Background to this inspection
Updated
1 April 2016
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This comprehensive inspection took place on 30 November 2015 and was unannounced. Three inspectors undertook the inspection. We spoke in detail with eight people who lived at the home, five staff members and the registered manager, two visiting relatives and a health care professional. We looked at areas of the building including people’s bedrooms, communal areas and the lounge/dining area. We spent time sitting and talking with people, staff and visitors and observed the delivery of care and interactions between people and staff. We also observed a staff handover meeting and lunchtime medicines being administered. We looked at a range of care records, staff records, medication administration records (MAR), minutes of meetings, incident and accident reports and audits and quality assurance documents.
Before the inspection we looked at the provider’s website and information provided to us by the local authority. We reviewed the information that we held about the home including previous inspection reports and safeguarding concerns that had been made and notifications that had been submitted. A notification is information about important events which the provider is required to tell us about by law. This ensured that we had identified areas of possible concern to be looked at during the comprehensive inspection.
On this occasion we did not ask the provider to complete a Provider Information Return (PIR), this is because the inspection was undertaken at short notice. A PIR is a form that asks the provider to give some key information about the service, what the service does well and any improvements they plan to make. Lady Anne Treves Memorial Home was last inspected in January 2014 and there were no concerns.
Updated
1 April 2016
Lady Anne Treves Memorial Home is a residential care home providing care and support for up to 21 people with age related conditions including dementia. The inspection took place on 30 November 2015. There were 16 people living at the home and two people having respite care on the day of the inspection. The provider, Pilgrim Homes, is a Christian charity that provides Christian care to people who are Protestant Christians. Accommodation was provided over three floors with stairs connecting all floors and a lift in situ.
A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. People living at the home, relatives and staff all spoke highly of the registered manager.
Some people had medicines to be given as required and there were no guidelines in place for staff to follow to ensure that these were administered in a safe and consistent manner. This meant that people were at risk of not being given these medicines consistently and in accordance with prescribed instructions. Although there was a system in place for monitoring administration of medicines the registered manager had failed to identify gaps in recording. This was discussed with the registered manager who immediately took steps to review the procedures to ensure that there was proper oversight of the administration of medicines and stock control.
Some information was not updated in care records for example where a person’s needs were changing rapidly the risk assessment and care plan had not been revised to illustrate the current situation, this meant that staff did not have the most up to date information to guide them when providing safe care. People were supported to be safe with systems in place to reduce the risk of harm and potential abuse. Medicines were stored appropriately and people received their medicines on time, one person said, “If I am in pain at all I just have to ask one of the staff for a tablet, I never have to wait.” Staff were knowledgeable about the correct procedures to follow should they suspect abuse. Care records included assessments to identify and mitigate risks to individuals to ensure that people were kept safe without restricting their freedom.
Environmental risks were identified and managed appropriately, the maintenance officer said, “Resident’s comfort and safety always comes first.” People told us they felt safe, one person said “I have confidence in the staff, that makes me feel safe.” Staff had been recruited through a safe and effective process, appropriate checks had been undertaken including character references and criminal record checks with the Disclosure and Barring Service (DBS) to ensure that staff were suitable and safe to work in the care sector. There were some vacancies in the staff team and staff told us they were under pressure sometimes. The registered manager told us she was recruiting to the vacant posts and used familiar agency staff to ensure adequate cover. The registered manager used a formal dependency tool to determine how many staff were required to keep people safe and meet their needs.
People told us they felt well supported by the staff, one person told us “The staff are wonderful really, they’re all good at their jobs, I couldn’t ask for better,” a relative said, “We feel really privileged that our (relative) is here, they are absolutely brilliant.” Staff told us that they had received a thorough induction before starting work, one member of staff said, “I was not new to care but the induction was very good.” Training opportunities at the home were good, staff were supported to gain the appropriate knowledge, skills and competencies to perform their job role. People told us that they had confidence in the skills of the staff, one person said, “They always know what to do when they move me, I’m never worried.” Staff were receiving support through regular supervision meetings and had annual appraisals to identify any areas of performance that could be improved.
Staff were working within the principles of the MCA and conditions or authorisations to deprive a person of their liberty were being met. Staff had undertaken recent training in this area and were able to demonstrate a good understanding of the MCA, including the nature and types of consent, people’s right to take risks and the necessity to act in peoples best interests when required.
People told us that they were supported to maintain good health and to have access to health care services. One person said “If I’m having any trouble they will always call the doctor or ask for the nurse to visit.” Staff were proactive in ensuring that people received additional support from professionals when required to meet their care and treatment needs. People’s dietary and nutritional needs were well supported. People told us that they enjoyed the food. One person said “I like the food here, they go to a lot of trouble to make it nice,” Staff were knowledgeable about individual preferences and specific dietary requirements.
People and relatives told us that the staff were very caring, one person said “The staff here are all good, kind people.” We saw many positive interactions between staff and people which emphasised the close relationships between them and demonstrated that staff clearly knew people well and understood their needs. People and their relatives had been included in the care planning process, this was evident from care records that were signed by individuals and /or family members and one visitor told us that she had been involved in planning her relatives care. We observed that people were offered choices and were supported to be independent whenever possible. We noted the calm atmosphere in the home and saw gentle interactions with staff giving people time to respond, showing consideration and treating people with dignity. One staff member said “Just because someone had dementia, it does not mean that they can’t feel undignified if they are not treated with respect.”
Staff were responsive to the needs of the people they were supporting. Care records were personalised and contained information about people’s health and care needs, their personal life history and their preferences and wishes. Staff were able to demonstrate that they were knowledgeable about the individual details in people’s care plans and we saw how this information was taken into account when providing care.
People were supported to follow their interests, one person said, “I love to knit and crochet and the staff bring in wool for me,” For some people their Christian faith was important and they were supported to attend their local church. Others had volunteers from a local community church coming in regularly to visit and pray together. People were supported to attend devotions in the lounge area, and the registered manager told us that if some people could not come down to the lounge they could still be included through the use of speakers in their bedrooms.
The home had an effective complaints system in place to ensure that comments or complaints we responded to appropriately.
People, staff and visitors spoke highly of the registered manager, a staff member said, “The manager is very supportive.” The ethos of the home reflected the Christian values of the provider organisation which included integrity, openness, honesty and that people should be treated with compassion, valued and respected. This was communicated to the staff through training and supervision. The registered manager had clear presence in the home, people knew who she was and said that she was approachable, with one person saying “She’s a very kind lady.”
The registered manager was committed to driving continuous improvement and involving people and staff in this process. Feedback on the service was collected through a variety of methods including through residents’ meetings, questionnaires, reviews and individual meetings. This information was analysed to inform
improvements. There were quality assurance systems in place and these were being used to monitor and improve standards of care delivery.
We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have asked the provider to take at the back of the full version of this report.