Chiltern Grange Care Home

Chiltern Grange Care Home can accommodate 75 people across three separate floors, each of which have separate adapted facilities. One of the floors specialises in providing care to people living with dementia. At the time of the inspection there were 54 people living in the home.

We found the following examples of good practice.

Visitors had their temperature taken and were asked about their health to identify signs of infection. On arrival, there was clear signage and visitors were encouraged to wash their hands and wear appropriate personal protective equipment (PPE). During periods when local and national guidance permitted visiting, relatives used an electronic system to book visiting slots. We observed safe arrangements for visits, including the use of substantial screens between the resident and visitors, designed to reduce the risk of viral transmission.

The home was registered to regularly test staff and people using the service for COVID-19 infection. Some people using the service could not consent to COVID-19 swab testing. Where staff believed a person was unable to give informed consent, the service had undertaken a mental capacity assessment and recorded best interests decision making.

Safe admission processes were in place when people arrived from the community or a hospital setting. This included testing for COVID-19 and a period of isolation on arrival, to minimise the risk to existing residents.

The service had a detailed infection control policy and a business continuity plan in place. Audits took place to monitor infection prevention and control across the service. The home environment was kept in a clean and hygienic condition throughout. During our site visit, we observed regular cleaning taking place. This included the frequent sanitisation of areas which could pose a higher risk of cross infection, such as door handles and surfaces.

We observed staff wearing appropriate PPE, and found the home had a good stock of face masks, aprons, gloves and eye protection. PPE stock levels were closely monitored. Staff had received training in infection prevention and control, including regular demonstrations in the correct use of PPE. We identified where improvements could be made to PPE donning and doffing areas, to ensure all areas included hand sanitiser, apron dispensers and appropriate signage. The service responded to our feedback immediately to confirm they had taken appropriate action.

The home had experienced a recent outbreak of COVID-19 infection and was required to isolate individuals with suspected symptoms of infection. This presented challenges, as some people living with dementia were independently mobile and required close supervision to prevent them from having contact with people who did not have symptoms. The service had already reflected on their response to the outbreak and shared a detailed action plan following our site visit. This demonstrated how future outbreaks could be effectively managed, including improved isolation protocols and the safe management of waste.

At the time of the inspection there were 44 people living in the home. Chiltern Grange Care Home can accommodate 75 people across three separate floors, each of which have separate adapted facilities. One of the floors specialises in providing care to people living with dementia.

The service 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.

When we completed our previous inspection on 23 and 24 April 2017 we found concerns relating to end of life care documentation. At this time this topic area was included under the key question of “Is the service caring?” We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework this topic area is included under the key question of “Is the service responsive? Therefore, for this inspection, we have inspected this key question and also the previous key question of “Is the service caring?” to make sure all areas are inspected to validate the ratings.

During our previous inspection on 23 and 24 April 2017 we found a number of breaches of regulations. These included Regulations 9, 11, 12 and 17 of the Health and Social Care Act 2008 and Regulation 19 of the Care Quality Commission (Registration) Regulations 2009. Following the last inspection, we spoke with the provider and asked them to complete an action plan to show what they would do and by when to improve all the key questions to at least good.

During this inspection we found improvements had been made to all the areas that we previously reported as required improvement. During this inspection we found records were up to date, accurate and appropriate. Records related to risks had clearly identified the risk and the methods used to minimise risk. Standards of infection control were high with clear policies and procedures in place to minimise the spread of infection. The management of risks in relation to fire, health and safety and risks related to the provision of care were clearly recorded.

We observed and records demonstrated that improvements had been made to the administration of medicines. During this inspection we found medicines were administered in line with the prescribed times. Records were kept up to date and audits had proved effective in ensuring people received their medicines correctly.

Improvements had been made in the way staff were deployed. Through our observations and records of staff rotas we could see there were sufficient numbers of staff to ensure people’s needs were met.

Systems were in place to ensure the risk of employing unsuitable staff was minimised.

During our previous inspection in April 2017 we found the provider had failed to comply with the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). During this inspection we found this had improved and the provider was now compliant with the requirements of the Act. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems at the service supported this practice.

We observed food was presented in an attractive way to encourage people to eat and maintain good health. People’s dietary needs were identified and understood by staff who were involved in the preparation and delivery of food. People told us they enjoyed the food on offer in the home.

Staff support had also improved, with staff receiving regular supervision and training. Staff appeared to enjoy their work, and there was a strong team emphasis throughout the home.

Consideration had been given to the environment that people living with dementia resided in. The décor and equipment purchased showed an improved level of interaction for people along with enjoyment and stimulation.

During our previous inspection we found confidential information related to people living in the home and their families was not stored securely. During this inspection we found this had been rectified.

People and their relatives spoke positively about the staff, the care they provided and the senior staff. We observed positive and meaningful interaction between staff and people living in the home. Staff were kind and gentle in their dealings with people. People responded well to attention from staff.

The home was complying with the Accessible Information Standard. The service had or could obtain information in different mediums, fonts and languages if required.

Consideration had been given to people with protected characteristics. Support was available from staff for people to enjoy their chosen lifestyle and gender. People’s cultural and religious needs were also acknowledged.

At our previous inspection we found a breach of Regulation 9 of the Health and Social Care Act 2008. This was due to the lack of evidence that people’s end of life wishes had been considered and documented. This area had improved and information was now available to guide staff to provide person centred care at the end of their life.

During our previous inspection we made a recommendation that the service increased the opportunity for people to participate in activities that were relevant to their individual interests. We found this had improved during this inspection. People participated in activities they appeared to enjoy, were in line with their choices and protected them from the risk of social isolation.

People, relatives and staff were able to feed back to the registered manager about how they felt the care being provided could be improved. This was listened to and evidence was available that showed action had been taken.

During our previous inspection we found a breach of Regulation 18 of the Registration Regulations 2009 because the provider had failed to notify us of safeguarding concerns in the home. During this inspection we found this was no longer the case and the Commission had been sent all relevant notifications.

The dedication, hard work and commitment shown by the registered manager was evidenced throughout the inspection. The improvements made to the running of the home and the provision of care was apparent. Staff appeared happy with their work. Audits were carried out to ensure improvements were continuous. Care standards were maintained due to close monitoring.

People, their relatives and staff spoke positively about the ability of the registered manager and staff to provide good quality care. There was a shared ethos of putting the needs of people first which we observed throughout the inspection.

During the previous inspection in May 2016 we found breaches of Regulation 12 and Regulation 17 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014.This was because people were not protected against the risks associated with the proper and safe management of medicines. Care related documents were not always up to date or accurately reflected people’s needs. During this inspection we found continued breaches of these regulations and further areas of concern.

The home had been without a registered manager since June 2015. Although there had been a number of managers in place since this time, none had completed the registration process with the Care Quality Commission (CQC). At the time of the inspection a new manager was in post. They had started employment at the home on the 6 March 2017. They intended to register with CQC. 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 had concerns about the safety of the service, For example, people living with dementia did not always have supervision from staff.

Records related to care were not always up to date and accurate. Care plans did not clearly document changes in people’s needs. Risk assessments were not always completed correctly. This placed people at risk of receiving inappropriate and unsafe care.

Staff recruitment was undertaken in such a way as to minimise the risk of employing staff who might be unsuitable to work with the people living in the home. Checks were made on the suitability and previous conduct of applicants.

Training, supervision and appraisals were provided to staff to encourage good practice and equip them with the skills and knowledge necessary to carry out their roles. Staff told us they felt supported in their role and they had received sufficient training to carry out their role competently.

The home was clean and odour free. The environment was comfortable and well maintained. Health and safety checks were completed to ensure the safety of the building and the wellbeing of the people living in the home, staff and visitors.

Staff did not understand the Mental Capacity Act 2005 (MCA) and how it applied to their role. Records did not demonstrate where decisions were being made on behalf of people who lacked the mental capacity to make their own decisions. The best interest process had not been followed. Mental capacity assessments were not always decision specific and these had not always been reviewed. People were not supported to have maximum choice and control of their lives. The policies and systems in the service did not support this practice. However, staff did support people in the least restrictive way possible. Where restrictions were in place to protect people’s welfare, appropriate applications had been made to the local authority for authorisation.

Staff were caring, considerate and treated people with respect. We observed positive interactions between staff and people. People spoke optimistically about their relationships with staff.

We had concerns that personal information was not always stored in a secure way, which preserved the confidentiality of information. Records related to Do Not Attempt Resuscitation forms were not always completed correctly or accurately. People’s preferences were not recorded clearly. This meant staff could not always be certain of people’s end of life wishes.

There was a lack of personalised activities being carried out in the home, which meant people were not always protected from social isolation and a lack of stimulation. Plans were in place to increase the staffing in relation to activities.

Not everyone knew how to make a complaint. We spoke with the manager about this who said they would address this issue. Those complaints that had been made had been dealt with appropriately and in line with the provider’s procedure.

The home had not been well led. The legal requirement to notify CQC of safeguarding concerns had not been carried out by the provider. With the introduction of a new manager, this had improved. Improvements had not taken place since our last inspection in some areas such as medicines and record keeping. Plans were in place to correct this situation.

People spoke positively about the new manager. Staff felt supported and relatives told us they had confidence in their ability. The manager had identified areas in the home that required improvement and had a plan in place to carry out those improvements. The Director of Nursing and Quality along with the manager were in discussions about how they could implement the necessary changes.

Some audits had been completed to ensure areas requiring improvements had been identified and we saw action had been taken. We found other areas of improvement had not been identified, and further work was still required to improve services to people.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

A requirement of registration is the necessity of a registered manager to be in place in the home. There was no registered manager in place, however a new manager had commenced employment in the home two weeks prior to the inspection. It was their intention to register with the commission. 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 previously inspected the service in October 2015 We found that people did not consistently receive safe care and treatment, in relation to medicines, record keeping, staff training, support for staff and notifying the commission of events in the home. The provider sent us an action plan, to tell us what action they were taking to improve the service.

Over all people spoke positively about the care and support they received in the home. Their only criticism was in relation to agency staff. This was because they felt the agency staff did not know what their individual needs were. The home had relied heavily on agency staff due to a high staff vacancy rate. This situation had improved recently due to a new intake of permanent staff.

The home has also been through many changes of management over the last couple of years, however a new manager is now in place and people and staff appear to have confidence in their ability to improve the service on offer.

Staff knew how to protect people against the risk of abuse, and the whistleblowing policy was up to date and accessible to staff.

We found a number of concerns related to the administration of medicines to people living on the ground floor. There were incomplete records of stock balances, and for one person with epilepsy there was no seizure chart. Another person’s pain chart had not been reviewed until the day of the inspection. One person’s medicine had not been signed as given and stocks of medicines did not tally with the expected recorded amount. Records on the other two floors were accurate and up to date.

The provider had a tool to assess the number of staff required on each floor to meet people’s needs. People and one staff member told us there were insufficient staff members on the ground floor. During our inspection we found there appeared to be enough staff available to meet people's needs. We have made a recommendation about reviewing the staff numbers on the ground floor.

Appropriate checks were made in relation to the recruitment of staff, to ensure where possible only candidates safe to work with people were employed.

Improvements had been made to the assessments of risk to people’s health and safety since the last inspection. This included Legionella, fire, control of substances hazardous to health (COSHH).

During our last inspection we had concerns regarding the lack of training and support for staff. This had improved. We found staff were encouraged to attend appropriate training to enhance their skills and knowledge. Further work was underway to ensure all staff received appropriate training and support.

Mental capacity assessments were appropriately completed and where appropriate applications had been made to the local authority for Deprivation of Liberty Safeguards (DoLS).

During our last inspection we had concerns about the lack of support for people with their eating and drinking. During this inspection we found this had improved. Food was both nutritional and appetising. It was well presented and both the staff and the chef were aware of people’s dietary needs.

Staff were observed to be kind and caring. People spoke positively about their relationships with staff. We saw staff interact with people in a friendly but respectful way.

During our previous inspection we had concerns about the way the provider responded to complaints. During this inspection we found improvements had been made to the way complaints were responded to and documents related to complaints. Improvements had been made to the relationship between the GP practice and the home,

Activities were available to people for their participation and to protect them from the risk of social isolation.

Care plans and risk assessments were in place; however we found it difficult to locate information in the care plans and had to search for information. Care plans were not all up to date and accurate. This was acknowledged by the management team at the home, and work had started to improve in this area.

The new manager was aware of the problems the home had faced in the past. They were visible within the home and staff felt comfortable coming to see them to discuss work issues. Daily meetings enabled all the senior staff to be aware of events in the home each day.

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

This is a summary of what we found-

Is the service safe?

We found the service was not safe because people were not protected against the risks associated with medicines. We found that there had been some improvements made to the way medicines were handled and managed in the service since our previous inspection but there were still actions that the provider needed to take to ensure that people received their medicines safely.

You can see our judgements on the front page of this report.

We looked at five outcomes during this inspection and set out to answer these key questions: Is the service safe? Is the service caring? Is the service responsive? Is the service effective? Is the service well led?

Below is a summary of what we found. This is based on our observations during the inspection and discussion with people using the service, their relatives, the staff supporting them and management team. Please read the full report if you want to see the evidence supporting our summary.

Is the service safe?

People told us they felt safe and knew who to speak to if they had concerns. One person said ''I feel safe here and the staff are very good.''

People told us they were treated with dignity and respect by the staff. One person told us they were offered privacy as they had a lock on their door and staff always knocked before entering. They said when staff helped them with their shower they always kept the doors closed and drew the curtains.

Systems were in place which ensured staff and management learnt from events such as accidents, incidents and any outbreaks of infections. The provider audited these events on a monthly basis and documented any actions to be taken. This helped them to improve the service and outcomes for people who used it.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). The home had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DOLS). We saw documentation in one person's file which showed these procedures were being followed. An appropriate referral to the Local Authority had been made and approved. This showed the provider had identified when people could potentially be deprived of their liberty and understood when an application should be made and how to submit one.

There were guidelines in place for staff to follow when completing risk assessments. These had not always been followed. For example, in two cases risk assessments in respect of pressure area care, use of bed rails and falls were incomplete. This meant people could potentially be placed at risk.

People were not protected against the risks associated with medicines because the provider did not have arrangements in place to manage them. Appropriate arrangements were not in place for the safe and timely administration of medicines or the recording of the administration of medication. There were no minimum or maximum temperatures recorded for the medication refrigerators to ensure the correct temperature had been maintained. Whilst the majority of administration records were printed, where they had been handwritten, they had not all been checked for accuracy. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the management of medicines.

The provider had safe and thorough recruitment procedures in place to ensure only suitable people worked with people who lived in the home.

Is the service effective?

People told us someone from the home had visited them to assess their health, care and social needs prior to them moving into the home. They told us they were involved in the process as well as family members. This enabled the home to access any necessary equipment prior to them moving in and to write an initial care plan with details of people's preferences and wishes. We saw people had signed documentation stating they had been involved in the care planning process and consented to the care and support detailed within them. We found the care and support provided reflected their needs detailed in their care plans and were regularly updated where those needs changed. We saw signed documentation in people's files to evidence they consented to the care and support detailed in them.

A relative was very pleased with the services provided and told us ''I can sleep peacefully and know he's being looked after properly...has improved tremendously since being here.''

People received co-ordinated care. We saw evidence in people's care plans which demonstrated people had been visited by their GP and other health care professionals and appropriate advice sought when required. This showed staff worked jointly with other health care professionals to meet people's needs in the most appropriate way.

People were provided with a daily programme of activities and entertainment each morning and afternoon which they could take part in if they wished. This included weekends. There was also a visiting hairdresser and chiropodist where people could book appointments if they wished. This ensured people were supported to meet their social and leisure needs.

It was evident through discussions with people living in the home, our observations and speaking with staff that they had a good understanding of people's needs and knew them well.

Is the service responsive?

People knew how to make a complaint or raise any concerns if they were unhappy. We saw the complaints procedure displayed in the home which detailed who to direct any concern to and the timescales in which complaints would be responded to. We looked at the complaints log and found complaints had been documented and included any actions taken in response to them. This showed the organisation responded to people's concerns and took actions to improve outcomes for people who used the service. One person told us ''I have raised concerns and they've been dealt with appropriately.''

Is the service caring?

People said they were happy with the care and support and their needs were met well. One person said ''They look after me well, I am very satisfied. They sometimes help me with my showering and always offer me privacy; they keep the doors closed and close the curtains... I am happy, I don't think you could improve on the care or service.''

We observed staff were gentle and patient with people and provided assistance to those who required help. Staff were respectful when they spoke with people and did not hurry them but enabled them to answer at their own pace.

We observed lunch and saw people were offered choice in what they ate. One person who previously asked for risotto asked to an alternative on the menu. Their chosen alternative was provided.

Is the service well led?

People's opinions were regularly sought. This was by way of surveys, care reviews and regular monitoring. We saw documentation and minutes of monthly resident's meetings. These enabled them to provide suggestions of ways to improve the running of the home. The meetings were chaired by a person who lived in the home which showed people were given the opportunity to take part in the monitoring process.

There were a range of audits and systems in place to monitor the quality of service. The results of the audits were collated and where any shortfalls were found an action plan was put in place to address them.

People and their relatives had the opportunity to visit the home before they moved in to ensure it met their needs and expectations. One relative told us ''I bought my mother here and X assessed her needs. We sat with X and went through the admissions procedure. Her care plan is an evolving plan.....the staff all know everything about her so the information has been passed on. We had lunch, looked around and chose her room.''

Care plans were in place and provided evidence that any risks to the safe delivery of care had been assessed. This ensured the safety and welfare of the person receiving care and the carers supporting them. They contained guidelines for staff but they were generally brief and there were inconsistencies in completing monitoring forms. People and their relatives confirmed they were involved in the care planning and review process

People said they felt safe and staff looked after them well. They knew who to speak to if they had concerns.

Daily activities were provided to those who wished to take part. They were provided in groups and as a one to one session for those who were either nursed in bed or who preferred a one to one setting. The activities included trips out into the community as well as in house activities.