County Homes

County Homes provides accommodation for up to 90 people who need help with nursing or personal care. At the time of the inspection 68 people lived in the home. Most people living in the home required nursing care and most people lived with dementia.

People's experience of using this service

At this inspection we identified concerns with the management of risk, care planning, the delivery of care, the management of medicines and governance.

People’s care plans did not contain adequate details of their medical conditions and the clinical care they required, to keep them safe and well. Some people had mental health needs or high-risk medicines that had not been properly risk assessed or care planned to ensure staff knew how to mitigate risks and support them appropriately. We also found that people’s medical and health needs were not sufficiently monitored by nursing staff to ensure their health and wellbeing was being maintained or to identify possible early signs of ill-health. This placed people at risk of avoidable harm.

Record keeping overall, in respect of people’s care was poorly maintained and at times this made it difficult to keep track of people’s progress and well-being.

Medicines were not managed safely. Information about some people’s medicines was not accurate or up to date. This resulted in some people not receiving the medicines they needed. Some people did not always receive the correct dose of their medicine, or missed doses of their medicines without explanation. Medicines that needed to be given at specific times were not always given correctly and staff did not have adequate information them on how to administer covert medicines (medicines hidden in food or drink), safely. We had service wide concerns about the safety of medication management so we referred our concerns to the Local Authority Safeguarding Team to investigate. After the inspection, the provider submitted an action plan to CQC outlining the immediate improvements they intended to take with regards to medicines.

Accident and incidents and safeguarding allegations were not recorded accurately to enable the provider to be assured that people’s safety was being maintained and the risk of injury or abuse mitigated.

The provider had a range of audits in place to monitor the quality and safety of the service. These audits had identified similar concerns with care planning, medicines and the environment, yet there was little evidence that any action had been taken to address these concerns. This resulted in the same concerns being identified at this inspection.

There was a staff and resident COVID-19 testing programme in place and appropriate safety measures in place for visitors and new admissions to the service. There were also arrangements in place to ensure that infection control standards were maintained. However, on the day of the inspection, parts of the environment were malodorous and unpleasant to live in.

The provider had a system in place to determine safe staffing levels. People and their relatives told us staff were kind, caring and respectful. The majority of people we spoke with felt there were enough staff on duty to support people’s needs.

People received support from a range of health and social care professionals including dieticians; mental health teams; speech and language therapy and their local GP.

The culture of the service was open and transparent. The manager and regional manager engaged with the inspection positively and were committed to making any necessary improvements.

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 01 December 2021).

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

During this inspection, the provider was found to be in breach of regulations 12 (Safe care and treatment) and 17 (Good Governance). This resulted in a change to the provider’s overall rating which is now rated as ‘Requires improvement’.

During this inspection, 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.

For more details, please see the full report which is on the CQC 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

At this inspection we found breaches of regulations 12 and 17 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches related to the failure to ensure people received safe care and treatment and a failure to ensure the service was always governed and managed adequately.

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.

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner. We will work with the local authority to monitor progress.

We found the following examples of good practice.

The provider and registered manager had implemented appropriate procedures within the service to help minimise the spread of infection and help maintain people’s safety during the COVID-19 pandemic.

Infection prevention and control (IPC) guidance was displayed on a notice board within the home and updates sent to relatives regularly, so everybody was aware of guidance and the procedures in place when visiting.

Staff had received IPC training, including the correct use of personal protective equipment (PPE) and we saw this in use during the inspection. Regular cleaning schedules had been developed for all areas of the home. Staff changed into their uniforms when they arrived at the home, to help prevent the spread of infection.

Staff followed shielding and social distancing rules and encouraged people to maintain social distancing where able to. Risks to people and staff had been assessed and appropriate measures taken to reduce any identified risks. People had their temperature and oxygen saturation levels monitored twice daily so any changes were identified and acted upon quickly.

Staff and people living in the home underwent regular COVID-19 testing and timely actions were taken if anybody tested positive, to help prevent further spread. Visitors also completed lateral flow tests on arrival.

An internal visiting room had been developed to enable safe, socially distanced visiting with plastic screens and a separate entrance from the car park, as well as a separate visiting pod in the garden. When people were unable to visit, staff supported people to maintain contact with their family members through regular telephone calls and Skype video calls.

Safe procedures were in place for admitting people into the service in line with current guidance. An isolation unit had been developed and any people newly admitted to the home would isolate for 14 days on there, before moving into one of the main units.

We were assured this service was following safe infection prevention and control measures to keep people safe.

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

The home is registered to provide personal care and nursing care for up to 90 people, however the manager told us that the maximum number of people accommodated is now 82 because a number of rooms were registered for double occupancy but are no longer shared.

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. The home had a registered manager who had been in post for several years.

The manager told us that all of the people accommodated were living with dementia and required nursing care. The home was divided three units known as Chester, Lancaster and York. Each of these had a unit manager. Each unit was further divided between ground and first floors, which meant that the maximum number of people living in each area was 14. Each area had its own lounge and dining room. Three areas accommodated men only and two accommodated women only.

At our last inspection of County Homes in July 2017, we found a breach of Regulation 9 of the Health and Social Care Act: Person-centred care, because care plans did not always provide sufficient details to enable staff to meet people's needs safely, and planned care was not always evidenced as provided. During this inspection we found that improvements had been made to the care plans and there was no longer a breach of regulations.

Relatives we spoke with told us that they felt their family members were safe in the home and that they had no concerns regarding their care. They told us the staff were kind and caring and protected the dignity and privacy of people living in the home. Visiting relatives were made welcome and were encouraged to be involved in the care and support of their loved one.

Staff were recruited safely. Staff were supported in their role through an induction, supervisions and an annual appraisal. Training was provided to ensure staff had the knowledge and skills to meet people’s needs.

People’s medicines were managed safely.

Applications to deprive people of their liberty had been made appropriately. Records showed that consent was sought in line with the principles of the Mental Capacity Act 2005.

Feedback regarding meals was mainly positive, however there were some room for improvement. Staff were knowledgeable about people’s individual nutritional needs and preferences.

A range of social activities was provided to keep people stimulated and occupied.

The manager and the area director completed regular quality monitoring audits which identified any areas needing improvement. Action plans were agreed and implemented by the manager and the staff team.

County Homes is a large care home set in its own grounds in the Woodchurch area of Birkenhead. The home is registered to provide personal care and nursing care for up to 90 people living with dementia, across three units within the home. Each unit is separated between the ground and first floor. Chester unit comprises of 14 beds for both male sand females on the ground floor and 14 male only beds on the first floor. Lancaster unit comprises of 14 male only beds on the ground floor and 13 female only beds on the first floor. York unit has 14 male only beds on the first floor and 13 female only beds on the first floor.

During the inspection, there were 71 people living in the home.

At the last inspection in November 2016, we identified breaches of Regulation regarding safe care and treatment, staffing, the governance of the service and person centred care. We issued warning notices to the provider in relation to safe care and treatment and the governance of the service. The provider submitted CQC with a plan of action which identified the actions they would take to address the breaches of regulation. During this inspection we looked to see whether improvements had been made.

In November 2016 we found that risk to people was not always assessed accurately. During this inspection we found that staff had completed risk assessments to assess and monitor people’s health and safety. These assessments were reviewed regularly and appropriate measures put in place based on the outcomes. PEEPs were in place for people, which were detailed and provided information on how to support people to evacuate the home. We found that improvements had been made in how risk was assessed and mitigated and the provider was no longer in breach of regulation regarding this.

At the inspection in November 2016 we found that the building was not always safely maintained. During this inspection we saw that internal and external arrangements were in place for checking the environment to help ensure it was safe. During the inspection we observed that three fire doors did not close adequately within their frames. The registered manager arranged for them to be repaired immediately. We found that improvements had been made and the provider was no longer in breach of this part of the regulation.

At the last inspection we observed that people received unsafe care and support, such as when mobilising and eating. During this inspection we observed safe care being provided at all times throughout the inspection.

In November 2016 we found that there were not sufficient numbers of staff on duty to meet people’s needs in a safe and timely way. During this inspection we found that improvements had been made and staff and relatives we spoke with told us there were enough staff on duty each day to meet people’s needs. We found that improvements had been made with regards to staffing levels and the provider was no longer in breach of regulation regarding this.

At the last inspection we found that systems in place to monitor the quality of the service were ineffective. During this inspection we found that audits were completed which identified actions required to improve the service. However it was not always clearly recorded as to whether the actions had been completed, though those we checked had been addressed.

In November 2016 we found that activities were not provided for all people living in the home and people’s hobbies and interests were not considered within activity provision. During this inspection we found that improvements had been made and activities were provided both in groups and on a one to one basis, based on people’s hobbies and interests. The provider was no longer in breach of regulation regarding this.

Care plans provided person centred information regarding the care and support people received and people’s preferences and life experiences were reflected throughout their plans of care.

At the last inspection we found that care plans did not provide sufficient detail to staff on how to support people who may present with behaviours that challenge due to their health conditions. During this inspection we saw that improvements had been made, however the improvements were not consistent. Not all plans provided sufficient detail as to how staff should best support people at these times and planned care was not always evidenced as provided. This meant that people’s individually planned care was not always evidenced as provided.

Steps had been taken towards the home being appropriate to assist people living with dementia to maintain their safety, independence and orientation. However this could be further developed. We made a recommendation about this.

Due to memory difficulties, most people living in the home were unable to speak to us about their experience of living in County Homes. Relatives we spoke with however told us that they felt their family members were safe in the home and that they had no concerns regarding their care. Staff were knowledgeable about safeguarding vulnerable adults and how to raise any concerns they had. We found that appropriate safeguarding referrals had been made.

A registered manager was 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. Feedback regarding the management of the home was positive.

Staff were usually recruited safely, although not all staff files we viewed contained full employment history. This was rectified during the inspection.

We looked at the systems in place for managing medicines in the home and found that medicines were managed safely. Staff had completed training in relation to safe medicine administration and had their competency assessed each year.

Applications to deprive people of their liberty had been made appropriately. Records showed that consent was sought in line with the principles of the Mental Capacity Act 2005. When people lacked capacity relevant people were involved in making decisions in people’s best interest.

Staff were supported in their role through an induction, supervisions and an annual appraisal. Training was provided to ensure staff had the knowledge and skills to meet people’s needs.

Feedback regarding meals was positive and staff were knowledgeable regarding people’s nutritional needs and preferences. The menu offered a choice of meals and staff supported people with their meals when required.

Care plans had been rewritten since the last inspection and provided information regarding people’s preferences. This helped staff to get to know people and provide support based on their preferences.

Relatives told us staff were kind and caring and protected the dignity and privacy of people living in the home. Staff worked in such a way as to promote people’s independence as much as possible.

We observed relatives visiting throughout both days of the inspection and they were made welcome. For people who had no family or friends to represent them, contact details for local advocacy services were available.

Relatives we spoke with were aware how to make a complaint and we saw that complaints made had been investigated appropriately.

Surveys and resident and relative meetings took place in order to gather feedback from people regarding the service.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory requirements.

Ratings from the last inspection were displayed within the home as required.

The home accommodates six individual units over two floors. Some units are mixed, other units are male or female units only. Each person in the unit has their own bedroom and some of the bedrooms have en-suite facilities. A passenger lift enables access to all floors for people with mobility problems. In each unit there is a communal lounge and dining room for people to use. There is also a pleasant garden for people to enjoy and a small car park.

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.’

During this visit, we identified concerns with the safety and quality of the service. We found breaches in relation to Regulations 9, 12, 18 and 17 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 this report.

We looked at the care files belonging to seven people. We found some people’s needs and risks were not properly assessed and some management plans did not give staff sufficient guidance on how to meet people’s needs and keep them safe.

Some of the people who lived at the home displayed challenging behaviours. We found that people’s support in relation to this was inadequate. Staff lacked sufficient information on the potential causes of the people’s distress and how to support people to communicate their needs in a more constructive way. The support provided was not person centred and in some instances not an appropriate way to meet people’s needs. Dementia care overall was poor and staff had limited guidance on to communicate with and provide emotional support to people who lived with dementia.

Some of the moving and handling techniques used by staff at the home to support people’s mobility was unsafe. People’s nutritional needs were assessed with advice sought from the dietician when required. People had enough to eat and drink but some people who required assistance to eat their meals were not supported in a safe way. This placed people at risk of harm. People we spoke with were generally pleased with the quality and choice of food that they had at the home.

Some of the people we spoke with said there was not enough to do. We saw that some activities were available upstairs in the home’s activity room but no thought had been given to those people who due to their dementia were unable to participate in these activities. We saw some people had no access to any meaningful or suitable activities and spent most of the day sat in a chair or wandering around the unit. This did not promote their emotional well-being or quality of life. People’s care files contained information about people’s previous hobbies and interests but there was no evidence that this information had been used to plan activities designed to occupy and interest people.

Of the seven people’s files we looked at, six had personal emergency evacuation plans (PEEPs)in place that contained personal information about their needs in an emergency situation. One person did not have a PEEP in place and the PEEPs we looked at did not contain adequate information about people’s support needs. This information was also displayed in the entrance area of the home which did not respect people’s confidentiality.

People’s capacity was assessed in accordance with the Mental Capacity Act but capacity assessments lacked sufficient detail of how the capacity assessment was undertaken and the person’s participation. Some people who were unable to keep themselves safe outside of the home had deprivations of liberty safeguards in place to ensure they were cared for appropriately.

We saw that the manager had responded to people’s complaints or concerns but had not always kept appropriate records in relation to these. The provider’s complaints policy also lacked important information in relation to who people could complain to.

Staff recruitment, training and support was satisfactory but the number of staff on duty was found to be insufficient. This placed people at risk of avoidable harm.

During our visit, we found the culture of the home to be warm, open and transparent. People who lived at the home and the relatives we spoke with during our visit told us staff were kind and caring. We observed interactions between staff and people who lived at the home that were pleasant, kind and compassionate. It was clear that people felt comfortable with the staff that supported them. Staff we spoke with spoke fondly of the people they cared for.

We saw that the home had been refurbished throughout and was tastefully decorated. There was also a new café area at the entrance of the home. We looked at the arrangements in place to ensure the premises was safe. We saw that improvements were required to the home’s emergency lighting and fire safety provisions. This had not been done. This meant the provider failed to take appropriate action to protect people from risk in the event of an emergency such as a fire. The manager contacted the provider the day of our visit to organise the required works.

Medicines were managed safely but staff needed appropriate guidance for when to administer people’s ‘as and when’ required medication so that people received these medicines as needed. People had prompt access to their GP when they became unwell and other specialist health and social care professionals in support of their health and well-being. We saw that where professional advice had been given, it was properly documented and followed.

Safeguarding incidents were recorded, appropriately investigated and reported. Staff we spoke with knew about types of abuse and the action to take if they suspected abuse had occurred.

The service was not consistently well–led. Systems in place to monitor and manage risk to people’s health, safety and welfare were in place but were ineffective. They did not pick up the concerns we identified during our visit. We had concerns about risk management, poor staff practices in the delivery of care, insufficient staffing levels, the lack of good person centred care, the access to meaningful activities for some people and inadequate support for people’s emotional and behavioural needs as part of their dementia care.

We discussed our concerns with the manager at the end of the visit. They were receptive to our feedback and demonstrated a positive commitment to improving the service for the people who lived there.

We reviewed five care records. We saw people's needs were assessed and regularly reviewed. Care records contained information about a person's needs and promoted the person's independence where possible. We saw that where people had limited mental capacity, care plans detailed how to communicate with people so they were able to be involved in decisions about their day to day care.

We found the building provided a safe and suitable environment for people to live in but noted some parts of the home needed redecoration and refurbishment. We were told there were plans in place to ensure improvements were made to the home.

We reviewed six staff files. We saw there were recruitment and selection practices in place that ensured appropriate checks on the suitability and competency of staff were undertaken prior to employment. We also saw evidence that staff were appropriately supported and trained to care for people.

Staff we spoke with were knowledgeable about people's needs and spoke fondly about the people they cared for. We saw they treated people kindly and supported them at their own pace.

At the time we visited, nobody living at the home was very ill or being looked after in bed. The staff team had completed the 'Six Steps' training programme for care homes to deliver the best end of life care and this was incorporated into the care plan for each person. People living at the home had a choice of several local GP surgeries. We spoke with a GP who told us that he visited County Homes twice a week and carried out regular reviews of all his patients. He described his relationship with the home as 'great teamwork' which ensured that people's needs, and changes to their needs, were recognised and met.