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The Holmes Care Limited Requires improvement

Reports


Inspection carried out on 19 October 2017

During a routine inspection

The inspection was unannounced and took place on 19 October 2017. We then arranged to return on the 26 October 2017 to complete the inspection. Prior to the inspection the relatives of one person had raised concerns about care at the home and the inspection followed up on these concerns and we also discussed the information with partner agencies. We last inspected The Sycamores on 22 May 2017, looking at whether the service was safe, which we rated as good.

The home is registered to provide accommodation and personal care, and the treatment of disease, disorder or injury for a maximum of 84 people. There were 78 people living at the home on the day of the inspection. The home is split across three floors comprising a nursing unit, a unit for people living with dementia and a residential unit.

The registered manager left the home in March 2017 and a new manager was appointed. The new manager has applied to CQC to become the 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 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 that people’s medicines were not always available and administered to them as prescribed to meet their health needs. Medicines for four people had been out of stock for a period of four days and action had not been taken to seek advice from a GP or make observations to assess the potential risk to the people concerned.

People told us that they felt safe and they were supported by staff who knew how to keep people safe from harm but they sometimes had to wait for support. Staffing arrangements need to ensure there were enough staff who were organised in the right way to meet people’s needs effectively.

Staff had a good understanding of protecting people from the risk of abuse and harm and knew their responsibility to report any concerns.

The principles of the MCA had not been consistently applied. Staff spoken to had limited knowledge of the MCA and how this impacted on the care provided to people. Systems for reviewing DoLS applications had not identified actions required.

Staff understood people’s individual care needs and had received training so they would be able to care for people living in the home. There were good links with health and social care professionals and staff sought and acted upon advice received, so people’s needs were met.

People’s nutritional needs were met. People were given a choice of meals, however they felt the quality of the food they received could be improved. The manager was working with staff to improve people’s dining experience.

People liked some of the staff who cared for them, however care was not provided in a person centred way. Care provided was task focussed and people were not always treated with dignity and respect.

People’s access to activities and support varied across the homes three units. We found improvements were needed to support people living with dementia. Relatives said they would like more dementia appropriate activities as there was little for their family members to do and our observations supported this.

Relatives told us communication was good and they were updated on any changes in their family member’s health. The manager had introduced new meetings and records which staff told us had improved communication within the staff group. People felt able to raise concerns; however they did not feel actions were always taken in response.

The provider had systems in place to check and improve the quality of the service but these had not been effective in identifying the concerns that we found at our inspection. Audits need to be developed further to ensure that actions had been applied in practice to improve standards of people’s care.

The new manager had made some improvements, for example, daily management meetings and a new handover process, but further action was required to ensure that changes were embedded and also further improvements made in a timely way.

You can see what actions we told the provider to take at the back of the full version of this report.

Inspection carried out on 22 May 2017

During an inspection to make sure that the improvements required had been made

We last carried out a comprehensive inspection at this service on 09 March 2016. The inspection was unannounced and we rated the service as providing a good service to people. After that we received concerns in relation to the safety of the service being provided. As a result we undertook a focused inspection to look into those concerns on 22 May 2017.

This report only covers our findings in relation to the concerns raised with us about people’s daily routines, the call bells not been answered in a timely manner and there being an unpleasant odour in the home. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘The Sycamores Nursing Home’ on our website at www.cqc.org.uk’

The Sycamores Nursing Home is a purpose built home providing personal and nursing care for up to 84 people. The home is in three discrete units on separate floors and supports people with learning and/or physical disabilities, people with nursing needs and people needing care because of mental health needs such as dementia. At the time of our inspection there were 73 people living in the home.

At the time of our inspection there was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People received support that was safe, met their needs and promoted choices. People were able to make the choice when they got up and when they wanted to go back to bed, this included returning to bed in the afternoon if they chose. People were able to choose where they ate their meals and people were supported to eat meals which met their nutritional needs and preferences

Staff responded to the call bell in a timely manner but we saw that on some occasions staff did not always attend people’s bedrooms when they accepted the call. People told us that the staff were excellent and responded to their requests for help in a timely manner but understood that on occasions they may have to wait a short while.

The home was clean and there were no unpleasant odours evident.

Inspection carried out on 9 March 2016

During a routine inspection

Our inspection took place on 9 and 11 March 2106 and was unannounced. We last inspected the service on 19 and 25 March 2015. At the last inspection we identified the provider needed to take action to improve in a number of areas, this was to ensure medicines were well managed, that people were protected from the risk of infections, that people’s consent was obtained in respect of their care and that people were always treated with dignity and respect. We found that the provider had made improvements in these areas and had addressed the breaches of regulation we had previously identified.

The Sycamores is a purpose built home providing personal and nursing care for up to 84 people. The home is in three distinct units on separate floors. Oak, the ground floor unit accommodates people with learning and/or physical disabilities. Ash and Elm, the middle and top floor units accommodate older people, Elm catering for older people living with dementia. People that need nursing care are accommodated on Oak and Ash units.

There was a registered manager in post at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People felt safe and well treated by staff. There was sufficient staff available to keep people safe. Staff were able to identify signs of abuse and knew when and how to raise concerns. People had their medicines when needed. Appropriate checks on staff ensured they were safe to work at the service. Individual risks to people were identified and staff were knowledgeable about these.

People’s rights were promoted, and their best interests considered. People had confidence in staff who they felt were skilled and competent. People had a choice of, and enjoyed the food and drinks that were available to them. People’s health care needs were promoted.

People felt staff were kind and caring. Staff showed people respect and ensured their privacy was maintained. People’s choices were recognised and promoted by staff who supported them to make these choices. People were supported to be independent by staff.

People were involved in the care and support they received. Staff demonstrated a good awareness of people’s individual needs and preferences. People were able to have involvement in daily pastimes they enjoyed and were supported by staff with these. People were able to complain and were confident issues raised would be addressed.

People and staff were able to approach managers, who listened to what people said. There were systems in place to capture and respond to people’s views so as to monitor and improve the quality of the service. Staff felt well supported, enjoyed their work and supported the provider’s improvement agenda.

Inspection carried out on 19 and 25 March 2015

During a routine inspection

We inspected the Sycamores Nursing Home on 19 and 25 March 2015. The inspection was unannounced. At our previous inspection on 2 April 2014 we found that the service was not meeting the law in respect of ensuring people’s privacy and dignity was respected. We checked to see if the provider had addressed this breach. We found the provider had not ensured that the actions they had taken were robust enough to ensure that people were consistently respected and their dignity upheld.

The Sycamores is a purpose built home providing personal and nursing care for up to 84 people. The home is in three distinct units on separate floors. Oak, the ground floor unit accommodates people with learning and/or physical disabilities. Ash and Elm, the middle and top floor units accommodate older people, Elm catering for older people living with dementia. People that need nursing care are accommodated on Oak and Ash units.

The service did not have a registered manager at the time of the inspection. 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.

The provider had not ensured the service was always safe. We found people were not always protected from the unsafe use of medicines. We found checks to ensure medicine was managed and kept safely were not always in place. In addition staff did not always follow infection control practices that promoted people’s safety. Systems for ensuring effective infection control needed improvement. People told us that they felt safe however and the staff were aware of, and knew how to report potential abuse. Where abuse had been identified by the provider this had been reported appropriately.

The provider did not ensure that people’s consent was always sought and that safeguards were in place to protect their human rights when they may be restricted.

People told us staff responded quickly when called but we did see some occasions on Elm unit where staff responses were delayed, this mostly at meal times. People said they liked their meals though, and had a choice of foods. We saw the provider offered appropriate foods for people of differing cultural backgrounds.

We found that while people’s health care needs were monitored and reviewed there were occasions where the advice from external health care professionals was not followed.

The provider had systems to ensure staff training was monitored but the practice and knowledge of some of the staff indicated that training may not always be effective. Some staff told us that they did not feel well supported by management.

The provider had not ensured that staff always ensured that people were consistently cared for in a way that ensured they were respected. We saw staff did not always explain the care they provided to people. While we saw some staff providing care that was considerate of people’s views and respectful this was not consistent. We saw some people were involved in planning their care although we saw others were not asked their choice at the point care was provided. Information on making complaints, to capture people’s views, was available but complaints raised were not always responded to so that people would be reassured their views were taken seriously.

The service had been run by various acting or senior managers over the last five years, with the manager only registered with us following this inspection. This had led to the provider not ensuring the service was managed in a way that has provided consistency and promoted strategies to consistently minimise risks to people. Systems for checking the quality of the service were in place but these had not always been effective in identifying and managing risks to people. Most people told us that they liked living at the home and felt well cared for and safe however.

We found breaches in respect of the safe management of medicines, safe care and treatment, consent to care and dignity and respect. This meant that the law about how people should be cared for was not met. You can see what action we told the provider to take at the back of the full version of this report.

Inspection carried out on 4 February 2014

During a routine inspection

We spoke with 15 people across the three units, four visitors, one visiting health professional, five members of staff and the manager. We also looked at seven people’s records as well as other records that supported the running of the home.

People expressed conflicting views about how they were involved in planning their care and treatment, and how their dignity was promoted. One person told us, “Most of what I want, I get. It suits me. There are little gripes, nothing much, just the odd thing”. Another person said, “Staff do not always tell me, I wanted to know about activities”.

We found that care and support was planned and delivered in a way that was intended to ensure people's safety and welfare. Most people we spoke with expressed satisfaction with the care provided, although some people said the care they received may vary dependent on the staff providing it.

We found that people who used the service were protected from the risk of abuse, because the provider had systems in place to identify the possibility of abuse and ensure it was reported.

There were enough qualified, skilled and experienced staff to meet people’s needs although people had differing views about whether there was sufficient staff available. One person told us, "I use my buzzer a lot if I want anything. Sometimes they come, other times if busy they take a bit longer”.

We saw the provider had systems in place to assess and monitor the quality of service.

Inspection carried out on 12 September 2012

During an inspection to make sure that the improvements required had been made

At our previous inspection in July 2012 we were concerned that people were at risk of receiving care or treatment that was inappropriate or unsafe. This was due to poor care records and a lack of assessment or provision for people’s specific or cultural nutritional needs. There was also poor medicine handling, storage; recording and monitoring might have resulted in people not being fully protected against the risks associated with medicines.

At this inspection we found that care people received was well reflected in their care records and staff we spoke with were aware of what people's needs were. This meant that the risk of people receiving unsafe care that did not meet their needs was reduced.

We spoke with one person who told us that they “get choice” and if “don’t get the care I tell them and its sorted”. Another said “they (the staff) care for us”.

We found that more choice of Jamaican meals were available. One person told us “the food is very tasty”. Another person told us they were also happier now Jamaican meals were available. We saw that people with swallowing difficulties had been assessed by speech therapists and their advice was followed by staff. This meant that people received support they needed.

We found that people were protected against the risks associated with medicines. We saw there was an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service.

Inspection carried out on 20 June 2012

During an inspection to make sure that the improvements required had been made

We visited The Sycamores on 20 June 2012 to check on improvements the provider had made after we raised concerns following our inspection in January 2012. We looked at all the information that we had received since our last inspection prior to this visit.

We spoke with five people living at the home, and one relative and six staff. We looked at six people’s care records and other records related to the running of the home. The inspection team also included one of our pharmacy inspectors. We also used the Short Observational Framework for Inspection

(SOFI). This is a specific way of observing care to help us understand the experience of people who could not talk to us.

One person told us that they “love the staff” and they respected their privacy. They showed us the key they had to their bedroom door and said that staff always knock before coming in. Two people said staff responded when they used the call system to summon staff. From our observations of the care provided we saw that staff were responsive to people’s needs. We saw that staff provided people with positive support. Staff were seen to spend time stimulating people, encouraging them to eat, drink and conversing with them. Some told us that staff respected their privacy and one said that they were helped to go to bed when they wished. We heard “It’s quite alright I love it” and that the staff were “Chatty and friendly”.

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We looked at six people’s care records and where possible spoke to people and staff about these. Three we found reflected the needs and support that people told us about. The other three care plans we looked at did not provide sufficient information to support staff understanding of people’s care, treatment and required support needs. We spoke with a unit manager and two care staff who confirmed it could be difficult to access essential information from care plans.

We spoke with five people who use the service about the meals provided who gave us conflicting information. For example, one person confirmed their satisfaction with the meals provided. However, three people told us that the home’s menu did not reflect their cultural dietary needs. We also found that where people experienced difficulties with swallowing, the home had not taken appropriate action to make a referral to the necessary healthcare professional, such as a dietician or speech and language therapist (SALT)

One person we spoke with told us how staff had taken action to protect them from abuse. They told us they were surprised how quick the matter they had reported was dealt with and that they felt safer living at the home as a result.

Whilst we saw that the home had improved the monitoring of the service, there were areas where these systems were not always fully effective in protecting people against risks of unsafe care and treatment. We looked at the management of people’s medicines and found that this remained unsafe and continued to place people at risk.

Inspection carried out on 21 February 2012

During an inspection to make sure that the improvements required had been made

We spoke with people living at The Sycamores, staff working there and the home’s manager. There has been significant change at the home over the last few months with the previous manager leaving and a new manager being appointed. Changes to systems, staffing arrangements and paperwork have been introduced, some in response to our reviews of compliance in 2011. People told us that they were unhappy with some of the changes and felt that they had not had opportunity to contribute to discussions about change or been able to contribute or influence improvements in the home. Processes which might have assisted in the change process such as meetings and individual supervision sessions had not been put in place.

Most of the people we spoke with during our visit said that they were satisfied with the accommodation, the staff and the food at The Sycamores. Some people expressed unhappiness with changes to the staff teams caring for them. Comments made by people living at The Sycamores included “I like it here”; “I feel safe here” and that staff would “do anything for anyone”. People generally told us that they received the care that they needed.

We have heard from people that have contacted us prior to and after our visits that some people are concerned about the safety of some practices at the home. People told us about poor management of people’s medication that resulted in risks to their safety. Our pharmacist inspector visited The Sycamores and found that people are not fully protected against the risks associated with the unsafe use and management of medicines.

We have also heard from people and Wolverhampton Social Services that there are a number of concerns surrounding people’s safety. These are being investigated by Wolverhampton Social Services. We have not received any information from the service as to any allegations of abuse or concerns.

The manager explained the way that they monitor the quality of the home. We saw that checks are being made. The provider’s operations manager also confirmed that there is a comprehensive audit system in place for 2012. It remains however that further work is required to ensure the effective and safe running of the home.

Inspection carried out on 7 October 2011

During a routine inspection

We spoke with a number of people who live at the home about the support staff provide them, and they told us that this is provided in accordance with their needs. They told us that “Here they are ever so nice, if you’re in trouble they will help you out”, “If need help they get it me – they’re good” and “Staff come to you, can’t grumble at the home”, “Home is lovely, staff are alright”.

People told us that they were aware of their care plans and where they were unable to consent this was managed through relatives doing so with their permission.

People also told us about how staff had followed up on their health care needs and one individual told us that their G.P. was changed at their request.

A person whose first language was not English told us that staff had explained their care plan to them and they had agreed this. We heard that staff that could speak their first language were available at the home. The staff told us that the staffing is managed so that there were bilingual staff available at any time. The person told us that their religious and cultural needs are met with staff careful not to disturb them at times of prayer (as we saw detailed in directions for staff). There was not a copy of a care plan for this individual in their first language though. The person told us that they would like this to be available, as with other key information about the home.

We asked people about how quickly staff responded to requests for assistance and they told us that they were fairly prompt. People also told us that they are aware that staff check on them at night. They also told us that they were generally able to follow their preferred routines, such as getting up and going to bed when they choose.

People also said that they have a choice of foods and can have different meals on request. We observed people having their lunch and saw appropriate assistance provided by staff, with the pace of assistance matching the speed at which people were eating. This was accompanied by verbal prompts from staff when offering food.

We spoke to people as to whether they felt safe at the Sycamores and they told us that they did. People said “I feel homely have no problems”, “Do talk to the nurse if problem, staff sort things out” “Go to office if problem and resolved” and “Feel safe nothing wrong”. We have heard comment to the fact the manager did not respond to concerns raised by one relative. They said that the manager promised to investigate and did not feedback to the complainant.

Some of the people we spoke to were aware of how to raise concerns and one told us that they would go to social services if they had concerns about their safety. Another person said that they would not stop at the home if they felt unsafe or were unhappy with the service. A person, whose first language was not English, did tell us they would like to see information about such as complaints in their first language, although said staff do explain things to them.

We spoke with some people about forms of restriction that are used to promote their safety and they told us that they have agreed to these, and feel safer with them. An example of such restriction was bed rails.

People told us that staff do assist them fairly quickly when requested and they are able to follow their chosen routines. We saw through our visit that people were able to move around their living areas freely.

Despite more positive outcomes we have heard of a number of recent allegations in respect of people’s care and welfare, and therefore safety. At the point this review was completed the outcome from these has yet to be determined by the investigating authority, although two safeguarding alerts from earlier in the year in respect of neglect have been substantiated.

We heard that there has been recognition of some areas where improvement is needed, with plans identified to reorganise staffing so that activities can be better provided across all the floors/units within the home.

Inspection carried out on 16 June 2011

During an inspection in response to concerns

Not all of the people we spoke with were able to fully voice their opinions of the service they received. We spoke with three people and a visiting relative.

People who we spoke with told us that the staff were very kind and they liked the staff who supported them. Some people told us that they enjoyed the food, other people commented on the unit being ‘very clean’.

A relative was very positive about the care her mother received. She said she was always kept well informed about her mothers changing health needs. She described staff as approachable and particularly good in promoting a good diet. She said staff were patient and offered meals that were smaller and liked by her mother to encourage her to eat, she also informed us that nutritional supplements had been sought to help her mother with a good intake. Staff had recently supported her mother to complete her medication to overcome an infection. She told us her mother always looked nice and well cared for.

Staff told us they feel they operate as ‘three separate units’. They said the daily handover between shifts is now a ‘clipper board ‘ with the names of people and comments such as ‘fine’ or where there is a concern this is recorded as ‘see care file’. Staff said that there is no verbal handover or a discussion of individual needs, or concerns. They felt this affected how well they understood the needs of people because they were not discussing them as a team.Some staff said they had not had regular meetings with managers to develop their care practice. Some staff said they had not had a staff meeting for the whole service in a long time and were not kept up to date with events. Other professionals who had visited The Sycamores Nursing Home have commented that there appears to be issues with regards to management and communication.

There are three ongoing safeguarding matters. These all relate to staff not recognising deteriorating health, seeking appropriate medical intervention, and the management of pain. This information raises serious concerns about the ability and competence of staff to recognise, respond to and protect people from unnecessary risks to their health and wellbeing, and to take the necessary action to report such incidents.

Organisation Review of Compliance