Archived: Bon Accord

Bon Accord 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.

Bon Accord is a nursing home providing accommodation for people who are living with dementia and who may require support with their nursing and personal care needs. Bon Accord is registered to accommodate 41 people. Some of the rooms were designed as shared rooms; however, rooms had been converted and were now single occupancy. This meant that the home could accommodate a maximum of 33 people. There were 26 people living at the home at the time of the inspection. The home is a large detached property situated in Hove, East Sussex. It has three communal lounges, two dining rooms and communal gardens.

There was 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.

At our last inspection in November 2017, the service was rated requires improvement. This was because the service was not at full occupancy and the provider could not demonstrate that existing staffing levels could be maintained if occupancy increased. We found that the provider was not always working in accordance with legislative requirements in relation to gaining consent. We also found that the provider had not always considered and recorded peoples end of life wishes. At this inspection on 6 and 7 November 2018 we found that the management team had taken steps to improve these areas. The overall rating for the service has improved to Good.

People, their relatives and staff spoke positively of the improvements made to the governance of the service. Quality assurance and information governance systems were in place to monitor the quality and safety of the service. Staff worked well together and were aware of their roles and responsibilities.

People and their relatives told us they had trust in the staff and felt safe and secure living at Bon Accord. Staff showed a good awareness of safeguarding procedures and knew who to inform if they saw or had an allegation of abuse reported to them. The registered manager was also aware of their responsibility to liaise with the local authority if safeguarding concerns were raised.

Staff remained kind and caring and had developed good relationships with people. People's privacy was respected and staff supported people to be as independent as possible. People were involved in making decisions about their care.

Risks relating to people's care were reduced as the provider assessed and managed risks effectively. People were encouraged to be as independent as possible. There were effective infection prevention and control measures in place.

People's medicines were managed safely by staff. People were supported by staff who had been assessed as suitable to work with them. Staff had been trained effectively to have the right skills and knowledge to be able to meet people's assessed needs. Staff were supported through observations, supervisions and appraisals to help them understand their role. The provider had ensured that there were enough staff to care for people.

People continued to receive care in line with the Mental Capacity Act 2005 and staff received training on the Act to help them understand their responsibilities in relation to it. People’s capacity to make decisions had been carefully assessed. 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.

People’s needs continued to be assessed and person-centred care plans were developed, to identify what care and support was required. People received personalised care that was responsive to their needs. People received compassionate support from staff at the end of their lives and staff were proactive in recording people’s wishes.

People were encouraged to live healthy lives and received food of their choice. People received support with their day to day healthcare needs and were encouraged to live healthier lives.

People were informed of how to complain and the provider responded to complaints appropriately. The provider communicated openly with people and staff. Staff worked closely with professionals and outside agencies to ensure joined-up support.

Managers and staff learnt from feedback and took action to improve service delivery following incidents, accidents and audits.

The home is owned by Four Seasons (No9) Limited, which is part of a large, national corporate provider called Four Seasons. Four Seasons (No9) Limited own a further three care homes in England. At the previous inspection on 31 May and 7 June 2017, a manager and a deputy manager from one of the providers’ other services had been in day-to-day management of the home. The manager was going to apply to become the registered manager. However, at this inspection, the manager had left employment and the deputy manager was in day-to-day management of the home. In addition, the regional manager and a member of the providers’ quality team visited the home twice a week to ensure that there was appropriate support and governance in place until a new registered manager was found. The provider was in the process of trying to recruit to the post of registered manager. However, the home had been without a registered manager for nine months. A registered manager is a ‘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 home is run.

At the previous inspection on 31 May and 7 June 2017 the home received a rating of ‘Inadequate’. This home has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this home is now out of Special Measures.

At this inspection the provider was found to have met the previous breaches of regulations, however, continued improvements were needed to sustain and embed the improvements that had been made. Although the management of risk had improved and people were receiving appropriate support to maintain their health and well-being, further improvements need to be made to ensure that all risks, specific to peoples’ lifestyles, are managed effectively. People were asked their consent and were able to make decisions about their care. When people had a condition that affected their ability to give their consent, mental capacity assessments had been completed and Deprivation of Liberty Safeguards (DoLS) applications had been made. Conditions associated to peoples’ DoLS had mostly been met. One person had a condition associated to their DoLS which informed staff that they needed to support the person to regularly access the community. Records showed that the person had been supported to access the community and had enjoyed car rides and visits to local cafes and shops. However, this had not happened frequently as outlined within the DoLS. These are areas of practice in need of improvement.

Records demonstrated that people had received appropriate support from staff and external healthcare professionals at the end of their lives. However, records did not always plan for or document peoples’ preferences and wishes for their end of life care. We recommend that the home consider current guidance on advanced care planning so that conversations with people about their preferences at the end of their life can take place.

People told us that staff were available to assist them when required and our observations demonstrated that staff were available to support people according to their needs. One person told us, “There seem to be staff on duty”. The home was not at full occupancy; however, the provider had made the decision to keep staffing levels the same as if the home was fully occupied. Although the consensus was that there was sufficient staff, one relative told us, “They have lots of empty bedrooms at present and they will need extra staff if they fill them”. We were unable at this inspection to determine whether the current service provision could be sustained over time, should the number of people living at the home increase.

People, relatives and a visitor told us that people were safe. One person told us, “I feel safe because I can always see staff around”. A relative told us they had “peace of mind” knowing their loved one was safe and protected from harm. Risks to peoples’ safety, in relation to their physical and healthcare needs, were regularly assessed and appropriate care was provided to ensure that people received safe care. One person told us, “I can go into the garden when I want and I still feel safe, there are no restrictions placed on me”. People were protected from the risk of harm and abuse as they were cared for by staff who had undertaken the relevant training and who knew what to do if they were concerned about a person’s welfare. The provider had a good approach to ensuring that lessons were learned when incidents had occurred. There had been health and safety incidents that had occurred at the providers’ other homes and they had ensured that these were discussed at a health and safety meeting to minimise the chances of the incidents occurring again. People had access to external healthcare services if they were unwell; there was good communication between different healthcare services to ensure people received coordinated and consistent care.

People had access to medicines when they needed them. The management team had worked hard to improve the management of medicines and there were good systems in place to ensure that people received their medicines when they needed them. The home was clean, there were good practices in place to minimise the spread of infection and cross-contamination. One person told us, “My room is cleaned every day”. Another person told us, “There are never any odours”.

People, relatives and a visitor told us that people were happy with the food that was provided, that they enjoyed the meals and were provided with choice. Comments included, “Food is quite good” and “I have a choice of food”. People had access to sufficient quantities of food and drink. Appropriate measures were taken when people had lost weight; they were regularly weighed and had access to food that was fortified to increase their calorie intake.

People were able to live in an environment that had been adapted to acknowledge their cognitive abilities. Pictorial signs informed people of where bathrooms were and equipment such as grab rails and toilet seats were in brighter colours to support people who were living with dementia to use facilities independently or with minimal assistance. Peoples’ bedroom doors resembled front doors and had been painted bright colours, displaying numbers to aid peoples’ orientation. Communal spaces enabled people to socialise with others if they wished and smaller, quieter spaces were available for people to use if they preferred to spend time on their own. People were able to access the communal gardens and some were supported to access the local community.

People were cared for by kind and caring staff. One person told us, “Kind people who treat you with dignity and respect”. A visitor told us, “They think about the person, not just the task, they always chat to everyone in the lounges and make sure they are comfortable”. Peoples’ privacy was respected and they were treated in a dignified and respectful manner. People and their relatives were involved in decisions that affected their care. Regular meetings and newly introduced care plan reviews enabled people to share their views and express their wishes. People were able to raise any concerns or complaints and these were listened to and acted upon.

Peoples’ needs were documented in care plans that informed staffs’ practice. These were regularly reviewed and updated to ensure they reflected peoples’ current level of need. People had access to activities and meaningful occupation to occupy their time. One-to-one time was offered to people who chose to spend time in their rooms and others had access to a varied range of activities such as arts and crafts and external entertainers. Local nurseries had been invited to regularly visit the home and observations showed people enjoying playing games with the children and listening to them sing. It was evident that this lifted peoples’ spirits as people were observed smiling and laughing.

The provider, management team and staff had worked hard to improve the experiences of people. People, relatives staff and healthcare professionals told us that the home was managed well. People, relatives and visitors had confidence in the deputy manager’s skills and abilities and were complimentary about the changes they had implemented within the home. Quality assurance processes audited and monitored the systems and processes to ensure that they were meeting peoples' needs. Shortfalls had been recognised and the provider and management team had undertaken a systematic approach and had concentrated their efforts on specific areas of practice to ensure that improvements were made. The management team worked with external agencies to ensure that

The home is owned by Four Seasons (No9) Limited, which is part of a large national corporate provider called Four Seasons. Four Seasons (No9) Limited own a further three care homes in England. A registered manager is a ‘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 home is run. The home did not have a registered manager in post at the time of the inspection. An acting manager was in post and they were present on the first day of the inspection.

At the last inspection on 6, 7 and 15 February 2017, we found multiple breaches of the regulations. The service was rated as inadequate overall and was placed in special measures. We undertook a comprehensive inspection on 31 May and 7 June 2017 to check whether the required actions had been taken to address the breaches we previously identified. This report covers our findings in relation to these requirements.

Although there had been some improvements we found continued breaches of the Regulations. The overall rating for the service remains as Inadequate and the service therefore continues to be in 'Special measures.' Services in special measures will be kept under review and, if we have not taken immediate actions to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. You can see what actions we have taken at the end of the full version of this report. The service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

At the last inspection on 6, 7 and 15 February 2017 medicine management was inadequate, there was unsafe moving and handling practice, failures in following health care professional’s advice and the lack of effective risk management placed people at serious risk of harm. At the inspection of 31 May and 7 June 2017 it remained that management of people’s medicines was not consistently safe. Improvements had been made to ensure that people had access to the medicines they needed but there were continued concerns regarding inconsistent practice in administering medicines.

Risks to people were not always managed effectively, this meant that some people who were living with diabetes were not being supported to manage the risks associated with their illness. Wound care and skin integrity were not always effectively managed because risk assessments and care plans had not been completed to guide staff. Systems for ordering wound dressings were not operating effectively and this meant that people were not always receiving the wound care treatment that had been prescribed by a health care professional. Referrals to health care professionals were not always made when people’s needs changed. This meant that there was a continued breach of the Regulations.

There was a lack of organisation, co-ordination and planning to address risks of social isolation. Although two activity co-ordinator posts had been filled they were not yet operational and there was a lack of planning and co-ordination to support staff in providing meaningful occupation and activities for people. Some people were at risk of continued social isolation as they spent extended periods of time in their rooms. Some measures were in place with regular checks to ensure their health and safety however there were no plans in place to identify how risks of social isolation could be mitigated for people.

Governance arrangements were not always effective in identifying issues with quality. For example, some audits had identified areas for improvement however actions were not always taken to address these issues. Management oversight was not always effective. For example, records indicated changes in people’s needs, however it had not been recognised when appropriate actions, (such as a referral to a health care professional), were not taken. Poor practice observed when administering medicines had not been addressed. Lack of appropriate care planning for wound care had not been recognised and acted upon. This means that there was not an effective clinical governance system in place to ensure that people received responsive care.

People’s care records continued to not always reflect the needs and care requirements of people and people were at risk of receiving inappropriate care because records were not up to date and accurate. Some care plans had been updated but the majority had not yet been reviewed. Some people were subject to Deprivation of Liberty Safeguards (DoLS) because they lacked capacity to make certain decisions and needed continuous supervision. Staff were aware that people were subject to DoLS and had an understanding of their responsibilities with regard to the Mental Capacity Act 2005. Some people had conditions attached to their DoLS authorisations such as ensuring that they were supported to go out on a regular basis. However the provider had not ensured that these conditions were consistently met.

People and relatives told us that staff were caring and kind and we saw many positive examples of sensitive and compassionate interactions between people and staff throughout the inspection. However there were some areas of practice that continued to require improvement. One person had fallen in their room and staff called the paramedics as they had banged their head. No staff member remained with the person while they waited for the paramedics to arrive until an inspector intervened to obtain support for the person as they were observed becoming distressed. People were not always wearing clothes that reflected their identity and this meant that their dignity was not consistently promoted and their choices were not always considered and respected.

People and their relatives spoke highly of the new manager at Bon Accord. One person said, “It is much better, I think it is generally a well -run home.” A relative said, “There have been a lot of improvements, it’s much better and the atmosphere has improved.” Staff were also positive about the changes, one staff member said, “We still have a long way to go but things are so much better. I can now go home and sleep knowing that people are being cared for.” Another commented, "There was no leadership before, now we have a strong manager who listens and acts.”

Staff had received training and support to ensure that they had the knowledge and skills to be effective in their roles. We saw that they were competent and confident in assisting people to move with the use of equipment such as a hoist. Some people who were living with dementia presented behaviours that could be challenging to staff. Specific training had been arranged to assist staff in responding to these situations. Staff told us that this had a positive impact and had helped them to be more effective when providing support. One staff member said, “I feel much better at de-escalating situations and have a better understanding of why sometimes, people behave as they do.”

Staffing levels had improved and people said that there were enough staff on duty. One person said, “The staff are very good and always come if I press the bell. I don’t usually have to wait long.” A staff member said, “Staffing is better.” Our observations confirmed that there were enough staff to care for people safely. People were supported to have a pleasant meal time experience and staff were attentive in ensuring that people had enough to eat and drink.

The provider had ensured that there was additional support for the acting manager and gave assurances that this would remain in place whilst the home continued to make improvements. The acting manager demonstrated a clear vision for the home and was transparent and honest regarding current shortfalls. We found that improvements had been made since the last inspection but there remained a

Bon Accord is a nursing home providing accommodation for people who are living with dementia and who require support with their nursing and personal care needs. It is registered to accommodate a maximum of 41 people, as some of the rooms are large enough for dual occupancy. However, rooms had been converted and were single occupancy; therefore the provider only accommodated a maximum of 33 people. On the first day of our inspection there were 31 people living in the home. On the second day of our inspection there were 30 and on the third day of our inspection there were 29 people living in the home. This was due to deaths that had occurred. The home is a large property situated in Hove, East Sussex; It has three communal lounges, two dining rooms and a garden.

The home is owned by Four Seasons (No9) Limited, which is part of a large, privately owned, national corporate provider called Four Seasons. Four Seasons (No9) Limited own a further three care homes in England. The management team consisted of a registered manager and senior care assistants. A registered manager is a ‘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 home is run. On the second day of inspection the registered manager resigned with immediate effect.

The overall rating for Bon Accord is ‘Inadequate’ and the service is therefore in ‘Special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the providers’ registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

There were systematic failings, poor leadership and management and ineffective governance that meant that people did not always receive good quality, safe care. Quality assurance processes, whilst sometimes recognising that there had been inadequate care, were not robust and had failed to adequately improve the care that people received. There had been on-going, long-standing issues with regard to peoples’ access to medicines that had not been suitably managed or improved. The registered manager, who was new in post, was not suitably supported to ensure that they were able to assess, monitor and improve the care people received. The provider had failed to ensure that people received a good quality service that they had a right to expect. This was echoed within a comment made by a relative, who told us, “The manager is so stretched I blame Four Seasons for not giving him the support he needs to do the job properly”. There was low staff morale, staff were unhappy and felt unsupported and this was embedded in most staffs’ practice and in the culture of the home.

There was a lack of assessments to assess risks to peoples’ well-being. People were at risk of social isolation and were not adequately monitored to ensure their safety, nor did they have access to call bells to enable them to summon assistance when needed. People did not receive safe care and there were wide-spread concerns with regard to their access to prescribed medicines. The provider had failed to ensure that people were provided with medicines to maintain their health and well-being. People had consistently not had their prescribed medicines for several days and this had a direct, negative impact on their health and well-being.

People did not always receive support to access healthcare that was responsive to their needs. A relative told us, “We weren’t happy, X had a high temperature for a few days, and they were coughing when they were drinking. Eventually my relative had to insist that they call the Doctor which they did and X had got a chest infection and was given penicillin. They hadn’t picked up on it and in the end X had to go to hospital and was diagnosed with pneumonia”.

Some people had lost significant amounts of weight, whilst this had been monitored; it was not apparent what action had been taken in response. Food and fluid charts lacked detail to identify if people had been continually refusing food and not all people had access to supplements or fortified food to increase their calorie intake. Not all people received appropriate support to eat and drink. A relative told us, I’m not confident that they would give X the attention they need to make sure they eat properly so I come in everyday to feed them and make sure they have fluids too”.

People were not always assisted to move and position in a safe manner. Observations raised concerns about some staffs’ practice. People were not always protected from harm and abuse. Some people, who were living with dementia, sometimes displayed behaviour that challenged others. Observations of staff practice when assisting people during times of distress, as well as records, raised concerns with regard to the use of restraint. Staff had not received training in how to deal with such situations and as a result asked a CQC inspector of the correct way to do this. There was a lack of understanding with regard to circumstances that could be constituted as abuse. The registered manager had failed to identify these and medication errors as safeguarding incidents and had not always reported the incidents to the local authority for consideration under safeguarding guidance.

There was a lack of stimulation and interaction with people, other than when they received support with their basic care needs. There were no meaningful activities for people to participate in and people spent their time in their beds or armchairs, sleeping or walking around the home looking for something to occupy their time. Staff did not take time to spend with people, other than when providing support to people who required one-to-one assistance from staff. Some people were socially isolated in their rooms. One person, whose room was on the upper floor of the home, and who had no access to a call bell, was continually crying and calling for help and was showing signs of apparent anxiety. There were no measures in place to assess the risk to the person or to prompt staff to undertake regular checks to ensure the person’s well-being.

Records, to document peoples’ needs and preferences were in place. However, although these contained information to inform staffs’ practice, such as how to move and position the person in a safe manner. Observations and discussions with staff raised concerns with regard to their implementation. People and relatives told us that they had not been involved in the review of the care plans. Comments included, “It used to happen in the early days but everything is just the same now” and “No we’ve not seen one at all and we’ve not had any reviews”.

People were not always treated with dignity and their privacy was not always maintained. Most staff treated people with respect. However, observations of some staffs’ practices demonstrated that they did not maintain peoples’ privacy when discussing sensitive information. Observations showed staff discussing peoples’ confidential healthcare needs as well as organisational information in front of other people and relatives. Peoples’ privacy was not always maintained when they were having their medicines. One person was assisted to have cream applied to their legs in the main corridor whilst another person was assisted to have their blood glucose levels tested and an injection administered whilst sitting at the dining table with other people.

Assessments to determine the required staffing levels to meet peoples’ needs were not always completed and as a result there was a risk that the tools that the provider used to determine the required staffing levels were out-of-date and did not meet peoples’ current needs. Observations showed that staffing levels were not effective during peak periods and when people required assistance from staff they were not always available. A significant amount of staff had left and there had been an influx of new care and nursing staff. Existing staff told us that new staff often lacked the skills and experience required to enable them to carry out their roles and that their inductions into their roles were not effective. Some staff held roles which enabled them to carry out certain nurs

Three of the residents we spoke with communicated with us and told us that they were treated with kindness and respect. One person said, "The staff are kind. I am happy here". We spoke with five relatives and one described the home as "A place where good care is provided and where the staff understands the needs of people with dementia". Another relative said, "I cannot recommend the home enough, they are simply superb and caring". We saw care and treatment was delivered in line with updated care plans which reflected individual needs.

We saw the food provided was of a high standard. Meals were hot, nutritious and well presented with attention to detail. A relative told us, "The food is always really tasty and the portions are generous".

We found Bon Accord and all its facilities were cleaned regularly and hygienic. The staff were vigilant and observed guidelines to minimise risks of infection for people who used the service. A relative said, "The place always smells really nice and clean".

There was an effective complaints policy and procedures in place, and we saw that the service learned from complaints and incidents in order to improve the service.