Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Knowles Court Residential and Nursing Home 2 Bridgeway, Bradford, BD4 9SN Date of Inspection: 10 October 2013 Date of Publication: November 2013 We inspected the following standards as part of a routine inspection. This is what we found: Care and welfare of people who use services Meeting nutritional needs Cleanliness and infection control Management of medicines Records Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 1
Details about this location Registered Provider Registered Manager Overview of the service Type of service Regulated activities Bupa Care Homes (CFHCare) Limited Ms. Louisa Hermann Knowles Court Care Home has four individual single storey houses and is situated in Holmewood, a residential area on the outskirts of Bradford. The home is part of BUPA Care Home (CFHCare) Limited and is registered to provide nursing and personnel care services for up to 146 people. Care home service with nursing Accommodation for persons who require nursing or personal care Diagnostic and screening procedures Treatment of disease, disorder or injury Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 2
Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 5 Our judgements for each standard inspected: Care and welfare of people who use services 6 Meeting nutritional needs 8 Cleanliness and infection control 10 Management of medicines 12 Records 13 About CQC Inspections 14 How we define our judgements 15 Glossary of terms we use in this report 17 Contact us 19 Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 3
Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 10 October 2013, observed how people were being cared for and checked how people were cared for at each stage of their treatment and care. We talked with people who use the service, talked with carers and / or family members and talked with staff. We were supported on this inspection by an expert-by-experience. This is a person who has personal experience of using or caring for someone who uses this type of care service. What people told us and what we found The accommodation at Knowles Court was based on four separate units. Headley House which provided care and support to people with dementia. Rycroft House which provided nursing care for older people, Fairfax House which provided care and support to older people and Rosewood House which provided support to people with learning disabilities. We used a number of different methods to help us understand the experiences of people who used the service. This was because some of the people who used the service had complex needs which meant they were not able to tell us their experiences. People who were able to tell us of their experience of living at Knowles Court told us they were happy living at the home. We found people who used the service and/or their representatives were involved in planning their care and treatment. We found the care plans were person centred and provided staff with accurate and up to date information about how to meet people's assessed needs. We saw there were systems in place which ensured people received their medication in a timely manner and ensured the accommodation was kept clean, tidy and free from offensive odours. We spoke with one visiting health care professional who told us they had no concerns about the care, support and treatment people received at Knowles Court and that staff followed their advice and guidance. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 4
You can see our judgements on the front page of this report. More information about the provider Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 5
Our judgements for each standard inspected Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. People experienced care, treatment and support that met their needs and protected their rights. Reasons for our judgement On our last inspection of the service in February 2013 we found people who lived on Rosewood House did not always receive care and treatment that met their needs. This was because we had observed staff did not always interact with people who used the service appropriately and records relating to their care and treatment were not fit for purpose. We judged this had a minor impact on people who used the service and required the provider to take action. On this inspection we found the organisation had introduced a new care planning system which was more person centred and which fully involved people who used the service and/or their representatives. However, the manager told us although the staff team had received training on the new care plans some staff still found them difficult to use and therefore the organisation were currently reviewing the documentation. In addition, the manager confirmed the number of beds on Rosewood House had been reduced to ten since the last inspection which had helped to improve the service people received. We observed staff on Rosewood House now interacted with people in a positive manner and had more time to spend with people either on a group or individual basis. We looked at the care records for two people who used the service and found they were person centred and there was a significant improvements in the information made available to staff in relation to their care and treatment. We also found evidence within the records which showed people who used the service and/or their relatives had been involved in the care planning process. This demonstrated to us the provider had taken steps to make sure the service met the needs of people living on Rosewood House and the unit was managed in their best interest. We looked at a minimum of two sets of care records on the three other units. In all the care records we looked at we saw there were care plans in place which addressed people's assessed needs and wherever possible people who used the service or their representatives had been involved in the care planning process. However, the provider Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 6
may find it useful to note on Fairfax House we found there was no communication care plan in place for one person who used the service who did not speak English. This was discussed with the manager who confirmed this matter would be addressed immediately. We saw risk assessments were in place where areas of potential risk to people's general health, safety and welfare had been identified. These included moving and handling, nutrition, tissue viability, medication and personal safety. On Rycroft House we found the staff were working closely with community matron and the community palliative care nurse specialist on the Gold Standard Framework (GSF) for end of life care. We were told staff had attended workshops and training on GSF and that it was planned to extend this programme to other units within Knowles Court. The manager told us the staff teams on all units had a good working relationship with other health care professionals and always followed their guidance and advice. During the inspection we spoke with one visiting healthcare professional. They told us they had no concerns about the standard of care and support provided at the home. The staff we spoke with told us they had input in to the care planning process through the key worker system and used the care plans as working documents. The key worker system meant that all people living at the home had a named member of care staff who took a specific interest in their care and support. The staff we spoke with also demonstrated a good knowledge of people's needs and how individuals preferred their care and support to be delivered. We spoke with several people who used the service and/or their relatives and they told us they were happy with the standard of care provided at the home. One person said "I am very pleased with the care provided and the staff always keep me informed of any significant changes in my relatives health." Another person told us "The staff do a really good job and I am always made to feel welcome when I visit." Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 7
Meeting nutritional needs Food and drink should meet people's individual dietary needs Our judgement The provider was meeting this standard. People were protected from the risks of inadequate nutrition and dehydration. Reasons for our judgement We observed the lunchtime meal being served on all four units and saw the mealtime was unhurried and people were given time to eat their food. We saw the tables were set appropriately and aids such as plate guards were available to help people eat their meals independently if they were able. We also saw people were offered help and assistance to eat their meals if required. On Fairfax House the expert by experience had a lunchtime meal with people who used the service and observed staff were attentive to their needs. They saw the portion sizes were adequate, the food was well presented and if people did not want what they had chosen they were offered an alternative. They also saw people were asked if they required a second helping and that there was a choice of fresh fruit and/or yogurt to finish the meal. We saw nutritional risk assessments were routinely completed for all people who used the service on admission and people were weighed monthly in order to monitor their weight. However, the manager confirmed if a person had a significant weight loss they would be weighed on a weekly basis and their GP would be asked to visit with a view to them either prescribing a diet supplement or referring them to a dietician. We saw evidence people were referred to speech and language therapists when needed and oral assessments were carried out. These included information about whether or not people had their own teeth or dentures. The manager told us food and fluid charts and food diaries would be used if they found people were potentially at risk of becoming dehydrated or not eating an adequate diet. We saw people were offered both hot and cold drinks throughout the day of the inspection. However, the provider may find it useful to note on Headley House we found the food and fluid charts were not always completed correctly. For example, the fluid chart for one person showed on the 5 October they had only drank a total of 650ml of fluid between 09:00 and 21:20. The food and fluid chart for another person showed on the 7 October they had only taken 650mls of fluid between 09:00 and 21:00. In addition, the record did not indicate if they had eaten at breakfast and lunchtime. The house manager told us they were confident people who used the service received sufficient food and fluids but acknowledged staff had not always completed the charts correctly. This was discussed with the manager who confirmed immediate action would be taken to address this matter. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 8
We spoke with the clinical service manager who told us one of their responsibilities was to monitor people's nutritional state and weight. They told us they organised a clinical risk review meeting when they identified people who were at risk of malnutrition or were losing weight. They told us an action plan was then put in place to address the concerns raised. We saw evidence of this in the care documentation we looked. We saw that In addition to the main menu the service had a "nite bite menu" which people could choose from if they wanted a snack during the evening or night when the main kitchen was closed. We spoke with the chef who told us they changed the menus seasonally and scored them for nutritional value. The manager confirmed the menus were then sent to the provider's headquarters to again be checked for nutritional value before they were implemented. This showed us the provider had taken action to make sure people received a varied and balanced diet. We asked the manager how they ensured people's cultural and religious dietary needs were met. They told us people's needs would initially be identified through the assessment process and then monitored through their nutritional care plan. People who used the service told us the meals provided were very good and said they were always offered an alternative if they did not like what was on the menu. One person told us "The meals are very good." Another person said "We get too much to eat at lunchtime after a big breakfast." Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 9
Cleanliness and infection control People should be cared for in a clean environment and protected from the risk of infection Our judgement The provider was meeting this standard. People were cared for in a clean, hygienic environment. Reasons for our judgement We found the service had infection control policies in place which included guidance on supporting people with infectious diseases and correct hand washing procedures. We looked at the training matrix and found approximately 93% of staff had attended infection control training as part of the new training programme recently introduced by the organisation. The manager told us at the time of inspection they were the lead person for infection control however they had designated the responsibility of carrying out regular audits to the clinical service manager and the head housekeeper. We looked around all four units accompanied by the senior member of staff on duty. We found the environment used by people who used the service which included bedrooms, bathrooms and communal areas were clean and tidy. We also found hand washing facilities available in all areas were people who used the service received personal care. However, the provider may find it useful to note that on Fairfax House we found soiled incontinence pads had been placed in the clinical waste bins in both sluice rooms without being double bagged. This demonstrated to us staff had not followed the correct procedure when transporting clinical waste from people's bedrooms to the sluice rooms. This was discussed with the manager who told us the matter would be addressed through staff supervision meetings and training. The provider may also find it useful to not on Headley House we found old stained commode pans on shelves in both sluice rooms. The house manager told us these items were no longer used and disposed of them immediately. We also found the carpet in the main lounge area was worn in high traffic areas such as in the entrance to the unit kitchen which might impact on the ability of the housekeeping staff to maintain cleanliness. We spoke with the senior housekeeper and looked at both the daily and weekly cleaning schedules in place. The senior housekeeper told us they had enough equipment and cleaning material for housekeeping staff to carry out their cleaning duties effectively. The housekeeping staff we spoke with confirmed they had sufficient time to clean the bedroom and communal areas and tried hard to keep the units clean, tidy and free from offensive odours. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 10
All the staff we spoke with told us they had completed training in infection control. They also told us about the procedures they followed when they provided personal care and handled clinical waste to reduce the risk of infection. This included such things as wearing appropriate protective clothing, using correct hand washing techniques and storing clinical waste correctly. People who used the service told us the home was always kept clean and tidy. One person said "My room is cleaned every day, the staff never seem to stop cleaning and putting things away" Another person said "The staff do a good job to keep it so clean and tidy." Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 11
Management of medicines People should be given the medicines they need when they need them, and in a safe way Our judgement The provider was meeting this standard. People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage them. Reasons for our judgement We saw the service used a monitored dosage system of administering medicines (blister packs) and medicines were stored either in a locked drugs trolley or cupboard. The manager told us only qualified nurses or senior staff administered medicines and only after they had received appropriate training. We observed medicines being administered on Rosewood and Headley House and no concerns were raised. We found appropriate arrangements were in place for obtaining medicines. All the medicines people needed were available in the home and discontinued medicines were disposed of appropriately and stored safely. This helped to prevent mishandling and misuse. We saw a stock control system was in place for "as and when required" medicines (PRN). We carried out a random check of the Medication Administration Record (MAR) against the actual stock held and we found no discrepancies. However, the provider may find it useful to note on checking the MAR on Headley House we found on four occasions medicines had been signed for as given but were still in the blister pack. This demonstrated to use staff had not followed correct procedures. This matter was discussed with the manager who confirmed action would be taken to address this matter. We looked at the controlled drugs register and found all medicines had been recorded and signed for correctly by two members of staff. We saw the clinical service manager carried out a medication audit on a monthly basis which ensured any discrepancies were picked up quickly and acted on. The people we spoke with told us they always received their medication in a timely manner. One person said "Because of my poor eyesight I am unable to see what tablets I am taking and therefore it is much safer for the staff to give them to me." Another person said "I have never been good at taking tablets and would probably forget to take them if left to my own devices; I much prefer staff to give them out." Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 12
Records People's personal records, including medical records, should be accurate and kept safe and confidential Our judgement The provider was meeting this standard. People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. Reasons for our judgement We found the care files we looked at were up to date and provided detailed information about the level of care each person required. However, the provider may find it useful to note we found the new care documentation recently introduced was not particularly user friendly as the same information was at times recorded in two or three different sections of the file. This increased the chance of mistakes being made. This was discussed with the manager who acknowledged there were some problems with the new documentation and confirmed the organisation was taking action to address this matter. The provider may also find it useful to note we did find some shortfalls in the record keeping on both Headley and Fairfax House relating to food and fluid intake charts, medication and care documentation. However, these issues were discussed with the manager and we were given assurance they would be addressed as a matter of urgency. We looked at the quality assurance monitoring system in place and saw different aspects of the service such as health and safety, pressure ulcer care, medication, care plans, finances, infection control and accident and incidents were audited on a regular basis. The manager confirmed people who used the service were involved in the quality assurance process and they continually looked for trends and areas for improvement. We saw records and reports were stored securely on each unit and there was a system in place for archiving records which were no longer relevant to people's care and treatment or the day to day management of the service. The manager and staff provided us with all of the records we asked for which demonstrated to us records were held securely and could be produced promptly when needed. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 13
About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social 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 essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 14
How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 15
How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 16
Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 17
Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 18
Contact us Phone: 03000 616161 Email: enquiries@cqc.org.uk Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: www.cqc.org.uk Copyright Copyright (2011) 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. Inspection Report Knowles Court Residential and Nursing Home November 2013 www.cqc.org.uk 19