Archived: The Moat House

The Moat House is a residential and nursing home registered to provide accommodation for up to 72 people in one adapted building, comprising of five suites known as Willow, Oak, Aspen, Maple and Thistle.

People residing in Willow require support to manage their dementia and nursing needs. Oak provides nursing care. Aspen accommodates people living with dementia. Maple is the residential unit and Thistle is currently closed. At the time of our inspection, there were 41 people using the service.

People’s experience of using this service and what we found

Changes within the provider’s management team, and frequent changes of manager at The Moat House have led to a lack of leadership, management and oversight of the service. This, combined with high use of agency staff, has impacted on the quality of the service provided and has resulted in a failure to identify, assess and manage risks to the health, safety and welfare of people using the service.

At this inspection there was no registered manager in post. The last of a succession of registered managers cancelled their registration with us, the Commission on 10 September 2019. Since that date, there have been two interim managers, one being the providers area quality director. A new manager has been appointed and due to commence employment at the end of October 2019. People, their relatives and staff told us this has impacted on the culture in the service and the quality of the care people have received. Staff did not feel valued and did not have a clear understanding of what was expected of them.

The providers governance framework and home improvement plan had identified where improvements were needed, but the lack of management oversight has failed to drive the required improvements. Safety concerns and risks to people, such as security of the premises, unidentified bruising and choking were not consistently identified or addressed quickly enough to keep people safe. People were at risk of harm because staff did not order, store and administer medicines safely, or follow current national guidance and standards in relation to infection control.

Safeguarding policies and procedures were not fully imbedded into practice. Staff were not clear of safeguarding and whistle blowing process, when and how to raise concerns and are wary of doing so, which meant there were times when people’s safety had not been protected.

The workforce in the service has been made up almost entirely of agency staff. Whilst some agency had worked at the service on a consistent basis, a high proportion had not. This inconsistency in staff who are unfamiliar with people’s needs had placed people at risk of harm. Staff recruitment checks, including agency needed to improve to ensure employees were safe to work with people using the service.

Staff had received training to give them the skills, knowledge and experience to carry out their roles, however not all training was up to date. People who ate little and often were not routinely offered snacks or being prompted to eat and drink. There were no visual aids, to help people living with dementia to choose and remember what they had ordered for their meals.

The facilities and premises were not designed to enhance the wellbeing of people living with dementia. The environment needed maintenance throughout, carpets were stained, and doors and woodwork were chipped.

Staff interactions were kind and caring. However, people were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Care plans were not always up to date where changes in people’s care, support and treatment had been made. Where people had known behavioural issues, there was minimal guidance for staff on how to support them at times of agitation and distress. The requirements of the Accessible Information Standards were not being met. There was minimal information available to support the communication needs of people with a disability or sensory loss.

Incidents where people had complained about staff actions or been party to verbal aggression by staff have not been addressed in a timely manner. There was little recognition for people wishes and preferred priorities at the end of their life. No end of life care plans was in place to guide staff on how to provide care to a person who was at the end stages of their life.

Rating at last inspection and update

The last rating for this service was requires improvement (published 10 January 2019) and there was a breach of regulation, good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, enough improvement had not been made and the provider was still in breach of the regulations.

The service is rated inadequate. At the last two consecutive inspections, this service has been rated requires improvement.

Why we inspected

The inspection was prompted in part due to concerns received about a lack of safeguards being raised by the service in relation to falls, unexplained bruising, weight loss, poor recording and high use of agency staff. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report. For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The provider sent us an updated service improvement plan on 30 October 2019 outlining how they intend to address the concerns we have raised at this inspection. Immediate action had been taken to make the premises safe and protect people at risk of choking.

Enforcement

We have identified breaches in relation to safe care and treatment, safeguarding people from abuse and improper treatment, meeting people’s nutritional needs and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during our inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements. If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

The Moat House is a ‘care home’. People in care homes receive accommodation and nursing or 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. The service accommodates 72 people in one adapted building, comprising of five suites known as Willow, Oak, Aspen, Maple and Thistle. People residing in Willow require support to manage their dementia and nursing needs. Oak provides nursing care. Aspen accommodates people living with dementia. Maple is the residential unit and Thistle is for people who require minimal support to live independently. At the time of our inspection there were 58 people using the service. This service was registered by the Care Quality Commission (CQC) on 25 August 2017 under a new provider RV Care Homes Limited. The last inspection under the previous provider, R V Moat House Limited in August 2016 was rated good. This is the first inspection under the new provider.

The service does not currently have a registered manager 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 previous registered manager resigned on the 22 June 2018. A new manager commenced in post on 11 June 2018, however, resigned on the 10 September 2018. Since this date a turnaround manager employed by the provider has been managing the service. They are making an application to be registered as the manager with CQC until a new manager is appointed.

Our inspection found the new provider had implemented their own systems to ensure performance, risks and regulatory requirements were understood and managed. However, these new systems were still being embedded and it was difficult to see how these were being used to assess and monitor the overall quality of the service. Although risks to people using the service were generally anticipated and managed well, there were occasions where risks had not been recognised. Safety concerns had not been identified and addressed quickly enough to prevent people being exposed to harm, or a significant risk of harm occurring. However, where an incident had occurred, lessons had been learned and measures taken to prevent a similar incident happening again.

People, their relatives and staff had mixed opinions about staffing levels. The provider had a dependency assessment tool they used to determine the number of staff needed. Rotas showed these numbers were being maintained, however the turnover of staff and high use of agency had added to the frustrations about staffing. The manager had taken steps to resolve this by arranging for regular agency staff to be booked to provide consistency. Ongoing issues with recruitment, largely due to the rural location, were being addressed by the provider. Recruitment processes ensured potential staff were of good character and suitable to work with people using the service.

Improvements were needed to ensure records kept about peoples’ medicines and the care they received, were accurate. Changes in people’s needs had not always been updated in their care plans, to ensure staff were working to the most up to date information. Staff were not using charts to monitor changes in people’s behaviours correctly to ascertain, potential triggers, or reflect they had been used to action change to prevent further incidents. The manager was aware that staff training was not up to date and below the percentage the provider expected. This had been addressed at a staff meeting. They had arranged for staff to complete training where there were gaps, including syringe driver, catheter care and managing risks to people with behaviours that could be challenging.

People were supported to express their views and were involved in making decisions about their care, support and treatment. Staff understood the need to obtain consent from people before providing care and support. However, not every one deemed by staff to lack capacity had a mental capacity assessment completed. Where people were being deprived of their liberty for their safety, appropriate applications had been submitted to the local authority for approval.

People were treated with kindness, and respect by staff. Staff knew people’s needs well and showed concern for their well-being in a caring way. People were supported to eat and drink enough to maintain a balanced diet, however people did not always have access to snacks, but this varied from unit to unit. People had access to a range of healthcare services, such as the dietician, Speech and Language Therapist (SALT), district nurse, continence nurse and the community mental health team. People’s relatives told us they were kept informed about changes in the family member’s health. Feedback from people’s relatives and discussions with staff confirmed people were supported to have a comfortable, dignified and pain-free death. However, further work was needed to ensure peoples care plans reflected their wishes about their end of life care.

People's privacy, dignity and independence was respected and promoted. The provider was meeting the requirements of the Accessible Information Standards. This set of standards sets out the specific, approach for providers of health and social care to identify, record, share and meet the communication needs of people with a disability, impairment or sensory loss. People had access to a range of activities, depending on their interests, within the home and via external sources, and chose if they wanted to take part. People were supported to follow their chosen faith and religious practices.

Processes were in place to ensure people’s concerns and complaints were listened and responded to and used to improve the service.

Staff felt supported by the management team, in particular the manager. The area director, manager and staff had a clear understanding of what was needed to improve the service to ensure people received high-quality care and support. The improvements being made showed that there has been a willingness to work in partnership with other agencies to improve the service.

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.