This inspection took place on 14 and 15 March 2017 and was unannounced.Larkhill Hall is a purpose built three storey residential care home in north Liverpool, providing specialist services for up to 66 people living with dementia. During the inspection, there were 64 people living in the home.
There was no registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had commenced in post in September 2016 and was in the process of registering with CQC.
Records showed that not all staff had completed recent training in relation to safe medicine administration and not all staff had had their competency assessed each year. Since the inspection the manager has confirmed that all staff who administer medicines has had a competency assessment completed.
We found that medicines were not always stored safely. Medicines were stored in two clinic rooms within the home; however they were not always secure. We observed one clinic room door to be unlocked during the inspection and on another floor, we observed keys to the clinic room to be left unattended in a dining room. We found that records regarding administration of medicines were not always accurate and there were gaps in the recording of medicines that had been administered.
The care files we looked at showed staff had completed risk assessments to assess and monitor people’s health and safety. Most were completed accurately and reviewed regularly. We found however, that not all assessments reflected people’s needs accurately.
We looked at the environment and found that risks to people were not always minimised. For instance, we observed unlocked bathroom cupboards which contained creams and razors. The manager rectified these issues straight away. A fire risk assessment of the building was in place and regular internal checks of the environment were completed, as well as external contracts to ensure the building was properly maintained.
People told us they felt safe living in Larkhill Hall and their relatives agreed. Staff were aware of safeguarding procedures and how to report any concerns they had.
We looked at how the home was staffed. Prior to the inspection we had received concerns regarding staffing levels within the home. We had written to the provider regarding this and they told us a number of new staff were being recruited. We found that a number of care staff had commenced earlier in the week and were now in post. Our observations showed us that there were sufficient staff on duty and people we spoke with agreed.
We found that safe recruitment procedures were followed.
Records showed that applications to deprive people of their liberty had been made appropriately.
The principles of the Mental Capacity Act were not always adhered to when seeking and recording people’s consent to their care and treatment. For example, one person's care file contained consent that was signed for by a relative who did not have the legal authority to provide consent on the person's behalf and there was also no evidence that the person lacked capacity to consent themselves.
Staff were provided with an induction that reflected the requirements of the care certificate when they started in post. All of the staff we spoke with told us they received regular supervision and records we viewed reflected this. There was however, no evidence that annual appraisals had taken place for all staff, although the manager had taken steps to address this. Training records showed that staff had completed training in a variety of areas, however not all staff had completed training that the provider considered mandatory, such as safeguarding.
A fire risk assessment dated July 2016 identified that staff required fire marshal training, however the manager told us that this training had not yet been completed. Since the inspection the manager has told us that head office are arranging this training for all senior carers, so that one staff member will be trained on each floor at all times.
People at the home were supported by the staff and external health care professionals to maintain their health and wellbeing. A visiting health professional told us that they received relevant and timely referrals from staff at the home and that any health advice they gave, was always followed by staff.
When asked about the food available, people told us they enjoyed it. We found that people had easy access to snacks and drinks throughout the day. People were offered a choice of meal and food was served hot and presented well. Staff were available to support people when required and this was done in a discreet way and people were not rushed with their meals. All staff we spoke with were aware of people’s dietary needs and preferences and this information was also available in the kitchen.
We observed the environment of the home and found that although the manager had taken some steps towards the environment being appropriate to assist people living with dementia with orientation and safety, this could be further developed.
People living at Larkhill Hall told us staff were kind and caring and treated them with respect. We observed positive and kind interactions between people living in the home and staff members during the inspection. We saw people’s dignity and privacy being respected by staff in a number of ways and staff described how they protected people’s dignity and privacy when providing care. One person however described care that was not provided in a dignified way.
Records containing people’s personal information were not always stored securely to ensure confidentiality was maintained.
Care plans we viewed were written in such a way as to promote choice and independence. Staff we spoke with told us they were aware of the importance of people maintaining as much independence as possible.
We observed relatives visiting throughout both days of the inspection. The manager told us there were no restrictions in visiting, encouraging relationships to be maintained. For people who had no family or friends to represent them, contact details for a local advocacy service were available.
We found that there was a variation in the quality of person centred information within care files we viewed. For instance, one person’s care file contained information regarding the person’s preferences in relation to their care and this helped staff get to know the person and provide care and support based on their preferences. Another care file however, contained little information that was specific to the individual and their needs. There was no evidence that people or their families had been involved in the creation or reviews of care plans.
People told us they were not always happy with the laundry system and records showed that these concerns had been raised with the manager. One relative told us their family member regularly had clothes go missing and that they had no socks on the day of the inspection as they were all in the laundry. The manager told us they had received complaints regarding the laundry and had recently increased staffing numbers so that dedicated laundry staff were on duty each day.
Staff we spoke with demonstrated a good knowledge of people’s individual care, their needs, choices and preferences.
There was no activities coordinator employed, but all staff were responsible for providing activities on a daily basis and a Programme of activities was in place. The manager also told us that external entertainers visited the home three times per week. People we spoke with were satisfied with the activities available and we were told that the home also arranged trips and outings to local places of interest. One person living in the home told us they were supported to attend a local church service and that a priest also visited the home and offered people communion.
Systems were in place to gather feedback regarding the service and listen to people’s views, such as resident meetings and regular quality assurance questionnaires.
People had access to a complaints procedure and this was displayed within the home. The manager maintained a log of all complaints received and we found that those we viewed had been dealt with appropriately and in line with the provider’s policy.
Systems were in place to monitor and assess the quality and safety of the service. We found however, that not all identified actions had been addressed. Although the manager was aware of some of the issues we identified during the inspection, the governance systems in place had not highlighted all of the issues we identified during the inspection. This meant that systems in place to monitor the quality and safety of the service were ineffective.
We asked people their views of how the home was managed and feedback was positive.
Staff were aware of the home’s whistle blowing policy and told us they would not hesitate to raise any concerns they had. A range of policies and procedures were in place to help guide staff in their role and ensure they were clear of their responsibilities and aware of the culture of the service.
The manager had notified CQC of events and incidents that occurred in the home in accordance with our statutory notifications. This meant that CQC were able to monitor information and risks regarding Larkhill Hall.
You can see what actions we have told the provider to take at the back of the full version of this report.