An unannounced inspection took place on the 9 December 2015. The inspection continued on the 11 December 2015 and was announced. The inspection was a planned comprehensive inspection carried out by one inspector.
The service is registered to provide accommodation and personal care for up to 24 people. At the time of our inspection there were 20 people living at the service.
The service provides accommodation over three floors. There are 23 bedrooms, six of which are suitable for two people. At the time of our inspection all the rooms were being used as single occupancy. Each room has an en-suite toilet and wash basin. There was a call bell system fitted in each room. There are two bathrooms with specialist bathing facilities on the first floor. We found that one bath had been out of action for several weeks due to a safety issue. We were told by the Director that they were in regular communication with the manufacturer to get the issue resolved. The first and second floors can be accessed by either a lift or staircase. On the ground floor there is a large dining room which also has cinema equipment installed for film shows. There is a conservatory that people used to spend time together which looks onto secure gardens that have level access from the building. There is a kitchen that produces all the meals for the service and an on-site laundry service.
The service has 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.
We found that the service was safe. People living at the service and their families told us that they felt safe. Staff had received safeguarding training and had a good knowledge of how to identify potential abuse and who to contact if they had concerns. Records showed us that the service report safeguarding concerns promptly and appropriately.
People’s risks were assessed prior to admission and then reviewed regularly. They included malnutrition, skin integrity and moving and handling. When a risk had been identified a care plan had been put in place. This explained what actions needed to be taken to minimise risk and keep the person safe. Other general risk assessments included slips and trips, infection control, accessing the staircase and staff related risks.
People did not have personal evacuation plans in place. These are needed to ensure each person’s individual risks are understood in the event of an emergency. Staff had completed fire safety and the correct use of fire extinguishers training. Fire equipment was regularly tested. The service did not have an emergency contingency plan in place. An emergency contingency plan needs to contain information on how the service would keep people safe in the event of a major incident which affected the running of the service. We raised this with the registered manager who agreed to complete personal fire evacuation plans and an emergency contingency plan.
Staff were recruited safely. Files contained evidence of criminal record checks, references and eligibility to work in the UK. Processes were in place to manage any unsafe practice and we found evidence in supervision records of them being used appropriately. People told us they felt there were enough staff to support them safely. We activated a call bell in a room and after 15 minutes no staff had come to answer the call. We discussed this with the Director who told us that staff had responded but the call had shown in the wrong location. The issue was immediately investigated and actions put in place to rectify the problem. Call bell records showed us that staff responded usually within one to three minutes.
Medicines were managed safely. People’s Medicine Administration Records (MAR) were maintained and medicine audits regularly carried out by the manager. Controlled medicines require additional security and recording processes. The records were well maintained and accurate. However creams were stored in people’s rooms and there was no consistent recording of their application. The deputy manager was in the process of introducing a new recording system. Records would include a body map showing where the cream needed to be applied and an administration recording sheet where staff signed to confirm application. Staff were aware of the process for reporting medicine errors.
We found the service was not always effective. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible.
People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes and hospitals are called the Deprivation of Liberty Safeguards (DoLS).
We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met.
We found that the service were not working within the principles of the MCA. We were told that some people were living with a dementia. People’s files did not contain any evidence that their capacity had been assessed when care plans had initially been developed or reviewed. People had not had their mental capacity assessed to determine whether they were able to consent to restrictions on their liberty or if a DoLs application was required in line with the MCA legislation. One person had a DoLs in place which their social worker had completed on admission to the service. Staff were aware of the conditions of the authorisation and when it needed to be reviewed. We discussed our findings with the registered manager who had completed MCA training but recognised her knowledge was out of date. During our inspection training was booked for January for herself and the deputy on the implementation of the MCA and DoLs legislation. We observed staff seeking verbal consent and giving people time to ask questions and consider the information before giving their consent.
Staff received an induction that enabled them to effectively carry out their roles. This included a four day introduction to the care certificate. The Care Certificate is a national induction for people working in health and social care who have not already had relevant training. Records were kept of the training staff had undertaken and dates for when it needed to be reviewed. Staff received regular supervision which included checking competencies after training.
People told us that the food was good. The kitchen had a good knowledge of the dietary requirements of people. We saw that one person had been losing weight. Risk assessments were in place and reviewed regularly. The kitchen and care workers had a good understanding of what they needed to do to support this person. The service had responded quickly in getting support from a GP and dietician. Staff supported people with their meals in a relaxed and discreet manner. Specialist equipment was used to support people to maintain their independence at mealtimes. People were regularly offered drinks throughout the day.
People had good access to healthcare. This included opticians, audiologists, chiropodists and specialist health professionals at the hospital, GP’s and district nurses.
We found that the service was caring. We spoke with people, their families and other professionals who told us that staff were caring, kind and compassionate. People were supported in a professional and unhurried way. Staff had a good understanding of people’s care needs. They knew people’s likes and dislikes and how they liked to receive their care and support. People were regularly checked upon when in their rooms. People felt involved in decisions about their care. Staff involved people in choices about how they wanted to spend their time. They were supported and encouraged to maintain their independence. People felt that their dignity and privacy was respected. Rooms had been personalised with photographs and personal belongings. People felt their rooms were their own personal space. Relative’s told us they were kept informed of any changes or concerns.
People had not been provided with information about advocacy services. We spoke with the registered manager who told us that they would source a local advocacy service and share the information with people including a poster with contact details.
We found that the service was responsive. People had their care needs assessed and reviewed regularly. Care files and reviews included involvement of staff, the person and their family. Changes in people’s care needs were identified quickly and when necessary other professionals were involved in supporting. Staff had a good understanding of people’s care plans and felt well informed about people.
People were supported to follow their interests which included bird watching and listening to music. Activities and entertainment were organised for most days in December. This included children from a local school visiting, musical entertainers, quizzes and games. People were supported to maintain contact with friends and family. The service had worked with health professionals to support a person with complex health issues regain the ability to sit in a chair so that they were able to engage more with activities.
People were aware of the complaints process and they felt staff listened. Complaints were recorded, investigated and responded to with findings and actions. Responses included information about the Local Government Ombudsman.
We found that the service was well led. The registered manager was available throughout our inspection and had a good knowledge of the people living at the service. Interaction between staff and the manager was relaxed and professional. We were made aware prior to our inspection that there had recently been a change in management arrangements. We asked people, their families and staff whether this had impacted on the care people received. They were aware that changes had taken place but had not felt any negative impact.
Notifications were not always sent to CQC in a timely manner. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. This had been identified by the registered manager who had accessed information on the CQC website which provides guidance for providers on their responsibilities.
Staff we spoke with felt supported and able to share their views or concerns with management.
The service bi-annually sends a quality assurance survey form to people, their families, staff and other professionals to gather their views on the service. Results from a survey in April 2015 had been analysed by the management team. We looked at the results and the feedback had been positive. The survey results had not been shared with people, their families or staff. We discussed this with the manager who told us they would introduce this into their quality assurance process.
The service carried out regular audits which included medicines, accidents and incidents, health and safety, fire, cleaning, staff training, care files, night checks, infection control , call bell and equipment maintenance checks. Audit records showed areas where issues had been identified and actions taken.