Kalmia & Mallow

Kalmia and Mallow is a purpose-built residential care home providing personal care to up to 13 people. The service provides support to people with learning disabilities and autistic people. The service is split into two bungalows which are linked together and share a garden. At the time of our inspection there were 12 people using the service.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right support

The management of risks, including those posed by the environment, required further improvement. Recording and monitoring of known risks was not always accurate and staff knowledge of risk was not comprehensive. This placed people at risk.

Safeguarding incidents were investigated, and the provider took action to reduce future risks. Staff understood their safeguarding responsibilities and there were enough staff to meet people’s complex needs. Infection control practices were good but the poor state of some areas of the building made the risk of infection harder to manage. A scheduled refurbishment programme began during our inspection period. Medicines were administered safely.

Right care

Care plans reflected people’s needs and choices and people were involved in decisions about their care. Records did not always document how often people had been supported to access the community to follow areas of interest. The provider was continuing to prioritise access to outside activities and relatives told us they had noticed improvements since the new manager had been appointed.

The model of care and setting was designed to maximise people’s choice control and independence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People were included in decisions about their care and support.

Right culture

Staff treated people who used the service in a way which upheld their dignity, privacy and human rights. Some written and verbal language needed to be more person centred.

Oversight of some aspects of the service required improvement. The provider had recognised this and was introducing a new recording system to address this. The new manager had made a positive impact on the service in a short time, supported by staff and senior management. The provider gave us assurances they understood where the improvement priorities were and would continue to work on these. There was a clear ethos in place and the provider’s values promoted inclusion and empowerment for the people who used the service. There was still work to do to fully embed these values but the direction for the service was clear.

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

Rating at last inspection and update.

The last rating for this service was requires improvement (published 11 January 2020). The service remains rated requires improvement. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulation. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We carried out an unannounced, comprehensive inspection of this service on 14 and 18 November 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve standards of person-centred care and governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-Led which contain those requirements.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection. We have made a recommendation relating to good governance.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Kalmia & Mallow on our website at www.cqc.org.uk.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Kalmia & Mallow is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. This service did not provide nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates up to 13 people with a learning disability and, or autism in two separate but interlinked services. The service had 11 people living at the service at the time of our inspection and there was a person moving into the service.

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

We have found evidence that the provider needs to make improvements. We have identified two continued breaches of regulation: Regulation 9: Person centred care of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and Regulation 17: Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found people mostly received good care and the staff team worked hard to ensure people’s needs were met. Some improvements had been made since the last inspection and a robust action plan showed the progress made by the service in the last year. Further, continued improvements were being made and documentation was being standardised and streamlined across all the provider’s services.

Despite these improvements we remained concerned about communication, management and leadership and record keeping within the service. The registered manager had oversight and duel registration for this and another site splitting their time between the two. Each service had a deputy manager and team leaders who led the shift. There had been significant changes in the staff team and staffing vacancies had impacted on people’s continuity of care and support. Regular agency staff were regularly used.

The organisation provided support to the registered manager and there was a new quality assurance manager in post who had only just started in the last six weeks. Although they had some great ideas about moving the service forward some of these changes had yet to be made and they were working with the staff team to upskill them and change staff’s mind-set.

People had complex physical health care needs, communication needs and learning disabilities. Gaps in health care provision meant people did not always have access to the services they needed in a timely way. This meant the staff were trying to manage changes in people’s needs and behaviours without the resources they felt they needed. The provider has resources they could utilise but there was poor evidence that they had. For example, there were people living with early onset dementia, staff were reactive rather than proactive. We suggested within ‘the organisation there was a dementia lead/coach who could support staff to further understand the function of behaviour and how best to support the person.

We found care and support plans contained significant amounts of information across a number of files, but these were not cross referenced, so we were not assured staff were taking into account all the necessary information. Gaps in record keeping were identified and there was some conflicting information.

Guidance on meeting people’s needs lacked personalisation and we were unable to establish how staff took into account people’s preferred routines when planning their care. People’s routines lacked structure and we could not see how people had a plan of care each day and regular opportunity to take part in meaningful activities.

Families spoken with did not feel they were regularly involved in planning and reviewing their relatives care or that their requests for health input was acted upon quickly enough. People’s health care needs could be established from the documentation, but omissions were noted which meant we were not assured people always received timely health care.

Individual goals for people and the objectives were not specific enough. They were not measurable, achievable, realistic or timely. Care plan reviews identified issues and changes in needs, but actions were not always carried forward.

Staff were not always able to demonstrate how they monitored and reviewed the hours each person needed to support their care and social needs.

People were safeguarded from abuse as far as reasonably possible and care staff knew how to recognise and respond to any allegations of abuse. Incidents between people using the service were prevented as far as possible but did occur occasionally and impacted on people’s experiences of using the service.

The service was mostly clean and well maintained but ongoing works were still required, particularly to the outside space so it was more accessible and appropriate to people’s needs.

Medicines were well managed by staff who were trained and assessed as competent.

Risks were assessed and there was sufficient oversight of this to help ensure people’s safety and the safety of staff. Planned and routine maintenance and servicing of equipment was carried as per schedule.

People were not always supported to have maximum choice and control of their lives, but staff did support people in the least restrictive way possible and in their best interests. There were policies and systems in the service to support best practice and best interest decisions were recorded where a person lacked mental capacity.

The service did not always apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. People's support did not sufficiently focus on them having as many opportunities as possible for them to gain new skills and become more independent.

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

Rating at last inspection

The last rating for this service was requires improvement. (Published 31 October 2018.) There were four breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made but the provider was still in breach of two regulations.

Why we inspected

This was a planned inspection based on the previous rating of requires improvement.

Follow up

We will continue to monitor the service and will request an action plan. We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Kalmia & Mallow is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. This service did not provide nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service accommodates up to 13 people with a learning disability and, or autism in two separate but interlinked services. The service was fully occupied at the time of our inspection.

The care service has not been developed and designed in line with the values that underpin the registering the 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.

Since the last inspection the registered manager had left this year and a new manager appointed who is not yet registered. 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 most recent inspection we found the service was no longer providing good outcomes of care for people using the service. We identified four breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They were for staffing, safe care and treatment, person centred care and good governance.

We found the staffing levels had not been assessed in line with people’s changing needs. Staffing levels did not enable people to go out when they chose or help them to become more independent.

Care records were not sufficiently robust in relation to risk or accidents and incidents. They did not show sufficiently what actions had been taken or if the situation could have been prevented. This meant lessons were not learnt.

People received their medicines as intended but the medicines guidance available to staff was not sufficiently robust.

There were adequate staff recruitment processes in place to ensure only suitable staff were employed.

The service was sufficiently clean but not adequately maintained. The service was not sufficiently homely.

Staff were not supported adequately to ensure they worked in line with the organisational values and best practice. They had not received all the training they needed to ensure they could meet people’s assessed needs.

Staff consulted other health care professionals to discuss how best to meet people’s assessed needs but records did not always show how people had their health care needs met.

People were supported to have adequate nutrition according to their assessed needs. However, the dining experience was poor.

Staff had sufficient understanding of the Mental Capacity Act 2005 but had not always acted in the person’s best interest.

The staff knew people well and their interactions with people demonstrated this.

Staff supported people with their assessed needs. Staff were kind and caring and tried to engage with people on a regular basis.

The service did not demonstrate how it was responsive to people’s assessed and changing needs. There was not enough for people to do at the service to stop them becoming bored.

The service was not always well led or run in the interest of people using the service. People received poor outcomes. The service audits had identified concerns but these had not been addressed in a timely way because there was a lack of leadership. There was poor consultation and involvement from the wider community.

This inspection took place on 15 June 2016 and was unannounced. Kalmia and Mallow is a service for up to 13 people who have a learning disability and is set across two adjoining bungalows. There was a registered manager in post overseeing this and, temporarily, one other care service. 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's relatives told us they felt their loved ones were safe. All staff had undertaken training on safeguarding adults from abuse, they displayed good knowledge on how to report any concerns and described what action they would take to protect people against harm. The manager had sought and acted on advice where they thought people's freedom was being restricted.

The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people at the service. Staff received a comprehensive induction and ongoing training, tailored to the needs of the people they supported.

Risks were identified through a range of comprehensive individual risk assessments to help keep people safe. Care plans were up to date, person centred and detailed in order that staff could support people in the way that they liked to be supported.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people's ability to make decisions for themselves had been completed. Staff were heard to ask people for their permission before they provided care.

Care plans were based around the individual preferences of people as well as their medical needs. They gave a good level of detail for staff to reference if they needed to know what support was required.

People were supported to maintain a healthy balanced diet. Dietary and nutritional specialists' advice was sought so that people with complex needs in their eating and drinking were supported effectively.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. When people's health deteriorated staff responded quickly to help people and made sure they received appropriate treatment. People's health was seen to improve due to the care and support staff gave.

The management team assessed and monitored the quality of the service. We looked at a number of audits that had taken place. This ensured the service continued to be monitored and improvements were made when they were identified.

We found a breach of Regulation 10 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.

Below is a summary of what we found. The summary describes what people using the service, relatives and staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

People told us that they liked living at Kalmia and Mallow. The environment was safe, clean and hygienic. Equipment used at the home was well maintained and had been regularly serviced. There were enough support staff on duty to meet the needs of the people living at the home.

Staff personnel records contained all of the information required by the Health and Social Care Act 2008. This meant that the staff members employed were suitable and had the qualifications, skills and experience needed to support people living at the service.

There was a process in place in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguarding (DoLS). Applications had been submitted when needed and records, policies and procedures were held. Staff had been trained and relevant staff knew how to submit a DoLS application.

Is the service effective?

People's health and care needs were assessed with them. Specialist dietary, mobility and equipment needs had been identified in care plans when required. Relatives told us their family member received the care and attention they required in a way that met their needs. Through our observations and speaking with staff we noted that the staff understood the care and support needs of each person. One person told us. 'I love it here the staff will do anything to help you.' Staff had received training to meet the needs of people living at the home.

Is the service caring?

People were supported by staff who used a kind and attentive approach. We saw that care workers were patient and encouraged people to be as independent as possible. People told us that the staff were sometimes busy but did not rush them. Our observations confirmed this. A visitor told us. 'I am so happy with the care given to my family member. The members of staff are so polite and respectful.'

Is the service responsive?

Care and risk assessments had been completed before people moved into the home and when their needs had changed. A record was held of people's preferences, interests and diverse needs. Relatives told us that staff members consulted their family member and encouraged them to make their own decisions. People had access to a range of planned activities and outings. They had been supported to maintain relationships with their friends and relatives.

Is the service well led?

Staff spoken with had a good understanding of the ethos of the home and quality assurance processes were in place. Relatives told us that they were asked for their feedback on the service their family member received and that they had filled in a customer satisfaction survey. Visitors and staff said that they had felt listened to when they had made a suggestion or raised their concerns. People told us that the management of the home had consulted with them before changes had been made to the environment. They said that their views had been taken into consideration.

Our observations showed us that people were given the support and attention they needed and had a positive experience of being included in conversations, decision making and activities.

Improvements had been made to the plans of care which contained the information staff members needed to ensure that the health and safety of people was promoted.

Improvements had been made and medication was administered, recorded and stored accurately and safely.

Relatives told us that people received the care and support they needed and that staff were very kind.

Staffing levels had been increased to ensure people received the personal, one to one care and support they needed.

Staff members were trained and were supported to provide an appropriate standard of care and support through increased supervision and staff team meetings.

Increased quality audits were being carried out to ensure policies and procedures were being followed and people were safe.

The organisation and accuracy of the records held had improved since our last inspection visit to ensure people safely received the care and support they needed.