Archived: Garden House

Garden House is registered to provide residential care for up to 40 older people. Accommodation is provided over two floors with both stairs and lift access to the first floor. An area of the service, ‘The Devonshire Suite’ provides support for up to 12 people living with dementia. The home is situated in Humberston, a suburb to the south of Grimsby.

Garden House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. At the time of this inspection 17 people were using the service.

At the last inspection on 17 and 21 November 2017, we rated the service as ‘Requires Improvement’ and we asked the provider to take action to make improvements in relation to person centred care, safe care and treatment, consent and good governance. Following the last inspection, we received an action plan and we met with the provider to discuss what they would do and by when to improve the key questions Safe, Effective, Responsive and Well-Led to at least good.

After receiving a number of safeguarding alerts about the home and information of concern from North East Lincolnshire Clinical Commissioning Group following their recent monitoring visits, we undertook this inspection. We found people were still not provided with safe care. Management of the service was disorganised and chaotic and there continued to be insufficient governance to mitigate the risks to people's health, welfare and safety. We found multiple concerns and are considering our regulatory response. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Immediately following our inspection, we formally notified the provider of our escalating and significant concerns. We asked the provider to tell us what urgent actions they would take with immediate effect to mitigate the risks we identified at this inspection. For example, in relation to the risks of poor staffing levels, the mismanagement of people's medicines and the unsafe moving and handling practises we had observed. We received a response with their improvement action plan on the 18 April 2018; this was not within the timescale requested.

There was no registered manager at the service. The registered manager had resigned and left the service in November 2017. A new manager had been appointed to the service in January 2018 and had resigned and left the service eighteen days before the inspection. A registered manager is a person who has registered with the CQC 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.

There was a lack of managerial oversight at all levels. There were shortfalls in how the service was managed overall and how care staff were overseen and supported when carrying out their roles. The office and recording systems were disorganised and some confidential information was not being stored securely. The provider had failed to ensure all statutory notifications of events and changes in the service had been submitted to the CQC.

We were told by staff and relatives and we saw evidence that there was a continued high turnover of staff, which was a concern. Appropriate recruitment procedures were not in place to ensure staff employed to work at the home were safe working with vulnerable people.

People were not always protected against the risks associated with the unsafe use and management of medicines. Some people had not received their medicines as prescribed due to errors in administration and non-application of creams.

There was a lack of robust risk assessment and management; people did not always receive safe care and support. Management oversight failed to ensure staff always followed policies and procedures, outcomes from risk assessment or sought and followed guidance from other health professionals.

There were concerns with the management of infection prevention and control due to the strong mal-odour present in one person’s room, the risk of cross contamination due to the build-up of laundry and staff’s inconsistent use of personal protective equipment and standards of hand hygiene.

There were not enough staff deployed to meet people’s needs. Staff rotas showed the levels of care staff frequently fell below the levels the regional manager told us were in place. We found staff were kind in their approach with people. However, most of the interactions were only brief as they were busy meeting people's personal care needs. At times people had to wait for assistance and staff were not always present in communal areas to ensure people's safety.

Training and induction of staff was not sufficient to ensure staff had the competencies and skills to meet the needs of people who used the service. Supervisions were not taking place regularly, which meant staff were not always appropriately supported in their role.

We found there was an inconsistent application of mental capacity legislation. Some people had assessments to determine their capacity to consent to specific restrictions such as bed rails, but others did not. Documentation showed best interest decision-making had not been completed appropriately. There were four people whom we felt should have been assessed to see if they met the criteria for a deprivation of liberty safeguard; they were living with dementia, resided in the Devonshire Suite and staff said these people wouldn’t be able to leave the home freely, as it would not be deemed safe for them.

Opportunities for people to be supported to lead meaningful lives and to participate in social activities of their choice and ability, particularly for people living with dementia were very limited.

People told us the staff were kind and caring, although they said some staff were better than others. Our observations identified people’s dignity was not always preserved.

Staff did not have up to date information about people’s individual needs which meant important person-centred care could be missed. There were gaps in some people's monitoring records for their food and fluid intake, weights, repositioning, bathing and bowel movements. Not everyone who used the service had a care plan and there were gaps in care planning for other people. Also care plans were not always updated when people’s needs changed and advice from health professionals was not transferred to the care plans.

People and their relatives told us that if they had any concerns they would discuss these with the management team or staff on duty. We saw a complaint had been received recently and managed in line with the provider’s procedures, however the senior management were not aware of the concerns and the complaints file and records were unavailable to evidence all complaints received and the actions taken to resolve these.

Staff knew how to recognise and respond to abuse although one member of staff was not aware of the external agencies they could contact. The service notified us of safeguarding incidents. There were a number of safeguarding concerns raised in recent weeks being investigated by the local authority safeguarding team.

The breakfast meal experience for some people on the first day of the inspection was poor, due to the length of time waiting for their meal. We saw meals were nicely presented and menus provided choice and alternatives. Staff supported people to eat their meals in an appropriate way and at a suitable pace for them. People told us they liked the meals provided to them.

The culture within the service did not promote a holistic approach to people's care to ensure their physical, mental and emotional needs were being met. Robust audit and monitoring systems were not in place to ensure that the quality of care was consistently assessed, monitored and improved. Quality assurance systems had failed to drive improvements from the last inspection or identify the majority of concerns we found during this inspection.

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, 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 in

We undertook this comprehensive inspection on the 17 and 21November 2017. At the last inspection in September 2016, we found the provider had made improvements in relation to the breaches in regulations we had found at the inspection in 2015. We found one new breach in regulations. We rated the service ‘Requires Improvement’ overall at the last inspection, as we needed to be assured the improvements were sustained. During this inspection on 17 and 21 November 2017, we found improvements in relation to the previous breach, but we identified shortfalls throughout the service and four breaches of other regulations.

There was no registered manager at the service. A new manager had been appointed to the service in January 2017 and registered with the Care Quality Commission (CQC) in April 2017. They had resigned and left the service three weeks before the inspection. The deputy manager was managing the service. A registered manager is a person who has registered with the CQC 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.

During the inspection, we found some concerns regarding quality monitoring which had resulted in gaps in the programme and shortfalls being missed when audits were completed. Examples included gaps in care plans and consent records, kitchen hygiene, weights, accident analysis and maintenance.

There were shortfalls in the administration and recording of some people’s medicines. We also found one person’s topical medicines were out of date and were not stored safely.

There was some inconsistency with the application of mental capacity legislation. Some people had assessments of capacity and records in their care files when restrictions were in place, but this was not consistent throughout the service.

People had care plans in place, however, we found these were not always person-centred and missed important information regarding how staff were to care for them. We found some people’s risk assessments had not been updated when their needs had changed. This meant that important care could be missed.

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

At our last inspection, we found the service did not have robust recruitment checks in place. At this inspection staff recruitment processes were improved. We found all relevant pre-employment checks had been carried out to help ensure appropriate candidates were employed. This helped to ensure people were protected from harm.

We found good standards of cleaning and hygiene had been maintained throughout areas of the service. Feedback from people who used the service and their relatives confirmed they were happy with the cleaning and considered there were no odours.

The care staffing levels had been increased in recent weeks to support the current occupancy and dependency levels. There were sufficient staff provided to meet people’s individual needs and support them safely.

We found improvements had been made to aspects of the environment. A new unit to support people living with dementia had been provided. This facility reflected national guidance in relation positive ‘dementia-friendly’ premises. Areas of the main facility had also been improved with refurbishment and redecoration.

There were policies and procedures to guide staff in how to keep people safe from abuse and harm. People who used the service confirmed they were kept safe and had no concerns about their safety.

New staff received an induction and staff had access to training, supervision and support to ensure they felt confident when supporting people who used the service.

We found people’s health care needs were met. People told us that they had access to their GP, dentist, chiropodist and optician should they need it. Staff knew what to do in cases of emergencies and each person who used the service had a personal evacuation plan.

We observed kind and caring approaches from the staff team. People’s privacy and dignity were respected and staff provided people with explanations and information so they could make choices about aspects of their lives. There were positive comments from relatives about the staff team.

People enjoyed the meals provided to them. Improvements had been made to the menus and quality and choice of the meals. People were provided with a visual choice at meal times. A good range of snacks were offered and we observed staff encouraged people to have these.

Although people living in the Devonshire Suite were provided with a good range of activities, we found there was less support for people in the main facility. The provider was reviewing the need for an activity coordinator.

People and their relatives told us that if they had any concerns, they would discuss these with the management team or staff on duty. People were confident that their complaints or concerns would be listened to, taken seriously and acted upon.

Staff spoken with told us the overall culture across the service was more open and they felt better supported by the management team. Staff told us that morale within the staff team had improved since our last inspection in September 2016.

We undertook this comprehensive inspection on the 8, 9 and 20 September 2016. At the last inspection on 2 and 3 June 2016 we found the registered provider was in breach in three of the regulations we assessed. We issued a requirement notice for concerns around providing sufficient numbers of staff. We also issued warning notices regarding concerns with standards of cleaning and hygiene and how the service was managed.

During this follow up comprehensive inspection we found improvements had been made in all areas. We have rated the individual domain for ‘Caring’ as Good; we have kept the rating in ‘Effective’ and ‘Responsive’ as 'Requires Improvement' and changed the rating from 'Inadequate' to 'Requires Improvement' in ‘Safe’ and ‘Well-led’. We have changed the rating of the service overall to 'Requires Improvement'. This is because we want to monitor the improvements further to be sure they are sustained over a period of time.

There was no registered manager at the service, the registered manager had left in May 2016 and a new manager had been appointed in July 2016, they confirmed they intended to submit their application for registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found improvements in the way the service was managed. A new quality monitoring system had been started which included audits and meetings to seek people’s views. We are keeping this area under review and monitoring it to make sure the improvement is consistent over time.

We found improvements had been made to the standards of cleaning and hygiene throughout areas of the service. To support more effective hygiene practices in the service, we found new furniture, furnishings, bedding and flooring had been provided. More comprehensive cleaning schedules and systems of daily checks had been put in place which helped the acting manager to monitor the standards of hygiene in the service and identify any shortfalls. The service smelled fresh. We are keeping this area under review to make sure the improvements are consistent over time.

We found the care staffing levels had been increased and better maintained; there were sufficient staff on each shift to meet people’s individual needs and support them safely. New dependency assessments had been introduced and the information was used to inform the staffing calculations. The domestic hours had been increased and hours provided for a new laundry assistant.

Staff recruitment processes were insufficient. You can see what action we have asked the registered provider to take at the back of the full version of the report.

We found improvements had been made to aspects of the environment. Although there were limited adaptations to support the orientation of people living with dementia the operations manager was planning address this issue within the service improvement programme.

We found there was an inconsistency regarding the application of the Mental Capacity Act 2005. The registered provider had not always followed best practice regarding assessing people’s capacity and discussing and recording decisions made in their best interests. We have made a recommendation about this.

Although people had detailed plans of care in place many of these now required review to ensure they were up to date and would sufficiently guide staff in how to care for people safely in ways they preferred. The operations manager planned to introduce a new care records system and provide training for staff in relation to person centred records.

There were policies and procedures to guide staff in how to keep people safe from abuse and harm. Staff had completed safeguarding training.

New staff received an induction and staff had access to training, supervision and support to ensure they felt confident when supporting people who used the service.

We found people’s health care needs were met. Health professionals were contacted to ensure people received treatment and advice when required. People received their medicines as prescribed. Staff knew what to do in cases of emergencies and each person who used the service had a personal evacuation plan.

We observed kind and caring approaches from the staff team. People’s privacy and dignity was respected and staff provided people with explanations and information so they could make choices about aspects of their lives. There were positive comments from relatives about the staff team.

People enjoyed the meals provided to them. The menus enabled people to have choice and special diets when required. We saw people’s weight, their nutritional intake and their ability to eat and drink safely was monitored and referrals to dieticians and speech and language therapists took place when required for treatment and advice. During the day, we observed people were served drinks and snacks between meals.

We saw people were encouraged to participate in a range of activities within the service and local community. They were supported to maintain their independence where possible. Relatives told us they could visit at any time and we saw staff supported people who used the service to maintain relationships with their family.

The registered provider had a complaints procedure on display. Relatives told us they felt more reassured with the new management in place that concerns they raised would be looked into and dealt with effectively.

There was no registered manager at the service, the registered manager had left their post three weeks before our inspection. The registered provider had appointed a new manager and they were due to start working at the service on the 6 June 2016, we were informed after the inspection the start date had been delayed. 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.

This inspection was unannounced and took place over two days on the 2 and 3 June 2016. The previous scheduled inspection of the service took place on 24 May 2013 and breaches in two regulations were identified. Further inspections took place in September and December 2013 when further breaches were identified. The follow up inspection in April 2014 found the service was compliant with the five regulations inspected. At this inspection there were 23 people residing at the service.

During this inspection we identified concerns about the management of the service. This had impacted on areas of care and support provided to people who used the service. The quality and safety of the service had not been monitored effectively and shortfalls had not been dealt with consistently or had not been identified. There was no annual maintenance and renewal programme in place.

Sufficient numbers of staff were not provided to ensure people’s needs were safely met. People had to wait for support in relation to personal care, toileting and meals. Staff did not have time to monitor people who wandered around the service or monitor lounge areas effectively.

We found areas of the environment required attention to make sure they were hygienic and maintained. There were malodours present and we found equipment, carpets and furniture were not clean and some required repair.

The above areas breached regulations in staffing, cleanliness and infection control and monitoring the quality of the service and management of risk. 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.

Although some redecoration and refurbishment had taken place, we found items of worn or broken furniture/ fittings and areas which required redecoration. We have made a recommendation about providing environmental adaptations to meet the needs of people living with dementia.

We found staff knew how to safeguard people from the risk of abuse and had received training in how to recognise the signs and symptoms and how to pass on information of concern. At the time of the inspection the local safeguarding team were conducting an investigation into recent concerns raised and we will report upon this once it has concluded.

Staff supported people to make their own decisions and choices where possible about the care they received. When people were unable to make their own decisions staff generally followed the correct procedures and involved relatives and other professionals when important decisions about care had to be made.

People told us they liked the meals, they were supported to make choices about their meals and appropriate advice was sought when people were unable to maintain a healthy weight or eat and drink safely. Staff supported people to have drinks and snacks between meals.

Most people told us staff were caring and kind. We saw staff were very busy and this impacted on the attention they were able to devote to people. Staff told us they felt overwhelmed by their workloads and frustrated that they did not have time to spend with people other than when they were assisting them with personal care and meals. We observed some areas of staff practice that could be improved and the regional manager confirmed they would be addressing this with staff.

People who used the service were seen to engage in a number of activities both within the service and the local community, they were encouraged to pursue hobbies and social interests. Staff also supported people to maintain relationships with their families and friends.

People’s physical health was monitored and we saw arrangements were in place to make sure people had access to health care professionals when required.

Staff had received regular formal supervision and an annual appraisal. Staff received training to be able to fulfil their roles and responsibilities.

New staff were generally recruited safely although some gaps in the recruitment records for established staff identified through audits had not been addressed.

People received their medicines as prescribed and they were held securely. We found some minor issues around storage, which we mentioned to the regional manager who informed us they would address this. Recent medicines audits had not identified an out of date medicine for one person and the regional manager confirmed they would action this straight away.

There were systems in place to manage complaints and people who used the service and their relatives told us they felt able to raise concerns and complaints. We noted from the records that some concerns had been raised by North East Lincolnshire Clinical Commissioning Group, Environmental Health Department and Humberside Fire and Rescue Service. Following the inspection we received confirmation from the registered provider that any outstanding work identified by those agencies would be completed within a short timescale.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

• Is the service caring?

• Is the service responsive?

• Is the service safe?

• Is the service effective?

• Is the service well led?

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

This is a summary of what we found-

Is the service safe?

The provider had worked closely with other regulatory authorities to make improvements to their management of fire safety and other health and safety issues in the service.

We found the service was safer, cleaner and more hygienic. Improvements had been made with cleaning practices. Comments from people included: "The cleaners do a good job" and "They keep my room nice and clean.”

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints and concerns. The service had some improved risk management processes in place which better protected people’s safety.

People received their medicines as prescribed. Prescribed medicines (including controlled drugs) were stored and administered safely in line with current regulations and guidelines.

The acting manager took people’s care needs into account when making decisions about the numbers of staff required. The staffing arrangements in place better ensured there were sufficient staff to meet people's needs, although the staff rota could more accurately reflect which staff were working each day. We saw people being assisted promptly and although staff were busy in the mornings they were seen to sit and talk to people in their spare time. Comments from people included: "Staff are lovely and kind, they don't rush me," "If I need help I ring the bell and they usually come quite quickly. I have my baths regularly" and “They seem short staffed sometimes, always rushing about and they don’t have a lot of time to spend with people.”

Is the service effective?

The provider had made improvements with staff training and supervision. This ensured people’s needs were met by skilled and competent staff. Staff confirmed the training had improved in recent months.

New equipment and furniture had been provided to ensure people were not put at unnecessary risk and the environment was more pleasant.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People spoke positively about the staff and the support they provided. Comments included, “Lovely staff, very kind and helpful” and “Staff are very nice.”

The home had involved appropriate professionals in the planning and delivery of care. Discussions with visiting health professionals during the visit evidenced satisfaction with the standards of care provided to their patients.

Is the service responsive?

Improvements had been made to the variety of activities provided at the service. People were encouraged to participate in a range of activities that were important and relevant to them.

Concerns and complaints were encouraged. People were made aware of how to complain.

Is the service well led?

There was an acting manager in post but they hadn't gone through our registration process yet.

The acting manager had improved systems in place to monitor and assess the quality of the service provided to people. Where gaps or shortfalls had been identified the acting manager had taken action to address the issues with positive results. However, some monitoring systems required more development which will better ensure the improvement work achieved in recent months is properly sustained and further progressed.

We found areas of the service were not clean or hygienic. Comments from people we spoke with included: “I think it’s alright; I would keep it better myself but the lasses work ever so hard, it’s not their fault” and “There could be some improvements with the cleaning, could do with more staff to do this.”

People told us they received their medicines on time. However, we found shortfalls with the administration, recording and provision of some medicines.

Records indicated that agreed staffing levels had not always been maintained. This meant people who used the service had not always received their planned care in a timely manner. Comments from people reflected this: “The staff are lovely, I really like them. Sometimes when you want the toilet it’s hard to find someone” and “The staff are very busy, there have been delays recently, but so many people need their help.”

We found that although the provider had quality assurance systems in place, they hadn’t been developed and maintained to properly identify, monitor and manage risks to people who used, worked in or visited the service.

The service had better systems in place to identify and manage the needs of people who were at risk from not eating and drinking sufficient amounts. We found improvements had been made to the menus, the care records, the monitoring of people’s weights and the support people received to ensure adequate intake of fluid and nutrition.

People we spoke with told us the food was very good and they had plenty of choice. Comments included: “I like muesli and some honey with a poached egg for breakfast. Do have a good lunch. Carers always ask me if I want more” and “I have no grumbles. Had what I wanted for breakfast which was toast and enjoyed it. You can have tea or coffee in the morning or orange juice. They are good at helping other people less able. I eat in the dining room; I like to be with people.”

We found some improvements had been made to the staff training and development programme. However this needed further development and needed to be sustained. This would better ensure the provider had a workforce who were appropriately supported and skilled to deliver care to people who used the service.

We found peoples' needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We spent time observing the care provided and speaking to people who used the service. People we spoke with were positive about the care they received. Comments included, “The staff are nice”, “They answer the bells” and “The staff look after me.”

Some people were not always provided with a choice of suitable and nutritious food and drink. We received mixed comments from people we spoke with. Some people told us they enjoyed the food offered to them. Comments included, "The food is alright, we get enough to eat", "The food is OK, very nice, I can't complain," One person told us, "The food is not so good, it has gone down and it’s tasteless." Another said "Don’t always get a choice."

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

There were effective systems in place to reduce the risk and spread of infection. We found the home to be clean, tidy and free from odours.

People were cared for by staff who were not always supported to deliver care and treatment safely and to an appropriate standard. This was because not all staff had received appropriate training, professional development, supervision and appraisal.