Review of compliance Mrs Lynn Nicolaou & Mr Christos Adamou Nicolaou The White House Region: Location address: Type of service: South East 95-97 Maidstone Road Chatham Kent ME4 6HY Care home service without nursing Date of Publication: October 2011 Overview of the service: The White House provides accommodation and residential care for up to 38 people with dementia. The home is a detached premises on a main road within easy reach of Chatham town centre and public transport. Bedrooms are on the ground and first floors and there are 2 shaft lifts. There is car parking at the front of the building. The White House is owned, run and managed by Mr and Mrs Nicolaou. Page 1 of 24
Summary of our findings for the essential standards of quality and safety Our current overall judgement The White House 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 as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider, observed how people were being cared for, looked at records of people who use services, talked to staff and talked to people who use services. What people told us We spoke with three people who live at the home and we observed the care and interactions of others who were less able to communicate. People were generally very happy living at the home and they said they liked the staff. People said the food was very good and they enjoyed coming to the lounge to chat with others and the staff. People commented "The staff are very good, they are a good bunch" and "the food's lovely" and "I like a bath once a week and that's what I get". Staff were observed interacting with all the people in the lounge and people were smiling, chatting and singing. Two people remained in their rooms during our visit as they were frail and unwell; staff were seen checking on them throughout our visit. What we found about the standards we reviewed and how well The White House was meeting them Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run People were supported to express their views and these were taken into account.. We did not find evidence that people were always consulted about the content of the menu and people were not offered variety of choice in the menu. The privacy and dignity of people was not fully protected by the use of shared records and the records not being stored securely. Overall, we found that improvements were needed for this essential standard. Page 2 of 24
Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights People experienced effective, safe and appropriate care, treatment and support that met their needs and protected their rights. This was not well evidenced in the daily records, which were brief and did not relate to all of peoples care needs. Overall, we found that the White House was meeting this essential standard, but to maintain this, we suggested that some improvements were made. Outcome 07: People should be protected from abuse and staff should respect their human rights People living at the home were protected from abuse as far as possible through the training, supervision and safe recruitment of staff. Overall, we found The White House was meeting this essential outcome. Outcome 10: People should be cared for in safe and accessible surroundings that support their health and welfare Although the home was satisfactorily maintained there were concerns about the management of unpleasant odours and the lack of maintenance in the gardens. This meant people were not always experiencing a pleasant place to live. Overall, we found that improvements were needed for this essential outcome area. Outcome 11: People should be safe from harm from unsafe or unsuitable equipment People living at the home benefited from having access to the equipment they needed to meet their care needs and to promote their independence. Overall, we found that The White House was meeting this essential outcome. Outcome 14: Staff should be properly trained and supervised, and have the chance to develop and improve their skills People were kept safe and their health and welfare needs were met by staff who received the training and support they needed. Not all staff were aware of the implications of the Mental Capacity Act. Overall, we found that the White House was meeting this essential outcome, but to maintain this, we suggested that some improvements were made. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care There were some systems in place to monitor the quality of the service people received. Information about the quality of the service had not been collated or made available to those using the service or considering using the service. Page 3 of 24
This shows the information gathered to assess the quality of the service provided was not being used to develop and improve the service. Overall, we found that improvements were needed for this outcome area. Outcome 21: People's personal records, including medical records, should be accurate and kept safe and confidential Records required to be held were maintained but not all were held securely. Overall, we found that the improvements were needed for this essential outcome area. Actions we have asked the service to take We have asked the provider to send us a report within 28 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. Any regulatory decision that CQC takes 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 24
What we found for each essential standard of quality and safety we reviewed Page 5 of 24
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 24
Outcome 01: Respecting and involving people who use services What the outcome says This is what people who use services should expect. People who use services: * Understand the care, treatment and support choices available to them. * Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. * Have their privacy, dignity and independence respected. * Have their views and experiences taken into account in the way the service is provided and delivered. What we found There are minor concerns with Outcome 01: Respecting and involving people who use services Our findings What people who use the service experienced and told us People told us about the choices they were given at meal times and said they could have a bath or shower depending on which they preferred. People said they could choose to stay in their rooms but preferred to sit in the lounge. People said that they were helped to get up and go to bed by the staff at times they preferred. Other evidence The service had a number of informal methods of involving people in the running of the home including what activities were being offered. Formal "service user meetings" also took place regularly. The care plans included information for staff about offering people choices in the daily lives, such as choosing their clothes. They also included information on people's individual likes, dislikes and personal preferences. For people who were less able to communicate their relatives had been asked for this information. We saw people being moved and guided in a sensitive way which took into account their preferences and needs. Throughout our visit we saw staff offering people choices about where they wished to sit, meals and drinks they would like and we heard staff addressing people by their preferred names. Page 7 of 24
The manager said that the menus reflected people's choices, though we did not find any written evidence to support this. People we spoke with said the food was very good. A four week rolling menu was in place with the main meal being served at lunchtime. The lunchtime menus for the week included two hot meal options as well as salads and sandwiches. Although there was a choice this was limited due to the lack of variation on the menu. For example Monday's choice was ham, egg and chips or sausage, egg and chips. Thursday's options for the same week were Ham, egg and chips or omelette and chips, and Fridays options were fish and chips or omelette and chips. It was unclear as to what if any vegetables were being offered. The menus for the days mentioned also had crabmeat and rice, or cheese and ham salad among the other options. A separate meal was cooked for people with special diets. We saw bathing charts, weight charts and a file containing continence charts, and information regarding who had been offered the Flu injection. Some of these charts were shared, in that, information about other people living at the home was also on these records. These records were stored in the dining area and were not locked away potentially compromising peoples privacy and dignity. People were supported to express their views and these were taken into account.. We did not find evidence that people were always consulted about the content of the menu and people were not offered variety of choice in the menu. The privacy and dignity of people was not fully protected by the use of shared records and the records not being stored securely. Overall, we found that improvements were needed for this essential standard. Page 8 of 24
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 People said that the care staff helped them with the things they were unable to do themselves. People said staff helped them with their personal care and with bathing and showering. People said that staff always gave them a choice of bath or shower. People said that they liked the activities at the home. Other evidence We looked at the care records for four people living at the home. The care plans and risk assessments were in one document which the manager was in the process of changing to handwritten documents. Care plans were up to date and had been reviewed regularly. Care plans included all aspects of peoples well being including their physical and mental needs, and social interests and needs. A verbal handover took place between staff at the beginning of each shift and staff said that they found this and reading through the care plans useful in finding out how to provide the right care for people. Care staff said that whilst they found the care plans useful they were not very user friendly. The care plans set out the different needs identified but they were repetitive, typed in very small print and could not be amended easily without re printing them. Staff were not writing about each care need on every shift or every day. This meant that there was no written evidence that all the care needs identified were being provided for. The daily record also did not contain much information about what activities people took part in or how they spent their days. One person living at the home had recently been identified as having palliative care Page 9 of 24
needs. The staff had involved the GP, district nurses and occupational therapists to provide the care, advice and equipment needed and the manager said that they planned to provide end of life care at the White House as long as they were able to meet her needs. Another person living at the home sometimes became verbally and physically aggressive, clear plans for identifying triggers and managing these behaviours were in the persons care plan and staff spoken with described how best to manage these behaviours, which was in accordance with the care plan. We saw that people were given the help they needed to be mobile, staff prompted people to visit the toilets, and people who needed assistance were helped discreetly and sensitively. Staff prompted people with their hot drinks and addressed people with their preferred name. Staff were seen reassuring one person who was disorientated and upset at times. This was carried out in a caring way and the person responded well. Staff reacted promptly to call bells and to people requesting help with going to the toilet. There was a good atmosphere in the lounge on the day of our visit with care staff taking time to chat with small groups of people, and giving one to one attention to others. Staffs were reading out newspaper and magazine articles, singing and chatting and joking with people living at the home. The activities plan was advertised on a notice board and activities for the week included quizzes, board games, a coffee morning, and ball exercises. Previous activity plans showed that outside entertainers and pets for therapy had visited recently. As stated earlier there was minimal written documentation to show that people had participated in activities or whether they had enjoyed them. People experienced effective, safe and appropriate care, treatment and support that met their needs and protected their rights. This was not well evidenced in the daily records, which were brief and did not relate to all of peoples care needs. Overall, we found that the White House was meeting this essential standard, but to maintain this, we suggested that some improvements were made. Page 10 of 24
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 We did not speak with people living at the home directly about this outcome area. Other evidence There were safeguarding policies and procedures in place for staff to follow and staff spoken with had been given copies of these policies. Staff spoken with confirmed that they had received recent training updates and that safeguarding was a part of the induction of new staff. The staff we spoke with had a good understanding of the safeguarding policies and of what constituted abuse. Staff were confident that the manager would act on any concerns they brought but knew which other agencies they might contact if they were not satisfied with the managers response. Staff had provided written references and been subject to CRB checks as part of their recruitment. As stated in other outcome areas staff had not received training in the Mental Capacity Act and whilst best interest meetings had been held, the process had not been formalised. People living at the home were protected from abuse as far as possible through the training, supervision and safe recruitment of staff. Overall, we found The White House was meeting this essential outcome. Page 11 of 24
Outcome 10: Safety and suitability of premises What the outcome says This is what people should expect. People who use services and people who work in or visit the premises: * Are in safe, accessible surroundings that promote their wellbeing. What we found There are minor concerns with Outcome 10: Safety and suitability of premises Our findings What people who use the service experienced and told us We did not speak with people living at the home directly about this outcome area. Other evidence The home has recently been extended to provide a further 13 bedrooms over two floors. Some of these rooms were occupied, but the home was not yet full. New assisted bath and shower rooms and a new lift have been installed to the extended area, and the laundry was also sited there. The extended area also provided another lounge area for people to use though it was empty on the day of our visit. Staff said that people preferred to use the lounge in the older part of the home, and that people had not got used to the new extension yet. We looked around the home and saw it was homely and comfortable. Some parts of the garden were overgrown and could impact on people's ability to safely use the garden. There was an unpleasant odour in some areas of the home. The homes own quality assurance surveys showed that a relative had commented on the odour and another said that "carpets are in poor condition". The manager said that now that the new extension had been completed some areas of the existing home were to be refurbished; the kitchen had already had some work completed. Although the home was satisfactorily maintained there were concerns about the management of unpleasant odours and the lack of maintenance in the gardens. This meant people were not always experiencing a pleasant place to live. Page 12 of 24
Overall, we found that improvements were needed for this essential outcome area. Page 13 of 24
Outcome 11: Safety, availability and suitability of equipment What the outcome says This is what people should expect. People who use services and people who work in or visit the premises: * Are not at risk of harm from unsafe or unsuitable equipment (medical and non-medical equipment, furnishings or fittings). * Benefit from equipment that is comfortable and meets their needs. What we found The provider is compliant with Outcome 11: Safety, availability and suitability of equipment Our findings What people who use the service experienced and told us We did not speak with people living at the home directly about this outcome area. Other evidence The manager and staff said that the home had the equipment needed to support the people living there. The advice of the occupational therapist (OT) had been sought recently for the specific needs of one person living at the home whose condition had deteriorated. The home and OT had sought a profiling bed and hoist and slings to ensure that the person's needs could be met by the home. The staff had undergone additional training to ensure they were able to use the equipment. Staff said that there was a variety of moving and handling equipment such as slide sheets, shower chairs, and raised toilet seats to enable them to meet the needs of all the people living at the home. People living at the home benefited from having access to the equipment they needed to meet their care needs and to promote their independence. Overall, we found that The White House was meeting this essential outcome. Page 14 of 24
Outcome 14: Supporting staff 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 competent staff. What we found The provider is compliant with Outcome 14: Supporting staff Our findings What people who use the service experienced and told us We did not speak with people directly about this outcome area. Other evidence Staff told us that the manager was proactive at organising training in both core training and training specific to meeting the needs of the people living at the home. Staff said that they were up to date with core training and had received recent training in safeguarding of vulnerable adults, fire, infection control, food safety and dementia. One newly employed staff member was working through her induction which was the nationally recognised common induction. Staff said that training was provided in a variety of ways including workbooks, with competency tests and face to face training. One staff member spoken with was doing NVQ level 3, and told us that several staff had NVQ's. Staff said that they received regular supervision every 6 weeks with the manager. Staff described clear lines of accountability and there was a clear management structure at the home. The manager said that the structure would be changed when the home started to fill, and some of the new roles included a designated activity coordinator, as well as laundry staff. Staff said they felt supported and that there was a stable staff group that worked well as a team. The manager kept a training matrix to monitor and ensure staff remained up to date with core training and to log specialist training. The matrix showed that staff were up to date, but that Mental Capacity Act training had not yet been organised for staff, though some staff were aware of the Act and some of its implications. The manager was aware Page 15 of 24
of the need to source training in this area. People were kept safe and their health and welfare needs were met by staff who received the training and support they needed. Not all staff were aware of the implications of the Mental Capacity Act. Overall, we found that the White House was meeting this essential outcome, but to maintain this, we suggested that some improvements were made. Page 16 of 24
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 minor concerns with Outcome 16: Assessing and monitoring the quality of service provision Our findings What people who use the service experienced and told us We did not speak with people directly about this outcome area. Other evidence There were some quality assurance systems in place which were both formal and informal. Staff were met with in small groups but large staff meetings did not take place, the manager said that staff were reluctant to attend when they weren't on duty. The smaller meetings tended to be used for group supervision, so minutes were not circulated. "Service user meetings" took place and minutes were seen for one conducted in February 2011. Minutes had been taken and among the requests were, a singer to visit, old films to be bought, and to attend the local church. The manager said that there was already a good variety of old DVD's available, some people had been taken to the church harvest festival, and that outside entertainment had been booked. As described in outcome area 4, this could have been better evidenced by care records reflecting what activities people participated in and what they had enjoyed. The manager audited accidents, incidents and complaints and these were put on a spreadsheet to look for trends. Questionnaires had been sent out to people's relatives in November 2010, these were positive overall, and the manager said that more questionnaires had been sent out in March 2011. The manager was not auditing care plans, and other documentation, although medication audits were carried out. The manager had not analysed all the information gathered and the information had not been collated into a formal report to give a clear picture of the services strengths and areas to improve. Page 17 of 24
There were some systems in place to monitor the quality of the service people received. Information about the quality of the service had not been collated or made available to those using the service or considering using the service. This shows the information gathered to assess the quality of the service provided was not being used to develop and improve the service. Overall, we found that improvements were needed for this outcome area. Page 18 of 24
Outcome 21: Records What the outcome says This is what people who use services should expect. People who use services can be confident that: * Their personal records including medical records are accurate, fit for purpose, held securely and remain confidential. * Other records required to be kept to protect their safety and well being are maintained and held securely where required. What we found There are minor concerns with Outcome 21: Records Our findings What people who use the service experienced and told us We did not speak with people directly about this outcome area. Other evidence As detailed in outcome one personal information about people using the service was recorded in communal records, which compromised confidentiality. We also found that these records were not stored securely when not in use. We found care plans were not easy for staff to follow, further details are under outcome four. Records required to be held were maintained but not all were held securely. Overall, we found that the improvements were needed for this essential outcome area. Page 19 of 24
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 9 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 04: Care and welfare of people who use services Why we have concerns: People experienced effective, safe and appropriate care, treatment and support that met their needs and protected their rights. This was not well evidenced in the daily records, which were brief and did not relate to all of peoples care needs. Accommodation for persons who require nursing or personal care Regulation 23 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 14: Supporting staff Why we have concerns: People were kept safe and their health and welfare needs were met by staff who received the training and support they needed. Not all staff were aware of the implications of the Mental Capacity Act. 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 2010. The provider's report should be sent within 28 days of this report being received. CQC should be informed in writing when these improvement actions are complete. Page 20 of 24
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 17 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 01: Respecting and involving people who use services How the regulation is not being met: People were supported to express their views and these were taken into account. We did not find evidence that people were always consulted about the content of the menu and people were not offered variety of choice in the menu. The privacy and dignity of people was not fully protected by the use of shared records and the records not being stored securely. Accommodation for persons who require nursing or personal care Regulation 15 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 10: Safety and suitability of premises How the regulation is not being met: Although the home was satisfactorily maintained there were concerns about the management of unpleasant odours and the lack of maintenance in the gardens. This meant people were not always experiencing a pleasant place to live. 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: There were some systems in place to monitor the quality of the service people received. Information about the quality of the service Page 21 of 24
had not been collated or made available to those using the service or considering using the service. This shows the information gathered to assess the quality of the service provided was not being used to develop and improve the service. Accommodation for persons who require nursing or personal care Regulation 20 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 21: Records How the regulation is not being met: Records required to be held were maintained but not all were held securely. 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 2010. The provider's report should be sent to us within 28 days of this report being received. 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 22 of 24
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 23 of 24
Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public 03000 616161 / www.cqc.org.uk 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 www.cqc.org.uk Telephone 03000 616161 Email address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 24 of 24