Review of compliance. Ashbourne (Eton) Limited The Old Rectory. East. Region: Spring Lane Lexden Colchester Essex CO3 4AN.

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1 Review of compliance Ashbourne (Eton) Limited The Old Rectory Region: Location address: Type of service: East Spring Lane Lexden Colchester Essex CO3 4AN Care home service without nursing Date of Publication: November 2011 Overview of the service: The Old Rectory provides accommodation with personal care for up to 60 older people. Some people who use the service may have dementia. Page 1 of 26

2 Summary of our findings for the essential standards of quality and safety Our current overall judgement The Old Rectory was not meeting one or more essential standards. Improvements are needed. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review because concerns were identified in relation to: Outcome 02 - Consent to care and treatment Outcome 04 - Care and welfare of people who use services Outcome 05 - Meeting nutritional needs Outcome 07 - Safeguarding people who use services from abuse Outcome 08 - Cleanliness and infection control Outcome 09 - Management of medicines Outcome 13 - Staffing Outcome 16 - Assessing and monitoring the quality of service provision How we carried out this review We reviewed all the information we hold about this provider and carried out a visit on 19 October What people told us People who use the service were supported to make decisions about their care and, where they were unable to, plans were in place to ensure their best interests were taken into account. For example one person told us they were involved in writing and signing their care plan. We saw that staff were respectful when speaking with people, taking time to explain what they were going to do. People were involved in activities and they were relaxed and happy to be in the group. One person with whom we spoke told us "I like it here, it's not the same as being at home but I am well looked after." People told us that they had nice meals and drinks when they wanted and they were involved in helping to choose the menu. People using the service told us that staff are lovely but sometimes don't have much time to spend with them as they are so busy. Page 2 of 26

3 What we found about the standards we reviewed and how well The Old Rectory was meeting them Outcome 02: Before people are given any examination, care, treatment or support, they should be asked if they agree to it The provider is compliant with this outcome. Consent to care and treatment was sought from people who were able to give it and there were processes in place to protect those who could not. Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights The provider is compliant with this outcome. People received care and support that meets their individual needs. Outcome 05: Food and drink should meet people's individual dietary needs The provider is compliant with this outcome. People receive good quality, sufficient and appetising meals. Their nutritional needs are met. Outcome 07: People should be protected from abuse and staff should respect their human rights The provider is compliant with this outcome. Recruitment procedures are robust and there are safeguarding procedures in place to protect and keep people who use the service safe from the risk of abuse. Outcome 08: People should be cared for in a clean environment and protected from the risk of infection The provider is compliant with this outcome. However, improvements are needed to ensure that people live in an environment that is kept clean and safe. Outcome 09: People should be given the medicines they need when they need them, and in a safe way The provider is not compliant with this outcome. Medication is not being administered in a timely and efficient way to ensure that people who use the service are being kept safe and well. Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs The provider is not compliant with this outcome. There were not sufficient numbers of staff available on a consistent basis to ensure that people who use the service have their needs met, are well cared for and kept safe. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Page 3 of 26

4 The provider is not compliant with this outcome. Systems were not in place to monitor and improve the quality of the service for the people who live there. Actions we have asked the service to take We have asked the provider to send us a report within 7 days of them receiving this report, setting out the action they will take to improve. We will check to make sure that the improvements have been made. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. When we propose to take enforcement action, our decision is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken. Other information Please see previous reports for more information about previous reviews. Page 4 of 26

5 What we found for each essential standard of quality and safety we reviewed Page 5 of 26

6 The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. A minor concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard. A moderate concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard and there is an impact on their health and wellbeing because of this. A major concern means that people who use services are not experiencing the outcomes relating to this essential standard and are not protected from unsafe or inappropriate care, treatment and support. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary improvements are made. Where there are a number of concerns, we may look at them together to decide the level of action to take. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 6 of 26

7 Outcome 02: Consent to care and treatment What the outcome says This is what people who use services should expect. People who use services: * Where they are able, give valid consent to the examination, care, treatment and support they receive. * Understand and know how to change any decisions about examination, care, treatment and support that has been previously agreed. * Can be confident that their human rights are respected and taken into account. What we found The provider is compliant with Outcome 02: Consent to care and treatment Our findings What people who use the service experienced and told us People with whom we spoke told us "It is lovely here, I can do really what I like. I was asked what I needed when I came and I signed forms about the help I needed." Other evidence The provider was compliant with this outcome at the time of our previous visit on 10 June However, for them to remain compliant, improvements needed to be made to ensure adequate recording about people's ability to make decisions. The provider produced an action plan and timescales within which they would put this improvement action in place. On our visit on 19 October 2011 we checked if these had been completed. Since our last visit in June 2011, the care plans had been updated with risk assessments and best interest decisions under the Mental Capacity Act 2005 and consent about medical treatment. This ensures that staff know and can act upon the wishes of people who use the service. The provider is compliant with this outcome. Consent to care and treatment was sought from people who were able to give it and there were processes in place to protect those who could not. Page 7 of 26

8 Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found The provider is compliant with Outcome 04: Care and welfare of people who use services Our findings What people who use the service experienced and told us We saw a group of people gathering for an activity with the activities coordinator. People appeared relaxed, involved and happy to be in the group. A person with whom we spoke told us "I really like the quizzes; it's good to keep the mind going." Other evidence The provider was not compliant with this outcome at the time of our previous visit on 10 June Concerns were raised by our review at that time. The provider produced an action plan and timescales within which they would be compliant with the essential standards of quality and safety. At our visit on 19 October 2011 we checked if these had been completed. The manager told us that care plan training was still in the process of being organised. However, they had provided instruction and guidance to staff during team meetings and individual staff supervision in July 2011 about recording and updating the care plans. The care plans we looked at showed that progress had been made. They were up to date, detailed and written in a style that was inclusive and involved people in making choices about their lifestyle and how their care was provided. The care plans we saw did not contain any cultural or life history details of the person using the service so that staff were aware of people's backgrounds. Also, only one of the care plans we saw was signed by the person using the service. The manager told Page 8 of 26

9 us that they still had to put in place a monthly monitoring system to ensure people were fully involved in their care plan and that it contained all relevant information about them as a person and not just their care needs. Risk assessments were completed for identified risks such as falls and the self management of medication. These had been reviewed and updated to reflect changing needs. We saw from the records that staff monitored people's physical health and were referred promptly to health care professionals when needed. We saw that most people had memory boxes outside of their rooms which contained familiar objects and photos. Some of the main rooms such as the lounge and bathrooms had signs with photos and large letters on the doors to assist people to find their way. The manager told us that a number of people who use the service had been reassessed by the continence advisor. People were more comfortable and receiving the most appropriate solutions for their needs. A range of activities took place most week days with the support of two activities coordinators. Activities included cards, dominos, quizzes and singing, softball and discussion groups. The provider is compliant with this outcome. People received care and support that meets their individual needs. Page 9 of 26

10 Outcome 05: Meeting nutritional needs What the outcome says This is what people who use services should expect. People who use services: * Are supported to have adequate nutrition and hydration. What we found The provider is compliant with Outcome 05: Meeting nutritional needs Our findings What people who use the service experienced and told us One person with whom we spoke told us "I had a full English breakfast this morning in my room, it was lovely." Another person told us "The food is nice, we have a choice. We can ask for drinks if we want them." Other evidence The provider was not compliant with this outcome at the time of our previous visit on 10 June Concerns were raised by our review at that time. The provider produced an action plan and timescales within which they would be compliant with the essential standards of quality and safety. On our visit on 19 October 2011 we checked if these had been completed. The manager told us that diet and fluid intake charts had been added to the care plans for everyone using the service to ensure that they were receiving sufficient fluid and a balanced diet. We saw these in the care plans we looked at. They were also in the process of putting in place a new system for recording diet and fluids with support from Colchester Hospital Nutritional Team. This system will be easier and simple for staff to use. The manager told us they had set up a system in cooperation with the local nutritional team to make referrals about individuals directly rather than have to go through the GP. This would ensure an individual received a quicker and more efficient service. The provider is compliant with this outcome. People receive good quality, sufficient and Page 10 of 26

11 appetising meals. Their nutritional needs are met. Page 11 of 26

12 Outcome 07: Safeguarding people who use services from abuse What the outcome says This is what people who use services should expect. People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld. What we found The provider is compliant with Outcome 07: Safeguarding people who use services from abuse Our findings What people who use the service experienced and told us The people with whom we spoke told us that they felt safe and cared for but sometimes there was not enough staff around for the people who called out for help. Other evidence The manager provided us with information to confirm that all staff had received updated training in safeguarding adults from abuse during the year. Guidance and procedures about safeguarding adults and reporting abuse were available to staff and on view to visitors within the entrance hall of the service. There had been a number of safeguarding concerns raised about the service since our last review on 10 June The majority of these have been resolved satisfactorily in line with the service's process for dealing with safeguarding concerns. The outstanding safeguarding concerns were being dealt with by external bodies. We found that all of the required checks had been carried out on all staff before they started working at the home. This ensured that people are protected through robust recruitment procedures. The manager had reported to us on 25 September 2011 that the lift had broken down. This had been repaired the same day and so no concerns were raised about people's safety or wellbeing. Page 12 of 26

13 The provider is compliant with this outcome. Recruitment procedures are robust and there are safeguarding procedures in place to protect and keep people who use the service safe from the risk of abuse. Page 13 of 26

14 Outcome 08: Cleanliness and infection control What the outcome says Providers of services comply with the requirements of regulation 12, with regard to the Code of Practice for health and adult social care on the prevention and control of infections and related guidance. What we found The provider is compliant with Outcome 08: Cleanliness and infection control Our findings What people who use the service experienced and told us People had no comments to make regarding infection control. Other evidence The provider was compliant with this outcome at the time of our previous visit on 10 June However, to remain compliant, improvements needed to be made to ensure that the building was free of strong offensive odours. The provider produced an action plan and timescales within which they would put this improvement action in place. On our visit on 19 October 2011 we checked if these had been completed. We received information of concern regarding an infection outbreak at the service. During our visit, the manager told us that they had contacted the Health Protection Unit and an officer had visited on 18 October 2011 and advised the manager and staff about how to deal with the infection. The manager and staff were taking appropriate steps to contain and eradicate the infection. The Health Protection Unit will support the service and monitor the process to ensure that people are treated and free from the infection. At the time of our visit in October 2011, the manager told us that the carpet cleaner was still under repair and whilst they had borrowed one, this was not cleaning the carpets adequately. The unpleasant odour when entering the building was still evident as identified in the visit on 10 June The manager had, since our visit in October 2011 informed us that an industrial cleaner had been purchased and was now in use throughout the building to ensure that the odour is eliminated and the carpets are effectively cleaned. Updated training in continence care had been organised by the manager but the home Page 14 of 26

15 had been let down on two occasions so the training had not yet been undertaken by staff. The manager had an infection control policy in place and a copy of the code of practice on the prevention and control of infections. The manager was advised to review this to ensure that staff were up to date with the regulations. The staff with whom we spoke confirmed that they wore gloves and aprons at all times and we observed this in practice. Two staff with whom we spoke were aware of infection control procedures and what needed to be done to eradicate the current infection outbreak. The provider is compliant with this outcome. However, improvements are needed to ensure that people live in an environment that is kept clean and safe. Page 15 of 26

16 Outcome 09: Management of medicines What the outcome says This is what people who use services should expect. People who use services: * Will have their medicines at the times they need them, and in a safe way. * Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf. What we found There are major concerns with Outcome 09: Management of medicines Our findings What people who use the service experienced and told us People with whom we spoke did not make any comments about their medication. Other evidence The provider was not compliant with this outcome at the time of our previous visit on 10 June Concerns were raised by our review at that time. The provider produced an action plan and timescales within which they would be compliant with the essential standards of quality and safety. On our visit on 19 October 2011 we checked if these had been completed. We had received information that the service was not handling and recording medicines safely and that medication rounds were taking too long to administer. We found that guidance was available to staff on the application of topical preparations (creams) as well as the administration of prescribed medication and PRN (as required) medication. A policy was available in the medication trolley and guidance was available in the medication administration records. Information was also available on the terms used in medication administration, as well as details of common drugs. Individual medication administration records gave detailed guidance on the administration of each PRN (as required) medication prescribed for an individual. This guidance included the reason the medication was prescribed, dosage, signs and symptoms to look out for to determine if the medication is needed, and possible side Page 16 of 26

17 effects. This guidance assists staff in the safe administration of this type of medication. Details of a person's prescribed medication were recorded in a number of systems - the care plan, on a medication profile record kept within the medication records, and on the medication administration record kept with the medicines. After a detailed review of those sampled, the records on each of the three documents corresponded with each other however this was difficult to follow. Individual entries were made to record medication that was not used any more or that which was newly prescribed. However, the list of medication itself was not updated, and therefore, on its own was inaccurate. Recording medication in three separate records gives room for error. Since our last visit to the home the PCT had undertaken an audit and suggested that whilst this was good practice to keep a medication profile there was less room for error if this was completed electronically. This recommendation had not been implemented. Some people were prescribed variable doses of medication, for example take one or two tablets at any one time. In one record checked on the 18 occasions when the medication had been given since the 13 October 2011, there were only four occasions when the actual dose given had been recorded. This does not promote safe administration of medication. It was evident that senior staff in the home undertook medication audits. The last one had been completed on 29 September A recommendation from this was to ensure an accurate record of staff signatures and names was available. Action had been taken to put this in place. There were no other concerns arising from the audit. When asked why the issue of recording variable doses of medication had not been identified we were told that the findings were based on a random sample. Separate records of creams were kept. The manager informed us that these were updated by the care staff who applied the cream. This practice is not suitable where creams are used to treat 'diseases' or specific conditions. At the time of our visit we were informed by the manager that medication rounds were taking an hour to an hour and a half to complete. However, we had received information that told us that the medication round was taking three and a half hours to complete. We saw this on the day of our visit, but were told it was because a senior staff member was being supervised doing the medication round. The area manager took the decision, at the time of our visit, to restrict the numbers of staff who could administer medication. This was to safeguard against any risks and reduce the possibility for errors. Arrangements were made for staff from other services to visit the home to carry out this function. When we visited the home again on Saturday 22 October 2011 at 10.15am we found a manager from another service administering medication, as well as a senior care worker. We were told the medication round, which had started at about 8.20am, would not be completed until about 10.45am. This means that medication may be administered too closely together, for example having lunch time medication too soon after the morning medication. There was evidence that where there were concerns about individual staff's Page 17 of 26

18 competence to administer medication that the manager took appropriate action. This included dealing with it through supervision and formal appraisal and disciplinary procedures. The provider is not compliant with this outcome. Medication is not being administered in a timely and efficient way to ensure that people who use the service are being kept safe and well. Page 18 of 26

19 Outcome 13: Staffing What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff. What we found There are major concerns with Outcome 13: Staffing Our findings What people who use the service experienced and told us People with whom we spoke told us that the staff are very kind to them but they are very busy. They told us that they would like to go out sometimes but they can't because there are not enough staff. Other evidence The manager told us that they had nine staff (two senior care workers and seven care staff) on each shift and four at night (one senior care worker and three care staff) and this was for 61 people some of whom had dementia. Only senior staff were able to administer the medication. When we asked how the ratio of staff to the level of need of the people using the service had been worked out, the manager told us that it was based on the available budget and not on any dependency tool or assessment of need. We saw that some shifts only had six staff on duty on a significant number of occasions. The manager provided staffing rotas for a seven week period. We looked at the rotas from 19 September to and including 19 October Of the 32 morning shifts, only 12 of them had nine staff working and of the afternoon shifts only eight shifts had nine staff working. The manager told us that the service had experienced a high turn over of staff over the past few months, with staff leaving, staff on long term sick, staff ringing in sick at short notice and new staff in the process of being recruited and trained but not yet available. The staff with whom we spoke told us that people do phone in sick a lot and that is Page 19 of 26

20 because there were not enough staff and people feel stressed and can't cope. They also told us that when people are off, they have to take on more responsibility and this puts extra stress on them. The lack of staff was also having an effect on the amount of time taken for senior staff to do the medication round as they were pulled away from this task to assist in care duties. One staff member with whom we spoke told us "It's very hard at the moment, you just want to do a good job and care for people and hope that accidents don't happen but they do." We saw that staff had received training in safeguarding adults, health and safety, manual handling, fire safety, medication for senior staff and infection control. All staff had received supervision during July 2011 to deal with outcomes from the last inspection and specifically medication and the signed records of staff supervision confirmed this. The provider is not compliant with this outcome. There were not sufficient numbers of staff available on a consistent basis to ensure that people who use the service have their needs met, are well cared for and kept safe. Page 20 of 26

21 Outcome 16: Assessing and monitoring the quality of service provision What the outcome says This is what people who use services should expect. People who use services: * Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. What we found There are moderate concerns with Outcome 16: Assessing and monitoring the quality of service provision Our findings What people who use the service experienced and told us One person with whom we spoke told us about how the home assesses and monitors quality and said, "We talk about how things are and X makes notes. I think some things change after we have talked about it but I am not sure." Other evidence A monthly meeting was organised by the activities coordinators to talk through what is going on in the home, what is good and what is not so good. Notes of the meetings were taken and given to the manager. We saw copies of these notes. The manager told us that they make changes to the service as appropriate but that they do not have a formal process for feeding back to people about what has been done as a result of their views. The manager told us that they monitored the service through talking with and listening to the views of relatives and professionals but we did not see any evidence of this. However, they were in the process of putting a formal quality monitoring process in place. The provider is not compliant with this outcome. Systems were not in place to monitor and improve the quality of the service for the people who live there. Page 21 of 26

22 Action we have asked the provider to take Improvement actions The table below shows where improvements should be made so that the service provider maintains compliance with the essential standards of quality and safety. Regulated activity Regulation Outcome Accommodation for persons who require nursing or personal care Regulation 12 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 08: Cleanliness and infection control Why we have concerns: Improvements are needed to ensure that people live in an environment that is kept clean and safe. The provider must send CQC a report about how they are going to maintain compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations The provider's report should be sent to us within 7 days of the date that the final review of compliance report is sent to them. CQC should be informed in writing when these improvement actions are complete. Page 22 of 26

23 Compliance actions The table below shows the essential standards of quality and safety that are not being met. Action must be taken to achieve compliance. Regulated activity Regulation Outcome Accommodation for persons who require nursing or personal care Regulation 13 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 09: Management of medicines How the regulation is not being met: Medication is not being administered in a timely and efficient way to ensure that people who use the service are being kept safe and well. Accommodation for persons who require nursing or personal care Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 13: Staffing How the regulation is not being met: There were not sufficient numbers of staff available on a consistent basis to ensure that people who use the service have their needs met, are well cared for and kept safe. Accommodation for persons who require nursing or personal care Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 16: Assessing and monitoring the quality of service provision How the regulation is not being met: Systems were not in place to monitor and improve the quality of the service for the people who live there. The provider must send CQC a report that says what action they are going to take to achieve compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations Page 23 of 26

24 The provider's report should be sent to us within 7 days of the date that the final review of compliance report is sent to them. Where a provider has already sent us a report about any of the above compliance actions, they do not need to include them in any new report sent to us after this review of compliance. CQC should be informed in writing when these compliance actions are complete. Page 24 of 26

25 What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. When making our judgements about whether services are meeting essential standards, we decide whether we need to take further regulatory action. This might include discussions with the provider about how they could improve. We only use this approach where issues can be resolved quickly, easily and where there is no immediate risk of serious harm to people. Where we have concerns that providers are not meeting essential standards, or where we judge that they are not going to keep meeting them, we may also set improvement actions or compliance actions, or take enforcement action: Improvement actions: These are actions a provider should take so that they maintain continuous compliance with essential standards. Where a provider is complying with essential standards, but we are concerned that they will not be able to maintain this, we ask them to send us a report describing the improvements they will make to enable them to do so. Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. Where a provider is not meeting the essential standards but people are not at immediate risk of serious harm, we ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 25 of 26

26 Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public / Copyright (2010) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Quality Commission Website Telephone address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 26 of 26