The Dell Care Home

The Dell is a care home providing personal care to 35 older people at the time of inspection. The service can support up to 40 people.

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

At the last inspection improvements were required to ensure care planning for risks was clear about how this was managed. At this inspection we found care planning and risk assessment was clear, concise and provided enough information for staff to care for people. This had been updated when people’s needs had changed.

At the last inspection we found that an inconsistent management and high turnover of registered managers had impacted upon the quality of the service provided. At this inspection we found the quality of the service had improved, despite the most recent registered manager having left. This reassured us that appropriate measures were in place to maintain standards in the absence of a registered manager.

There was a comprehensive quality assurance system in place which was capable of identifying areas for improvement. We saw evidence that areas for improvement identified by the system had been acted upon, such as in care planning, as this had improved by the time of our inspection.

Medicines were stored safely within the home and administered in line with the instructions of the prescriber.

There were sufficient numbers of staff to meet people’s needs in a timely manner. Staff were recruited safely.

The service was clean and there were appropriate procedures in place to minimise the risk of the transmission of COVID19.

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’ (30 July 2021).

Why we inspected

This inspection was planned to assess progress with shortfalls identified at our previous inspection on 7 June 2021.

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.

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.

The Dell Care Home is a care home providing personal care to a maximum of 40 older people. At the time of visit there were 38 people using the service.

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

The management of the service had been inconsistent, and this may have led to the deterioration in compliance we identified at this inspection. The current registered manager was also the registered manager of two other services owned by the provider, which meant they could not focus on any one service.

Improvements were required to ensure that care planning in place for identified risks, such as pressure ulcers, was clear about how the risk was reduced. Improvements were required to ensure that staff could evidence that they had carried out care interventions in line with people’s care plans.

The environment was safe and checks were carried out to identify any areas for action. There were appropriate infection, prevention and control procedures in place and staff were following these.

Medicines were managed and administered safely, and in line with the instructions of the prescriber.

Sufficient numbers of staff were deployed to ensure people were provided with support when they needed it.

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 ‘Good’ (Report published 25 July 2018)

Why we inspected

We received concerns from whistleblowers about management, staffing and the safety of the service. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

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

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.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of Good. 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.

The service had clear and effective governance, management and accountability arrangements. Staff understood their roles and responsibilities, were motivated, and had confidence in their management team. Moreover, they were supportive of each other to ensure people received excellent care. The management team placed a great importance on ensuring everybody was treated as an individual and giving them person-centred care. They also ensured the staff team felt valued. They had worked hard and established a strong and visible person-centred culture. The service was building links with the local community being actively seeking opportunities which would benefit people. They encouraged and sustained contacts with other resources and

support groups.

The staff and management teams showed a genuine and in-depth understanding and compassion for people they supported. They had a number of schemes and initiatives in place driving improvement and continuously encouraging innovation to benefit people in the service. The staff team always tried to enable people to express their own views ensuring people received the care they needed and wanted. People were encouraged to be as independent as possible. The management and staff team monitored people's health and wellbeing and took appropriate action when required to address concerns. The service had dedicated

champions for different areas of speciality such as infection control, hydration and diet and falls to effectively support people's health and wellbeing. They were constantly researching for creative and innovative ways to ensure people lived their lives to the full. The whole staff team were very responsive to the needs of the people and enabled them to improve and enjoy their life.

People were able to engage in a range of meaningful activities and maintain regular links with the community. This helped them avoid becoming isolated. People really enjoyed getting involved in activities and outings because it made them feel busy and useful. People could also spend time with their visitors or occupying themselves if they wished to. Their choices were respected by attentive and understanding staff. We observed staff were positive, respectful and considerate of people and their relatives. People and relatives confirmed staff always respected their privacy and dignity. People benefitted from living at a service that had a very open and welcoming culture.

The management team spoke with passion about the care and support they provided to people and their families. They worked hard to ensure this was also shared by the staff team. There was a great atmosphere in the service filled with lots of enthusiasm, laughter and friendliness. The management team encouraged staff to go the 'extra mile' when supporting people. Staff were motivated to provide care with kindness and consideration.

People felt safe while supported by the staff. Staff had a good understanding of how to keep people safe and their responsibilities for reporting accidents, incidents or concerns. Staff had the knowledge and confidence to identify safeguarding concerns and acted on these to keep people safe.

The management and staff team recognised, reviewed and explored better ways of working when things went wrong. The management team had planned and booked training when necessary to ensure all staff had the appropriate knowledge to support people. Staff had ongoing support via regular supervisions and daily communications. They felt supported

by the registered manager and senior staff, which supported good team work.

The registered manager ensured there were enough qualified, skilled and knowledgeable staff to meet people's needs at all times. Staff were knowledgeable and focused on following best practice at the service making sure people received high quality care and support. The service had an appropriate recruitment procedure to follow before new staff were employed to work with people. They checked to ensure staff were of good character and suitable for their role.

The service assessed risks to people's personal safety, as well as those to staff and visitors, and actions were taken to minimise those risks. There were safe medicines administration systems in place and people received their medicines when required. There were contingency plans in place to respond to emergencies.

Care plans were kept under review and updated as necessary. People's rights to make their own decisions, where possible, respected. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The management team had quality assurance systems in place to monitor the running of the service and the quality of the service being delivered. They were able to identify issues and any improvements necessary, and took actions promptly to address them.

Further information is in the detailed findings below

We visited the service again on 20 November to ensure that the provider had taken action to address the shortfalls. We found that despite support and monitoring from external organisations, the management of the service were unable to show that they had taken sufficient action to ensure people were receiving adequate amounts of food and drink.

A pharmacist inspector visited the service on 26 November 2014 to follow up a warning notice for the administration of medications, which was issued in September 2014. A warning notice is part of the CQC's enforcement framework. It allows us to give the provider a short timescale within which to make improvements. We found that whilst some improvements had been made, errors were still identified which the service had not picked up on.

We spoke with three people who used the service. We also spoke with the owner of the service, the manager and care staff. We observed the care and support provided to people to check that people received care that met their needs. We looked at twelve people's care records. We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Is it safe?

We found that the management of the service failed to ensure that those people who needed support to eat and drink were provided with sufficient and consistent help. We observed that staff were often unaware of what a person had eaten, even when being monitored, and records reflected the amounts people had eaten inaccurately. The service had not taken appropriate and timely actions to safeguard some people from further weight loss.

Is it effective?

During our inspection visits, we found that the management of the service was continuing to fail in this area. This was because people using the service were not supported to eat and drink sufficient amounts. Staff were not deployed in a way that ensured people's needs were met.

Is it caring?

We saw some positive and caring interactions between staff and people using the service. However we also observed staff who displayed poor practice which did not ensure people were consistently treated with dignity and respect.

Is it responsive?

Observations did not demonstrate that staff delivered the care people needed in line with their plan of care. This meant that people using the service could not be assured of receiving the appropriate care in a timely manner.

Is it well-led?

Following our first visit we contacted the provider to share our concerns about the service. We also requested information to assure us that action was being taken to address shortfalls we had identified. The provider was unable to provide all the information in the timeframe we gave them so we inspected again the following week to check if improvements to the care provision had been made.

The provider was present during the second day of our inspection. They shared information on how they were addressing the concerns we had raised. In addition they told us how they were planning for the future oversight and management of the service.

Despite this we found the management of the service did not have in place an effective and robust system to identify shortfalls in staff practice and in service provision before they were identified by us. This meant that we were not assured that the service was well-led.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

The service failed to learn from incidents and accidents, and put in place measures to protect people in the future. We saw that people did not have the care they needed delivered to ensure they were safe and their welfare was protected.

Is the service effective?

People's care records we reviewed were inconsistent, and did not always reflect their current needs. This meant that the service could not demonstrate through its records that it took prompt and appropriate action to ensure people received the care they needed.

Is the service caring?

Records we reviewed did not evidence that people were receiving care that met their needs. People's hydration and nutrition records showed that people who needed support to eat and drink had low intakes of food and fluid in the month prior to our inspection. This meant that we could not be assured that people were well supported.

Staff we spoke with had a poor or limited knowledge of people's needs which meant that although their approach was kind they did not understand fully how their needs should be met.

Is the service responsive?

The service had failed to take action where people continued to lose weight and refer them to specialist services such as the dietician.

The service had failed to seek support for people developing pressure areas from specialists such as the district nurse.

Is the service well-led?

There was no effective quality monitoring process in place. This meant that the management of the service was unable to identify risks and put in place measures to protect people.

The management of the service failed to make the necessary improvements to safeguard people from harm. This meant we were not assured that the service was well-led.

We looked at how information in medication administration records and care notes for people living in the service supported the safe handling of their medicines. We found that not all medicines could be accounted for numerically and so we could not be assured people's medicines were being administered as intended by their prescribers. We found there to be evidence that some people did not receive their medicines as scheduled and we found failings and inaccuracies in supporting records which could have led to people not receiving their medicines appropriately and as intended by prescribers. We found people were at risk of accessing external medicines in their rooms with the potential for causing themselves harm. We noted that the competence of staff handling and administering people's medicines had not recently been assessed.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service effective? Is the service well-led?

This is a summary of what we found;

Is it safe?

We found that people were not being protected against the risks of malnutrition, because the service was not taking appropriate action to meet people's needs. We saw that the service was not identifying where people were losing weight and needed to be referred to a dietician.

We found that the service was not taking action to protect people from the risks of developing pressure areas. For example, we found that for six people whose records we reviewed, care planning for the prevention of pressure areas was not being followed by staff.

Care staff working in the service did not have access to sufficient information to provide safe and appropriate care to people. Care planning was not up to date, and for three people whose records we reviewed, did not accurately document their current care needs.

Is the service caring?

We found that staff did not always treat people in a caring and respectful manner. During our inspection we overheard a staff member shouting to another staff member that they were, 'Going to toilet [a person using the service].' This did not promote the dignity of this person. We saw that staff worked in a task orientated manner which did not take into account people's individual needs.

Is the service responsive?

We found that the service did not take prompt action to refer people to other health professionals where appropriate. For example, people using the service who had lost weight were not referred to a dietician in a timely manner, and were therefore put at risk. We also found that where offers of support from external agencies or bodies had been made, these had not been acted on or accepted. This meant that we were not assured that the service was acting in a responsive and communicative way.

Is it effective?

We found that the service did not have an effective process in place to identify issues and put these right to protect people from risk. There were no effective systems in place for auditing the quality of the care delivered to people, and significant failings in this care were not identified prior to the inspection.

Is it well-led?

Between October 2013 and January 2014, the service was issued with three warning notices by The Care Quality Commission (CQC). The management of the service failed to ensure that sufficient improvements were made to the service in order to comply with the terms of these notices. In addition following a meeting with CQC in January 2014 reassurances given about development and timescales for improvements were not adhered to. The management of the service failed to make improvements within a two month period between our inspection visits in April and June 2014. This meant that people continued to be put at significant risk. This told us that the service was not well-led.

We looked at the care records for eleven of the 30 people using the service at the time of our inspection. In addition, we reviewed audit records, staff records, incident records, nutrition records, medication records and staff rotas. We considered our inspection findings to answer five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? and is the service well led?

Below is a summary of what we found during our inspection;

Is the service safe?

We found some care needs assessments had not been reviewed as regularly as required and did not always reflect the actual care being delivered. In one case one person's care records were not available in the service for staff to access or for us to review. This meant that we could not be assured that people were not at risk of receiving unsafe or inappropriate care.

We found records were not available so we could not be assured that staff had received the appropriate training to administer medications safely.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the service was failing to assess people appropriately which meant we were not assured that people's rights were being protected.

We reviewed the staff rotas for the end of February and March 2014. On multiple occasions, the staffing level fell below what the manager told us they had assessed as safe. This meant that we could not be assured there were enough staff to meet people's needs.

Is the service effective?

An audit of the service carried out by the manager in March 2014 failed to identify issues occurring in February 2014 which we picked up during our inspection. This meant this audit was ineffective in identifying and addressing shortfalls in the service people received.

Staff records showed that some staff had not received training in key competencies relating to care. This meant that we could not be assured staff were performing their role effectively.

The service was failing in a number areas which meant that we couldn't be assured that the service is effective.

Is the service caring?

We found that each of the eleven care records we reviewed contained generic information which was not individualised. For people living with dementia, there was no information about their likes, dislikes or past history which could help care staff better understand and engage with them.

Care records we reviewed showed that people's care was not planned and delivered in a way which promoted their dignity and ensured their safety and welfare. These records had not been reviewed and updated as needed, and we could not be assured that people's needs were always being met.

We observed that staff interacted with people in a caring way. However, staff did not always promote people's dignity and confidentiality.

Is the service responsive?

Records showed that people using the service were not always supported to receive input from health professionals in a timely manner. One person, who had a very low weight and body mass index, had been referred to the dietician in January 2014. However, the service had not followed up this referral and the person was still waiting at the time of our inspection.

Given concerns identified at previous inspections the service continued to be unable to demonstrate that it was responding to concerns in a managed and planned way. This meant that people were still at risk of not receiving the care they needed.

Is the service well-led?

The leadership of the service were unable to demonstrate that they had taken the necessary steps to ensure the service met the needs of the people it provided care for. Despite enforcement action being taken the service made no contact with us prior to the inspection to explain any reason for delays or for revising timescales for achieving improvements. For this reason we were not assured that the service was well led.

We found that the service was not taking appropriate action after incidents occurred to ensure the person was protected in the future.

We found that people's risk of malnutrition was still not being assessed adequately by the provider. The provider was not able to provide us with the evidence we requested to assure us that actions were being taken to protect people from the risks of malnutrition and to keep them safe.

Changes in people's health and care needs were on occasions, poorly communicated between staff which resulted in people not seeing a relevant healthcare professional in a timely manner.

The service did not protect people against the risks associated with the unsafe use and management of medication by way of appropriate arrangements for the recording, using and safe administration of medicines.

The required checks on staff before they started working for the provider had been put in place.

We found that some staff had not received up to date training and were not receiving regular, formal supervision.

There was no effective system in place to monitor the quality of the service provided.

A number of separate records in relation to the people who used the service were being kept. Staff demonstrated confusion as to where certain records were being kept. We found that some records were inaccurate and incomplete.

During a previous inspection, we found that the provider was not meeting this standard. We warned the provider and told them that they had to be compliant with this standard by the 20 October 2013. While we found improvements in the arrangements for the management and safe administration of medicines, people were not fully protected against the risks associated with medicines because the provider did not have appropriate arrangements in place for the recording of medicines.

The majority of people who used the service were living with dementia and had limited ability to communicate with us verbally their views of the service. We spoke with two people who told us they were satisfied with the standard of food that was provided. However, they also told us that there was limited choice of meals provided. We also found there was limited snacks and drinks available during the day.

We looked at the care records of eight people who used the service. We found major shortfalls in the assessment, planning and management of risk for people who had a diagnosis of diabetes and those at risk of malnutrition. Following our observations and findings during this inspection we took action and made a referral to the local authority safeguarding team for them to investigate our safeguarding concerns. The overall review of this matter has not been concluded.

We looked at the premises and found the all communal areas including bathrooms to be clean and tidy. We found that the provider had implemented a schedule of cleaning of the premises and equipment.

We looked at the provider's complaints policy. We saw that they had a system in place to receive and respond appropriately to concerns and complaints. Investigations were seen to be thorough and outcomes were recorded.

We observed staff interactions with people and for the most part found the interactions to be positive. However, we observed one incident where one person's request for a drink went ignored by care staff who told us they were too busy to respond.

During this inspection, we spoke with four people who used the service, two care staff and three members of the management team. We found that improvements had been made in some areas.

The people we spoke with were happy with their care. One person said, 'They are getting things sorted.' Another person said, 'I am happy here.'

The provider had conducted a full assessment of the needs of the people who used the service. The risks to people's safety had also been assessed. However, we found that people's medications were not being managed by the service correctly and that therefore, we could not be assured that people were receiving their medication when they needed it or that it was being given in a safe way.

The people who were able to give us their feedback on their care told us that they were happy with the staff. One person said, 'I like the staff.' Another person said, 'The staff are kind, I get on with them well.'

There were enough staff to help people when they required assistance and to spend time with them to meet their social needs and aid their wellbeing. However, the provider did not have effective recruitment procedures in place to ensure that all of the staff employed by the service were of good character and had the necessary skills and qualifications to care for the people who lived at the service.

People's care records were up to date and accurate.

We spoke with five people, one relative and seven staff. One person told us, 'This is a good place, the staff are kind and helpful.' Another person said, 'I am happy here.' A further person told us, 'The care is good, they look after me well.' One person said, 'I tolerate it here.' One relative said, 'X is being cared for ok.'

We saw that people who lived at the service had access to various healthcare professionals such as doctors and district nurses when they needed them. However, some people experienced inappropriate or unsafe care. People's care needs were not always being regularly reviewed. The manager had plans in place to review each person's needs.

The management of medication had improved. However, further improvements are required to ensure that medicines are managed safely.

The number of staff had been increased since the last inspection and plans were in place to recruit more staff however, we saw that there were not always enough staff to assist people in a timely manner.

Some people's care plan records contained inaccurate information and were not always being regularly reviewed. The manager had plans in place to review each person's care plan to ensure that they were accurate.

People gave us their views regarding living at the Dell. One person said, 'It's ok.' Another person told us, 'I like living here, it's nice.' People told us that they were satisfied with how the staff cared for them. One person said, 'On the whole they (the staff) are pretty good.' A relative told us, 'I am happy with the care, the staff are lovely and know my (relative) well.'

However, people told us that there were not always enough staff to meet their needs. One person said, 'When you ring the bell they don't come very quickly.' A relative told us, 'There's not enough staff, they do what they can.'

We looked at the management of medication. We found that this was stored appropriately however, we could not be assured that all medication was being administered as intended by the prescriber.

We looked at three care plans and found that the documentation was inconsistent and that some risk assessments had not been reviewed. This meant that not everyone who lived at the service had risks to their care and welfare regularly assessed.

The service had not always informed the appropriate authorities in relation to safeguarding issues that had occurred.