerts had been made in relation to incidents at the home or other issues. The home were proactive in making referrals to the local safeguarding team for any incidents that raised concerns. This should ensure that people felt protected. For some referrals made, records did not clearly indicate what actions had followed, or what the outcome of the referral or investigation had been. It was advised that a summary of events and outcomes be provided for each incident. The manager said that this was sometimes difficult, as where an incident was managed by another agency they were not always given concluding information. Training records showed us that all staff have received training in safeguarding people. The manager and operations director were both trainers in adult safeguarding and ensured that staff were kept up to date in this area. Items covered in the training included types of abuse, whistleblowing and reporting procedures. When we spoke to staff they said that they understood the importance of safeguarding and would always report any concerns. A new member of staff told us about their training and understood about different types of abuse. Information about safeguarding was available on the different units so that people had information to refer to. We spoke with professionals involved with safeguarding issues within the home at this time, they told they felt that Safeguarding is not being taken as seriously and as professionally as we would like, I feel the home is going backwards at this time. Some residents at the home due to their conditions could present with behaviours that might be challenging for staff to manage. Some staff had received training in this area. When we looked at the care plan of a person who could be challenging, we saw that the information available for staff was not particularly helpful. Further detail is included in the Health and Personal Care section of this report. If people have particular behaviours care plans need to be descriptive and robust so that staff are consistent in their approach. Care Homes for Older People Page 25 of 39 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a modern purpose built home that is generally clean and fresh however the environment does not always support the needs of people living with dementia. Evidence: We took a physical tour of the entire home during the course of this inspection visit. The home was generally clean and free from malodours with the exception of some areas of the Dementia unit. There was good signage in the Dementia unit clearly indicating to people where toilets and bathrooms were. However, name plates on their bedroom doors were small and above the average residents eyeline meaning it was difficult for people living in this unit to be able to locate their own rooms. The home was large and consequently peoples bedrooms were arranged over many corridors, the decor did not support people to identify where they were within the home. Overall the home was in a good state of repair however there were some areas that were tired and in need of refurbishment. For example, on the first floor we noted a door to the laundry chute was broken so that it could not be secured. We saw some overbed tables on the nursing unit that were damaged, with fixing screws coming Care Homes for Older People Page 26 of 39 Evidence: through the laminated surface from underneath. This meant this surface could not be effectively cleaned, there was also a build up of detritus at the joint of the table top and the upstand. Some peoples bedrooms were in need of re-decoration. We noted cupboard door and cabinets knobs missing in various bedrooms around the home. The manager told us that a furniture audit had been undertaken in December 2009 and replacement furniture was scheduled for February 2010. It was evident that people were able to bring personal items into the home to make their personal space more homely. However, we noted some rooms that were stark and uninviting, especially in the Dementia unit. In one bedroom on the Dementia unit we saw that a clock was showing the wrong time, the light in the en suite bathroom was not working and the decor was cold and unhomely. This environment does not effectively support the needs of people living with Dementia. There was a lack of storage in the home generally. This meant that equipment such as hoists, trolleys and wheelchairs were stored in the various bathrooms around the home. There remained a lack of storage for the laundry facility as reported at the previous inspection. 1 washing machine was out of order but laundry person said they were coping alright and that the repair was due to be effected the day following this visit. The laundry person was not wearing uniform or protective apron whilst dealing with soiled laundry. This could be a potential infection control hazard. There was a box of gloves on the windowsill by the sink, next to an open box of Tea bags. Staff training records showed that 50 of the people working at the home had attended training in the control of infection. Of these, 11 people had received this training in the past year. In surveys 6 people said the home was always fresh clean and 7 said this was usually the case. Care Homes for Older People Page 27 of 39 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People cannot feel confident that there will always be sufficient, safely recruited staff, to meet their needs. Evidence: On surveys people felt that staff were kind and caring, but that there were not enough of them, and that they were often overstretched. People said, The vast majority of staff are kind and well intentioned but seem overworked, Staff are attentive and care for [relative] well but there is a noticeable shortage of staff. At times you cannot find anyone to talk to if needed, particularly at the weekend, and, Sometimes difficult to find a carer or nurse, weekends especially, could do with more staff. Staff themselves felt that more staff were needed. Out of five surveys received only one felt that there were always sufficient staff available to meet peoples needs. One person said that the home could do better To have more staff in all departments to improve better quality to residents. Queens Court is a large home with 90 beds being available. The home is divided up into four different units with different staffing levels provided to meet peoples needs in the different areas. The managers hours are supernumerary to staffing levels. Ancillary staff are provided for domestic, maintenance, catering and administrative duties. Care Homes for Older People Page 28 of 39 Evidence: Our observations, survey responses and discussions with people during the site visit showed that the current staffing levels being provided, or the deployment of staff, are not meeting peoples needs. Evidence to support this is included within the Health and Personal Care section of this report. Another issues raised by people on surveys and at the site visit was that communication with staff was sometimes hard because of language difficulties. Comments received included: Communication or lack of it is the main weakness. This can be due to language problems or the fact that, in my opinion, there is just not enough staff. Many different languages among the staff team, there are occasions when they dont understand each other They really do try hard, I cant stress how kind hearted they are but communication is an issue Some staff struggle to understand us and we struggle to understand them. During this visit we encountered communication difficulties with some members of the staff team and observed a resident trying to engage staff in conversation but the staff member did not understand what was being said to them. Since the previous inspection the home has experienced quite a high turnover of staff. When the AQAA was completed in November it was stated that in the preceding three months 380 care, senior or nursing staff shifts had been covered by agency staff. This will not help in providing people with care from staff that they know and are familiar with. At the site visit the manager reported that the use of agency staff is now much reduced, and that there are no staff vacancies at the home. So that people receive care from a well trained workforce it is recommended that at least 50 of a homes care staff achieve a National Vocational Qualification (NVQ) in care at level two or above. The home has a large care staff team of about 50. Information provided on the AQAA and confirmed through training records indicated that of these 16 have an NVQ at level two or above. The home have therefore have some way to go in order to meet the 50 basic target. We looked a number of staff files during our visit. This was to ensure that people living at the home were protected through staff being recruited safely, with proper checks being carried out to ensure that they were suitable to work at the home. Files viewed were well organised and showed that proper procedures such as Independent Safeguards Authority checks were carried out, references taken up, proof of identification sought and health declarations made had been undertaken before people started work. Criminal Records Bureau checks had been applied for but were not in place. The manager said that the staff were still working in a supervised capacity. We Care Homes for Older People Page 29 of 39 Evidence: saw that people had undergone an interview process before being offered a position. When people applied for jobs at the home the application forms completed did not provide a full and satisfactory employment history. No dates of employment were given, so it was not possible to see if there were any gaps in employment. One person had a reference from a job where they had worked as a cleaner this was not listed on their job history. It was not possible to tell if references given related to the most recent employment. These issues need to be addressed to ensure that recruitment procedures are robust. Staff files of new members of staff looked at showed that a satisfactory induction process was in place. This will help staff to understand their role and have some basic training to ensure that they work safely. We saw that staff had worked through initial induction modules in line with Skills for Care Common Induction Standards. A new member of staff spoken with explained to us about their initial training which had covered moving and handling, safeguarding and health and safety. They explained that they were working alongside established staff to learn practice and procedures in the home. Staff spoken with during the day identified that they had undertaken a good level of basic training. They felt that the home offered them good training opportunities. People said, The home provides us with different training, and that really helps because it makes our job easy to do, and The home also has lots of training for staff which is great. Training information viewed showed that staff had undertaken good levels of core training but not undertaken much additional training that might be relevant to their role. This might include conditions relevant to old age. We saw however that the program was ongoing with training in oral care shortly to be undertaken by a number of staff. Most staff had undertaken training in dementia care, but the manager said that this was a short course lasting only about three hours. In spite of this we observed that some staff had good skills in working with people who have dementia. Eight staff were shortly to undertake a more robust course in dementia care. It is hoped that more will follow to establish good knowledge and skills throughout the staff team. Care Homes for Older People Page 30 of 39 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that management continue to work to bring about improvements in the service. People cannot be confident that their personal monies will be managed safely. Evidence: Queens Court had an experienced and well qualified manager in post. Since the previous inspection they had successfully completed their registration process with us (CQC.) In discussion with the manager they demonstrated good awareness of things happening in the home. Feedback on management at the home was varied. For example one person said, The home is very well run, and another that, The home is managed from an office with a closed door there is little or no interaction between management and residents/staff. However last June fourteen people responded to a quality survey. On this people felt that access to the manager was excellent 50 , very good 29 and good 21 . Care Homes for Older People Page 31 of 39 Evidence: We saw a notice from the manager to all relatives. This informed people that the manager was available for a weekly surgery, this was held during two time slots on a Wednesday and that no formal appointment was needed. People we spoke with felt this was the only time they were able to speak with the manager and that this was restrictive. Queens Court had a friendly atmosphere and people seemed comfortable and at ease with staff. People had opportunities to express their views at regular residents meetings that were chaired by a person living at the home. Minutes viewed and discussion with the manager showed that peoples views were listened to and where possible acted on. As previously stated there were other opportunities for people to express their views through comments forms and one to one discussions. The last quality assurance exercise at Queens Court took place in June 2009. Fourteen completed feedback forms were received. Responses to different aspects of the service were variable but more positive responses than negative. Monthly visits to review the service by the registered person or nominated individual are required by Regulation. We saw that these were being undertaken by the operations director. The visits included talking to people about their experience of the service. The home had internal processes in place that contributed to the overall quality monitoring at the home. The manager completed a monthly report that summarised events in the home. Audits were undertaken of medication systems and sampled care plans. The AQAA was completed by the manager. It was fairly briefly completed and some areas could have given us more information. The importance of this document and the need to provide good information was discussed with the manager. People cannot feel fully confident that if they needed the home to take care of monies for them, that this would be done in a well managed and robust manner. We sampled two peoples monies and records. One person had too much money as a previous negative amount had not been removed. However the amount had been audited as correct. Balance sheets were designed to be signed by two people, but mostly only one signature was in evidence. People, such as the hairdresser and chiropodist, only provided block receipts. These were not numbered or cross referenced on individual balance sheets. A good audit trail was not therefore provided. This was pointed out at the previous inspection. The manager was aware that systems needed to be improved in this area. A new administrative person had just been appointed. In discussion they were aware of the things they needed to do to put things right, and were committed to doing so. Care Homes for Older People Page 32 of 39 Evidence: The AQAA completed identified that systems and services were monitored and maintained. A partial tour of the home highlighted some health and safety issues. The home suffered from a lack of storage areas. This meant that a number of hoists were left in corridor areas creating a potential trip hazard. Doors labeled keep locked were often found to be open. A fire risk assessment was in place. Fire records were well maintained. Systems were tested weekly, and in an improvement from the previous inspection, regular fire drills were carried out to ensure that staff know what to do in an emergency. Accident records were maintained. Numbers of falls etc. are monitored as part of the managers monthly report. A training matrix and discussion with staff showed that, although there were some gaps in the training provision, the core areas such as moving and handling, fire awareness, health and safety and basic first aid was kept up to date. Information on the different units identified staff and contacts available in relation to first aid, infection control and health and safety. Care Homes for Older People Page 33 of 39 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 27 18(1)(a) Residents must be 30/03/2009 supported by staff in sufficient numbers so that all their needs can be met in full when required. This is a repeat requirement not met within given timescales 01/03/07, 30/08/07 and 01/06/08. Care Homes for Older People Page 34 of 39 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Pre-admission assessments need to include detail about the support people need to meet their specific needs. This is so that their needs can be effectively met as soon as they enter the home making the experience as anxiety free as possible for them and the established residents at the home. 28/02/2010 2 7 15 Peoples care plans need to include more detail about their preferred choices in all aspects of their health, personal and social care needs and how these will be met. This is so that the staff are able to deliver consistent care and support according to peoples personal needs and preferences. 31/03/2010 Care Homes for Older People Page 35 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 3 9 13 Consideration needs to be given around the timing of medication rounds. This is to ensure that people safely receive their medicines at the right time with appropriate lapse of time between doses. 28/02/2010 4 10 12 Personal records relating to the people living at the home need to be appropriately stored. This is so as to promote peoples confidentiality and dignity. 28/02/2010 5 12 16 All staff need to enagage 31/03/2010 more with the people living at the home over routines of daily living. This so that people are more stimulated and engaged in routines of their everyday lives. 6 15 16 People living at the home 31/03/2010 must be offered a nutriltionally balanced menu involving meaningful choices that is served to them at an acceptable temperature and at appropriate intervals of time suitable to them. This is so that people enjoy thier food, receive Care Homes for Older People Page 36 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action appropriate nutrition and do not have long intervals inbetween meals. 7 27 18 Dependency levels of the people living at the home need to be assessed to ensure the number and deployment of staff on duty is appropriate to meet their needs. This is so that people can be assured their personal and social care needs will be met according to their needs and preferences and in a timely manner. 8 29 19 Staff application forms need to be fully completed including an accurate work history. This is so that any gaps in previous emplyment may be explored during the recruitment process. 9 35 17 The system for the storage and administration of residents personal monies needs to be reviewed to ensure it is robust and managed in the residents best interests. 28/02/2010 28/02/2010 31/03/2010 Care Homes for Older People Page 37 of 39 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is so that people can be confident their personal monies are being looked after safely. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 28 Work needs to continue on the NVQ staff training programme so that residents can be assured they receive support from a suitably skilled and knowledgeable staff team. Care Homes for Older People Page 38 of 39 Helpline: 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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