Archived: Gorseway Care Community

After this inspection CQC was made aware of a person’s death at this location which has been brought to the attention of the police and local authority.

Gorseway Care Community is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Gorseway Care Community can accommodate up to 88 people, some of whom live with dementia. This can be provided across two houses, one of which can accommodate up to 28 people and the second can accommodate up to 60 people. The provider was not using the house which could accommodate up to 28 people. The regional manager told us they would only provide support to up to 50 people in the building currently in use. Accommodation in this building was provided over two floors one of which was for people living with dementia and called ‘Memory Lane’. At the time of this inspection there were 42 people living in the home.

At the time of our inspection visit there was not 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. A new manager had been appointed and has submitted an application to CQC to become the registered manager. Throughout the report we refer to this person as the manager.

The last inspection of the service was on the 7 and 8 March 2016 and we rated this service as overall “Good”. At this inspection we found the overall rating showed improvements were required and the extent to which people were being kept safe by the service had deteriorated and was now rated as inadequate.

The information available to guide all staff, including new and temporary staff on how to support people safely and minimise risks to people were not always accurate, sufficiently detailed and consistent. Actions identified in risk management plans were not always followed by staff which placed people at risk of not receiving safe care and treatment.

The provider had used a dependency assessment tool to calculate the staffing levels in the home. Whilst this showed sufficient staff were available to meet people’s needs, we found this was not always the case in practice. During the inspection the provider told us about the recent staffing changes they had made and were confident these would achieve improvements for people. However, following the inspection we received information from the provider in response to concerns raised which showed these changes had not been made.

Care plans were not in place to guide staff as to how people should be supported with their medicines. Risk assessments were not in place for medicines which pose an increased risk to people such as those to thin their blood and we found errors had occurred. When errors had been identified the actions taken to address the error was not always recorded to show how this had been addressed for people’s safety.

Systems were in place to support learning and improvements when things went wrong. There was evidence to show when these were used improvements had taken place. However, this was not always consistent and incidents were not always identified and followed up to ensure the cause was established to enable learning to take place.

People told us they felt safe living at the home. Staff understood their responsibilities to protect people from abuse and referrals had been made to the local authority when incidents or allegations occurred.

Equipment used to support people’s needs such as hoists and bed rails was checked and maintained to ensure it was safe for people. The premises were safely managed by maintenance staff including protective equipment such as fire safety equipment and there were arrangements for the safe evacuation of people in an emergency.

Improvements had been made in the stock management of people’s medicines to ensure they were always available as required. Actions had been taken to address medicine errors made by agency nursing staff. Supervisions and daily audits had been implemented to improve the management of people’s medicines in the home.

The home was clean and free from malodours. People and their relatives told us they were satisfied with the environment and the standard of cleanliness.

People’s needs were assessed on admission to the home. We found people’s mental capacity to consent to their care and treatment was not always assessed and decisions were not always recorded in line with the Mental Capacity Act 2005 (MCA). Deprivation of Liberty Safeguards (DoLS) applications had been made to the appropriate authority. However, people’s care plans did not include information to guide staff as to how they should support people appropriately in line with their authorised DoLS. This meant there was a risk people were not supported to have maximum choice and control of their lives. We have made a recommendation about this.

People spoke positively about the staff in the home and told us they were “Well trained”. Staff training and evidence based practices enabled staff to develop the knowledge and skills to support people effectively. Processes such as supervision, competency assessments and appraisal were in place to support staff in their role and check they remained competent.

People’s dietary needs were met including when people were at risk of choking or malnutrition and dehydration. Some improvements were required in the monitoring records of what people had eaten and the level of prompting people received from staff when they required this, to support them to eat and drink sufficiently.

People had access to healthcare professionals as required. People’s health was monitored by nurses on site and people’s needs were communicated to staff through handover and a diary to book health appointments and follow up as required.

People and their relatives told us most staff provided kind and compassionate care. One person thought some staff could be more attentive and another person said agency staff did not know them as well as permanent staff. We observed staff to be mostly kind and caring in their interactions with people. However, staff did not always have sufficient time to spend with people and information about people's safety needs was not always available to guide staff and promote a caring approach.

Meetings were held to enable people and their relatives to give their views about the care and treatment provided in the home. In addition a weekly ‘open surgery’ was available for people’s relatives to meet with the manager to discuss their views and concerns.

People told us they were treated respectfully by staff and were able to have privacy as required. The provider promoted the principles of equality, inclusion and diversity through policy, procedures and staff training. Peoples’ cultural, spiritual and inclusion needs were assessed and staff we spoke with demonstrated their commitment to challenging discrimination in practice.

People’s care plans lacked person centred information and how the person and their representatives had been involved in the decisions made about their care. We received mixed feedback from people about their involvement in care planning and review. The provider had identified the improvements required in people’s care plans and this was being addressed at the time of our inspection.

Activities were provided for people by activity staff. These included a programme of events and entertainment as well as activities with people on a small group or individual basis.

People and their relatives told us they would know how to raise a concern or complaint. Most people we spoke with who had raised a concern told us this had been dealt with to their satisfaction. Staff spoke positively about the manager and deputy manager and said they felt confident any concerns they raised would be addressed. The managers told us they were committed to making improvements and ensure staff acted to provide care in line with the provider’s values.

A quality assurance system was in place and information from audits was used to inform a central action plan to drive continuous improvements. We found some improvement was needed to ensure all incidents occurring in the home were identified by staff, recorded and reviewed to ensure the system was effective in addressing risks and driving learning and improvement.

There had been recent management changes in the home and as a result most people and their relatives did not feel able to comment on the management of the service. Although some people told us the manager was ‘approachable and visible’.

People, their relatives and staff were asked for their views on the service through annual surveys. The results of these were not available at our inspection. A programme of resident and relatives meetings, staff meetings and a management surgery for people’s relatives was in place to enable people, their relatives and staff to give their views and receive a response from management.

We found five 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.

Gorseway Care Community is a registered care home and provides accommodation, support and care, including nursing care, for up to 88 people, some of whom live with dementia. This is provided across two houses, one of which can accommodate up to 28 people and the second

can accommodate up to 60 people. At the time of this inspection the provider was not using the house which could accommodate up to 28 people and the registered manager told us they would only provide support to up to 50 people in the other building.

During our inspection there were 22 people living on what was known as the elderly frail floor. This provides support to older people who require more physical care and nursing support. There were 14 people living on the floor known as 'Memory Lane'. Memory Lane provides support and nursing care to people living with dementia.

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. The registered manager was also a director of the company and the nominated individual.

There has been a history of breach of regulation in this service since July 2013. Multiple action has been taken by CQC to encourage the provider to make the improvements needed. This has included requirement actions and enforcement action. The provider did make improvements to the service and the last comprehensive inspection in January 2016. However they did remain in breach of Regulation 17, Good governance because systems used to assess quality were not always effective in identify the need to ensure records for people were clear and accurate. The seriousness of this breach was assessed as low because the impact on people was minor. We issued a requirement notice and asked the provider to send us an action plan detailing what they would do to rectify this concern.

At this inspection we found further improvements had been made in the service. Records had improved and contained all relevant information, however some wording needed review and one person records regarding their mobility were slightly conflicting. The registered manager was open about the need to ensure these improvements were further developed, fully embedded and sustained. As such they had implemented additional measures of checking records. Systems and processes to monitor the service continued although a change to the provider’s regional structure had supported some of the systems to be more responsive. Although there was no longer a breach of regulations, there were still areas for improvement in records. We made a recommendation about this.

People were supported by staff who knew them well and demonstrated kind, compassionate care. At times staff were not always able to respond promptly to verbal calls for support because they were supporting other people. People, their relatives and staff consistently raised concerns that the staffing levels were not sufficient. We found staff were responsive to people’s needs and provided the physical care they required but there was general feedback that staff had little opportunity to spend time ‘with’ people other than when delivering care. The regional manager and registered manager told us they would explore the reasons why people felt there were not enough staff with people, relatives and staff.

People were safeguarded from harm as the provider had systems in place to prevent, recognise and report any suspected signs of abuse. Medicines were managed safely and risks associated with people’s needs had been assessed with plans developed to mitigate such risks. People could be confident they were being cared for by staff appropriate to do so because the provider operated safe recruitment processes.

Staff felt well supported and received the training they required to effectively support people. Supervision meetings for staff had improved and regular meetings were held which they could attend to make any suggestions or raise concerns. People had access to a range of health and social care professionals and staff acted on specialist advice given when planning and delivering care and support.

Staff knew their responsibilities as defined by the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and had applied that knowledge appropriately. They understood the importance of obtaining people's consent when supporting them with their daily living needs. People were involved in decisions about their care and support. Care records reflected people’s needs.

A complaints policy was in place and people knew how to use this if they needed to. The provider responded appropriately to complaints.

The registered manager was visible in the service and consistently described in a positive manner. They were open and transparent and supported staff to work proactively.

Gorseway Care Community is a registered care home and provides accommodation, support and care, including nursing care, for up to 88 people, some of whom live with dementia. This is provided across two houses, one of which can accommodate up to 28 people and the second

can accommodate up to 60 people. At the time of this inspection the provider was not using the house accommodating up to 28 people but remains registered for 88 people.

During our inspection there were 20 people living on the elderly frail floor and 6 people living on another floor known as ‘Memory Lane’. Memory Lane provides support to people living with dementia.

Whilst CQC had a named registered manager on our system, this person had left employment at the home in August 2014. As such there was no 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.

There has been a history of non–compliance with this service since July 2013. Following an inspection in September and October 2014 enforcement action had been taken by the Commission and the Commission had placed a condition on the registration of the home to restrict admissions, meaning that the provider could only admit people to the home with our written permission. A comprehensive inspection in March 2015 showed the service had made significant improvements and were rated at requires improvement overall. At that inspection we identified breaches in two of the 201 Regulated Activity Regulations in place at the time which we judged to have had a minor impact on people. The provider sent us an action plan telling us the action they would take to ensure they met the requirements of the law. The Commission lifted the condition to restrict admissions on 9 July 2015. In August 2015 we carried out a focused inspection following receipt of information of concerns. We identified breaches of the 2014 Regulated Activity Regulations and served a warning notice for one of these regulations, requiring the provider to take action.

At this inspection, people said they felt safe and well cared for by staff who were knowledgeable of their needs. Observations showed staff were kind and caring. They were respectful in their interactions with people and engaged people positively. Staff showed a good understanding of people’s right to privacy and dignity. Staff knowledge of safeguarding was good and they were confident concerns would be reported and action taken where needed. Risks associated with people’s needs were well known and managed effectively by staff. The management of medicines had improved however records of some medicines administration required improvement. Care plans reflected people’s likes, dislikes and preferences. Staff knew people well but care plans were not always kept up to date and accurate.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA 2005) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. People were involved in making decisions about their care and treatment. Where people were unable to make these decisions, staff knew the process they should take to ensure that any decisions made were in the person’s best interests. The manager understood when a DoLS application may be needed and these had been submitted.

People, staff and others shared concerns that the number of care and nursing staff available to meet people’s needs may not always be sufficient. Tools were in place to determine staffing levels and this was being followed, however we have recommended the provider revisit this tool and deployment of staff to ensure it meets people’s needs at all times. Recruitment procedures ensured safer recruitment of staff and staff received training and supervisions to support them in the role.

People were supported to eat and drink sufficient amounts of food and drink. Where there were concerns about a person’s nutritional intake, action had been taken to ensure appropriate advice was sought. People were supported to access a range of health care services to ensure their needs were met.

Feedback was sought from people and action taken to address any complaints. However records held of complaints were not always clear. Systems were in place to monitor the quality of the service and drive improvement; however these were not all effective meaning that records continued to be inaccurate at times.

Another change in the management of the home had taken place, however staff spoke positively of this change and felt the manager was open, transparent and approachable.

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 this report.

During this two day inspection we found significant concerns about the care people received and we took immediate action to safeguard them. This included passing information to the Local Authority for them to look at under their safeguarding vulnerable adults procedures.

The inspection team was made up of two inspectors and an expert by experience. We set out to answer our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a Summary of what we found.

Is the service caring?

We received some positive comments about the staff and the care people received. One relative said, '.it's like a seven star hotel.' A person who lived at the home said, 'As there are so many different carers and nurses that change you don't get to know any one person but they're all good'.

However our observations did not support what these people told us. We saw examples of a lack of care and compassion for people. Staff entered people's rooms without knocking. Staff talked over people and about them to other staff. We heard people calling out for help from staff and staff ignored them and walked past the people who relied on them for their care and support. We observed a staff member refer to a person as 'that' and staff laughing loudly at a person in a disrespectful manner.

People's confidential care files were left unlocked and freely available for other people to look at. People were not always cared for in a caring and compassionate way.

Is the service responsive?

There were no effective systems in place to enable people to give their views on the service on a regular basis. Whilst a few people had been involved in a review of their care with staff and their family, many people had not been given this opportunity. Care records were not up to date and did not always reflect people's needs. We saw no complaints had been logged on the provider system, although we were aware several had been raised. There was no evidence to show if incidents and accidents had been investigated and responded to. This meant we could not be assured complaints, incidents or accidents were responded to in a way which identified any learning had arisen from these.

People told us they did not always receive their care in a timely way. One person told us, 'Sometimes you have to wait 45 minutes for someone to come.' This person also said, 'The nurse should give me my tablets morning and suppertime'.I have to beg them for it and you feel like they're doing you a favour.' We saw staff did not always provide medicines at the times these were prescribed. We saw a number of concerns relating to the management of medicines which the home had not identified.

Is the service safe?

Many people told us they did not feel safe at this home. One person told us, 'I don't feel safe to be left alone here. I just don't know, I'm so confused I feel like I've lost my grip on all reality.' A second person told us, '.No I don't feel safe.'

A member of staff told us, 'People say they do not feel safe with agency staff as they don't know them. Residents say that to me all the time'. A second member of staff described a situation they had witnessed whereby a person had fallen and said, 'I was in tears, all I see is neglect, so understaffed'. Staff had a limited understanding of the safeguarding of vulnerable people.

We found the service did not always respond appropriately to allegations of abuse and whilst actions had been identified as a result, these had not been acted upon. We found no learning appeared to have taken place as a result of safeguarding alerts from the local authority.

We found medicines management was unsafe. We found lack of stock control and staff not completing all medication administration record (MAR) charts at the time the medication was given. Temperature checks of storage areas for medicines were not being carried out consistently. The audit of medicines was ineffective. Medicine errors were not being effectively identified, investigated and appropriate action taken. At the time of our inspection we identified two medicines errors which the home had not identified. These left people at high risk of receiving unsafe and inappropriate treatment.

Care records were not accurate and did not provide clear information for staff to ensure they provided care which ensured the safety of people. Risk assessments were not in place for people with identified health risks. We found care plans did not ensure care was delivered safely and in a way which reflected current guidance and professional advice. People were at risk of receiving care which was not safe and did not reflect their needs.

Is the service well led?

We saw evidence that the provider had systems in place to assess the quality of the service provided to people who lived at the home. However we found these were not effective. The provider had identified concerns in July 2014 such as the ones we found in relation to the management of medicines but no action had been taken to ensure the care and safety of people living in the home had improved. There was a general lack of direction and leadership in the home during our inspection with the manager and the nurses not visible to people or leading staff in care delivery.

Is the service effective?

We found people did not receive care and support which met their needs and supported them to stay healthy. The risks associated with people's care had not been assessed and plans of care had not been put in place to reduce these risks. People were left in bed for long periods of time during the day and lacked stimulation or support from staff. People were not being protected against the risks of developing a pressure ulcer or from the risks of falls and injuries from falls.

We saw some people had lost weight and staff had not given them support to maintain their nutrition. The provider had not ensured the care people received was effective and in line with their needs.

We will be using our enforcement powers.

At the time of our visit there were a total of 45 people living across the two houses. We looked at the care records for five people and spoke with nine people. We spoke to 11 staff including the manager and clinical lead. We also spoke with two relatives and the specialist nurse providing support to the service.

This inspection was carried out by two inspectors. The focus of the inspection was to answer our five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found.

Is the service safe?

People were treated kindly and with dignity and respect by staff. People told us about their satisfaction with the home and told us they felt safe. Staff were clear they would report any concerns about potential safeguarding to the manager and these would be acted upon.

There was a system in place for monitoring incidents and accidents which supported learning from these.

We looked at the staffing levels and skill mix within the home. We were not assured that there was always suitable numbers of staff who were effectively deployed on shift throughout the day and night. Staff received a variety of training including; challenging behaviour, first aid, food hygiene. The provider supported staff to complete the Health and Social Care Qualification and Credit Framework if they wished to undertake this. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to staffing.

CQC monitors the operation of the Mental Capacity Act and Deprivation of Liberty

Safeguards (DoLS) which applies to care homes. Management we spoke with had a good understanding of the Mental Capacity Act, DoLS and their responsibility in this.

Is the service effective?

People's health and care needs were assessed and care plans were developed to enable staff to support people in the way they not only chose but also required. Where there were risks associated with people's care and treatment these had been assessed and agreed actions to reduce these risks had been identified. This meant people received care which was planned and delivered in a way that was intended to ensure people's safety and welfare. Care plans were reviewed regularly. However where decisions had been made by healthcare professionals we could not always be assured that these were in line with people's current wishes. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to making decisions for people.

Some improvements had been made by the provider to ensure they could demonstrate they supported their workers. However supervisions and appraisal were not consistent and staff meetings were not taking place. This meant that staff were not provided the opportunity to raise any issues or concerns about people, and feel they would be acted upon. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting workers.

Is the service caring?

People were supported by staff who were kind and patient in their approach. We saw care workers showed patience and gave encouragement when they supported people. People described their satisfaction with the home.

Is the service responsive?

People knew how to raise concerns if they needed to. Relatives knew how to make a complaint. The manager described the action they were taking to resolve a complaint.

Where people's needs changed care plans were reviewed to reflect their changing needs and the support to be provided.

Is the service well-led?

All of the people we spoke with who used the service said they felt supported and listened to. Staff told us the local management in the service were supportive but they were concerned that they may not be supported by the organisation.

We saw there were systems in place to monitor and assess the quality of the service including satisfaction surveys. Other systems included unplanned provider visits and a schedule of audits.

We carried out an inspection in June 2013 when we identified concerns with care and welfare, staffing levels and how the service was monitored. We made compliance actions asking the provider to take action in order that we were reassured that people were in receipt of safe and adequate care. The provider wrote to us and told us what action they were going to take and they sent us an action plan in July 2013.

We inspected on 16 December 2013 to review the progress the provider had made. We found that the provider had taken steps to improve care planning and delivery. Care plan provided good information about people's needs, staff were knowledgeable of people's needs and people we spoke with told us staff knew them well.

Staffing levels had improved and we found that there were sufficient numbers of suitably qualified, experienced and skilled staff. However we have made the home aware that these were not effectively deployed at all times and that the skill mix did not always fully meet the provider's standards.

Whilst we found that the provider had clear systems in place for monitoring and assessing the quality of the service as well as setting actions for the home to implement changes. However not all of the identified actions had been monitored to ensure they were acted upon and effective.

During our visit we became concerned about the supervision of staff. We explored this further and found that whilst staff are supported to undertake their roles, supervisions and appraisals were not carried out. Therefore this meant that people were at risk of being supported by staff who had not received suitable supervision to ensure they had the skills and knowledge to meet people's needs.

Five relatives we spoke to told us that staff knew people well and knew how to support them. One told us 'they look after {them} well and they are very gentle'. Another told us 'they meet {their} needs well and are always helpful'. One person we spoke with told us about staff 'their ok, they do their best'.

People's needs were mostly assessed, however care was not always delivered in line with what people wanted or needed.

Staff members on duty were hurried and rushed in their approaches and we found that whilst the staffing levels were planned in line with the company's approach, they were insufficient to meet the individualised and personalised support people needed and wanted.

We found that whilst the home had a system in place for assessing and monitoring the quality of the service, this was not always effective.