This inspection took place on 7 and 8 August and 5 September 2018. We carried out an unannounced inspection visit on 7 August out of hours, during the evening. This was done to help give us a more comprehensive picture of the service. At that visit we told the provider of our intention to carry out a daytime visit the following day on 8 August. The inspection visit on 5 September was unannounced and was carried out to gather further information following feedback from the local authority safeguarding team, the local clinical commissioning group and relatives. Lower Farm Care Home with Nursing provides accommodation, support and care for up to 46 people, some of whom are living with dementia. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. At the time of our inspection 40 people were using the service. Lower Farm is an adapted older building on three floors. The building is spread out and people have access to the ground floor areas via a lift. It is near King’s Lynn town centre but transport would be needed to access local facilities.
There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.
At our previous inspection, which was carried out on 8, 13 and 19 September 2017, we rated the service as Requires Improvement. During that inspection we identified breaches of Regulations 9, 11, 12, 14 and 18. These breaches related to person centred care, consent, safe care and treatment, nutrition and hydration and staffing. Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the all the key questions to at least good. At this inspection we found that, although the provider had made some improvements and introduced new systems, there were still some significant concerns about the management of risk and the leadership of the service. We have identified continued breaches of Regulations 9, 12 and 18 as well as additional breaches of Regulations 15, 17 and 20a. These new breaches relate to the suitability of the premises, leadership and a failure to display the CQC rating.
We could not be assured that medicines were always managed safely as stocktaking measures were not effective, medicines were not always in stock and medicines were not being stored safely. We also noted a medication error during our inspection.
Risks were not always well managed. Risks assessments were present in care records but the risks posed by an unfenced lake and doors which gave access onto a main road, had not been fully assessed and mitigated. Some risks had been noted at our previous inspection and the provider had not taken effective action to address them. Staffing levels meant sometimes people were left without staff support which increased any potential risks. Systems did not fully protect people from the risk of dehydration or of developing a pressure sore.
Staff understood their responsibilities with regard to keeping people safe from the risk of abuse and appropriate safeguarding referrals had been made. We noted a safeguarding matter during our inspection and this was referred to the local authority by the service.
Infection control procedures were in place but some staff practice placed people at potential risk and had not been addressed by the provider.
Staff received a comprehensive induction and the training they needed to carry out their roles. Staff felt well supported but information systems were not robust and did not ensure that staff always had all the information they needed. This placed people at potential risk.
People had access to healthcare professionals and staff worked well with them to meet people’s healthcare needs. People enjoyed the food and people’s individual likes and dislikes were respected. Where people experienced unplanned weight loss, staff referred them to the dietician for advice and support. Improvements were needed with regard to the oversight of people’s drinking, especially in the extreme hot weather.
The service was working in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. We found that staff understanding of MCA and DoLS was adequate and appropriate DoLS referrals had been made for people. Some staff needed to ensure they asked informally for consent before providing care and treatment.
The environment had been refurbished and much improved since our last inspection. However further improvements were needed to ensure it was suitable and safe for the client group, especially those people living with dementia.
Staff were kind and caring and demonstrated that they had built up good relationships with the people they were supporting and caring for. People were supported to be as involved in decisions about their care where they could be. Although staff were respectful, staffing levels sometimes meant decisions were taken by staff which did not always reflect people’s preferences and expressed wishes. Sometimes a lack of staffing meant people’s dignity was compromised.
Opportunities for people to follow their own hobbies and interests were limited and feedback was negative. People were not meaningfully occupied during the day and many people spent a lot of time in their rooms watching television.
Care plans were being transferred onto a new electronic record. Those which had been reviewed reflected people’s individual needs and preferences, others contained some contradictory and confusing information. Regular reviews of plans were taking place, although some current information had not been recorded.
Care for people at the end of their life required improvement. Records did not demonstrate how people were being cared for and did not assure us that people’s individual needs were being met. People’s preferred priorities for end of life care were documented but information was very basic and did not give staff sufficient guidance.
A complaints procedure was in place and complaints were appropriately managed, although we did receive some negative feedback from two relatives. People who used the service and relatives were given the opportunity to raise any issues and informal complaints at residents’ and relatives’ meetings or in the regular surveys which were sent out.
The provider had not carried out all the actions documented in their action plan from the last inspection. We noted some issues had continued and there were further breaches of the same regulations. We found that in introducing new systems and improvements the provider had not had sufficient oversight of the service to ensure that it remained safe and staff were working efficiently.
Whilst we fully recognise the improvements the provider has made, and the scale of the job which faced them when they took the business over, they have failed to ensure systems were in place to fully protect people and maintain their wellbeing. We are, however, pleased with the level of engagement the provider and registered manager have shown and their willingness to bring about the further improvement.
The overall rating for this service is 'Inadequate' and the service is in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.
The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their
registration within six months if they do not improve.
This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.