The Laurels

The Laurels is a residential care home registered to provide care and support to up to 20 people. The building had been adapted and care was provided over two floors with stairs and a stair lift as access. There were 13 people living at the home at the time of inspection.

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

Improvements were needed to the governance within the service. Systems were either not established or effective in identifying the shortfalls found within this inspection. Statutory notifications had not been submitted to CQC as required to ensure we are informed of events that happen with services.

Safety checks were not always carried out as planned to ensure people were living in a safe environment. We raised this immediately with the provider who sought to rectify the shortfall by arranging external professionals and trades people to carry out the checks. Risk assessments were not always in place to ensure people were safe from avoidable harm. Reviews did not take place as planned. We have made a recommendation about risk management within the service.

Accidents and incidents were recorded, and the necessary actions taken. However, analysis was not robust to ensure lessons were learned to prevent reoccurrence of incidents. This meant people could be at increased risk. The Laurels did not actively seek formal feedback from people, their relatives, staff and professionals in order to drive continuous improvements.

We have made a recommendation about recruitment processes; they had not always been followed which meant staff did not always have the necessary checks to ensure they were safe to work with people who required care and support.

People received their medicines as prescribed. However, some improvements were needed to guidance for staff where medicines were taken occasionally and storage arrangements.

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.

Safeguarding procedures were in place and staff knew them well and were confident the provider would take any concerns seriously. Infection control procedures were robust and in line with the latest government guidance for best practice.

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 (published 3 March 2022).

Why we inspected

We received concerns in relation to the management of the home. As a result, 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 good to requires improvement based on the findings of this inspection.

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

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

Enforcement and Recommendations

We have identified breaches in relation to the management oversight in the home and failure to notify CQC of events as required by law at this inspection. We have made a recommendation about the providers recruitment process and risk management within the home.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Laurels is a residential care home registered to provide care and support to up to 20 people. The building had been adapted and care was provided over two floors with stairs and a stair lift as access. There were 11 people living at the home at the time of inspection.

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

Improvements had been made to the governance systems within the home. The provider and registered manager told us they felt confident the management processes within the home were now robust. A range of audits and checks meant there was an opportunity to make continual improvements and learn lessons along the way.

People had risk assessments in place for all of their care and support. Specific COVID-19 risk assessments were in place. Visiting and COVID-19 testing guidance was being followed. Infection control procedures were in place and frequently monitored to ensure they were robust. People and their relatives felt The Laurels was a safe place to be, communication had been consistent throughout the COVID-19 pandemic and this was appreciated.

Staff told us people living in the home were their family and many had worked in the home for a long time. There were enough staff on duty to meet people’s needs and people told us staff were there when needed. People were protected by staff who had training in safeguarding and raising concerns. Staff told us they were confident the provider and registered manager would take concerns seriously.

Medicines were managed safely. Staff, people and their relatives were complimentary about the management of the home. The provider and registered manager were seen as transparent in their approach to keeping people safe and the effective running of the home.

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.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 5 August 2021) and there was a breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We received concerns in relation to visiting the home. As a result, 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.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection. We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well led sections of this full report.

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

Follow up

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

About the service

The Laurels is a residential care home registered to provide care and support to up to 20 people. The building had been adapted and care was provided over two floors with stairs and a stair lift as access. There were 13 people living at the home at the time of inspection.

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

Improvements were needed to the governance systems within the home. The systems for monitoring and checking that the home operates in a safe way were not effective. The registered manager accepted that this was an area for improvement and had started to make plans to improve.

People had risk assessments, but some needed to be more detailed; this had not had a negative impact on people as staff knew them well. The registered manager had started to devise a plan to improve this.

People received their medicines as prescribed. However, improvements were needed to the systems for monitoring the storage of medicines. Recruitment procedures were not as robust as they needed to be to ensure people were safe. We have made a recommendation to the provider about the recruitment of staff.

People and their relatives felt that the home was safe. Staff were confident that people were safe and knew how to identify concerns and what to do if they had them. The home made all necessary referrals to the local authority and the safeguarding teams.

The home had general risk assessments in place to ensure safety within the home. Equipment was checked regularly, and fire safety procedures were in place. The home was clean and tidy and had measures in operation to prevent the spread of infections. Accidents and incidents were recorded and analysed and used to learn.

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 Laurels involved people, their families and staff, using surveys as a way of getting feedback on the care they provide. Everyone we spoke with was complimentary about the registered manager and the provider. Health and social care professionals told us they had a good working relationship with the home and that staff sought their input in an appropriate and timely manner.

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 (published 9 November 2018).

Why we inspected

We received concerns in relation to moving and handling, staffing levels and the management of the home. 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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. You can see what action we have asked 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 The Laurels on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We have identified breaches in relation to the management of the service at this inspection.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

People, staff and visitors to The Laurels were protected from risks of infection as policies and staff practices reflected best practice guidance. Visiting was by appointment and safeguards on arrival included a rapid Covid-19 test, a health questionnaire and provision of appropriate PPE.

The premises and equipment were visibly clean. Cleaning materials were in line with government guidance. Flooring in communal areas had been replaced to enable more effective cleaning to take place. To further protect people new carpets were being fitted into bedrooms prior to a new admission.

People and their families had been kept up to date with government guidance including visiting arrangements, testing and vaccines. Consent for testing, socially isolating and vaccinations had been obtained from people. Families, social workers and health professionals had been involved in best interest decisions for people who lacked mental capacity ensuring their legal rights were upheld. Risks to people’s mental well-being were understood and actions to support them had been assessed to minimise the risk of avoidable infection. Technology had been used to aid contact with families and friends including video calls.

PPE was available throughout the home and in good supply. Regular testing of people and the staff team were being completed in line with government guidance. Staff were up to date with infection, prevention and control training including how to put on and take off PPE safely.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions of safe, effective, responsive and well led to at least good.

The Laurels is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home is registered to accommodate up to 20 people in one adapted building and provides care to older people some of whom are living with dementia. At the time of our inspection 16 people were living in the home. Accommodation is over two floors and access to the first floor is by stairs or a stair chair lift. Rooms on the first floor are not able to accommodate people who need the use of a hoist to support with moving and transferring.

People were supported by staff who understood their role in recognising and reporting signs of abuse. Risks to people had been assessed and were regularly reviewed. Staff understood the actions needed to prevent avoidable harm including prevention of avoidable infection. People had their medicines ordered, stored, administered and disposed of safely including medicines prescribed for as and when required. When people had topical creams prescribed a body map had been completed providing care staff with details of where and how often it should be applied.

Staff recruitment checks included the disclosure and barring service to help ensure they were safe to work with vulnerable adults. Staffing levels met people’s assessed care needs. All staff completed an induction and had on-going training and support that enabled them to carry out their roles effectively. Opportunities for professional development had included national diplomas in health and social care.

People had their care needs and choices assessed prior to admission and these had been used to create person centred care plans that reflected people’s individuality and lifestyle choices. Care plans were reviewed at least monthly and changes to people’s care needs communicated to staff at a daily handover meeting. People had their eating and drinking needs met. Information was shared with the kitchen who produced well balanced meals that provided choice and catered for any special diets. People had access to healthcare whenever needed including emergency and planned appointments. Records showed us that working with other professionals such as nurses, opticians and dieticians had enabled effective, consistent care to people. People had an opportunity to be involved in end of life planning and had their religious and cultural needs 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. A complaints process was in place and people felt if they raised concerns they would be listened to and actions taken.

People had access to areas in the home for private time and a lounge and dining area for socialising. Refurbishments were under way to increase the lounge area and create a more dementia friendly environment for people. People were able to independently access a secure courtyard garden.

Relationships between people and all the staff team were warm, friendly and caring. Staff had a good knowledge of people’s past histories and the family and friends important to them. People had their communication needs understood which meant they were involved in decisions about their day to day lives. People had their dignity, privacy and individualism respected.

The management of the home was visible, open and transparent. Staff felt able to share ideas and felt listened to and appreciated. Teamwork and effective communication provided a positive working environment and staff had a clear understanding of their roles, responsibilities and level of decision making. Opportunities were available for people, their families and staff to be involved and engaged with service development. Feedback had been used to continually develop the service both in respect of people and the environment.

Quality assurance processes and systems had been reviewed and new audit tools implemented that were more effective at monitoring quality and regulatory standards. The staff team worked with other organisations and professionals such as ‘Skills for Care’ to keep up to date with best practice guidance.

The care home accommodates 18 people in one adapted building and specialises in providing care to people living with dementia. Accommodation is over two floors and access to the first floor is by stairs or a stair chair lift. Rooms on the first floor are not able to accommodate people who need the use of a hoist to support with moving and transferring.

The home has 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 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 not protected from risks associated with the prevention and control of infection.

Equipment such as bed rail bumpers were torn and dirty, not all staff were up to date with infection control training and infection control audits were not taking place. Staff involved in food preparation had not all completed food safety training. We found five rooms without hot water.

Environmental risks to people had not always been identified or actioned in a timely way which meant that people with cognitive or sensory impairments were at risk of avoidable harm. The physical environment had not been adapted to meet the needs of people living with a dementia. Signage and props were limited in helping people maintain dignity and independently orientate themselves to time and place. People, their families and staff told us that there was not enough activity and stimulation. We found the service had not been proactive in ensuring links with the wider community. Family and friends were welcomed and information had been collected on people’s likes, interests and hobbies. Organised music and exercise activities took place and in-house games. .

Medicine was not always stored or administered safely. Medicine had been stored in the main kitchen fridge rather than a separate locked medicine fridge. Protocols were not in place for medicines that had been prescribed for as and when needed. Topical creams were in people’s rooms and administered by care staff but there was no supporting documentation to ensure the creams had been applied to the right place and to the right frequency.

Statutory notifications had not been made to CQC. A statutory notification is a legal requirement for the provider to inform CQC of certain situations as part of their oversight of care provision. Records relating to staff and people using the service had not always been stored securely. The registered manager had not kept their knowledge up to date or had robust quality monitoring systems in place to ensure regulations were being met.

A complaints log had been maintained by the registered manager but actions had not always been completed. A complaints policy was in place that people and their families were aware of and felt able to use.

People and their families described the care as safe and were supported by staff that had been trained to recognise signs of abuse and knew what to do if abuse was suspected. People were protected from discrimination as staff had completed equality and diversity training. People were supported by enough staff to keep them safe and who had been recruited safely including checks to ensure their suitability to work with vulnerable people. Staff had received an induction but were not always up to date with on-going training such as infection control and food safety. Staff felt supported through supervision and had opportunities for professional development.

People had individual care and support plans that explained how they liked to be supported and included information about their health, how they liked to communicate and emergency details. Risk assessments had been completed and included falls, skin damage, malnutrition and mental health and actions had been put in place to minimise any identified risks. Reviews took place weekly and an on-going action plan was shared with staff to keep them up to date and aid learning and development. People were involved in decisions about their care and when they were assessed as not having the capacity to make specific decisions these were made in their best interest within the framework of the Mental Capacity Act. People had access to healthcare when needed.

People described staff as kind, caring and felt their dignity and privacy was respected. They were encouraged to express their views and be involved in decisions about their day to day lives. People’s individual communication needs were understood and when needed an independent advocate could be accessed.

People, their families and staff described an open culture that empowered them to share ideas and raise concerns. Staff felt listened to and felt able to share their views on service development. Positive relationships had been developed with health and social care professionals.

We have made a recommendation that the service consider NICE guidance on dementia friendly care home environments or similar professional guidance when reviewing decorations and adaptations to the home. Also we recommended the service consider NICE guidance on improving the mental wellbeing of older people with a dementia living in care homes or other professional guidance when reviewing activities.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The service is registered to provide accommodation and personal care for up to 20 people. At the time of our inspection there were 15 people living at the service.

The service provides care to older people living with a dementia. Accommodation is provided in single rooms although one room has the capacity to be used as double room. All the rooms had a hand wash basin and two had an ensuite toilet. Bedrooms were on the ground and first floors. They were accessed by two staircases both of which hada stair lift. There were three rooms on the ground floor that could accommodate a hoist. All other roomswere only suitable for people who can walk independently. There was one working shower room and a bathroom. The bathroom was not being used as the hoist was out of action. A second shower room was being installed at the time of our inspection.

Communal areas included a lounge with access onto a small rear patio garden and a dining room. There was a well equipped kitchen area and an on site laundry.

The home is required to have 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 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 the service was not always well led. The service had not had a registered manager to lead the home for over two years. The service had not notified us of the absence of a registered manager. Systems were not in place to enable the service to gather the views of people, the families and other stakeholders about the quality of service being provided. Resident and relative meetings were not being held.

Staff felt listened to and involved in the service. Managers and staff communicated together in a professional and friendly manner. Managers had a good knowledge of people, their families and the staff team. Staff understood their roles and responsibilities.

Audits were being carried out by the manager. They included care plans, medication and health and safety audits. Audits clearly identified actions needed where shortfalls where identified and the final outcomes. Audit results and outcomes were shared with staff.

Notifications were not always sent to CQC in a timely manner. A notification is the action that a provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them.

We found that the service was safe. Staff had completed safeguarding training. They understood how to look for signs of abuse and actions they needed to take if they suspected abuse. Staff were aware of the services whistleblowing policy.

People were protected from harm because risk assessments had been completed and included actions needed to reduce any identified risk. Reviews of risk assessements included there effectiveness. Accidents and incidents had been recorded and reviewed by the manager. Potential hazards in the environment had been identified and risk assessments had been completed.

Staff had completed fire safety training. Regular checks had been carried out on equipment and a weekly fire alarm test had been completed. Each person had a personal fire evacuation plan in place. The service had an emergency contingency plan in place in the event of a major incident and the building needed to be evacuated.

There were enough staff to support people. Staff were able to respond to requests for assistance in a timely way. We observed staff regularly checking people in their rooms and providing supervision to people in the communal lounges. We looked at two staff files and checked recruitment practice. Files contained evidence that references and a criminal record check had been completed. Checks reduce the risk of staff not being suitable to work with vulnerable people.

The service employed agency staff. A profile had not been provided. We discussed with the manager who told us it was the person’s first shift and had been arranged as an emergency. They contacted the agency and obtained a profile.

People received their medicines safely as they were prescribed. Any medicines administered had been recorded on a medicine administration record (MAR). Medicines were stored in a locked trolley. Controlled drugs were stored in a separate locked wall cupboard in line with legislation. One person had their medicines administered covertly. They were administered in line with the services medicines policy. Peoples creams and sprays that had been opened were dated and in date for safe use.

We found that the service was effective. People were supported by staff who had received the right training to ensure that they had the skills to support people effectively.. Agency staff had been supported with an induction on their first shift which included reading people’s care plans.

Staff had regular supervision. This included formal supervision and observational checks of competencies of the day and night shift staff. Staff meetings were held quarterly.

We found the service was working within the principles of the Mental Capacity Act (MCA). We saw evidence of best interest decisions where people had not had the capacity to consent.

People were able to take their meals in the dining room, lounge or their rooms. The food looked appetising and people were offered choices. The cook who had a good knowledge of people’s likes and dislikes and any special diets. People had their weight monitored regularly and any changes were reviewed by the manager with actions recorded in care plans.

People had good access to healthcare.

We walked around the home and looked at the environment. We could see that some areas had been refurbished but other areas were in need of maintenance work. The manager had completed a maintenance audit and prioritised actions. Plans included new water tanks, electricity board, and decorating lounge areas.

We found that the service was caring. We spoke with staff who had a good knowledge of people, their families and important events in their lives. People were being offered choices and being involved in decisions about how they would like to spend their day, what meal they would like and where they would like to sit. People had not been given information about advocacy services. People had their dignity respected. Staff supported people to maintain a level of independence.

We observed staff interacting with people in an unhurried way. Staff were attentive to people’s needs, spent time listening to what people were saying and giving them their full attention. Conversation between people and staff at times was light-hearted and fun.

We found the service responsive. Staff had a good understanding of what peoples care needs were and what they needed to do to support people.

Care plans and risk assessments were reviewed monthly and shared with families and care staff.

People took part in a wide range of activities. They had included individual activites such as hand massage, nail care, foot rubs and watching a cookery programme. Group activities had included singers, quizzes and films

Relatives told us that they felt staff listened to them. The service had a complaints policy and had a log for recording formal written complaints. The log contained no formal complaints for the past year. We discussed with the manager that a record of verbal concerns raised would be helpful in supporting their formal complaints process.

We used a number of different methods to help us understand the experiences of people using the service. This was because due to people's mental frailty some people were not always able to tell us about their experiences.

One person told us "I am happy here, the food is good and I have no complaints at all".

People were provided with a healthy and nutritious diet and were encouraged to help set up the dining room area.

One relative told us "There is such a warm and homely atmosphere, it's great". And another relative told us "staff are amazing, they do a great job".

We observed the atmosphere in the home it was relaxed and calm. People were cared for in a respectful and dignified way.

People who lived in the home were seen listening to music, playing bingo and chatting to each other. People appeared happy and relaxed in the home.

People's bedrooms were clean and hygienic and personalised to meet people's individual needs. People's bedrooms had individualised door plaques displayed and during our visit we saw that communal areas had signs placed up to support people that used the service to identify the different rooms within the home.

Staff had a good understanding of people's needs and were observed supporting people in a sensitive and respectful manner.