Archived: Thurlestone House

This inspection took place on the 7, 12, and 13 September 2017; the first day of the inspection was unannounced.

Thurlestone House has been inspected four times, since April 2015. There have been three comprehensive inspections and one focussed inspection. At each of these inspections we found breaches of regulation and the service were rated ‘Requires Improvement’.

Although people are happy living at the home, the risks to them are not sufficiently well managed. Governance systems have not been sufficiently robust over a period of three years to identify and bring about the required improvements.

In April 2015 the service was rated as requires improvement. In June 2016 we judged the service as requires improvement again. We served a Warning Notice, telling the provider what action they needed to take in relation to safe care and treatment.

In September 2016, we found action had been taken to address the issues identified in the Warning Notice. However, the service still required improvement in some areas.

At this inspection we identified improvements were still required. We found four breaches of Regulations with repeated breaches of Regulation 12 (safe care treatment) and Regulation 17 (good governance). We found the provider had not taken sufficient steps to assess, monitor or mitigate risk to people living at the home and quality assurance systems had not been established or operated effectively to ensure compliance with the regulation.

The home did not have a registered manager, although this person's name will show on this report as they have not deregistered with the Commission. The registered manager had resigned from their position four weeks prior to this inspection. A new manager had been appointed and had been working alongside the registered manager. They have not made application to the CQC for registration, and are referred to in this report as the manager. 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.

The home’s quality assurance and governance systems were not effective. Although some systems were working well, others had not identified the concerns we found during this inspection and there was a lack of management oversight.

Risks to people health and wellbeing were not always managed safely. For example where people had been identified as being at risk of malnutrition, we saw people’s food and fluid intake were not always recorded in sufficient detail, recorded correctly, totalled, or analysed. We found staff were not following the Malnutrition Universal Screening Tool (MUST) guidance were people had been identified as high risk of dehydration or poor nutrition.

Where risks had been identified, action was not always taken to minimise these risks. For example one person’s falls diary indicated they were at high risk of falls and directed staff to refer this person to the specialist falls team for further assessment. Records showed this had been identified by the homes quality assurance systems in July 2017; however at the time of the inspection this referral had not been made. We asked for the referral to be made, and the manager confirmed this had been done.

Staff displayed a good understanding of the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguarding (DoLS). People were encouraged to make choices and were involved in the care and support they received.

People can only be deprived of their liberty to receive care and treatment when this is in their best interest and legally authorised under the MCA. Records showed the registered manager had made six applications to the local authority for authorisation to deprive people of their liberty. This was because people were not all free to leave the home if they wished, due to safety considerations and because they were under constant supervision by staff.

Four of the six people we looked at had not had their capacity to consent to these arrangements assessed prior to applications being made. Another person assessment did not contain sufficient information as staff failed to complete the assessment in full and therefore were unable to determine the person’s level of capacity or their ability to consent to these arrangements

A system was in place to monitor the status of DoLS authorisations and DoLS applications that were in progress. We found these systems and process had failed to identify that people were potentially having their rights restricted unlawfully.

People received most of their prescribed medicines on time and in a safe way. However quality assurance systems had failed to ensure people’s medicines were managed safely or administered by appropriately trained staff. People’s MAR’s were not accurate and therefore staff were unable to assure themselves people were receiving their medicines as prescribed. This meant people may have been placed at risk as staff were not able to tell if people had received their medicines as prescribed by their doctor.

People told us they were happy living at Thurlestone House. One person said, “I choose to live here, I was able to pick my room and although it’s not my own home I’m happy here,” Another said, “The staff are really kind, caring and very helpful, especially [Staff name] she always seems to go out of her way to make sure that I’m ok and have everything I need.” Relatives we spoke with told us they were happy with the care and support people received.

People told us staff treated them with respect and maintained their dignity. Throughout the inspection, there was a relaxed and friendly atmosphere within the home. Staff spoke about people with kindness and compassion.

People and relatives told us they were involved in identifying their needs and developing the care provided. People's care plans were informative, detailed, and designed to help ensure people received personalised care.

People told us they enjoyed the meals provided by the home, describing them as "very good.” One person said, "there's always a choice and if you don’t like something all you have to say and they will make you something else.” Another said “I don’t have any concerns about the food or the quality”.

People spoke positively about activities at the home and told us they had the opportunity to join in if they wanted. The home had a programme of organised activities that included arts and crafts, music sessions, exercise classes, quizzes and regular trips out to local places of interest.

People, relatives, and staff spoke highly of the management team and told us the home was well managed. Staffs described a culture of openness and transparency where people, relatives and staff, were able to provide feedback, raise concerns, and were confident they would be taken seriously.

The home maintained a high standard of cleanliness and steps had been taken to minimise the spread of infection. We saw the premises and equipment were clean and staff had been provided with aprons and gloves. Equipment used within the home was regularly serviced to help ensure it remained safe to use.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Thurlestone House was previously inspected on 3 and 8 June 2016, where we identified a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (safe care and treatment). We found some people did not get their medicines when they needed them; some prescribed medicines were not in stock and risks assessments did not reflect changes to people’s needs. The home was rated as ‘requires improvement’.

We issued a warning notice to the provider and registered manager telling them they must make the necessary improvements in relation to the management of medicines by the 24 August 2016. The provider wrote to us with an action plan telling us how they would make the required improvements. Some improvements had been made, however further improvements were needed.

We carried out an unannounced focused inspection on 20 and 21 September 2016 to check the provider and registered manager had complied with the warning notice. This report only covers our findings in relation to the warning notice served following our previous inspection in June 2016. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for residential care home on our website at www.cqc.org.

There was a registered manager in post; however they were not available at the time of this inspection. The registered manager was due to retire following this inspection. A new manager had been appointed and was working alongside the registered manager until they retired. They are referred to in this report as the manager. 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.

Improvements had been made to the way medicines were managed. These included medicines which required refrigeration were now being stored in a way that prevented unauthorised access; where people were prescribed medicines to be given “as required” guidance was provided for staff as to when this medicine should be given; records relating to medicines which were legally required to be recorded in a separate record, were maintained in a way that met the providers legal responsibilities and staff were only applying medicated creams which had been prescribed by their doctor. However, some prescribed medicine was not in stock and people’s Medicine Administration Records (MARs) were not accurate and therefore staff were unable to assure themselves people were receiving their medicines as prescribed.

Records relating to people’s care had improved. One care record was not complete and did not provide guidance for staff. However, staff understood what this person’s needs were and how to meet them. Other records were accurate and up to date, and gave guidance to staff.

Since the last inspection, the provider had introduced a new falls management process which identified action staff should take following an accident/fall. Whilst some records were not completely up to date, staff were taking action to protect people from risks such as falling, and from behaviours that might be harmful.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Care plans and risk assessments reviews were taking place monthly but had not identified the lack of clear information or instruction for staff in how to meet people’s needs. The processes in place to manage medicines had not always ensured people received their medicines when they required them and as prescribed.

The home had a registered manager. 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’s medicines were not managed safely. Some people did not get their medicines when they needed them and some prescribed medicine was not in stock. People’s medicine administration records (MARs) were not accurately completed. Staff did not have information about when they should give variable dose medicines. Staff did not always administer medicines safely. Where specific medicines needed additional monitoring, staff did not always ensure best practice was followed. Staff were applying medicated creams to people which did not correspond to the creams they had been prescribed. There was a safe system in place to monitor the receipt of medicines held by the home. Medicines were disposed of safely when they were no longer required. The service had appropriate arrangements in place to dispose of unused medicines, which were returned to the pharmacy for disposal.

Risk assessments were not always up to date or did not always reflect changes to people’s needs. For example, one person’s falls risk assessment stated they had not fallen for at least 3 months. However, this person’s care records indicated they had fallen 3 days prior to the risk assessment being reviewed. In general, accidents and incidents were recorded. However, some incidents relating to people’s behaviour were not recorded and therefore were not included in the review of accidents and incidents. This meant the reviewer would not be able to identify any themes and take any necessary action.

People’s individual needs were not always assessed, planned for or delivered. Where people had specific needs relating to their dementia or the behaviours they displayed, guidance had not been provided for staff to ensure they met each person’s individual needs. Whilst people’s care plans were personalised they lacked clear guidance for staff to follow to ensure each person’s needs were met in an individualised and consistent way. People’s dignity was not always being maintained. We have recommended the provider seeks further advice and training to ensure that were people can’t protect their own dignity, staff take appropriate action.

At our previous inspection, we identified that the provider did not have adequate infection control arrangements for managing laundry. We found significant improvements had been made during this inspection. We saw that the laundry room had been completely redecorated and was clean and clear from the build-up of excessive laundry waiting to be washed. There was a clear system for the separation of clean and contaminated laundry. Following our last inspection, the provider had introduced a new quality auditing system. Although some systems were working well others had not identified concerns we found during this inspection.

The management and staff structure provided clear lines of accountability and responsibility. Staff knew who they needed to go to if they required help or support. There were systems in place for staff to communicate any changes in people health or care needs to staff coming on duty, however these meetings had not effectively supported the sharing of information.

The registered manager had not always notified the Care Quality Commission of significant events, which had occurred in line with their legal responsibilities.

People said they felt “safe and secure,” one person told us “I do feel safe and very secure here,” another person told us” I do feel safe it’s my home. One relatives told us “I’m confident that people are safe” and another relative said, “I have no concerns about my relative safety. Health care professionals told us people were safe: one said, “people are safe and looked after here” and another said they would be happy for their relative to live at the home. People and relatives told us there were sufficient staff on duty to meet their needs. One person said, “all you have to do is press that button if you need anything and someone will come and help.” Another person told us “you don’t have to wait long if you need someone.” People, their relatives and health care professionals were positive about the quality of the care provided and told us that staff understood people’s needs and knew how to meet them.

Staff had received training and demonstrated a clear understanding of the principles of the Mental Capacity Act 2005 (MCA) in their practice. Although the registered manager did not have a clear understanding of the Deprivation of Liberty safeguards (DoLS). We have recommended the provider seek further advice and training in relation to Deprivation of Liberty Safeguards.

People were able to choose where they had their meals and we saw on both days of inspection that people were able to have their meals in the dining room, their bedrooms and in the conservatory if they wished. Meals looked appetising and were served in dishes on each table, which allowed people to choose which vegetables they wanted. People were able to have snacks and drinks when they wanted. People told us that the “food was very nice,” “I enjoy the food here,” and “There’s always plenty to eat.” One relative told us “there always plenty for people eat, they have good quality fresh food.”

Throughout our inspection, there was a relaxed and friendly atmosphere within the home. Staff spoke affectionately about people with kindness and compassion. Staff told us “I love working here, I really enjoy it.” People and relatives told us they were involved in making decisions about their care and staff continually asked how they would like to be supported. People felt their views were listened to and respected. We saw from people’s care records their views had been sought as their needs had changed. People had access to a range of activities to suit their abilities and preferences. We saw a range of activities were available and readily advertised for people including church services, exercise, hairdressing, crafts, games and quizzes. Throughout the home we saw a range of dementia friendly sensory cushions that people could pick up and interact with, which had different textures to stimulate their senses.

People told us they knew how to raise concerns and felt sure their concerns would be dealt with. We saw the homes complaint procedure clearly informed people how and who to make a complaint to and gave people guidance along with contact numbers for people they could call if they were unhappy. People who used the service told us they were encouraged to share their views and were able to speak to the manager when they needed to.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We spoke with the manager, training officer, three members of staff and people who used the service. They told us that they enjoyed their lives within the home. One person told us "The staff are very good here" another told us "The Staff are very friendly and helpful". All people who used the service had clear assessments of their needs and plans and strategies were in place to meet them. Individuals care plans were reviewed regularly.

We saw written evidence of a robust staff selection process and training program for any new members of staff.

Staff listened to each individual and encouraged their independence within the range of people's disabilities. Individuals were given choices about their care and how they spent their day. People had access to informal and organised social activities.

All medications were given as prescribed by peoples own doctors and were being administered in a safe fashion. All staff members responsible for giving out medication had undergone training to do so.

The staff we spoke to were all aware of safeguarding vulnerable adults and recognising signs of abuse and knew how to report any concerns. People told us they felt safe within the home.

People living at the home we spoke with told us they were looked after very well. One said 'There is nothing more I need, the staff are lovely, the food is really good and I am very happy'.

Assessments of people's needs had been completed and care was planned and delivered accordingly. People's needs were reviewed and appropriate referrals were made to health professionals. People's rights were protected when they were unable to make decisions for themselves. Systems were in place to protect people from abuse.

Staff had the knowledge and skills to meet people's needs. Staff were employed in sufficient numbers.

Systems were in place to involve people in the service, and their suggestions were encouraged and acted upon. Processes for assessing quality and managing risk were in place.