The White House

We found the following examples of good practice.

Procedures were in place to prevent the transmission of infection to and from visitors.

Staff complied with the requirement to use Personal Protective Equipment (PPE) and had supported people so that they also understood the need for this.

Whole home testing was carried out and the provider kept other information to make sure that staff were safe to return to work.

Cleaning of the home, including frequently touched surfaces, had increased to reduce the risk of transmission of infection.

The provider ensured additional staff were available and made sure agency staff did not work at other services to reduce the risk of transmission of infection.

Further information is in the detailed findings below.

People’s experience of using this service:

¿ People felt safe and were protected from avoidable harm.

¿ Enough staff were on duty during our inspection.

¿ Staff were recruited safely and received on-going support and training to be effective in their roles.

¿ Staff knew people well and risk management plans contained clear instructions for staff to follow.

¿ The environment was clean and staff followed good infection control practices.

¿ Medicines were managed safely and were available when required.

¿ People were supported to access healthcare professionals when needed.

¿ People's nutritional and hydration needs were met. Staff understood people's dietary needs.

¿ Staff cared about people and were responsive to their needs. Care plans supported staff to provide personalised care.

¿ People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

¿ People were supported to be independent, their privacy was respected, and their dignity was maintained.

¿ People's end of life wishes were documented to ensure their wishes would be respected at the end stage of life and following their death.

¿ People were occupied with meaningful activity and had opportunities to maintain positive links with their community.

¿ People and relatives were happy with the care they received and spoke positively about the leadership of the service.

¿ Complaints were managed in line with the provider's procedure.

¿ Systems to monitor the quality and safety of the service were effective.

¿ Feedback from people, their relatives and staff was welcomed to drive forward improvement. Action had been taken in response to the feedback.

Rating at last inspection: At our last inspection of 11 and 12 December 2017, which was published 27 February 2018, we rated the service as ‘Requires Improvement’ overall.

Why we inspected: This was a planned comprehensive inspection that was scheduled to take place in line with Care Quality Commission scheduling guidelines for adult social care services.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our inspection programme. If any concerning information is received, we may inspect sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The White House provides care for up to 33 older people, some of whom are living with a diagnosis of dementia or experience short term memory loss. The service is situated in a residential area of the market town of Beccles.

The White House 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.

There was 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.

People and staff told us that there were not sufficient staff to meet people’s needs. People told us that this meant that care staff were not always able to provide the response they needed. Care staff told us that it meant they were rushed and not always able to provide people’s care in a manner they would like.

People told us that they did not always receive their medicines when they required. This was discussed with the registered manager during the inspection who took immediate action to address our concern. Medicines were stored and administered safely.

The building was adapted to meet people’s individual needs. This included ramped access to the garden area and personalised bedroom doors. The service had effective infection control training and procedures in place. People told us they were happy with the cleanliness of the service.

Care staff received a comprehensive induction and training prior to providing people’s care and support. Training was regularly refreshed.

People received the support they required to maintain adequate nutrition. People told us there was a choice of food and that it was of good quality. Where people’s food and fluid intake needed monitoring this was carried out. We found a concern with the action taken where people had a poor fluid intake. We spoke with staff who were aware of the issue raised and told us they would take further action to address this.

The service worked with other organisations to ensure people’s physical and social needs were met. Prompt referrals were made to other healthcare professionals regarding health concerns. The activities co-ordinator was developing links with groups in the local community to provide people with relevant activities. For example local schools and entertainers.

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 in the service supported this practice. We observed staff providing care and support in accordance with legislation.

Staff provided people’s care and support in a caring manner, treating them with kindness and compassion. People’s dignity was also supported when care was being provided.

People were involved, as far as they wished or were able, in their care planning. They were also involved in some decisions about the running of the service. Care plans contained information which enabled care staff to provide people’s care in support in accordance with their needs and preferences. Care plans were regularly reviewed with the person’s involvement to ensure they were up to date and relevant.

The service did not maintain improvements. We have found repeated breaches of staffing regulations since our inspection of June 2016. Management monitoring and assessment tools were not effectively checked to ensure they were relevant.

Management support for staff to provide good quality care was inconsistent. We found some good examples of support around whistleblowing but some staff had mixed views on the communication and support they received.

The provider carried out regular audits of the service. These were used to develop an improvement plan.

You can see what action we told the provider to take at the back of the full version of the report.

During our June 2016 inspection we identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the service was placed into Special Measures. We told the provider to take urgent action and kept the service under review, with the expectation that significant improvements would have been made within a six month timeframe.

We also served a warning notice on the provider in relation to the staffing levels in the service which posed risks to people's safety. The warning notice included a timescale by when compliance with the legal requirements needed to be achieved. We undertook a focussed inspection on 8 September 2016 to check that the provider had made improvements to meet the legal

requirements in the warning notice, within the given timescale. We found that staffing levels had improved.

You can read the reports from our last comprehensive and focussed inspections, by selecting the 'all reports' link for The White House on our website at www.cqc.org.uk.

The provider had acted on our concerns and at this inspection we found that there was a positive, open and inclusive culture in the service. There had been significant progress made in making the required improvements, however there were some aspects of the service provision where further work was needed to ensure that safe, effective and responsive care was delivered at all times.

The White House provides accommodation and care for up to 33 people who are elderly and frail some of whom are living with dementia. On the day of our inspection there were 23 people living at the service.

There was 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.

Staffing levels had improved but staff were not always effectively deployed to provide a holistic approach to people’s care, ensuring all aspects of their well-being were being attended to.

Although progress had been made with the care plans we found that records continued to be inconsistent in areas. Parts of the care plans which were complete had been written in a person centred manner and included details which reflected people’s personal preferences.

There had been some improvements with regard to the provision of activities. People were positive about the planned activities which took place throughout the week. However, There was a lack of staff training and resources to support people with physical or mental stimulation appropriate for people living with dementia or other mental health conditions.

People and their families were positive about the care they received from staff who respected their privacy, dignity and independence. Staff demonstrated a knowledge and understanding of people’s preferred routines, likes and dislikes and what mattered to them. Additional training was now needed to equip them with a greater awareness and understanding with regards to supporting people living with dementia.

Improvements had been made to the environment following an extensive refurbishment project. This was also having a positive impact in the way in which infection control procedures could be followed. These had been further improved by additional guidance for staff and action taken by the management team when shortfalls were identified.

Improvement had been made to the way in which risk assessments relating to peoples care and support needs were recorded and reviewed. Suitable arrangements were in place for the management of medicines and staff had been trained to administer medicines safely.

People presented as relaxed and at ease in their surroundings and told us that they felt safe. Staff knew how to minimise risks and provide people with safe care. Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. People knew how to raise concerns and were confident that any concerns would be listened and responded to.

Staff understood the importance of gaining people’s consent to the support they were providing. The management team and staff understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However, although care plans contained mental capacity assessments where appropriate they did not always reflect how individuals were supported with individual decision making.

People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice.

People’s nutritional needs were assessed and professional advice and support was obtained for people when needed. The dining experience had improved but additional thought needed to be given to ensure that this was not determined by which dining area people were seated in.

People were supported to maintain good health and had access to appropriate services which ensured they received ongoing healthcare support.

At our last comprehensive inspection we found that quality assurance mechanisms had proved ineffective at identifying areas for improvement, and not all aspects of the service were being effectively monitored. At that inspection we found that the provider did not have robust oversight of the service's operations. The provider had acted on our concerns and at this inspection we found that there was a positive, open and inclusive culture in the service. A comprehensive development plan together with a robust quality assurance system meant that shortfalls were being identified, addressed and used as an opportunity to drive continuous improvement.

Where areas requiring further improvements were still needed, the management team were open and transparent and shared with us the provider’s plans to continue to develop and make improvements within the service.

Although significant progress had been made in improving the service it was not possible for the provider to fully demonstrate the impact of the changes because of the short time they had been implemented for. The provider now needs to demonstrate that the improvements will be sustained and embedded in practice so that people can be confident they are receiving safe, effective and responsive care.

The White House residential home provides accommodation and personal care for up to 33 people. At the time of our inspection there were 29 people using the service.

The service had 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.

We carried out an unannounced comprehensive inspection of The White House on 15 and 20 June 2016, and we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and the service was given an overall judgement rating of 'inadequate' and is therefore 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.

Following the comprehensive inspection on 15 and 20 June 2016, we served a warning notice on the provider in relation to the staffing levels in the service which posed risks to people's safety. The warning notice included a timescale by when compliance with the legal requirements must be achieved.

We undertook this focused inspection to check that the provider had made improvements to meet the legal requirements in the warning notice, within the given timescale. This report only covers our findings in relation to the warning notice and those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The White House on our website at www.cqc.org.uk.

Improvements had been made in the way the service determined its staffing levels. The provider had introduced a dependency profile tool which calculated the number of hours which were required to meet each person’s needs. This resulted in an increase in staffing levels during the afternoon/evening and night shifts.

The management team had started to explore how staff were deployed, and how leadership could be improved to ensure the most effective use of staff resources.

New care workers were being inducted into the service, which would reduce the need for agency staff, and provide a more consistent staff team. Induction processes were more robust, and new staff were observed to ensure they were competent.

People were asked their preferences on how often they would like to take a bath or shower, and at what time of the day. Refurbishment to wash room facilities had taken place which meant that people could choose to take a bath or a shower.

The activity co-ordinators hours had been increased, which enabled them to provide a service five days per week. An activity forum has been set up so people can discuss the provision of activity on a regular basis, and whether this is meeting their needs.

Other issues identified in the June inspection under the domain ‘Safe’ were not followed up at this inspection. We will review our rating for ‘Safe’ at the next comprehensive inspection.

The White House residential home provides accommodation and personal care for up to 33 people. At the time of our inspection there were 29 people using the service.

There had not been a registered manager in post for four months. 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 current deputy manager in post had made an application to become the registered manager, and this was being processed.

The overall rating for this service is ‘Inadequate’ and the service remains 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.

During this inspection, we found that the registered provider was in breach of four regulations 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.

The provider had not ensured that people were receiving safe and effective care provided by sufficient numbers of skilled and knowledgeable staff. Staffing levels were not always adequate to ensure that people were kept safe at all times. People did not always receive the time and attention they needed to fully meet their needs. At times care was task focussed and hurried with staff unable to respond to people as quickly as they would like.

There were gaps in how the service assessed and monitored the quality of its provision. While there were some quality assurance mechanisms in place, these had proved ineffective at identifying areas for improvement, and not all aspects of the service were being effectively monitored. Where issues were identified, such as equipment which was faulty and the need to increase staffing levels, action had not been taken promptly. The provider did not have robust oversight of the service's operations.

Risk assessments were completed to ensure that people were kept safe. These included risk assessments in relation to people's personal care, moving and handling and medicines. However, we found that the level of information held was not consistent across the service, and this meant that staff did not always have up-to-date and clear guidance to help them support people safely.

Care plans for people were not always reviewed or reflective of people’s current needs. Information held in people’s care plans was not consistent across the service and there was a risk that staff did not have the most appropriate information to enable them to tailor the care they provided to people.

Infection control procedures and audits were not effective, and did not identify the issues we found.

Activity provision was not sufficient to meet the individual needs of people using the service.

Staff were trained in areas relevant to their role, however, the induction for newly recruited staff was not robust enough to ensure they felt confident to do their job and care for people safely. Staff supervision was not routinely provided, which supports staff to improve their practice.

Whilst staff worked within the principles of the Mental Capacity Act 2005 (MCA), some MCA assessments and DoLS [Deprivation of Liberty Safeguards] authorisations were out of date and had not been renewed.

Staff had knowledge of safeguarding adult’s procedures and what to do if they suspected any type of abuse, and who they should report this to.

Safe recruitment procedures were in place, and staff had undergone recruitment checks before they started work to ensure they were suitable for the role.

People’s medicines were administered and stored safely.

People’s individual needs were not met by the adaptation, design or decoration of the service, which could compromise the ability of people moving around the service independently. We have made a recommendation about how accommodation can be adapted to meet people’s needs more effectively.

The dining experience was not conducive to an enjoyable mealtime and did not give opportunity for social interactions. We have made a recommendation about improving the dining experience for people.

People and relatives said if they needed to make a complaint they would know how to. There was a complaints procedure in place for people to access if they needed to. However, complaints and feedback received were not comprehensively recorded or used routinely as an opportunity to learn and improve.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We looked at five people's care records and there was clear evidence to show that risks were assessed, care planned and activities arranged to meet the people's needs.

There were maintenance and cleaning schedules in place for the building, ensuring the premises were clean and well maintained.