Care Home: Trinity Court

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What the care home does well This service has significant shortfalls in every standard and outcome area. There was no evidence to indicate the service is doing well. What has improved since the last inspection? There have been no improvements. The service has deteriorated. What the care home could do better: This home is failing to meet the needs of service users, and failing to ensure they are protected from harm. A theme running through all outcome areas is poor management and leadership of the home. This is having a detrimental effect on the lives of people living there. The home has failed to achieve compliance in any standard assessed. All standards were assessed as `not met`, and all outcome areas were assessed as poor, with the overall rating for the service being assessed as a 0* poor service. The service must put urgent measures in place to ensure service users are protected from harm and abuse. The service must ensure they address all areas of concern identified in this report, and ensure they comply with all identified breaches of Regulation. There are a total of 23 breaches of Regulation on this report. 10 are outstanding requirements where breaches identified in November have not been addressed. These are: 1. The statement of purpose. 2. Service user contracts. 3. Care planning. (Goals and aspirations) 4. Care Planning. (Assessed support needs). 5. Decisions and Choices. 6. Activities. 7. Meals and Nutrition. 8. Health Care Plans (personal support preferences and PRN medication). 9. Staff numbers. 10. Quality assurance. Two requirements had not reached their timescale for action. They are: unrestricted access to communal areas and keeping the home in good repair and decorated to an acceptable standard; and ensuring the home has sufficient time and resources to keep the home clean. The action plan sent to us by the provider indicated that the requirement regarding unrestricted access to communal areas had been met prior to our requirement date. We found additional breaches with regard to cleanliness of the home (infection control). We were unable to assess a requirement made in November 2009 regarding pre admission assessments of service users as there have been no new admissions to the home. The 13 new breaches, identified at this inspection are: 1. Risk Assessments. 2. Storing of confidential records. 3. Health Care Plans (support needs and records of appointments and outcomes). 4. Ensuring service users are supported to access healthcare appointments. 5. Medication practices. 6. Safeguarding service users from harm and abuse. 7. Ensuring bathrooms and toilets are in good repair. 8. Infection control. 9. Recruitment checks (references). 10. Staff supervision. 11. Management of the home. 12. Regulation 37 notifications. 13. Skills and Competencies of staff. The service must ensure they address all areas of concern identified in this report, and ensure they comply with all identified breaches of Regulation. Key inspection report Care homes for adults (18-65 years) Name: Address: Trinity Court Station Road Staplehurst Kent TN12 0PZ     The quality rating for this care home is:   zero star poor 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: Sarah Montgomery     Date: 3 1 0 3 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 Adults (18-65 years) Page 2 of 51 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 Adults (18-65 years) 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 51 Information about the care home Name of care home: Address: Trinity Court Station Road Staplehurst Kent TN12 0PZ 01580895288 01580895310 trinity@consensussupport.com www.consensussupport.com Consensus Support Services Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users to be accommodated is 10. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Learning disability (LD). Date of last inspection Brief description of the care home Trinity Court is a registered care home providing care and support for up to 10 adults with learning disabilities who may have additional challenging behaviours. Service users are supported by a team of staff which includes; a manager, deputy manager, senior support staff and support staff, and waking night staff. Trinity Court is part of a group of homes owned by Consensus Support Services Care Homes for Adults (18-65 years) Page 4 of 51 Over 65 0 10 3 0 1 1 2 0 0 9 Brief description of the care home Limited. They have additional structures in place to provide support to the home. This includes an area and a regional manager as well as support from human resources, specialist behavioural staff and a quality assurance manager. Trinity Court is a detached three storey property on the outskirts of Staplehurst. The ground floor is available for use by service users. The home provides for 10 single ensuite bedrooms, a lounge, dining room and kitchen. There is a large secure garden to the rear of the property. There is easy access to local shops, medical centre, post office and pubs. Car parking space is available to the front of the property. Buses to local towns stop close by. There is a mainline railway station near the home. Trinity Court are not currently accepting referrals for admissions to the home as there are significant ongoing safeguarding concerns and significant breaches in Regulation. Care Homes for Adults (18-65 years) Page 5 of 51 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: zero star poor service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: This key unannounced inspection was undertaken on the 31st March 2010 by two Regulatory Inspectors. We were in the home from 06:55 until 17:05. A total of 10 hours and 10 minutes. On the day of inspection there were 5 service users living at the home. Two service users had recently moved out, one service user was moving to another home on the day of inspection, and a further two service users are planning to move within a matter of weeks. This is all due to significant safeguarding concerns. 3 senior support workers and 3 support workers were on duty. The responsible individual and acting deputy manager were informed of the inspection by staff on duty and arrived at the home later in the morning. During the inspection we spent time with service users, observed interactions between staff and service users, spoke to staff on duty, and assessed records and documents. Care Homes for Adults (18-65 years) Page 6 of 51 These included care plans, risk assessments, accident records, medication records, and the statement of purpose. Following requirements made at the previous inspection in November 2009, the home sent us an action plan. The home also sent us an up to date annual quality assurance assessment on the 5th March 2010. This document is a self assessment undertaken by the home which details how they are meeting National Minimum Standards, and tells us what improvements have been made and what they are planning to do to improve their service. These documents assisted us in planning our inspection, and we have used information in them to assist us with our inspection process, including cross referencing the information the home had sent us with evidence we gathered at the inspection. The quality rating for this service is 0 star. This means that people who use this service experience poor quality outcomes. Care Homes for Adults (18-65 years) Page 7 of 51 What the care home does well: What has improved since the last inspection? What they could do better: This home is failing to meet the needs of service users, and failing to ensure they are protected from harm. A theme running through all outcome areas is poor management and leadership of the home. This is having a detrimental effect on the lives of people living there. The home has failed to achieve compliance in any standard assessed. All standards were assessed as not met, and all outcome areas were assessed as poor, with the overall rating for the service being assessed as a 0* poor service. The service must put urgent measures in place to ensure service users are protected from harm and abuse. The service must ensure they address all areas of concern identified in this report, and ensure they comply with all identified breaches of Regulation. There are a total of 23 breaches of Regulation on this report. 10 are outstanding requirements where breaches identified in November have not been addressed. These are: 1. The statement of purpose. 2. Service user contracts. 3. Care planning. (Goals and aspirations) 4. Care Planning. (Assessed support needs). 5. Decisions and Choices. 6. Activities. 7. Meals and Nutrition. 8. Health Care Plans (personal support preferences and PRN medication). 9. Staff numbers. 10. Quality assurance. Two requirements had not reached their timescale for action. They are: unrestricted access to communal areas and keeping the home in good repair and decorated to an acceptable standard; and ensuring the home has sufficient time and resources to keep the home clean. The action plan sent to us by the provider indicated that the requirement regarding unrestricted access to communal areas had been met prior to our requirement date. We found additional breaches with regard to cleanliness of the home (infection control). We were unable to assess a requirement made in November 2009 regarding pre admission assessments of service users as there have been no new admissions to the home. The 13 new breaches, identified at this inspection are: 1. Risk Assessments. 2. Storing of confidential records. 3. Health Care Plans (support needs and records of appointments and outcomes). 4. Ensuring service users are supported to access healthcare appointments. 5. Medication practices. 6. Safeguarding Care Homes for Adults (18-65 years) Page 8 of 51 service users from harm and abuse. 7. Ensuring bathrooms and toilets are in good repair. 8. Infection control. 9. Recruitment checks (references). 10. Staff supervision. 11. Management of the home. 12. Regulation 37 notifications. 13. Skills and Competencies of staff. The service must ensure they address all areas of concern identified in this report, and ensure they comply with all identified breaches of Regulation. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Adults (18-65 years) Page 9 of 51 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 51 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, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. 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 the person 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users and their representatives are not provided with correct information about the home as the statement of purpose is misleading and inaccurate. Evidence: Standard 1 was assessed. To assess this standard we looked at the homes statement of purpose. The statement of purpose was cross referenced with all other information gathered during the inspection to assess whether the services and facilities described in it are followed through and are offered to service users. We also looked at information given to us by the home in their action plan following the previous key inspection, and looked at information supplied by the home in their annual quality assurance assessment (AQAA). At the previous key inspection in November 2009, we required the responsible individual to review and update the statement of purpose to ensure service users had correct information about facilities and services at the home. In the action plan sent to the Commission, they do not mention the statement of purpose, nor is it mentioned in their annual quality assurance assessment. Care Homes for Adults (18-65 years) Page 11 of 51 Evidence: We assessed the statement of purpose. It has not been updated. Statements made in this document do not correspond with our evidenced findings. For example, it states: the service user plan will be reviewed every six months. It may be reviewed more frequently if the needs of the service user change significantly or if the individual requests it. You will see in Outcome area 2 (individual needs and choices) that one care plan we assessed (we assessed three care plans) had not been reviewed or updated since June 2008, and in discussions with the keyworker, assessed needs had changed so significantly that she did not recognise who we were talking about when reading the care plan to her. The two other care plans assessed demonstrated that although needs had changed, care plans, health care plans and risk assessments had not. The statement of purpose asserts: all service users, as part of compiling their service user support plan, will be included in drawing up their programme of daily activities. We found that activities are poor (please see Outcome area 3 - Lifestyle). There was no evidence to indicate that service users had been involved or consulted regarding activities. As with our findings in November 2009, we found the statement of purpose to be aspirational and not factual (examples are given throughout this report). Our evidenced findings do not correspond with the services and facilities described in this document. At present, the statement of purpose does not give clear or relevant information about the home. Care Homes for Adults (18-65 years) Page 12 of 51 Individual needs and choices 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 needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users assessed and changing needs are not reflected in their care plans or risk assessments. Service users are not supported to make decisions and choices about their lives. Evidence: Standards 6, 7, 9, and 10 were assessed. To assess these standards we looked at documents which told us how service users are supported in their everyday lives through care planning, risk assessments and decision making. We also looked at how the home stores confidential information about individuals. To assist us in our assessment we referred to the homes statement of purpose, their annual quality assurance assessment, and to the action plan they sent us following the key inspection in November 2009. At the previous key inspection in November 2009, we required the responsible individual to ensure the assessed support needs of service users, including their personal wishes and preferences were recorded on care plans to ensure appropriate Care Homes for Adults (18-65 years) Page 13 of 51 Evidence: and consistent support was given. We also required the responsible individual to ensure service users are supported to make decisions about their lives. The action plan stated that the management are distributing distance learning packs on care planning to staff, and all care plans will be revised by the 31st March 2010. The action plan also said that service users would be offered choices and a record of these choices would be implemented by the 31st March 2010. Evidence gathered at this inspection told us that the responsible individual has not met the requirements set by the Commission, or his own action plan. We found that the three care plans we assessed had not been updated and were poor, and found no evidence to suggest service users are offered choices in their daily lives. At the random inspection on 3rd March 2010, we issued an immediate requirement which stated the responsible individual must ensure that service users support needs are known and recorded on care plans, health care plans and risk assessments. Evidence gathered at this inspection tells us this requirement has not been met. Furthermore, the annual quality assurance assessment (AQAA) stated that key worker meetings are held monthly which records the wishes and outcomes of the individual. We asked to see evidence of these key worker meetings and were told none had occurred. The AQAA also stated we have become more person centred by implementing support plans and risk assessments which have been individualised. We found no evidence to support this statement. We requested evidence of how the home supports service users to make decisions and choices. As already stated, the keyworker meetings indicated in the annual quality assurance assessment had not occurred. We asked staff how service users are involved in planning their activities or in developing their care plans. We were told that the managers write the care plans and the activities timetable. We asked staff several times what activities or choices had been offered to service users on the day of inspection. We were told none had. We looked in detail at the files of three service users. Significant shortfalls were identified in care planning, risk assessments, decision making and the storing of confidential information. As stated, we found that care plans had not been updated or reviewed. Moreover, information in one care plan was so out of date, that the keyworker of the individual did not recognise the person we were describing when reading out information from a Care Homes for Adults (18-65 years) Page 14 of 51 Evidence: care plan to her. An example of this is the care plan stated: may choke whilst eating and may hit out at service users, staff and members of the public. Both care plans were dated June 2008. They had not been reviewed or updated. The keyworker informed us that the service user was not at risk of choking, nor was the service user physically aggressive. We asked why the care plan had not been reviewed or updated. The keyworker did not know. We asked two members of staff to tell us about the care plan of an individual living at the home. This individual has epilepsy and requires careful monitoring including a specialist sensor for use at night. Both members of staff were not aware of any care plans pertaining to this individual. One member of staff said I havent read it (the care plan) recently, I dont know. When questioned about the night routine for this individual, the staff member told us She has the buzzer thing for fits. She has fits. We try to avoid her. She is difficult. We asked if there were specific guidelines for supporting this individual. The staff member told us Yes. I havent read them. We asked another member of staff about the care plans for the same individual. He told us I have no idea how it looks now. I last read a file 2 to 3 months ago. When looking at incident and accident records, we saw that one of the service users whose care plans and risk assessments we were assessing had been involved in an incident on the 15th March 2010. It is stated tht he physically assualted another service user. We looked for evidence to demonstrate that following this incident the care plan and risk assessment for this service user was updated. No review or update had taken place. We looked at a kitchen risk assessment for a service user. The date of the risk assessment is June 2008. At the bottom of the risk assessment is a review date of June 2009. It was not clear if this risk assessment had been reviewed at this time. The risk assessment stated there is a significant hazzard with regard to electrical equipment, boiling kettles, knives, and falls. The risk assessment further states that this service user is to be supervised in the kitchen at all times. This service user has a key to the kitchen and has unsupervised access. A member of staff showed us scratches and scars (on her) from incidents with a service user in November 2009 and February 2010. She said the manager had said she would not allocate her as a worker to this service user but no other safeguards had been implemented in terms of care planning or risk assessments. On all three care plans assessed, we found significant shortfalls in health care Care Homes for Adults (18-65 years) Page 15 of 51 Evidence: planning. This will be discussed in detail in outcome area 4 (Personal and Healthcare Support). We found daily activity records of a service user in another service users file. We were told by a staff member that several confidential files had been left in an unlocked upstairs room for a period of at least one week. Care Homes for Adults (18-65 years) Page 16 of 51 Lifestyle 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 can take part in activities that are appropriate to their age and culture and 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 and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are not supported to lead valued and fulfilling lives. Evidence: Standards 12, 13, 14, 16 and 17 were assessed. To assess these standards we looked at records which told us how service users are supported to lead the lifestyles of their choice. These records include individual weekly planners, daily notes, records of community participation, and evidence of maintaining and development of independence skills. We also spoke to several members of the staff team about activities at the home, and looked at information sent to us in the action plan and annual quality assurance assessment. At the previous key inspection in November 2009, we required the responsible individual to make suitable arrangements and provide sufficient support for service users to participate regularly in activities of their choice, and to ensure that service Care Homes for Adults (18-65 years) Page 17 of 51 Evidence: users received a diet which is balanced and nutritious. The action plan stated that an activity folder has been devised which offers a choice of activities throughout the day, evening, and organised trips. Service users are offered a choice of 3 activities. It further states that new menus are in the process of being typed up, these menus offer two choices and will be more seasonal. The annual quality assurance assessment states Trinity Court enables clients to make choices regarding outings and activities and meals. Evidence gathered at this inspection tells us that the responsible individual has not met the requirements set by the Commission, or his own action plan. We found that activities remain poor, and service users have little opportunity for meaningful activities either in the home or in the community. Diet remains poor, and new menus offering choice and seasonal foods have not come into effect. We looked at menus and spoke with staff about meal preparation and food available at the home. Staff told us that menus are not always followed as necessary ingredients are not available. This also means that choice is not offered, and service users are given what is available. Examples being: on the 30th March the main meal should have been either meat pie or lamb chops. They had spaghetti bolognese. On the day of the inspection service users should have been offered soup and chicken burgers for lunch. This was not available and so service users were given pitta bread. There are sporadic records kept of food eaten. When we looked at daily notes for a service user, there was no entries on March 22 2010, nor for breakfast or lunch on 25th March 2010, or for lunch and dinner on 27th March 2010. Some records are not specific and just say sandwiches. We also found no evidence of nutritional screening. Records for a service user who has high support needs around food and nutrition were exceptionally poor. This service user has some meals through a peg feed, and some meals are eaten (for example cereal). We could see from correspondence from speech and language specialists that it was crucial to record the amount of food eaten. Records assessed by us demonstrated that the home has not recorded any food eaten, and has just signed for breakfast, lunch and tea. When spoken to by healthcare professionals, staff had no idea why the service user was using a peg feed for some meals but not others. In addition, Consensus has failed to ensure staff have received essential training in peg feeding. Health professionals have told us that during a recent visit it was noted that the peg tube was cracked and leaking water. They added that it appeared the home had made no efforts to rectify this situation. The two care plans for this service user regarding Care Homes for Adults (18-65 years) Page 18 of 51 Evidence: eating and peg feeding have been described by the head of speech and language as totally inadequate and has no stated rationale. She added that the last two care plans for meals were written by the manager and were inaccurate and not adequate for support required from staff. This service user has since left the home. On the day of inspection there were five service users living at the home. One service user was leaving the home that day to live in another care home, and another service user was receiving visitors in the afternoon. There was also staff training being delivered at the home in one of the upstairs meeting rooms, and additional staff were on the rota to provide cover for the staff attending training. These were all planned events which the team knew of in advance. We were told that activities for the day were decided at the handover meeting in the morning. We were present at the home for 10 hours (7am - 5pm). During that time, there was no evidence of any planned activities for the service users. Several occasions during the day we were in communal areas of the home where service users were (the lounge and dining room) but no staff were present. We asked a number of staff in the morning what activities were planned that day. One staff member told us activities were written on the daily planner by the shift leader, but the shift leader was upstairs training and no one knew where the planner was. We asked why they couldnt remember what activities had been planned in handover that morning. They were not sure any had. None of the staff referred to individual service users daily activity planners, and no staff member took responsibility to organise meaningful activities for service users. Eventually, a member of staff said she would take two service users for a walk. Service users were left in the lounge or to wander around the home. We observed staff to be mainly in the office. When we questioned the acting deputy manager why staff were congregating in the office, she told us it was difficult to get staff out of the office and to be with the service users. On numerous occasions we observed a lack of interaction and engagement between staff and service users. Staff seemed unable to support service users in a positive way. One service user spent the day following staff and visitors around. When we requested that staff support this service user, and offer an activity which he would like, we were told there is nothing we can do. The service user who was moving out spent the day being very distressed. We questioned why he wasnt allocated a 1-1 staff member on such a stressful day. We Care Homes for Adults (18-65 years) Page 19 of 51 Evidence: were told he had been allocated a 1-1 but the staff member could not be found. The service user spent much of the day alone, banging the wall and shouting. The service user who was moving out had lived at the home for almost 7 years. We asked if he had had a leaving party and were told he didnt have one as he wouldnt understand. We questioned that statement and also commented that a leaving party would be a chance for the other service users to say goodbye, the member of staff said yes, I take your point, he should have had a party. We looked in detail at activity records for three service users. Each service user has a weekly timetable for activities. On these timetables domestic tasks are described as activities. For example, take clothes to laundry, tidy bedroom. When we looked at activity logs, recording was poor and inappropriate, and activities were not recorded. For example, on the entry for March 13th 2010, the activity log for the morning (for one service user) states he was good, and in the afternoon it states he was happy. On the 30th January 2010 it was recorded he was trying to be naughty to staff. Many activity timetables are the same, or have very little difference between them. This tells us that activities are not person centred. We could find no evidence of consultation with service users about their preferred activities. We also found the activity timetables to be inappropriate to the season. For example water vegetable patch, swing chair. There were no alternatives provided to take into account cold weather. When we cross referenced daily notes with activity planners we found the information did not correspond. Service users most consistent activity was sitting in the lounge watching television with staff. Senior management are aware of the lack of activities provided at the home. At the Regulation 26 visit in January 2010 it was noted by the responsible individual that activities were sedentary in nature which did not meet the needs of several of the service users. In February 2010 it was further noted that all service users happy but not particularly challenged. Care Homes for Adults (18-65 years) Page 20 of 51 Personal and healthcare support 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 receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people 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. If people are approaching the end of their life, the care home will respect their choices and help them to 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users personal and healthcare support needs are not met. Evidence: Standards 18, 19 and 20 were assessed. To assess these standards we looked at records which told us how service users are supported with their health and personal care. These included health care plans, health appointment records including evidence of specialist support if required, records which told us how service users receive personal care, and records which tell us about medication practices and protocols in the home. We also looked at information in the statement of purpose, the annual quality assurance assessment, and the action plan. At the previous key inspection in November 2009, we required the responsible individual to ensure all health care plans were reviewed and updated, and to ensure that guidelines for PRN (when required) medicines were updated to ensure there is detailed information on when to administer this medication. The action plan stated that all health action plans to be revisited and amended by 31st March 2010. The annual quality assurance assessment states under our plans Care Homes for Adults (18-65 years) Page 21 of 51 Evidence: for improvement: to continue to ensure that all health needs are met for each individual, for all support plans regarding health to be more in depth and individualised. Evidence gathered at this inspection told us that the responsible individual has not met the requirements set by the Commission or his own action plan. We found that health care plans had not been updated, and found that some service users had suffered a detriment due to their health needs not being met. We also found that PRN guidelines had not been updated. At the random inspection on the 3rd March we found significant shortfalls in health care planning. We issued an immediate requirement which stated The responsible individual must ensure that appropriate recording systems are in place to record health care concerns, visits with healthcare professionals, and a record of any outcome of the visit, including actions for the staff team. Evidence gathered at this inspection tells us that this requirement has not been met. We looked at 3 individual health care plans. Of the three service users whose files we looked at, two of them had epilepsy. We looked at records in both files which told us how the home supports the individual to manage their epilepsy. There is no evidence in any of the files inspected of a pro active approach to service users health care. File 1. We saw a risk assessment for personal care. This was dated 8th April 2009. The date for reviewing this care plan was stated as October 2009. This risk assessment has not been updated at all. The risk assessment tells staff to monitor unobtrusively and not to leave (the service user) for longer than 5 minutes. When we asked staff about this service user they had no knowledge of her care plan. We looked for a seizure chart and could not find one on file. We spoke to the service users key worker. She told us there was no seizure chart and that the epilepsy was much better. We later found seizure charts on the file. They were behind an incident report. We saw that this service user had had 3 seizures in three days (March 2010). There had been no update to her care plan or any re assessment of support needs. We saw that in May 2009 this service user had a prolonged seizure (longer than 5 minutes) in which her lips and nose turned blue, and an ambulance was called. There was no re assessment of support needs or any update to the care plan. Care Homes for Adults (18-65 years) Page 22 of 51 Evidence: We found letters regarding healthcare appointments. Some of these letters were torn. None were in any kind of order. We read a detailed letter from a recent appointment with an epilepsy specialist nurse dated 6th October 2009 . This letter contained a list of symptoms for the epilepsy. None of this information had been transferred to a health care plan or risk assessment. The health action plan is not dated. On the final page it says we will look at this again in six months time. Information on this health action plan has no context in time. There is just one healthcare appointment recorded on the health action plan (17th July 2009), yet on the service users personal file we saw that appointments have been attended with the GP and a specialist nurse. Information on this health action plan is conflicting and is not recorded in the appropriate section. An example of this is, under mental health and emotional needs it states: I have an illness called epilepsy. It goes on to say (under this is how it affects me) I sometimes have seizures which doesnt occur frequently. My seizures are normally tonic clonic and need frequent attention. This service user wears reading glasses. The last recorded eye test was in August 2008. The health action plan states I sometimes get sore heels and painful legs, need lots of exercise. The last recorded appointment regarding feet was in April 2009. There is no health care plan in place for exercise or any care plan which takes account of painful legs. We saw a body chart dated 20th May 2009. Accompanying text stated that staff found swollen leg on her left leg, senior staff informed. There was no indication on file that this was followed up with a healthcare appointment. The health action plan stated I use a wheelchair when walking long distance. There is no mobility assessment on file, no moving and handling assessments, no care planning around mobility, and no further indication of mobility difficulties. We asked the key worker to tell us more about this service users support needs with regard to mobility. She told us she was not aware there were any, and it was the first she had heard that this service user had mobility issues. She told us that the service user does not have a wheelchair. This health care plan stated I need to be weighed monthly at least, or weekly if possible. There was no evidence on file that this service user had ever been weighed. Care Homes for Adults (18-65 years) Page 23 of 51 Evidence: File 2. All care plans on this file had been updated in February and March 2010. This service user has epilepsy. There is no information on the epilepsy care plan regarding the type of epilepsy this person has. We found an assessment package in another area of the file. It was not dated. It stated that the seizures are frequent (every two to three days), that the service user wears a helmet, is prone to drop seizures, and that the seizures range from absences, atonic, myoclonic, and tonic clonic. Information in the assessment package also states that the service user has poor muscle tone in her legs, and for support wears splints on both legs. At the back of this file is a health action plan. This is not dated. Information in this health action plan conflicts with previous information read in the assessment package: under my ongoing health needs it states that the splints are worn to prevent the service user twisting her ankle during a seizure. It does not allude to poor muscle tone in her legs. The epilepsy care plan is inadequate. It fails to indicate what type of seizures the service user has, and there is no guidance or support plan in place for the service user following a seizure. The staff are told on the care plan to always carry the PRN medication, but guidance on administering this is kept on a separate document in another file. Lack of clear support guidelines on the care plan for staff to follow means that this service user is at risk of harm. Again, as with the previous file, in the health care plan the service users epilepsy diagnosis is under mental health and emotional needs. The care plan for medication is blank. It directs the reader to the attached self administration of medication assessment. We read this assessment. It stated that the service user does not have the mental capacity or physical ability to self medicate. We know that this service user needs complete staff support to enable her to take medication. Failure to address this in a medication care plan further demonstrates the homes incompetence and lack of knowledge. Information in the health action plan is inadequate and does not address the significant health concerns of this service user. Under my ongoing health needs there is one sentence which states my peg tube needs to be kept clean to prevent infection. There is no explanation about the peg fed, why it is used, or no further Care Homes for Adults (18-65 years) Page 24 of 51 Evidence: information about how to clean it. In the previous outcome area (lifestyle) we have told you of the concerns from the head of speech and language about the homes incompetence in both maintaining the peg correctly and in poor and unsafe care planning and practice regarding the peg. A care plan on peg feeding was read. This was updated in February 2010. This care plan is confusing to the reader, and amalgamates medication, eating, and care of the peg tube. It is unclear what the aim of the care plan is. It contains no detailed support guidance. Statements such as staff must be aware of how to administer foods and liquids via the peg, are not supported by any guidance. The care plan then tells staff to flush with water and this is followed by the first dose of medication. The medication is not noted on this care plan, and as we have already identified, the medication care plan is blank. Information in this health action plans tells us that the home has failed to ensure the service users health needs are met. This service user has known health needs with feet and ankles. The last health care appointment recorded regarding this was in January 2009. This service user wears glasses. She was last supported with an eye test in August 2008. Her hearing has never been tested. Under my teeth, it states I visit the dentist at least twice every year for a thorough check up. The most recent dentist appointment was in December 2008. There is no record of any immunisations. There has been no personal health screening with regard to breast screening or smear tests. File 3. We found information on health support plans spread over two different files: the care plan file and personal file. The files were full of disparate information, so current information was difficult to find readily. Information on this file evidences further that service users health care needs are neglected: We found a letter from West Kent Primary Dental Services dated 16th January 2009. It states that the service user did not attend a dental appointment scheduled for 1st December 2008. The letter requests contact if dental treatment is to be continued. There was no evidence of any response to this letter, and no evidence that alternative dental treatment was sought. Another letter dated 13th March 2008 from Kent and Medway NHS Speech and Language Therapist states that the service user had been referred by a Doctor and Consultant in Learning Disabilities for an assessment and advice on communication strengths and limitations. The letter states: since my previous letter dated 25th Care Homes for Adults (18-65 years) Page 25 of 51 Evidence: October 2007 I have received no contact (from the home). The letter goes on to say the service users file will be closed, and if support is needed another referral will be necessary. There was no evidence the home followed this up, and we could find no evidence as to why this referral from the consultant was not followed through. There was no evidence of nutritional screening for this service user. During the early morning handover we observed the night support worker telling the day staff that this service user was checked twice and changed both times. We read many night reports in respect of this service user which confirmed this was the case every night. The care plan states check two times per night and change if required. We looked on the health care file for evidence of support and guidance from continence specialists with regard to continence management. None had been sought. Assessment of medication protocols evidenced that current practice is unsafe and places service users at risk. We began by inspecting the medication cabinet. Every shelf was dirty. The dirt was compounded by a thick film of sticky substances covering every shelf. We understood this to be spilt liquid medicines. The tablet counter was dirty and had remnants of crushed tablets left on it. This is not only a health hazard but potentially could indicate that it has not been cleaned after each use. If careful dispensing was not observed service users may have been given contaminated medicines. We brought both the tablet counter and the unclean medicine cabinet to the attention of the responsible individual. He agreed with our findings, took the tablet counter to clean immediately, and assured us the medication cabinet would be cleaned that day. We inspected the controlled drugs register. We found significant shortfalls in all areas of recording: there was one entry for a service user for a controlled drug. This was dated December 2008. There was no further record for this medication. Nor was there any record that this medication was discontinued, returned or destroyed. For another service user the name of the drug is not recorded in the correct column. Under date received it just records 12/7. There is no year recorded. In the controlled drugs cabinet there is medicine stored without a label. Just the initials of the service user have been handwritten on the box. We asked to look at homes records for ordering and returning medicines. There is no order book for medicines. The home does not have a system in place to ensure medicines are ordered or returned. We were shown an envelope in which all prescriptions are kept. None of the staff on duty had any knowledge of how to obtain medication. Staff told us that the Doctor takes care of ordering all medication. Care Homes for Adults (18-65 years) Page 26 of 51 Evidence: 10 empty tablet bottles were stored in the medicine cabinet. All had hand written labels. We were told they had been there for years. We looked at PRN guidelines. None had been updated. The PRN guidelines are inadequate and do not give clear guidance to staff about what circumstances the medicine is to be administered. Current guidelines leave service users at risk and staff without appropriate support. Inspection of the accident and incident records evidenced significant failures of the home in ensuring service users receive appropriate healthcare support. An example of this is an incident on 3rd February 2010 in which a service user fell backwards on an escalator, suffering injuries to his head, back and legs. No medical attention was sought. The service user was not seen by a healthcare professional. On the incident form under action taken/recommendations, it is blank. The form was not signed. This and other failures to address the healthcare needs of service users following accidents and incidents will be further addressed in Outcome areas 5 and 8 (Complaints and Protection, and Conduct and Management of the Home). Care Homes for Adults (18-65 years) Page 27 of 51 Concerns, 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. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are not protected from harm. There are not robust systems in place to ensure service users are safeguarded from harm or abuse. Evidence: Standard 23 was assessed. To assess this standard we looked at records which told us how the home ensures service users are kept safe from harm and abuse. These include accident and incident reports, Regulation 37 notifications, risk assessments, and staff recruitment checks. We also looked at information sent to us in the annual quality assurance assessment, and looked at information in the statement of purpose. The annual quality assurance assessment makes no reference to how the home ensures service users are protected from abuse, neglect and self harm. Evidence gathered at this inspection tells us that service users are not protected, and potentially are at risk of significant harm. We looked at incident and accident forms. There were a number of incidents which had not been reported to the Commission (Regulation 37 notifications). The responsible individual accepted this and agreed to complete and forward Regulation 37 notifications to the Commission. We read an accident report (dated 3rd February 2010) in which a service user fell backwards while on an escalator and sustained injuries to his head, back and leg. No Care Homes for Adults (18-65 years) Page 28 of 51 Evidence: medical attention was sought either immediately following this incident or any time since. Nothing had been written on the form in the action taken/recommendations section and the form had not been signed. We were informed at a recent safeguarding meeting about the home (9th March 2010) by a funding authority that they had visited the home that day (prior to the meeting) and had discovered incidents, accidents and serious health concerns regarding their funded service user had occurred. They had not been informed. When checked, nothing was recorded on file, and verbal feedback from staff did not match medical notes. The funding authority was assured that all paperwork would be updated. We looked for evidence of accident and incident reporting for this service user in the accident/incident file. There were none. Inspection of a staff file evidenced that the home had not sought references prior to commencement of employment. Inspection of care plans, risk assessments and health care plans evidenced that support needs were not adequately recorded, and service users needs were not being met. Discussion with staff evidenced little knowledge of care planning, and some staff demonstrated a disregard for service users dignity and feelings. We witnessed a staff member being physically abusive towards a service user. We witnessed staff ignoring service users, even when they were distressed. This evidence points to an environment where service users are not protected from harm, and are exposed to and suffer abuse and neglect. Srvice users are not protected by the homes policies, and working practice and the current culture of the home is poor. Care Homes for Adults (18-65 years) Page 29 of 51 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, comfortable, 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. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users live in a poor environment which is not clean, safe or homely. Evidence: Standards 24, 25, 27 and 30 were assessed. To assess these standards we looked at communal areas of the home and some bedrooms. We also looked at records which told us about how the home ensures correct infection control measures are in place and at records which demonstrated the home has the correct adaptations to keep people safe. In addition, we looked at the action plan, the statement of purpose, and the annual quality assurance assessment. At the previous key inspection in November 2009, we required the responsible individual to make improvements to the environment and to ensure service users have appropriate support to access all communal areas of the home. Although this timescale for action had not been reached (the timescale was 23/4/10), the responsible individual had informed us this requirement would be met by the 31st March 2010, and provided evidence in the action plan which indicated this to be so. The action plan stated that risk assessments for all communal areas are in the process of being implemented by management. Evidence gathered at this inspection tells us that this has not been done, and the responsible individual has failed to meet Care Homes for Adults (18-65 years) Page 30 of 51 Evidence: his own action plan. A service user showed us around his home. Although we could see that some improvements had been made to the environment in terms of decorating the hallway and lounge, significant shortfalls were identified in relation to decor, infection control and general upkeep and maintenance. We saw that the home was not clean. Skirting boards in all areas were excessively dirty. In the dining room and the corridor by the dining room, skirting boards were thick with black grease. The serving hatch in the dining room was dirty and had dried on food and grime. There was a stale odour present in the dining room, and the walls were dirty and the paint was chipped in several areas. In the kitchen the skirting boards under the sink were damaged, and part of the ceiling paint was coming away. When we looked at the fridge and freezer temperature monitoring information, we could see that recording of temperatures is sporadic, and when temperatures have been taken, records show readings of between 6.9 and 7.7. Fridge temperatures should not be higher than 5. There was no evidence that these records are monitored or that any action is being taken with regard to warm running fridges. The handle on the inside of the kitchen is coming away. When we arrived at the home the kitchen was locked. The dining room next to the kitchen had chairs on the tables, and one service user was sitting in this room with a cup of tea. At the inspection in November 2009 we questioned why service users were locked out of the kitchen. We were told it was because the taps did not have thermostatic valves, and could be hazardous. We required the registered person to ensure the valves were fitted, and to enable service users to have access to communal areas of their home within a risk assessment framework. As stated, the action plan indicated that risk assessments were being implemented. We had also been informed by the responsible individual prior to this inspection that all communal areas of the home were accessible to service users. When we questioned why the kitchen was locked we were told they kept going in and eating all the food. We asked to see risk assessments for each individual service user which documented why they were denied access to the kitchen. We were told that none had been completed. The responsible individual informed us that one service user was able to use the kitchen independently and had been given a key. We asked how this was risk assessed as the service user would have to lock themselves in the kitchen. Staff told us they were not sure about a risk assessment. When we looked in this service users file for a risk assessment, we could see that a kitchen risk assessment had been completed. The date of the risk assessment is June 2008. At the Care Homes for Adults (18-65 years) Page 31 of 51 Evidence: bottom of the risk assessment is a review date of June 2009. It was not clear if this risk assessment had been reviewed at this time. The risk assessment stated there is a significant hazzard with regard to electrical equipment, boiling kettles, knives, and falls. The risk assessment further states that this service user is to be supervised in the kitchen at all times. This service user has a key to the kitchen and has unsupervised access. A service users bedroom was considered to be dirty and hazardous. The carpet was dirty and had debris scattered, including a long screw. Curtains that matched this service users bedlinen were hanging in another service users bedroom. The ensuite bathroom had an unpleasant odour. We saw that tiles at the end of the bath were damaged. The shelves in the vanity unit in the bathroom were thick with dirt. There were two razors in this vanity cabinet. We questioned if there was a risk assessment in respect of these razors, and were told there was not. (This was particularly pertinent as the service user picked up the razors and thrust them into an inspectors face. A member of staff removed the razors and subsequently discovered other razors and nail polish remover in other bedrooms, none of which had been risk assessed). This same bedroom had very poor quality bedding. There was one pillow on the bed. It was completely flat. The bedlinen was dirty and required washing. In a bedroom which is currently vacant, the ensuite bathroom has damaged wall surfaces, and another vacant bedroom has damaged wall surfaces around the toilet. In another service users room we saw that the soft chair was stained. The coving was coming away from the ceiling in the ensuite. A metal stacking tray and metal toilet brush holder in the bathroom were rusted. The carpet in the doorway from the bedroom to the ensuite was raised and is a trip hazard. Inspection of a further bedroom evidenced that the wood panel on the bath and parts of the wooden vanity unit is damaged. Plaster work between the bath and vanity unit is damaged. We saw that a further bedroom had missing handles to the wardrobe and drawers, and protruding screws had been left in place. The curtains were attached with velcro, but one curtain was missing so the window could not be fully covered. In the ensuite there was significant staining to the wood around the handbasin. Tiles around the toilet were damaged. The toilet seat and lid were missing. We checked the matress in a room of a service user who we were told can be incontinent of urine. The matress was a fabric divan. This is not conducive to Care Homes for Adults (18-65 years) Page 32 of 51 Evidence: managing continence or infection control. The laundry room is very small. Clean and dirty laundry is stored in there. The size of the room would make it difficult to separate these items. The washing machine was out of order. We were told that an aerosol can had been put in the machine on a wash cycle. Staff are using a local launderette until the machine is fixed or replaced. Cleaning materials are stored in this room. We saw that a mop had been stored in a bucket rather than suspended. The communal toilet next to the laundry has damage to the wood behind the toilet. The bin is missing and in its place is the frame part of a foot pedal operated bin. The extractor fan was dirty and requires cleaning. The communal bathroom (close to the office) had damaged plasterwork on the wall near the bath and behind the door. The toilet seat was detached and left on a shelf. The foot pedal bin was broken. The body of the soap dispenser was missing and no alternative was provided. Near the front door, a room which had previously been a bedroom had been recently converted into a small lounge. The sofa was covered in bin bags. We questioned why this was and were told because a service user is incontinent. When we questioned the appropriateness of using bin bags to manage continence, and referred to treating service users with dignity and respect, the bin bags were removed. In this same lounge we saw that blue tack was left on the ceiling from old decorations. The ensuite facility attached to the lounge is not equipped with a soap dispenser or hand drying facilities. The toilet seat is damaged, and a wooden pedestal stored in the ensuite is causing an obstruction. We noticed there was no lightbulb in the small lounge. We were informed that a support worker had removed the lightbulb that morning to use in a service users bedroom as the location of where lightbulbs are stored are not known to staff. Care Homes for Adults (18-65 years) Page 33 of 51 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, qualified 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. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are not skilled or competent. Service users do not receive appropriate support or have their needs met. Staff do not receive appropriate supervision and support from their managers. Evidence: Standards 31, 32, 33, 34, 35 and 36 were assessed. To assess these standards we looked at records which told us about the skills and competencies of staff. These included staff training, the staff rota and recruitment practices. We also observed staff working with service users and looked at information in the action plan, the annual quality assurance assessment and the statement of purpose. At the previous key inspection in November 2009, we required the responsible individual to ensure sufficient numbers of staff are on duty and to ensure the needs of service users are met. The action plan stated that staffing levels were increased, but reduced as some service users have left the home. Evidence gathered at this inspection tells us that current staffing levels have not ensured the needs of service users are met, and the responsible individual has failed to meet the requirement set by the Commission. Care Homes for Adults (18-65 years) Page 34 of 51 Evidence: When we conducted our random inspection on March 3rd 2010, records assessed demonstrated that service users at Trinity Court were poorly supported by staff with their healthcare needs, care planning, risk management, and activities. When we asked the responsible individual during that inspection if he felt service users at the home were safe, he replied no. We left immediate requirements in respect of care planning, health care plans, risk assessment, record keeping and an immediate requirement to ensure the home was appropriately managed. The recent annual quality assurance assessment states: the staff who work at Trinity Court are committed and enthusiastic in supporting clients with their needs and wishes. Our inspection today evidenced that service users continue to be poorly supported by staff. This was demonstrated in our observation of interactions with service users and staff, assessment of care plans, health care plans, risk assessments, and daily records, and in speaking with a range of staff at the home. Staff told us that recent changes to the management team (the manager has left, the deputy manager is currently suspended, and the home has an agency manager and an acting deputy manager brought in from a day centre run by Consensus) has brought some improvements, and they find the new management more approachable. However, staff are still not involved in care planning, and our discussions with staff evidenced they are not aware of service users care plans, or if any changes have been made. When asked to describe a care plan of a service user, a member of staff told us I have no idea how it looks now. Another staff member told us (when asked the same question) I havent read it recently, I dont know. The staff member (who was a night support worker) went onto say we try to avoid her (the service user), she is difficult. This service user has epilepsy and requires close supervision. We witnessed staff speaking sharply to service users, and on two occasions staff used physical force with a service user. Neither time was it a recognised physical intervention technique. One involved pushing a service user onto the sofa, and the other involved pushing a service user on the stairs. We reported both incidents to senior management at Consensus. There were other instances in which it was evident that staff had little regard or respect for service users dignity and feelings. We saw staff ignore service users who were distressed. We observed staff issuing one word instructions to service users: come, sit, stay. When asked about numbers of service users in the home, a staff Care Homes for Adults (18-65 years) Page 35 of 51 Evidence: member nodded towards a service user standing with us and informed us he is leaving, we only found out yesterday. The service user stood listening with his head down. We felt uncomfortable that this exchange had happened, and tried to include the service user by stating that we were talking about him, and how did he feel. He remained standing with his head down. For the most of the 10 hours we were in the home, no positive interactions were observed. As stated in the lifestyle outcome area, most of the service users spent their day wandering around the home, and staff were not actively supporting them to engage in activities. We had to request intervention on numerous occasions on behalf of service users. We observed staff to be unmotivated and unwilling to engage in any positive way with service users, and in complete contrast to what was written in the annual quality assurance assessment, were not committed or enthusiastic. Staffing numbers on the day of inspection were adequate to provide 1-1 for all service users. However, this did not happen. Our evidence demonstrates that staffing numbers were inadequate as staff on shift did not have the necessary skills or competencies and failed to engage with service users, failed to provide meaningful activities, and failed to support service users with their individual assessed needs. At the random inspection on March 3rd 2010 we looked at Regulation 26 reports from October 2009 to February 2010. In this five month period senior management at the home had raised concerns over absence of staff supervision. We asked to see the Regulation 26 report for March 2010, and was informed that a visit had not been undertaken. The most recent comment recorded by the responsible individual about staff supervision (in the February 2010 Regulation 26 report) stated supervision structure poorly maintained. I have instructed managers to commence supervisions with immediate effect and bring up to date. We asked to see supervision records. We were told none were available. We asked three members of staff how frequently they had received supervision. One staff member who has been at the home for three years told us They never give us supervision, I have never had it. Another member of staff employed at the home for over a year said I havent had any. A member of staff who has been at the home for 19 months told us she has had one supervision. We asked a member of staff how frequent staff meetings are. We were told that prior to the new management structure there were none, but now every Wednesday the seniors have a meeting. There have been no staff meetings, and none are planned. In the February 2010 Regulation 26 report it was noted that a staff meeting had been Care Homes for Adults (18-65 years) Page 36 of 51 Evidence: held in January. We asked to see records of this meeting. None could be found. We looked at the staff training matrix. We could see that most staff had received recent training in moving and handling, protection of vulnerable adults, first aid, reporting and recording and conflict management. However, shortfalls were noted in training in challenging behaviour (5 staff), training in epilepsy (3 staff), and just 5 staff trained in infection control. We noted that only one member of staff had completed a National Vocational Qualification, and that 5 staff had been registered to start on NVQ2 on March 19th 2010. We question the effectiveness of the recent reporting and recording training. In several of the daily records assessed, recording was poor, and on numerous instances, nothing had been recorded. We looked at one service users daily logs and noted that over a thirteen day period, two full days of daily reports were missing, and on eight separate days, either the morning or afternoon notes are blank. We also saw that some comments recorded were inappropriate. For example he was good, and he was trying to be naughty to staff. Staff do not always record important events. We looked on one service users daily log to see what had been written on his birthday. There was no reference to it whatsoever. The only indication that the birthday has been celebrated was by looking in another service users daily log for the same day which stated she enjoyed a birthday party. The home employs a high number of agency staff, and is dependent on them to maintain adequate staffing levels. These staff have become long term staff members, and have been employed at the home for a significant period of time (in one case, three years). There are no systems in place to monitor whether the agency staff are up to date with essential training, and when questioned, the responsible individual had no knowledge of what the agency employees had received training in, and told us that he believed that training was provided by the agency. Consensus have made no attempt to ensure that agency staff are suitably qualified in epilepsy, challenging behaviour, medication, infection control, food hygiene, or moving and handling. Competence in these areas are required on a daily basis at Trinity Court. Coupled with the fact that none of the agency staff (or permanent staff) are receiving supervision, Consensus has failed to ensure these staff members have the suitable skills, competencies and training necessary to provide support to service users at the home. Three staff files were assessed. On all three files the Employee Commencement Form and the Personal File Checklist was not completed. One file had no references, nor was there any evidence to indicate these been requested. When we questioned the responsible individual about these references he told us they cant have started Care Homes for Adults (18-65 years) Page 37 of 51 Evidence: without references. He went away to check, and later confirmed that they had, and references had not been obtained. The registered person and Consensus have failed to ensure service users are protected as not only have they failed to obtain references prior to making an offer of employment, they have employed a member of staff to work at the home without receiving appropriate references. Care Homes for Adults (18-65 years) Page 38 of 51 Conduct and management of the 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 have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because 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. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is not well run. There are poor management systems in place. Service users living at the home are at significant risk of neglect and abuse. Evidence: Standards 37, 38, 39, 40, 41 and 42 were assessed. To assess these standards we looked at records which told us how the home is run, and records which tells us how the home self - monitors their performance. These records include the annual quality assurance assessment, staff supervision records, and all records relating to meeting the support needs of service users, for example, care plans. We also referred to the action plan and to the statement of purpose. At the previous key inspection in November 2009, we required the responsible individual to ensure that quality assurance at the home is robust to enable them to identify and respond to shortfalls in the service provision. The action plan stated that monthly management audits will take place to identify shortfalls. Evidence from this inspection and from the random inspection on the 3rd Care Homes for Adults (18-65 years) Page 39 of 51 Evidence: March tell us that although monthly audits (Regulation 26 visits) have taken place, and identified shortfalls, these shortfalls have not been addressed and the same shortfalls have remained month after month. The responsible individual has failed to meet the requirement set by the Commission and has failed to meet his own action plan. Furthermore, at the random inspection on the 3rd March 2010, we issued an immediate requirement which stated the responsible individual must ensure the home is appropriately managed to ensure the health, safety and welfare of service users is met. Evidence gathered at this inspection tells us this requirement has not been met, and the home does not have robust management systems in place. 31 National Minimum Standards were assessed. Every Standard had significant shortfalls and was assessed as poor. Consensus has failed to ensure service users are adequately protected or are safe in this home. The numerous management changes at the home over a period of five months has not resulted in a rising of standards, or provided positive outcomes for service users. Instead, this home has deteriorated, service users have suffered, and their health, safety and welfare have been and continues to be neglected. The Commission have lost trust and confidence in this Company and in their ability to bring about positive change. The home is still without a registered manager. The agency project manager recruited to oversee management of the home in the short term has told us the home is the most chaotic she has ever worked in. She informed us that it was never possible to begin management of the home, as each day there was chaos, and it was not unusual to have to spend the day trying to get money for food or activities, and repeatedly guiding staff and reminding them of their tasks and duties. Even with the new management structure in place, service users were not safeguarded from harm or neglect. We have detailed in this report significant concerns about a service users peg tube being cracked. We observed ourselves staff neglecting and also physically assaulting service users. We read care plans and risk assessments which were years out of date and bore no relevance to the service user today. We saw care plans which had no guidance for support. We saw evidence that service users are not supported to attend important health care appointments. The home was dirty, infection control is non existent, service users are left alone frequently, and staff are unmotivated and unwilling to engage with them. We saw that staff are poorly supported, receive no supervision, and lack the skills and competencies necessary to support the vulnerable service users at Trinity Court. Care Homes for Adults (18-65 years) Page 40 of 51 Evidence: There is no effective quality assurance at the home. Trinity Court is a home in crisis. Yet no Regulation 26 visit was conducted in March 2010. The only documents in the quality assurance folder at the home were some old annual quality assurance assessments, a Regulation 26 report from July 2008, and staff questionnaires from May 2009. Throughout our inspection (and detailed in this report) we referred to three key documents provided by Consensus. These were the Statement of Purpose, the action plan, and the annual quality assurance assessment. The assertions made in all of these documents were evidenced to be untrue. Staff at the home do not understand how to support the clients with dignity, respect, offering choices in all aspects of individual lives (annual quality assurance assessment). The home does not offer service users a high level of support twenty four hours a day from skilled and experienced staff (the Statement of Purpose), and the home has not ensured that the home runs more robust and will ensure shortfalls can be identified (the action plan). Information contained in the action plan and annual quality assurance assessment demonstrates that the home and Consensus have no insight into their significant failures to meet the support needs of service users, and their continued failure to meet standards and Regulations. Care Homes for Adults (18-65 years) Page 41 of 51 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 1 4 The registered person must produce a statement of purpose and service user guide which tells service users and their representatives about the home. The registered person must ensure that prospective residents and their representatives have correct information about all services and facilities at the home. 31/03/2010 2 2 14 In order to meet individuals 31/03/2010 particular support needs, the registered person must ensure that prospective service users are competently and thoroughly assessed prior to admission to the home. . 3 5 5 All people living at the home 31/05/2009 need to have a contract/terms and conditions, which is available to them. It needs to tell them what services they are paying for at the home and what is extra. The contract needs to be signed by the service user/representative and the registered manager. Care Homes for Adults (18-65 years) Page 42 of 51 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 To make sure people know what they are paying for. 4 6 15 The care plans need to 31/05/2009 contain the relevant information to meet the individual needs of the service users. They need to be used as a daily working document by the service users and staff. Goals and aspirations should be written clearly and simply with steps detailed to reach these goals, with care plans kept up to date. To make sure that all the needs of the service users have been identified and that there is an accessible plan in place to show how these needs are going to be met by the service. This will a. tell staff what they have to do to look after the person in the way they wish and have chosen. b. to make sure that any changes in service users care is identified and the appropriate action is taken. 5 6 15 The registered person must 31/03/2010 ensure the assessed support needs of individuals, and personal wishes and preferences of individuals are recorded on care plans. To ensure that service users receive appropriate and consistent support. 6 7 12 The registered person must ensure service users are 31/03/2010 Care Homes for Adults (18-65 years) Page 43 of 51 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 supported and enabled to make decisions about their lives. The registered person needs to develop systems which evidence service users are offered choices and are making decisions about their lives. 7 9 4 The responsible individual must ensure that service users support needs are known and recorded on care plans, health care plans and risk assessments. To ensure the health, welfare and safety of service users is met. 8 13 16 The registered person must 31/03/2010 consult service users about a programme of activities taking into account hobbies, interests and aspirations. The home must then make suitable arrangements and provide sufficient support for service users to participate regularly in activities of their choice. To ensure service users social and lifestyle choices are met. 9 17 16 The registered person must ensure that service users receive a diet which is balanced and nutritious. To ensure service users Care Homes for Adults (18-65 years) Page 44 of 51 03/03/2010 31/03/2010 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 nutritional needs are met. 10 18 13 The responsible individual 03/03/2010 must ensure that appropriate recording systems are in place to record health care concerns, visits with healthcare professionals, and a record of any outcome of the visit, including actions for the staff team. To ensure the health, welfare and safety of service users is met. 11 18 13 The registered person must 31/03/2010 ensure that all health care plans include details of the personal preferences of service users with regard to how personal care support is to be provided. This must include detailed information on when to administer PRN medication. To ensure all healthcare needs of service users are met. 12 24 23 The registered person must 23/04/2010 ensure that service users have unrestricted access to commual areas in the home and are provided with appropriate support and risk assessments to allow this to happen. Furthermore, the registered person must ensure that all areas of the home are kept in good repair and decorated to an acceptable standard. This includes providing adequate Page 45 of 51 Care Homes for Adults (18-65 years) 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 ventilation in the kitchen. To ensure that service users live in an environment which is clean, safe and homely. 13 30 23 The registered person must 16/04/2010 ensure the home has sufficient time and resources to keep the home clean. To ensure the health and safety of service users. 14 33 18 The registered person must 01/03/2010 ensure that sufficient numbers of staff are on duty. To ensure the needs of service users are met. 15 37 10 The responsible individual must ensure the home is appropriately managed. To ensure the health, safety and welfare of service users is met. 16 39 24 The registered person must 31/03/2010 ensure that quality assurance at the home is robust. This will enable the home to identify and respond to shortfalls. 03/03/2010 Care Homes for Adults (18-65 years) Page 46 of 51 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 9 4 The responsible indvidual 10/05/2010 must ensure that all service users have up to date risk assessments, and that these risk assessments detail the support required as well as accompanying guidance for staff if necessary. To ensure the health, welfare and safety of service users is met. 2 10 17 The responsible individual must ensure that information about service users is stored appropriately. To ensure records are secure and confidential. 10/05/2010 3 19 12 The responsible individual 26/04/2010 must ensure that all service users have health care plans which are up to date and detail their healthcare support needs, including a record of health care Page 47 of 51 Care Homes for Adults (18-65 years) 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 concerns, visits with healthcare professionals including a record of any outcomes and actions from appointments. To ensure the health, welfare and safety of service users is met. 4 19 13 The responsible individual must ensure that service users are supported to access health care professionals for appointments and advice. To ensure the health, welfare and safety of service users is met. 5 20 13 The responsible individual 26/04/2010 must ensure there are robust systems in place for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. To ensure the health, welfare and safety of service users is met. 6 23 13 The responsible individual must ensure there are robust systems in place to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. 26/04/2010 26/04/2010 Care Homes for Adults (18-65 years) Page 48 of 51 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 To ensure the health, welfare and safety of service users is met. 7 27 23 The responsible individual must ensure that all bathrooms and toilets are in a good state of repair and are suited to the needs of the service user. To ensure the health, welfare and safety of service users is met. 8 30 16 The responsible individual must ensure there are effective infection control measures in place in the home. To ensure the health, welfare and safety of service users is met. 9 32 18 The responsible individual must ensure that staff have the necessary skills and competencies required to support service users. To ensure the health, welfare and safety of service users is met. 10 34 19 The responsible individual must ensure that references are obtained prior to employment commences. 30/04/2010 17/05/2010 03/05/2010 17/05/2010 Care Homes for Adults (18-65 years) Page 49 of 51 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 To ensure the health, welfare and safety of service users is met. 11 36 18 The responsible individual 10/05/2010 must ensure that all staff working at the home receives regular supervision. To ensure the health, welfare and safety of service users is met. 12 37 10 The responsible individual must ensure the home is appropriate managed. To ensure the health, welfare and safety of service users is met. 13 41 37 The responsible individual must ensure the Commission is notified of any significant event at the home as listed in Regulation 37. To ensure the health, welfare and safety of service users is met. 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 03/05/2010 10/05/2010 Care Homes for Adults (18-65 years) Page 50 of 51 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). 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