Larchfield House

People's experience of using this service: The service met characteristics of Good in all areas. The provider was following safe protocols for the receipt, storage, administration and disposal of medicines. The service ensured care plans with regards to medicines were up-to-date and accurate. Staff were recruited safely and there were enough staff rostered and deployed to meet peoples needs safely. The service completed checks and remedial work to ensure the environment was safe.

Care planning documentation identified people’s diverse needs, preferences and choices. The service responded to people’s changing needs and involved relatives and other professionals where relevant. Complaints were investigated, outcomes shared and apologies issued to people when things went wrong. Where people were at the end of life, their wishes were identified and respected by staff.

The registered manager understood their duty to be open and transparent and notified other agencies of events and issued apologies where relevant. The service had quality assurance processes to measure, document, improve and evaluate the quality of care. The registered manager provided strong leadership to a motivated staff team who felt valued.

The home had undergone refurbishment and replaced flooring and created a café which improved the environment and social opportunities for people using the service. Staff received appropriate training and support to ensure they could carry out their roles effectively. 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.

Staff demonstrated compassion and respected people’s preferences and decisions. People and their relatives were valued and involved in people’s care and the development of the service.

Rating at last inspection: At the last inspection the service was rated Requires Improvement (21 March 2018). Following the last inspection, we met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key questions Safe, Responsive and Well-led to at least Good. At this inspection we found these key questions had improved to Good.

Why we inspected: This was a scheduled inspection based on the previous rating.

Follow up: We will continue to monitor the service to ensure that people receive safe, high quality care.

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

Larchfield House accommodates 75 people across four separate units (referred to by the provider as communities), each of which have separate adapted facilities. It provides care and support to people living with dementia and or a learning disability or physical disability. At the time of our visit there were 55 people living in the home.

The care service has been developed and designed in line with the values that underpin the Registering Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen. Registering the Right Support CQC policy.

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.

At our previous inspection on 27 and 28 February 2017 we found a number of breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and a breach in the Care Quality Commission (Registration) Regulations 2009. The provider was given an overall rating of ‘inadequate’ which placed them into special measures. We took enforcement action against the provider due to the concerns found.

Following our last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions, is the service ‘Safe’, ‘Effective’, ‘Caring’, ‘Responsive’ and ‘Well-led’ to at least good. The provider submitted the action plan by the required timescale and informed us improvements would be made by 31 August 2017.

During our most recent inspection we found noticeable improvements had been made but further improvements were required.

Appropriate action was not always taken to reduce the risk of cross infection. We have made a recommendation for the home to seek current guidance and best practice in relation to a documented process for cleaning practices in order to monitor; prevent; detect and control the spread of infections. People and their relatives felt they were kept safe from harm. However, information in people's care records were not always accurate and medicines received by staff were not always processed. This meant people did not always receive their medicines when required.

Legionella was still present in the home. We saw continued monitoring was carried out to ensure people's safety.

People were supported to have maximum choice and control of their lives and staff did support them in the least restrictive way possible. The policies and systems in the service supported this practice. The service was compliant with Mental Capacity Act and its codes of practice.

People and their relatives gave positive feedback about how the service met their nutritional needs. We have made a recommendation for the service to seek current guidance and best practice in regards to the deployment of staff when meals are served to people in their rooms. Staff’s interaction with people was being continually monitored. Staff were appropriately trained; supervised and appraised. The service achieved good health outcomes for people.

People and their relatives felt staff treated them with kindness and compassion. Staff knew how to respond to people’s diverse cultural and spiritual needs. People were supported to access external bodies, community organisations and advocacy services. People were treated with dignity and respect.

Information relating to people’s disabilities were not always clearly communicated and understood by staff. We have made a recommendation for the service to seek current guidance and best practice in order to be compliant with all aspects of the Accessible Information Standard.

Complaints were not always thoroughly investigated. The service made sure people’s preference and wishes in regards to end of life care were captured. Social activities were meaningful and tailored to meet the needs of people living with dementia.

The systems in place to check for accuracy of records were still ineffective. There was no managerial oversight of lessons learnt from incidents and no analysis of information gathered to drive improvements. The provider did not comply with its condition of registration; duty of candour and had failed to achieve all of the improvements it stated would be made by 31 August 2017.

People, their relatives and staff felt the improvements had been made to the service and it was well-managed.

As a result of the improvements made the service has been removed from special measures.

We found breaches of regulations as a result of this inspection. You can see what action we told the provider to take at the back of the full version of the report.

The registered manager had recently left the service and an interim home manager was 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.

At our previous inspection on 29 February 2016 and 3 March 2016 we found breaches of Regulations 9, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider to take action to make improvements in the areas of person centred care; management of medicines and governance of the service. This was because minutes of best interest meetings did not evidence any involvement from other health professionals or people's representatives. Best interest decisions were not reviewed for their effectiveness. Staff did not follow policy and procedures in regards to recording medicines and reporting medicine errors. The service did not ensure there was sufficient details in care plans to enable staff to care for people. Systems and processes that enabled the service to identify and assess, monitor and mitigate risks to people's health, safety and welfare were not effective. After our visit the provider sent us an action plan by the required deadline which stated the required improvements would be made by 30 September 2016.

During our most recent inspection we found the requirements from the previous inspection had not been met.

People were at risk of harm because staff did not understand how to complete nutritional assessments correctly. This resulted in people experiencing unplanned weight loss which was not being identified. People were not always protected from the risk of health and safety associated with the premises because the provider failed to act in a prompt and timely manner when issues had been identified.

People were not protected against the risks associated with medicines. Medicine errors were not responded to appropriately and the provider did not have appropriate arrangements in place to manage people's medicines safely. Where people were identified at risk of choking, risk assessments put in place did not accurately detail how prescribed medicines should be administered.

A review of the service’s infection control and prevention systems showed cleaners’ trolleys were not lockable, and left unattended for a period of time. Chemicals which posed a risk to people were stored on the top or side of the trolleys. This risk had not been identified by the provider and we have made a recommendation for the service in this area.

There was a high use of agency staff within the service which meant people did not always receive care from consistent staff familiar with their individual needs.

We found the service’s safeguarding policy and procedures contained missing information. This meant there was a potential for people to receive unsafe care because staff were not aware of correct working practices.

People were not consistently treated in a caring manner. The delivery of kind and compassionate care was variable throughout the home. We have made a recommendation for the service in regards to dignity and respect.

People’s nutritional needs were not always met and where people had special dietary needs their food was not always prepared in line with specialist nutritional advice. We observed some people waited a significant length of time to be served or to be assisted to eat their meals. The rate of staff training, supervisions and performance appraisals was inadequate. End of life care plans did not capture all of people’s preferences and wishes. We have made a recommendation for the service regarding end of life care plans.

The provider had consistently failed to work in accordance with the Mental Capacity Act 2005 (MCA). Documentation related to the application and authorisation of Deprivation of Liberty Safeguards required improvement. We have made a recommendation for the service in regards to DoLS.

People were supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service (do not) support this practice.

It was not always possible to establish whether care delivered was responsive to people’s needs as relevant records relating to people’s wishes and specific care needs were archived by the service. We found people’s choices were restricted in regards to various aspects of care.

We spoke with people and their relatives in regards to their views about management and leadership of the service. We found some people and their relatives were aware of the change of management but others were not. This meant where there were significant changes that affected people who used the service the provider did not have effective system to communicate with them.

Systems failed to effectively assess; monitor and improve the quality and safety of the service provided. We saw a consistent theme of insufficient and inaccurate record keeping related to care and the management of the service.

The overall rating for this service is 'Inadequate' and the service 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, they 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 a set 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.

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

The registered manager has been in post since February 2016 but was not present during our visit. 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 most recent comprehensive inspection of the service was on 23 & 24 July 2015. We found care and treatment was not always provided in a safe way. The service did not have effective communication systems used to improve the quality and safety of the service and did not take in account the experiences of people. Audits undertaken were not effective as they did not clearly evidence the outcomes of action taken. The service did not notify the Care Quality Commission (CQC) without delay of Deprivation of Liberty Safeguard application that had been approved by supervisory bodies. The service was not meeting the requirements of the regulations at that time and was rated, ‘requires improvement’ in all areas inspected.

Since our last visit in July 2015 we found the service had made some improvements. However, there is still a need for further improvements required in the areas of safe, effective and well-led.

We found areas for further improvements required in this visit in regards to safe included care records. These were not consistently accurate; did not have sufficient details or were being not followed by staff. When medicines errors occurred the service did not respond appropriately. Safer recruitment practices and procedures were not consistently being followed. For instance, the service did not consistently ensure potential candidates completed medical health questionnaires to evidence their fitness to work. We have made a recommendation for the service to seek current legislation in regards to the completion of recruitment processes.

We found areas for further improvements required in this visit in regards to effective related to the service not ensuring registered nurses had completed the necessary medicine competency assessments. These assessments ensure registered nurses are competent to administer medicines. Where best interest meetings took place, these meetings evidenced how decisions were made in regards to people who did not have the capacity to make specific decisions, we saw no involvement from other health professionals and people’s next of kin. Changes in best interest decisions were not always reviewed for their effectiveness. This meant the service was not working within the requirements of the Mental Capacity Act 2005 (MCA).

Although the service provides specialist dementia care, there was no clear evidence of what specialist dementia care was on offer. This was reflected in the staff training records reviewed.

We found areas for further improvements required in this visit in regards to well-led related to quality assurance systems which were not always monitored, or reviewed for their effectiveness. For instance, systems in place to ensure staff had received all relevant training failed to capture whether all registered nurses’ had completed their medicine competency assessments. There were no effective system in place to ensure the accuracy of care records and whether they contained sufficient information.

People said they felt safe with the care provided and knew what to do if they had concerns. Staff had attended relevant training and demonstrated a good understanding of how to keep people safe from abuse. Risk management plans were in put in place when risks were identified. These clearly outlined what staff needed to do to minimise the risks.

We observed there was sufficient numbers of staff to provide care and support to people; this was supported by our review of staff rosters and people’s dependency needs records.

People received care and support from staff who received appropriate induction; supervision and appraisal. This was supported by our reviews of staff records and what staff had told us. Staff demonstrated a good understanding of how to work with people who were unable to make specific decisions.

People’s meal times were reasonably spaced and given at the appropriate times and they were supported to have enough to eat and drink. People spoke positively about their dining experience. This was supported by care records which showed people’s nutritional and hydration needs were being met.

People and their relatives spoke positively about the delivery care and how staff interacted with them. They said staff involved them in the planning and delivery of care; promoted their independence and supported them to make choices. Staff had established good working relationships with the people they supported.

Admission assessments ensured the service captured essential information about people in order to establish what their care and support needs were. People said staff were responsive to their needs and review of care meetings enabled them to communicate if changes in care provision were required.

People and their relatives knew how to raise concerns and the complaints log evidenced all complaints received was responded to in line with the service’s complaint policy and procedure.

People’s social needs were met. The service was in the process of improving the activities on offer for people who were restricted to their rooms.

People and their relatives felt the service was well managed and acknowledged the improvements that had been made to date. Staff felt management was approachable and gave them to opportunity to give their views at team meetings. The service sought feedback from people.

Before our visit the management team had carried out a number of internal audits of the service and had already identified some areas of concern that we had found during our visit. We reviewed their ‘plan of action following the internal audits visit for January/February 2016’ which showed what actions were required; the individuals responsible for them and dates the task had to be completed. This showed the service acknowledged further improvements were required and were taking action to address them.

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 this report.

We saw changes to the way people's privacy and dignity were maintained. The location had changed the way they provided care to ensure people could be involved as much as possible and maintain their independence. People and relatives told us they would enjoy more activities and social stimulation.

We found that people who use the service had care plans detailing their assessed needs and how they would be supported. People were supported and encouraged to live active lives and maintain their independence as much as possible.

Some changes to the premises made it easier for staff to carry out cleaning tasks. For example, we saw janitorial sinks were installed and new hand-washing facilities. However the practices of some staff members were not in line with the national standards set by the Department of Health guidance document on infection control and meant there was a risk of cross infection between areas of the care home.

We saw there had been significant investment in the premises to improve the safety and suitability for people who use the service. The provider had taken account of feedback from various agencies and used their own risk assessments to determine works that were required. These were completed over a period of time to reduce risks and improve safety for people who use the service, visitors and others.

Improvements had been made in the recruitment and selection of new care workers. However we saw the provider still had gaps in their documentation on personnel files required by the regulation.

There were improvements to staff numbers and training of workers who carried out the training. However we found evidence that showed there were still insufficient staff to meet people's needs at some times. People and relatives told us that at times there were not enough staff and they had to wait for support to be provided.

Better identification, assessment and management of risks to safety and the quality of care were in place at Larchfield. There were more checks in place, people were listened to and their feedback was acted on. A robust system was implemented and performance against an operational plan of corrective actions was regularly assessed and monitored to ensure people's welfare.

The provider had a policy for storing, archiving and destroying records. All records relevant to the management of the service were stored securely in a locked cabinet or the office and were easily accessible to staff.

The registered person failed to notify the Commission, without delay, of an interruption in the supply of water to the premises where the interruption lasted for longer than a continuous period of 24 hours. This means that people living at the home cannot be confident that important events relating to the management of the home are reported to us when required so that, where needed, we can take appropriate action.

We used a number of different methods to help us understand the experiences of people using the service, because the people using the service had complex needs which meant they were not able to tell us their experiences.

We spoke with five relatives of people who use the service. They all gave us positive feedback about the care their family member received at the home. One relative said 'whenever we come [to the home] they are so caring' and described how the staff supported their family member with their dementia care needs. We saw occasions when staff spoke to and supported people in a caring way. However, we also saw and heard occasions when staff did not speak to people or support them in a caring way.

The provider was not always ensuring that people who use the service were experiencing effective, safe and appropriate care, treatment and support which met their needs. There was a risk that people would not be protected from receiving care that was inappropriate or unsafe.

The provider was unable to demonstrate there were sufficient numbers of staff with the right qualifications, skills and experience to meet the needs of people who use the service at all times. They were also unable to demonstrate they had carried out a needs analysis and risk assessment as the basis for deciding sufficient staffing levels. They were unable to respond appropriately to unexpected changes in circumstances in the service, for example, to cover sickness. There was a risk they would not be able to safeguard the health, safety and welfare of people who use the service.

The provider was not keeping accurate personal records for each person who uses the service. This meant there was a risk that people who use the service would not be protected against the risks of unsafe or inappropriate care and support. Records were not being stored securely. There was a risk that people's personal records would not remain confidential.

We spoke with the person managing the service on the day of our inspection. Throughout this report, we have referred to this person as the acting manager. At the time of our inspection the provider did not have a registered manager in post.

We were accompanied by two specialist advisors and a pharmacist inspector for this inspection, which took place on three days. We checked whether Larchfield had taken action to meet compliance actions made at our last inspection on 15 January 2013. We also inspected regulations where we had received information of concern since that time.

Improvement was observed in the management of medicines and the support of care workers. The provider had changed pharmacy supplier, re-written policies and procedures and trained staff about medicines in order to improve the safety of medication delivery for people. Improvement in staff training had occurred and more frequent and detailed supervision sessions had taken place with workers across all departments.

Although improvements to the safety and suitability of the premises were observed, there were still issues which placed people and others who use the service at risk. We saw the home's redecoration programme during our visit and people we spoke with were positive about the improvements made on the units.

Suitable checks of employees were not always undertaken prior to people starting work. We looked at 10 personnel files and found gaps in some of the documentation required by legislation.

We saw there were a series of audits which had taken place to monitor the quality of service provision to people. However, the risks to people were not always identified, assessed or managed. People were at risk of unsafe or inappropriate care as a result.

We observed lunch in three separate dining rooms. We saw some improvements had been made since our last visit. For example, two dining rooms had been decorated, there were table cloths, napery, condiments and more visible menus for people who use the service. However, relatives we spoke with were dissatisfied with the continued lack of dignity and respect by care workers for people who use the service. One relative told us, 'Residents' dignity is not always respected. There is a culture in the home of some of the carers who do not understand dignity and from time to time residents are not respected'.

We inspected the outcome for medicines because the local authority told us about concerns regarding the management of medicines in the home. For liquid medications we were unable to assess if the medicine was given due to poor recording. We also saw several examples where the medicine was prescribed by the doctor as a variable dose. The records did not indicate the exact amount administered.

We inspected the safety and suitability of the premises during our visit because we became aware of issues regarding the risks to people.

We observed the interaction between staff and people who used the service in three dining rooms at lunch time. There was poor communication between staff and people during lunch. The environment in the dining room was also not satisfactory for people who have dementia.

People we spoke with were dissatisfied. They told us there was a lack of social stimulation in the home. One person told us, "'I sit here all day long, nothing to do". We also spoke to visitors about the activities offered at the service. Their feedback about this was also negative. One responded, "'We are not happy. I look after mum's affairs and when she first came here it was magic, singing and dancing which she loved. There are no activities, now they are just waiting to die".

We saw the risk assessments and care plans had been rewritten on new templates and were set out in an easier format to interpret. We also saw reviews of the risk assessments and care plans were occurring mostly monthly, although there were some gaps. We spoke to the home manager and the business support manager who told us audits of the home were now conducted, in line with the internal company policy.