South Hayes Care Home

South Hayes Care Home is registered to provide accommodation and personal care for up to 39 older people; the home does not provide nursing care. Accommodation is provided over two floors with lift access. At the time of the inspection 18 people were using the service.

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

The provider had made improvements since our last inspection and had mitigated risks to people, the environment and improved their governance systems.

The provider had systems and processes in place to protect people from the risk of abuse. Staff had received training and shared good knowledge of how to raise concerns. People and relatives told us they felt safe and would be listened to if they raised concerns.

People were supported by caring and compassionate staff who knew them well. Staff were recruited safely into the service and had received the relevant recruitment checks.

Medicines were managed and stored safely. Accidents and incidents were monitored, with lessons learned and action taken to mitigate further risks to people.

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.

The provider had a consistent management team and governance systems were in place to provide regular oversight of the service. Internal audits were completed by the provider, registered manager and deputy manager.

Effective systems were in place to gather feedback from people, relatives and staff which was used to drive improvements and positive outcomes.

Rating at last inspection and update

The last rating for this service was Inadequate.

Why we inspected

This inspection was carried out to follow up on actions we had told the provider to take at the last inspection.

In our previous inspection we identified ongoing breaches, and the provider was not working within their current registration conditions. At this inspection the provider had completed the actions after the last inspection and improved their environmental monitoring and governance systems.

We undertook a focused inspection to review the key questions of safe and well-led only. 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 changed from inadequate to good based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for South Hayes Care Home on our website at www.cqc.org.uk.

Enforcement

At the last inspection we identified the provider had failed to meet their conditions. This was a breach of regulation and we issued fixed penalty notice. The provider accepted a fixed penalty and paid this in full.

Follow Up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

South Hayes Care Home is registered to provide accommodation and personal care for up to 39 older people; the home does not provide nursing care. Accommodation is provided over 2 floors with lift access. At the time of the inspection 25 people were using the service.

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

This was a targeted inspection to review actions taken on the fire plan from Hereford and Worcester Fire and Rescue Service and to look at areas of concern from our last visit.

Some people remained at risk of harm as the provider had failed to provide sufficient fire evacuation equipment and safely secure stairwells.

The provider had failed to follow conditions placed on their registration at the last inspection and had admitted people into the home in unsafe conditions.

The provider had completed the actions required by Hereford and Worcester Fire and Rescue Service.

Staff were being safely recruited into the service and medicines were stored safely.

Rating at last inspection and update

The last rating for this service was Inadequate [published 22 June 2023]. At our last inspection the provider was in breach of regulations regarding keeping people safe and the overall management. At this inspection concerns remained regarding the safe provision of care and provider oversight.

Why we inspected

We undertook a targeted inspection to follow up on specific fire safety concerns which we had about the service. A decision was made for us to inspect and examine those risks. We found continued breaches regarding keeping people safe and provider oversight.

You can see what action we have asked the provider to take at the end of this full report.

The overall rating for the service has not changed following this targeted inspection and remains inadequate.

CQC have introduced targeted inspections to follow up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement

We have identified continued breaches in relation to keeping people safe and provider oversight. Therefore the provider still has additional conditions on their registration relating to the admission of new people.

Please see the action we have told the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for South Hayes Care Home on our website at www.cqc.org.uk

Follow up

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.

South Hayes Care Home is registered to provide accommodation and personal care for up to 39 older people; the home does not provide nursing care. Accommodation is provided over two floors with lift access. At the time of the inspection 25 people were using the service.

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

People were at increased risk because environmental risks were not managed safely. Actions from a fire service visit in December 2022 went without action which failed to keep people safe. Fire doors in increased risk areas did not always close or were defective so any potential risks to control the spread of fire, or to stop people being harmed, were ineffective. Fire evacuation procedures were not effective and some staff were unaware of what process should be followed in the event of a fire.

Not all windows were secured with window restrictors and where there were window restrictors in the building, they were inadequate. We saw exposed hot water pipes and electrical cables, placing people at increased risk of harm. Some hot water regulators were not working correctly, putting people at risk of scalding. This had not been identified through health and safety checks. People had unrestricted access hazardous substances and areas of the home that posed a significant risk.

Medicines were not always stored safely.

Staff were not recruited into the home safely, the relevant checks to assess a person’s character before employment were not completed.

Infection prevention and control practices required improvement. During our visit, we saw areas of the building were not clean. There was no cleaner employed for weekends, staff completed this as part of their daily tasks.

There was a lack of provider oversight of the home. There were no audits for some aspects of the home and where audits were in place, these failed to identify issues found during the inspection. Systems to monitor the quality and safety of the service were ineffective and placed people at risk of harm.

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 supported to maintain relationships and they spent their time doing things they enjoyed. The atmosphere at the home was relaxed, and people enjoyed the company of each other and staff. Staff felt supported. Despite our findings people were satisfied with the service they received, and people and their relatives felt the service was safe. There were sufficient staff on duty to meet people’s needs.

Rating at last inspection and update

The last rating for this service was good [published 26/03/2019]

Why we inspected

We undertook a targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about fire safety. A decision was made for us to inspect and examine those risks.

We inspected and found there was a concern with fire and premises safety, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

Enforcement and Recommendations

Following our visit, we asked the provider to respond to the immediate concerns we found at our visit. We continued to seek their updates and assurances they had mitigated the immediate risks to people.

We have identified breaches in relation to the safety and maintenance of the building and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

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 .

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

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

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At this inspection we found the service remained Good.

People told us they felt safe living at the home and were supported to have choice and control of their lives. Staff supported people in the least restrictive way possible, which we observed during the inspection; the policies and systems in the service supported this practice.

There were sufficient staff available to ensure people's wellbeing, safety and security was protected. An appropriate recruitment and selection process was in place which helped to ensure new staff had the right skills and were suitable to work with people living in the home.

Staff had a good understanding of systems in place to manage medicines and safeguarding matters.

Accidents and incidents were recorded and audited to identify any trends or reoccurrences. The home had been responsive in referring people to other services when there were concerns about their health. Staff had a good knowledge and understanding of people's health conditions.

The provider learned from comments received from people and their relatives and used them to improve the service.

Risk assessments were in place for a number of areas and were regularly updated.

The service worked in partnership with other professionals and agencies to meet people's care needs.

Feedback received from people who used the service and their relatives was positive and people were encouraged to contribute their views. People were positive about the staff who supported them and told us they liked the staff and were treated with dignity and kindness.

People were satisfied with the food provided at the home and the support they received in relation to nutrition and hydration. Mealtimes were unrushed and calm and dining tables were nicely presented.

There was an open and transparent culture and people told us they were aware of how to make a complaint and were confident they could express any concerns and these would be addressed. Staff told us they enjoyed working for the organisation and spoke positively about the culture and management of the service. They also told us that they were encouraged to openly discuss any issues.

There was a homely atmosphere and due consideration was given to the needs of people with dementia. Refurbishment of the building was being undertaken and new en-suite bedrooms were being created. Links to the local community had been made.

Audit and governance systems were in place and operated effectively and statutory notifications were sent to CQC appropriately.

There was an up to date certificate of registration with CQC and insurance certificates on display as required. We saw the last CQC report was also displayed in the premises as per legal requirements.

Further information is in the detailed findings below.

South Hayes is registered to provide accommodation and personal care for a maximum of 39 people. There were 21 people living at home on the day of the inspection.

There was a register manager in place. A 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 were supported by staff to be safe and protected from the risk of abuse. All staff knew each person which helped them to understand and reduced their risk of harm or abuse. All staff felt confident in recognised the potential signs of abuse and would report these through the senior staff or management at the home. Where needed the team took steps to prevent further harm and make referral to external agencies as required.

People had staff that were available when needed and to meet their care needs. Where people had risks identified as part of their daily living staff supported them to reduce those risks. People told us they received their medicines as prescribed and at the correct time. All relatives we spoke with told us there were enough staff to support their relative and did not have to wait for care to be provided.

People were cared for by staff the who told us their training reflected the needs of people who lived at the home. We saw that all staff provided care and support to people in a confident and caring way. People consent to their care and treatment had been sought where needed. The registered manager and staff had a clear understanding on what to do if they felt people were not able to make a decision on their own.

People had access to snacks and meals throughout the day and night. People told us they enjoyed the meals and were able to make suggestions to the chef about what they would like on the menu. People had accessed other healthcare professionals to support them and had visits from their GP when needed.

Staff developed positive and respectful relationships with people and were kind in their approach. People’s privacy and dignity were respected and were supported to be independent as possible in aspects of their lives. People’s care needs were met quickly and in an unhurried way.

People were involved in the planning of their care and this had been recorded in their care plans. All relatives we spoke with felt they were involved in their family members care and their view and opinions mattered. People’s care plans also reflected their preferences and life histories.

People were happy to raise any concerns or worries directly with the staff who were able to provide solutions or answers at that time. All relatives we spoke with knew how to make a complaint if needed. The registered manger told us they were happy to answer people’s concerns as they happened so they could respond immediately.

People were seen to approach and make request through the day with all staff, including the registered manager. The staff team felt it was important that they were approachable and visible which people and relatives liked.

People and their relatives were involved in making decisions about their care. We looked at the assessments of people's care and support needs. We found that people's choices and preferences had been discussed with them and included in the assessment. Care plans provided sufficient information to ensure staff had clear guidance and information on how to support people and keep them safe.

We looked at the medicines for three people who lived at the home. We found that people had received their medicines as prescribed by their doctors to meet their health needs. One person told us: 'They (staff) always give me my medicine, this is important to me".

The provider had procedures in place to listen to people's complaints so that these could be resolved to their satisfaction. People who lived at the home had no complaints about the suitability and cleanliness of the home. Without exception all people that we spoke with liked their rooms and the lounge, and told us the views were wonderful.