Inspection Report on - gweddill.gov.wales · care plan. We shared our concerns with the former RI...

Inspection Report onThistle Court Nursing & Residential Home

Thistle CourtTy CanolCwmbranNP44 6JD

Date of Publication 28 March 2019

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Description of the serviceThistle Court Nursing and Residential Home is currently operated by FRP Advisory LLP. At the time of the inspection visit the home was operated by 786 Magan Care Private Limited. Since this time the home has been placed under administration and is currently under a new management organisation. The home is situated in Cwmbran, Torfaen and is registered with Care Inspectorate Wales (CIW) to provide nursing care to 37 adults over the age of 55 years living with dementia. There is a nominated responsible individual (RI) acting on behalf of the company. The manager had been absent for more than 28 days at the time of the inspection.

Summary of our findings

1. Overall assessment

While we found some positive examples of care from some staff during this inspection, we found there were a number of issues throughout the service which required urgent attention to ensure people’s wellbeing. These included monitoring and maintenance of care documentation, attention to people’s nutritional needs and management of risk with regard to people’s safety. Following the inspection visits discussions were held regarding the immediate need to secure improvement through enforcement action and this resulted in the service being deemed a service giving cause for concern. On 18 February the home subsequently became subject to administration and a subsequent change of control was implemented prior to the publication of the report.

2. Improvements

We did not identify any improvements since the previous inspection and noted there had been insufficient action taken to address the previous areas of non-compliance and recommendations identified at the last inspection.

3. Requirements and recommendations

Section five of this report sets out where the home is not meeting legal requirements and recommendations to improve the service. The legal requirements identified are in relation to leadership and management, provision of care, failure to protect people from harm and risks to people’s health and safety, recruitment processes, timely notifications to CIW and the provision of activities.

A recommendation was also made in relation to the need to address staffing issues which are impacting upon the delivery of care.

1. Well-being

Summary

People’s experience of living at the home can be varied. There are plans for staff increases to promote activities for all residents. Improvements are required to ensure people have sufficient choice around their diet and this needs to be monitored effectively. People should be treated with dignity and enjoy privacy and confidentiality within the service.

Our findings

People living at the home cannot always be certain their wellbeing is given the highest priority. We observed people in both their own rooms and communal areas throughout the home, and saw some examples of support being offered with kindness and sensitivity. We observed one person demonstrating some signs of agitation and a staff member responded with patience and used effective distraction techniques to offer reassurance. We saw people were generally dressed appropriately. We saw relatives were able to visit at any time they chose and encouraged to spend time with residents in a variety of locations. However, we also observed some people requiring attention were not always responded to in a timely manner. We spoke with one person who told us they were “Not allowed” to go bed at their chosen time. We also witnessed one person waiting for their breakfast for a prolonged period of time. We concluded people’s experiences of daily activities are not consistently positive.

There is consideration of activities in the home; however, there are improvements needed to ensure all people have regular opportunities to take part in these. We spoke with the activities co-ordinator and the former RI, who told us this was an area of development within the home. As such, we were informed plans for staffing in this area were being increased to ensure there were increased opportunities for people to enjoy both group and individual opportunities. We saw evidence of numerous activities that had previously taken place in the home and heard details of further plans, including opportunities for external entertainers to come into the home and increased musical sessions, which are the most popular group activity. However we did not witness any planned activities taking place on either of our visits and the activities co-ordinator was often involved in delivering care rather than being able to conduct activities. We found overall there are limited opportunities for people to enjoy meaningful activities, particularly those who would benefit from individual pursuits.

There are improvements needed to improve and monitor people’s nutritional needs. On our first visit we saw people were given two varied menu options at each meal and staff were present in the dining room at mealtimes, although we noted one person was being fed but the staff member involved did not offer any encouragement or interaction with the resident. We saw in documentation that people’s needs were highlighted when a specialist or modified diet was required but we were told people would have the same meal blended, rather than having separate meals specifically made for people with these needs. On our second visit we saw there was only one menu choice for each meal, and a specific time was set for daily meals, meaning people were not given flexibility to eat when they chose. We saw one person who had sustained significant weight loss had been awaiting an

appointment with a dietician for several months and while care staff informed us this had been undertaken, we could not locate written evidence of this. We also found there were gaps in people’s care notes where regular weights had not been recorded. We informed the former RI of our concerns, and were assured this would be addressed. We concluded this is an area to be addressed as a priority.

Attention is needed to ensure people’s privacy and dignity are respected at all times and confidentiality is observed. We saw one person in the home was being barrier nursed due to an infection during our visit. We noted that as a result of this, the resident’s daily notes and confidential information were being stored outside the room in a communal corridor. In one area of the home we also noted a person’s care file was left unattended on a table. We observed some staff entered people’s rooms without knocking first. We recommend improvements are made in this area to ensure people’s right to confidentiality is observed at all times.

2. Care and Support

Summary

There are significant improvements required to ensure people enjoy a consistent level of care and support throughout the home. People cannot currently feel confident they are being supported by care staff who have been suitably equipped to carry out their roles. The delivery and recording of all aspects of care needs significant attention.

Our findings

There are some issues within the service which directly impact upon the care and support given to people. Staff told us they enjoy their work, although they feel they do not always have sufficient guidance and support to carry out their duties. We spoke with eight staff members during our visits. Care staff told us they “loved working with the residents” but felt things were “up in the air” as they felt there was a lack of communication about recent and planned changes within the service, and they did not have a clear understanding who to approach for guidance as there was no one person managing the service. Staff told us they felt this had impacted negatively upon staff morale and resulted in a lack of team spirit on occasions. We saw there had been no recent team meetings since the last inspection so care staff had not had an opportunity to express this collectively. We saw a supervision matrix showing some supervision sessions had been undertaken since the last inspection. However we could not see any supervision notes on the six staff files we viewed so were unable to establish if the supervision sessions had taken place or been of value. Other staff told us they had not received supervision for several months. We observed there were clear tensions between some staff members and this resulted in some people directly ignoring directives from some senior staff. We noted there was a lack of continuity for residents as some people requiring greater levels of support had a variety of different people sitting with them during the day which can be counter-productive for people living with an organic mental health condition. We conclude this is an area where improvements and increased oversight are required as a matter of priority to ensure people’s support is consistently prioritised.

Staff recruitment files require further attention and processes need to be followed. We looked at six staff files during inspection. We saw that one person had commenced work before their “Disclosure and barring” certificate (“DBS”) had been received. DBS numbers were not kept in people’s files and were stored on a separate list which contained details of people no longer involved with the organisation. We saw some files did not contain evidence of people’s references. We found there was very little evidence of a detailed induction for new members of staff and staff told us their inductions had been “Non-existent”. Processes need to be followed to guarantee people receive support from an appropriately qualified and trained workforce.

Improvements are needed to the direct delivery of care. We found a “bath list” on the wall, stipulating people should have baths at specific times. We explored this with residents who told us they were “Told when they could have a bath” rather than being given a choice. We found some care files were missing information and did not reflect people’s needs. In one case we saw the file contained information about the wrong resident and also saw

important information about the delivery of care (such as people’s allergies) were not recorded correctly. We found there was a lack of recording in people’s daily care notes and one person’s oxygen levels had not been regularly monitored, placing them at risk of harm. We found people’s wellbeing was not being checked every hour in accordance with their care plan. We shared our concerns with the former RI who acknowledged there were issues which were being addressed, and we raised safeguarding referrals in respect of the issues we identified.

3. Environment

Summary

People live in an environment which does not consistently promote their health, or protect them from harm. Some investment has been made to secure some improvements; however significant action is required to ensure people can be assured of their safety and wellbeing.

Our findings

People live in a maintained building which requires improvements to ensure people’s safety. The last inspection highlighted there were no signs in the home to guide residents safely around the building. We found this had not been addressed, although we were informed some staff had put up signage, which had then been removed by other staff. We were informed that extensive fire works had recently been undertaken to promote people’s safety and we looked at the last fire inspection which recommended that the kitchen hatch be closed at all times when not in use. We saw domestic staff and maintenance staff were working during both visits and conducted a fire alarm test. However, we noted on both visits the hatch was left open throughout our visits and raised our concerns with the RI, who assured us it was shut when the kitchen was empty. We looked around the home and found there some areas where action was needed to protect people from harm or accident. On both visits we found stair gates to the upstairs floors were left open. The front office lock was not working and this area contained people’s confidential information. On our second visit the locked medication trolley was left unattended in the dining area with a bowl of soapy water on it, which could have been easily accessed by some residents. We found the activities room was unlocked at our first visit and hazardous substances were left unattended. We discussed this with the RI, who told us there were extensive works planned to develop the home and signage would be completed when this was done. We concluded there are improvements required to ensure the building is safe for people living there.

There is insufficient consideration given around protecting people’s health. We saw one room where someone’s food had been left immediately next to an unemptied commode. We reported our concerns to the local safeguarding team. We saw there were communal towels and products for use in bathroom areas on both visits, despite raising this issue at the first inspection visit. We saw pedal bins in the bathroom area were broken and waste was left exposed and accessible. We noted staff who were barrier nursing one resident were wearing gloves but not protective aprons to manage the risk of cross-infection. The kitchen area had a Food Standards Agency (FSA) rating of five, meaning this was very good; however we found some opened products in the fridge did not visibly record when they had been opened. We concluded this was an area of significant concern and shared our findings with the former RI who offered assurances improvements would be made.

4. Leadership and Management

Summary

There have been changes in the management of the home which have resulted in processes not being followed and maintained. There have been omissions in recording information and notifying the relevant external agencies when issues have occurred.

Our findings

There is a current lack of leadership and oversight of the service. We saw there had been significant changes to the management of the home in the last year, with a change of provider and RI and the temporary absence of the manager. We found there had been no replacement for the absent manager but two deputy managers were in place and we saw there were plans to produce and implement new paperwork to ensure information was recorded. However, staff told us they were unsure who to approach if advice or support was needed. We discussed with the former RI that appropriate actions needed to be taken to address the current management situation as we found it to be inadequate for the needs of the service. We also informed the new provider of our concerns following the change of ownership.

Improvements are needed to carry out audits, review the quality and provision of care at the service and to ensure processes are correctly followed. We found there had been a lack of attention and oversight in this area since the absence of the substantive manager in September 2018. We found there were no audits undertaken since that date and as a result people’s care had not been robustly monitored. We found there had been insufficient preparation for a quality assurance report since the last report was compiled January 2018, although we were assured this was being prepared. There had been no resident or relative meetings since the manager’s departure. We saw there had been two reports by the RI in accordance with regulatory requirements which were very similar in content. However we were informed of a complaint received by the service which we found had not been recorded appropriately and we identified a number of incidents in people’s files had not been reported or monitored. This included instances of residents demonstrating distressed behaviour which should have prompted a referral to other specialist professionals but was missed due to the lack of recording and oversight. We also found relevant information had not consistently been shared with CIW. We therefore concluded the level of leadership and management of the home was insufficient and shared our concerns with the RI, who told us there were changes to the management structure being planned.

5. Improvements required and recommended following this inspection

Areas of non-compliance from previous inspections

At the previous inspection the registered persons were informed improvements were needed in relation to the following to fully meet the legal requirements:

Staff recruitment (Regulation 19(1) of the Care Home (Wales) Regulations 2002). A notice was not issued at the last inspection as improvements were required to ensure that recruitment decisions and any relevant actions are documented where necessary. At this inspection we found informant was missing from staff files and appropriate checks had not always been undertaken before people were allowed to start working at the service. This non-compliance remains outstanding.

Notification to CIW of significant incidents and occurrences in the home (Regulation 38 of the Care Home (Wales) Regulations 2002). A notice was not issued at the last inspection as the manager issued notifications following the inspection and undertook to notify CIW of all future occurrences. However at this inspection we identified a number of reportable incidents that had not been shared with CIW. We therefore consider this non-compliance remains outstanding.

5.1 Recommendations for improvement

During the inspection, we identified areas where the registered person is not meeting legal requirements and this is resulting in potential risk and/or poor outcomes for people using the service. Therefore we have issued non compliance notices in relation to the following:

Regulation 10(1) of the Care Home (Wales) Regulations 2002 – the home is not being managed with competence, care and skill. At inspection we identified people were not receiving induction training or regular supervision. We also noted audits of care had not been carried out since the last inspection and there had been insufficient consideration of quality assurance processes. There is no active manager currently in place. A notice of non-compliance is set out at the end of this document.

Regulation 12 (1)(b) of the Care Home (Wales) Regulations 2002 – proper provision is needed to ensure the health and welfare of service users. At inspection we identified people’s care was not being managed in accordance with their care plans and people were not being monitored appropriately. We saw there were gaps in care notes and people were not referred for appropriate specialist care in a timely manner. A notice of non-compliance is set out at the end of this document.

Regulation 13(6) of the Care Home (Wales) Regulations 2002 – failure to ensure people are protected from risk of abuse and harm. At inspection we identified people live in an environment which is not consistently safe, and residents are not consistently given adequate choice about daily living or treated with dignity and respect. A notice of non-compliance is set out at the end of this document.

Regulation 13(4)(c) of the Care Home (Wales) Regulations 2002 – unnecessary risks to people’s health and safety. At inspection we identified there were insufficient measures taken to protect people from risk of cross-infection through poor hygiene practices. A notice of non-compliance is set out at the end of this document.

Regulation 16(2)(n) of the Care Home (Wales) Regulations 2002 – activities. At inspection we found there was a lack of planned activities offered at the home and the activities coordinator worked hours that would not be conducive to activities and provides direct care delivery rather than undertaking direct activities. We have not issued a notice of non-compliance on this occasion as we were informed this situation was being immediately addressed and heard there were plans to increase staffing numbers around activities.

Recommendations were made in respect of the following:

Attention needs to be given to promoting staff relations to ensure communication is improved and people’s care is co-ordinated.

We expect the registered persons to take immediate action to address the issues identified. This will be tested at the next inspection.

6. How we undertook this inspection This was an unannounced full inspection undertaken by two inspectors on 29 January and 7 February 2019. Two inspectors also attended the home on 19 February 2019 following confirmation that the home had been placed under administration.

The following sources of information were used to inform this report:

Information held by us about the service, including notifications and concerns. Observation of daily routines and care practices at the home. Study of a variety of documentation held at the home. Staff supervision and training records. Accident and incident records. Discussions with the responsible individual and deputy managers Subsequent discussions with the administrators taking over operations of the home. Discussions with five members of staff. Discussions with two residents. Examination of five resident’s files. Examination of five staff files. Discussions with other professionals working with the service. Questionnaires were sent to residents, staff and relatives – at the time of writing no

questionnaires had been returned.

Further information about what we do can be found on our website: www.careinspectorate.wales

http://www.careinspectorate.wales/

About the service

Type of care provided Adult Care Home - Older

Registered Person 786 Magan Care Homes Private Ltd at the time of inspection, and FRP Advisory LLP at the point of publication.

Manager There is no active manager in place as the substantive manager has been absent for more the 28 days.

Registered maximum number of places

37

Date of previous Care Inspectorate Wales inspection

19/06/2018

Dates of this Inspection visit(s) 29/01/2019 and 7/2/2019. A further visit to the home to give feedback to the new provider was undertaken on 19 February 2019.

Operating Language of the service English

Does this service provide the Welsh Language active offer?

This is a service that does not provide an 'Active Offer' of the Welsh language. It does not anticipate, identify or meet the Welsh language needs of people who use, or intend to use their service. We recommend that the service provider considers Welsh Government’s ‘More Than Just Words’ follow on strategic guidance for Welsh language in social care.

Additional Information:

Care Inspectorate Wales Care Standards Act 2000

Non Compliance Notice

Care Home - Older Adults

This notice sets out where your service is not compliant with the regulations. You, as the registered person, are required to take action to ensure compliance is achieved in the

timescales specified.

The issuing of this notice is a serious matter. Failure to achieve compliance will result in Care Inspectorate Wales taking action in line with its enforcement policy.

Further advice and information is available on CIW’s website www.careinspectorate.wales

Thistle Court

Torfaen

28 March 2019

www.careinspectorate.wales

Quality Of Leadership and Management

Non-compliance identified at this inspection

Timescale for completion 31/3/2019

Description of non-compliance/Action to be taken Regulation number

10(1) of the Care Homes (Wales) Regulations 2002 – Leadership and Management: the home is not being managed with competence, care and skill.

10(1)

EvidenceThe registered provider is not compliant with Regulation 10(1) of the Care Homes (Wales) Regulations 2004. This is because the registered person has been unable to demonstrate there is adequate oversight across the whole of the service.

Evidence: The manager has been absent for more than 28 days. No interim manager has been

appointed and the role has been shared between two deputy managers who are not registered with Social Care Wales.

Complaints, incidents and accidents are not being recorded appropriately and there is no clear evidence of effective action being taken.

There is no evidence new staff members have received appropriate induction training, including basic fire alarm safety.

Staff are not receiving regular supervision.

There have been no audits carried out to monitor the effective delivery of care in the last five months.

There is insufficient evidence that quality assurance processes are being followed. No team meetings have been held since September 2018. No residents’ and relatives’ meetings have been held and information has not been communicated to families about changes in the service.

Impact:

The impact for people has been negative outcomes for people’s general health and wellbeing through a lack of robust monitoring.








Thistle Court

Torfaen

28 March 2019






12 (1)(b) of the Care Homes (Wales) Regulations 2002 – Care and Support: There is not proper provision for the health and welfare of service users.

12(1)(b)

Evidence

The registered provider is not compliant with Regulation 12 (1)(b) of the Care Home (Wales) Regulations 2002– proper provision is needed to ensure the health and welfare of service users.

Evidence:

People’s care is not being managed in accordance with their care plans and people were not being monitored appropriately. There are gaps in care notes and people have not been not referred for appropriate specialist care in a timely manner.

There is lack of management of documentation and people’s files are not maintained. Care records have been removed on several occasions.

Resident W has not had oxygen saturation levels routinely recorded

Resident M has not had pressure areas appropriately monitored or recorded

Resident S has not been monitored on an hourly basis and has not been supported with nutritional needs.

There are a number of examples of weight loss which have not been identified or monitored.

Impact:

The impact upon people is a noted deterioration in some people’s wellbeing and general health, including sustained weight loss and increased emotional distress.








Thistle Court

Torfaen

28 March 2019






13(6) of the Care Homes (Wales) Regulations 2002 -Leadership and management: Failure to ensure people are protected from risk of abuse and harm.

13(6)

Evidence

The registered provider is not compliant with Regulation 13(6) of the Care Home (Wales) Regulations 2002 – failure to ensure people are protected from risk of abuse and harm.

Evidence:

People are not given adequate choice around activities of daily living, including times to retire to bed, bathing and times to eat.

People are not given a varied and nutritional diet of either sufficient quantity or quality.

People’s confidential information is not secure

Hazardous substances are not locked away in communal areas

People are not given privacy or consistently treated with dignity and respect; people’s rooms are accessed without knocking first. Staff have been heard to use inappropriate language in front of residents.

Impact:

The impact upon people is a significantly increased risk to their safety and wellbeing, with evidence people have sustained weight loss and distress as a result.








Thistle Court

Torfaen

Date of publication: 28 March 2019






13(4)(c) of the Care Homes (Wales) Regulations 2002– Leadership and management: Unnecessary risks to people’s health and safety.

13(4)(c)

Evidence

The registered provider is not compliant with Regulation 13(4)(c) of the Care Home (Wales) Regulations 2002 – unnecessary risks to people’s health and safety.

Evidence:

Insufficient measures taken to protect people from risk of cross-infection through poor hygiene practices. Staff were seen not wearing protective aprons when providing care to a resident being barrier-nursed.

Food has been seen left immediately next to a dirty commode.

Communal products and towels have been noted in bathroom areas on separate occasions.

Residents have been sharing slings when hoisted rather than having individual equipment.

Impact:

The impact for people is a significantly increased risk of cross-infection and threat to their general health and well-being, as well as impacting upon people’s dignity.

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