Archived: River View Care Home

Following receiving this information, we carried out a comprehensive inspection and found these concerns to be valid. The first inspection visit was carried out in the evening due to the safety for people in the service. We also found several other concerns which are summarised below.

We had concerns raised about fire safety, we notified the local Fire Safety Officer who attended on the 18 October 2017 and found concerns that have been communicated to the provider. During and following the inspection, we have also contacted the district nursing service, the local GP surgery, the police, the local Environmental Health Officer, Health and Safety Executive and local authority safeguarding department. Not everyone had Personal Emergency Evacuation plans in place. Not all maintenance concerns had been addressed as needed. Not all staff knew how to evacuate people safely in the event of a fire.

The service was registered under this provider on the 5 November 2014. The inspection was inspected on 26 August 2015 and rated Requires Improvement in all key questions and overall. Breaches of regulations in respect of Regulation 9, 12 and 17 were found. Requirement notices were served. The service was re inspected on 21 September 2016. The service was then rated Good in all key questions and overall.

River View Care Home (referred to as ‘River View’) is registered to accommodate up to 80 older people who may be living with dementia and/or have a sight impairment and physical impairment. People can receive nursing care at the service. On the first day of the inspection, there were 37 people using the service (with one in hospital) and 32 people using the service on the last day, with one person in hospital. River View has four floors but two were currently not being used.

A registered manager is registered for the service but last worked in the service at the end of September 2017. 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. A temporary manager had been placed in the service by the provider. They and the regional manager were at the service daily (Monday to Friday) with duty cover provided over the weekend.

Staff were not always treating people with respect and dignity. Staff were task focused. Although some positive feedback was received, the concerns had raised with us told us people were not in control of their care, and were not being treated in a way that showed the service was compassionate and caring. This included people at the end of their life. People’s religious and cultural needs were not being planned for at the time of the inspection.

People’s care was not personalised and people’s basic needs were not always being met. People were also not being given the opportunity to have a say about their care on all occasions and where they could not communicate, family were not involved in planning and designing bespoke care.

People’s capacity was not assessed in line with the Mental Capacity Act 2005. Decisions had been made in respect of people’s care without detailing if this had been in people’s best interest. Staff had minimal understanding of the legal processes they were required to follow to respect people’s human and legal rights.

People had risk assessments in place but these were out of date, not reflective of the risks they presented and not clearly linked to their care plans. People’s risks associated with specific needs to that person were not always in place and guidance was not then available to staff. For example, there were no records for people with diabetes of how staff could identify when their blood sugar was too high or low and what action to take. People experiencing several falls were not being reviewed in a timely way. There was no analysis of incidents including falls to reduce the likelihood of further injury to people.

People’s health, nutritional, hydration and care needs were not always met. People’s health needs and the support required were not always identified quickly enough to prevent them experiencing further harm. We found one person left in faeces, and others where their hydration status was not clear. Staff did not always notice changes in people’s health needs, did not pass on health concerns to ensure people were checked and reviewed by health professionals.

People were not always partners in planning their own care. People’s preferences were not always recorded or acted on. People told us they could only have a bath when staff told them. People were also happy that they could have the choice of food they liked.

The administration of medicines was unsafe. We found that when people had medicines prescribed to be taken “when required” that the care plans on how these were to be managed were not complete. We found that a number of people had covert medicines agreements in place. This means that people may be given their medicines disguised in either food or drink. These agreements did not follow either best practice guidance or the provider’s own policy. This meant that people may not have their wishes respected about how they wish to take their medicines. We saw that some medicines were left in an unattended area where they were accessible to people who may have a diagnosis of dementia. Medicines requiring refrigeration were not guaranteed to have been kept at the optimum temperature. The application of prescribed creams was not recorded consistently.

Training identified by the provider as mandatory training had not been completed. This included ensuring all staff were up to date with their medicines training and competency checks. For example, in respect of people living with dementia and presenting behaviour that may challenge. This impacted directly on people where staff were required to assess a person in respect of “as required” sedative medicines. The lack of training for staff in dementia care may have contributed to the reasons why staff did not appear to understand the needs of people living with dementia. Also, it failed to ensure a good basic standard of care among all staff new to care. Staff were not being supported to maintain good standards of care through supervision, appraisals and checks on their competency.

Staffing the service safely had been an issue prior to and during the start of the inspection. There had not always been sufficient staff on duty to deliver care safely. People were not protected by staff and systems which would ensure abuse was identified and reported. Staff on duty were not deployed based upon their skills and experience. Nursing staff were frequently called to advice on residential people at the service, rather than the district nursing team.

People were not being supported to be socially stimulated or physically active. Activities were not provided in groups or on a one to one basis. During the first week of the inspection the activities co-ordinator was on annual leave. On the second week the activities co-ordinator provided activities on floor two, however, we did not observe them on floor one until the last day of the inspection. People’s links with the community were not maintained. People’s religious needs were not being met.

Staff were not always following safe infection control practices to ensure people were protected from the likelihood of cross infection. Floor one smelt of urine on the first two visits which was addressed but the floor remained sticky under foot. However, the provider has advised,

cleaning processes were in place, and the stickiness may have been caused by non-slip safety treatment. We found people were not kept clean and on two occasions found one person nearing the end of their life lying in faeces. One staff member was allocated on some days to work in the laundry and to do the cleaning. They told us they struggled to cope with all that was required in the time available.

We found there had been poor leadership and governance. Poor auditing and a lack of action led to multiple breaches of the regulations. Where concerns had been identified, they had not been acted on. Staff described how they hoped things would now change with the new managers or in the future. Other staff and relatives were wary as they had seen so many managers come and go.

There was a complaints process in place but complaints were not recorded and acted on since the last inspection. Those wishing to raise a concern did not receive the required feedback and resolve.

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

The home had 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 a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We carried out a previous unannounced comprehensive inspection of this service on 26 August 2015. The service was rated as requires improvement overall. Breaches of legal requirements were found in relation to risks to people not being well managed, people’s records not being kept up to date, people not receiving their medicines as prescribed by their doctor, staffing numbers not being adequate, people’s care not always reflecting their individual needs and preferences and the quality assurance systems at the service being ineffective.

The provider sent us an action plan which detailed how they were planning to meet the regulations and told us these actions would be completed by the end of 2015. At this inspection we found action had been taken to respond to our concerns and the service was no longer in breach of those regulations.

This inspection took place on 20 and 21 September 2016 and the first day was unannounced. At the time of our inspection there were 29 people living in River View Care Home. The home’s accommodation was set across four floors. However, only two of those were being used to accommodate people due to the number of people living in the home. The first floor of the building served as accommodation for 18 people, of which one person required nursing care. The second floor of the building provided accommodation for 11 people who were living with dementia, of which six people required nursing care. People had a range of needs, with some people being more independent and others requiring more support with their mobility and health needs.

Following our previous inspection in August 2015 a new manager had started at the home and had recently registered with the CQC. Since the registered manager had started in the service they had made a number of improvements. People’s care plans had been reviewed, new auditing systems had been introduced, significant work had gone into making the environment more suitable for people living with dementia, new medicine management protocols had been introduced and staffing numbers had increased.

People were supported to have enough to eat and drink. People were supported to make choices about what they wanted to eat. Each meal consisted of a number of alternative dishes to meet people’s preferences. Where people required changes to their diets, the consistency of their food and the support they required from staff and food supplements, this was provided. Where people required closer monitoring of their food and fluid intake because of identified risks, this was being completed and people were referred to specialist healthcare professionals where required.

Where people were at risks relating to their health, their mobility, their nutrition or their behaviours, specialist input had been sought and plans had been put in place to ensure these risks were minimised. Where accidents and incidents had taken place, the registered manager had reviewed these, had learned from them and had taken action to reduce the risk of reoccurrence. There were arrangements in place to deal with foreseeable emergencies.

Although we found some gaps within people’s care records, these were immediately acted upon by the registered manager who put in place new auditing systems to ensure these did not reoccur. People’s records contained detailed information about their individual care needs, likes, dislikes and preferences. During our inspection care plans were starting to be reviewed by a peripatetic manager who was planning on delivering further improvements in this area.

People who lived in River View Care Home were supported by trained staff to take their medicines safely. People confirmed they received their medicines on time and we observed staff following best practice when administering medicines.

Staffing numbers at the home were sufficient to meet people’s needs. Staff spent time chatting to people and dedicated one to one time with each person. Staff responded to people without delay and cared for people in an unrushed manner.

The environment on the second floor, the dementia floor, had been changed to improve the experience and the independence of people living with dementia. There were items for people to pick up and handle available throughout the hallways, dining room and living areas. Hallways were easy for people to navigate with signage available and toilet and bathroom doors had been painted in a bright colour to help people find them independently.

Staff treated people with kindness and respect. People enjoyed pleasant and affectionate interactions with staff who spent time individually with people throughout our inspection. Staff knew people’s needs and preferences and worked hard to ensure they met people’s personal likes and dislikes.

Staff had the competencies and information they required in order to meet people’s needs. Staff received a comprehensive induction and the registered manager was in the process of developing an improved regular training programme for staff. There was a schedule in place to ensure staff had supervision and appraisal regularly. Staff had a good understanding of the Mental Capacity Act 2005 (MCA) and put it into practice. Where people had been unable to make a particular decision at a particular time, best interests decisions had taken place and had been recorded. Where people were being deprived of their liberty for their own safety the registered manager had made Deprivation of Liberty Safeguard (DoLS) applications to the local authority.

Recruitment procedures were in place to ensure only people of good character were employed by the home. Potential staff underwent Disclosure and Barring Service (police record) checks before they started work in order to ensure they were suitable to work with vulnerable people. People were protected by staff who knew how to recognise possible signs of abuse. Staff knew what signs they would look for and the procedures they would follow to report these. Safeguarding information and contact numbers were accessible to staff who told us they felt comfortable and confident reporting concerns.

There was open and effective management at River View Care Home. Staff had a good understanding of their roles and responsibilities and the registered manager led by example to ensure best practice was followed. People, relatives, healthcare professionals spoke highly of the registered manager and told us they were approachable and open. There were systems in place to assess, monitor and improve the quality and safety of the care being delivered. People, relatives, healthcare professionals and staff were encouraged to share their views, concerns and feedback and these were listened to and, where appropriate, acted upon.