Archived: Serendipity Home Also known as Urmston Cottage Nursing Home

Serendipity Home is a care home providing personal and nursing care to a maximum of 45 older people some of whom may be living with dementia and/or physical disability. At the time of the inspection the service was supporting 30 people.

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

People at risk of harm were not always adequately protected. Risk management was poor, with risks not always being assessed or reviewed. Incidents were not always being recorded or reported

appropriately. We made an urgent referral to the Greater Manchester Fire and Rescue Service (GMFRS) as we were concerned the homes fire risk assessment highlighted a number of outstanding works. We are currently liaising with GMFRS and the local authority to ensure these works are completed.

People who developed pressure ulcers or whose health needs changed were not always referred to health care professionals in a timely way. Staff were not always responsive to people's changing needs to ensure that the care and support they provided to people was personalised.

We found there were continuing, multiple and serious shortfalls significantly increasing the risk people would not receive safe care and treatment. Safeguarding incidents were not reported or investigated appropriately. The manager and staff did not recognise or respond to safeguarding incidents or follow established local procedures for reporting and investigating them.

The service was not well-led. There was insufficient risk management and quality monitoring. Statutory notifications were not always submitted when required. The registered provider and manager lacked an understanding around their regulatory requirements.

People did not always have access to enough staff to meet their care and support needs. People, their relatives and staff told us on many occasions that there was not enough staff to support people safely.

People living with dementia, did not always receive person centred care. There was a lack of meaningful and stimulating interactions with staff to occupy people's time.

The environment needed investment. We found areas within the home were tired and required decoration. We have also made a recommendation the provider reviews dementia friendly environments and consults current guidance, as we found aspects of the home lighting and patterned carpets did not support a dementia friendly environment.

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. We have made a recommendation about capacity assessments and best interest decisions.

People's medicines were managed safely, and the home had greatly benefitted from Trafford Council’s medicines optimisation team with improvements to the medicines systems.

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 Requires Improvement (published 27 February 2019) with breaches in regulations 12 (safe care and treatment) and 17 (good governance). We requested that an action plan needed to be completed, however this was not done by the provider. At this inspection improvement had not been made and the provider was still in breach of these and new regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to person-centred care, safe care and treatment, dignity and respect, safeguarding service users from abuse and improper treatment, good governance, staffing and duty of candour.

Full information about CQC's regulatory response to the more serious concerns found during inspections is

added to reports after any representations and appeals have been concluded.

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

Follow up

We will work with the 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.

Special Measures

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service.

This will usually lead to cancellation of their registration or to varying the conditions of 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.

Serendipity Home 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. Serendipity Home can provide accommodation and nursing care for up to 45 older people, some of whom were living with dementia. At the time of the inspection there were 31 people living at the care home.

We last inspected Serendipity Home on the 7 and 8 March 2017, we rated the service Good. We re-inspected this service earlier than planned due to a serious incident that had occurred at the home on 30 January 2017 in relation to the homes passenger lift. At the time of this inspection the Health and Safety Executive were still investigating the cause of the incident. This matter is subject to an ongoing investigation and as a result this inspection did not examine the specific circumstances of this incident.

This inspection was brought forward in part following the outcome of a coronial investigation, concluded in December 2018 in relation to a death of person who resided at the care home. A Regulation 28 Report (Prevention of Future Death Reports) was served against the provider and other interested parties in relation to the incident involving the homes passenger lift. Coronial investigations or inquests are undertaken to determine the cause or manner of a person’s death. The coroner identified a number of failures in respect to the failure of the passenger lift. An area of concern noted in this Regulation 28 Report against the care home was in relation to the provider not having a system in place to ensure details from lift examinations were read; considered and passed on to the lift servicing company. At the time of this inspection, we found the provider's specific response to the concerns raised in the coroner’s report was satisfactory.

The provider was also at time of inspection in the process of replying to the HM Coroner to the concerns noted in the Regulation 28 Report. We will monitor this conversation in line with our regulatory responsibilities.

At this inspection we did identify two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to the provider not taking reasonable steps to mitigate risks to the health and safety of service users and lack of provider oversight and good governance at the service. You can see what action we have told the provider to take at the end section of this report.

The service had a registered manager in place as required by their Care Quality Commission (CQC) registration. 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 registered managers health and safety audit in December 2018 identified 10 bedroom fire doors were not closing fully when the fire alarm was activated. This meant in the event of a fire these rooms would be compromised and potentially have an impact on the homes progressive horizontal evacuation. We were concerned this work had not been considered a priority by the provider as work to repair the fire doors had not been arranged. Shortly after the inspection we received a call from the registered manager who informed us this work had now been completed.

People using the service said they felt safe and that staff treated them well. There were enough staff on duty and deployed throughout the home to meet people's care and support needs. Appropriate recruitment checks took place before staff started work.

Safeguarding adult's procedures were robust and staff understood how to safeguard the people they supported. There was a whistle-blowing procedure available and staff said they would use it if they needed to report poor practice. Prior to our inspection we received whistle-blowing concerns in relation to poor moving and handling carried out by care staff. The local authority attended the home and a service improvement plan was implemented as a result of these concerns.

We reviewed the systems for the management of medicines and found that people received their medicines safely.

People continued to receive effective support from staff with a sufficient level of skills and knowledge to meet their specific needs. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible. People were assisted to access appropriate healthcare support and received an adequate diet and hydration.

The care people received was provided with kindness, compassion and dignity. People were supported to express their views and be involved as much as possible in making decisions. People's diverse needs were recognised and staff enabled people to access activities should they so wish.

The registered provider was complying with the principles of the Mental Capacity Act, (MCA) 2005. Consent to care and treatment was gained in line with the MCA. People's capacity was assessed from the outset and records contained the relevant information in relation to the persons capacity. Appropriate Deprivation of Liberty Safeguards (DoLS) were submitted to the local authority and records contained relevant 'best interest' information and restrictions which were in place.

People and their relatives knew about the home's complaints procedure and said they were confident their complaints would be fully investigated and action taken if necessary.

We noted there were a number of quality audits at the service; these included medicines, infection control, care records and health and safety. Actions were identified following the audits. Although we found a number of effective audits in place and action plans devised to support these, we found a lack of provider oversight and governance. The provider confirmed they were in the process of looking to bring in an external social care consultancy firm to assist them with their auditing processes of the service.

We last inspected Serendipity Home on 18 and 19 January 2016 at which time the home was found to be non-compliant in relation to Safe Care and Treatment. The breach of Safe Care and Treatment was with regards to staff not being suitably trained to provide care and treatment safely.

During this inspection we found that the provider had taken action to address the breaches identified at the last inspection.

A serious incident had occurred at the home on 30 January 2017. The Greater Manchester Police and Health and Safety Executive are investigating the cause of the incident. This matter is subject to an on-going investigation and as a result this inspection did not examine the specific circumstances of this incident.

The service had a registered manager in place as required by their Care Quality Commission (CQC) registration. 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 the last inspection we found end of life care was not always planned in the correct way. At this inspection we found a number of improvements had been made. The service was registered with the Six Steps end of life programme. We saw people were supported to discuss their wishes for their care at the end of their lives.

At the last inspection we found the system for managing medicine needed to be improved. We saw improvements had been made since the last inspection. We reviewed the systems for the management of medicines and found that people received their medicines safely.

During our visit we saw examples of staff treating people with respect and dignity. People living at the home and their visitors were complimentary about the staff and the care and support they provided.

At the last inspection people living at Serendipity Home were not always involved and consulted with decisions about how they wished to be cared for. At this inspection we found the provider had implemented a number of positive changes, allowing people and their family members to meet with the registered manager to discuss their care.

People were offered adequate food and drinks throughout the day, ensuring their nutritional needs were met.

Effective recruitment and selection procedures were in place and we saw that appropriate checks had been undertaken before staff began work.

People told us, and records showed that people had regular access to health care professionals, so changes in their health care needs could be addressed.

Staff received training and supervision they required to be able to deliver effective care. Staff were supported to complete a nationally recognised qualification in health and social care.

At the last inspection staff told us they did not think there were sufficient numbers of staff on shift to meet people's needs in a timely way. Whilst some people told us this was still the case this was not what we observed over the two days of inspection. We saw no one waiting for support, nor calling out for long periods of time. Call bells, when sounded, were answered in a timely way and the atmosphere on all units was calm and unhurried.

The needs of people using the service had been assessed and planned for. Risk assessments had been completed alongside each care plan where appropriate, to help staff to identify and control potential and actual risks. Care and support plans viewed were person centred and included key information about what was important to people, their likes and dislikes, tips for promoting effective communication and key information on their support needs.

During the inspection we continued to receive differing opinions from people in relation to the activities on offer. There were a number of activities planned during the year which people said they enjoyed. Some people told us they would like to do more meaningful things each day. The registered manager confirmed she would continue to monitor the activities on offer.

People and their relatives were invited to regular ‘resident meetings’ at the home. Discussions included the food and activities on offer at the home.

Policies were in place relating to the MCA (Mental Capacity Act (2005) and DoLS (Deprivation of Liberty Safeguards). Staff had received training in relation to this protective legislation.

We saw that the provider had an effective system in place for dealing with any complaints. We found that people felt confident that staff would respond and take action to support them.

Appropriate checks of the building and maintenance systems were undertaken to ensure health and safety. We found that all relevant infection control procedures were followed by the staff at the service.

The registered provider had developed a range of systems to monitor and improve the quality of the service provided. We saw that the provider had implemented these and used them to critically review the service.

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Before this visit we had received information about people's care and support not being appropriately delivered and some issues relating to staffing. Due to the nature of the concerns which were raised, we arrived at the home at 9.30 pm. The visit was unannounced.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

There were enough qualified, skilled and experienced staff to meet people's needs.

Is the service effective?

We saw evidence in each of the care records we looked at that people had access to other healthcare professionals.

Is the service caring?

During our visit to the service we saw the interactions between staff and people who used the service were relaxed and friendly.

Is the service responsive?

The manager had a system in place which reviewed the staffing requirement of the home.

Is the service well led?

The manager had a program of recruitment in place to address shortfalls in staffing.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found-

Is the service safe?

We spoke with five people who lived at the home. People told us they felt safe living at the home. Some of the people who lived at the home were unable to speak to us due to their complex needs. We gathered evidence of those people's experiences by observing the interactions between staff and the people they cared for. We observed staff helping two people move from a wheelchair to an armchair with the use of a hoist. The hoist was used appropriately and staff spoke to the people they were helping explaining at each stage what they were doing.

There were safeguarding procedures in place. Staff had received training to enable them to identify the various types of abuse and the action they needed to take if they suspected abuse had taken place.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw policies and procedures were in place and the manager was able to explain the procedure for submitting an application to the supervisory body (local authority). Two of the four care plans we looked at contained DoLS authorisations. We saw these had been reviewed on a regular basis by the local authority.

Equipment was well maintained and serviced regularly which ensured people were not put at unnecessary risk.

Is the service effective?

During our inspection we saw people were able to speak to the manager if they wanted to. The people we spoke with told us they saw the manager or one of the management team on a daily basis.

We spoke with staff who were knowledgeable about people's care and support needs. We spoke with people who lived at the home and their comments included: 'They are marvellous.' 'The staff are very good and work hard.' 'I am quite content.'

We looked at a sample of people's care plans and saw evidence to show where possible, people had been involved in developing their care plans. This meant they received care and treatment in a way they preferred.

We saw staff sat with people completing a social history and a life map. This helped staff understand the person and their life experiences and to develop a more person centred approach. The aim was to enhance the person's experience in relation to the care they received.

The people we spoke with told us there were forums in place for them to express their views and opinions about the service they received. People told us they had regular 'residents meetings' and an annual questionnaire. We saw minutes were taken during residents meetings and we saw topics such as; changes, activities, new staff and menus. We looked at the most recently completed quality assurance survey and saw comments were positive.

Is the service caring?

We spent time observing the interactions between people who lived at the home and staff. We observed that staff were patient and approached people with respect and worked in a way that maintained people's dignity.

We looked at a sample of people's support plans and found they contained information about preferences and interests. This meant care and support was provided in the way the person wanted.

We spoke with people who lived at the home. Comments included: "They look after me.' 'They know that I like to sit in my room." "The staff show me respect.' 'They ask me if I need anything.' 'They leave me the call bell so I can call if I need help."

We spoke with visitors who told us: 'My (relative) looks much better.' 'There has been a marked improvement recently.'

A visiting GP told us: 'I see the staff speaking to people as they walk past, just passing the time of day asking if they are okay, I think that is nice they acknowledge people rather than just rushing past.'

Is the service responsive?

We saw documentary evidence that people were able to express their views and opinions during resident meetings. People's views were taken into account about the day to day running of the home.

Is the service well led?

The manager who had been in post for eight weeks; told us she had made changes to the staffing structure to introduce department heads. They had also introduced a daily brief to cascade information to the heads of department and the staff team. We spent time speaking with staff who told us: 'We are actually involved in everything now.' 'The manager invites us to reviews and meetings that we were never invited to.' 'We have much more information now.'

We saw written evidence of people expressing their views at resident meetings and the provider taking people's views into account in the way the service was provided and delivered.

We carried out the inspection to follow up on a warning notice we issued in relation to the safety and suitability of the premises to ensure the improvements required had been carried out.

There was an annual maintenance planner and service contract file in place. This meant the service had a system of planned, preventative maintenance, which protected people who used the service against the risks associated with unsafe or unsuitable premises.

On the day of our inspection electrical engineers were completing work required to ensure the provider's electrical hard wiring was safe, to enable them to issue an electrical safety certificate.

We sampled the hot water in 10 rooms and three bathroom/toilets. In all but three rooms there was hot water readily available. In three of the rooms it took 5 to 7 minutes for hot water to run. Maintenance work to rectify the problem was planned for the summer.

The nurse call system had been serviced, re-wiring had taken place and cords replaced since our last inspection.

We arrived at the home at 6am following concerns people were being woken early. When we arrived, 5 people were up and dressed. We spoke with four people who told us they preferred to get up early.

During our inspection we observed care, reviewed records, spoke with staff, people living in the home and one relative.

Throughout the day we observed positive interactions between staff and people living in the home. One relative told us: 'The staff are very good with X and I have no concerns about the care.' However we observed some staff practice and health and safety concerns which compromised people's welfare and dignity.

We observed some positive staff practices however we identified health and safety concerns which compromised people's welfare and dignity.

We saw there were no clear procedures in place for the premises to be maintained. We saw no evidence to show people were protected against the risks associated with unsafe or unsuitable premises by ensuring adequate maintenance and complying with legal requirements.

We reviewed records and saw the provider did not have suitable arrangements to ensure staff were appropriately supported, to enable them to deliver care and treatment to service users safely and to an appropriate standard.

We spoke to three members of staff about how they ensured people were involved in their care and how they respected people's dignity, they told us: 'I go off how I would like to be treated, if people can do things for themselves we should not take that away from people, but support and encourage. When providing personal care I ensure people are covered, and when we go into the shower room make sure we have everything with us.' 'It is important to take your time with people, time to explain and give people time to understand.' 'I say to staff just imagine if it was you in this position.' 'I talk to people, reassure, and explain each step in a gentle voice.'

We spoke to two people who chose to stay in their own rooms, they told us: 'Staff visit me on a regular basis, and I have access to my alarm button if I need anything.' 'I'm happy here, I like my own space.'

The new manager told us that at present there were no systems in place to involve people living in the home or their relatives in the planning or reviews of care, and this was something they planned to rectify over the next couple of months.

The manager discussed in detail the new staffing levels and mix of nursing staff, senior carers and care staff they had implemented in July 2013. This was reflected in the rotas. One of the nurses told us: 'Staffing levels are the best they have ever been, and moral is improving.'

The new manager showed us detailed plans they had in place to monitor the quality of the care and treatment within the home.

The manager discussed with us improvements planned in daily records and provided us with copies of the monitoring forms they had developed to monitor fluid and nutritional in-take, and these would be implemented week beginning 15th July 2013.

During our inspection we found that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

The activities coordinator told us: 'I go through the care plan with people to ensure that I have details of what they like to do during the day.'

People living in the home told us: 'I like to stay in my room, but I get involved with cleaning, I enjoy dusting and I help out in a morning.' Another person told us that: 'They check on me all the time, I was in hospital recently and it has taken me a while to readjust, but everyone (staff) told me it was lovely to have me back.' A third telling us: "X (staff member) is wonderful.'

During our inspection we toured the home and found it to be in good condition having recently undergone a period of renovation. The bathrooms and toilet facilities were clean and hand wash instructions were in place.

We looked at five medication administration records (MAR) and found that in four of the five records medicines were prescribed and given to people appropriately. However the provider might like to note the importance of providing clear guidance as to how and when medication is to be administered, and ensure that staff are recording appropriately.

During our visit nine people living in the home told us that they had no concerns about the quality or quantity of the food provided. People told us, "If you are off your food the chef will provide your favourite meals to tempt you to eat", "The chef talks to us about the menus and makes sure that they include our favourite meals" and "The chef goes out of his way to make sure that we eat enough, especially when we are not well. There are always plenty of choices and if we ask for anything special we get it."

A relative of a person living in the home said, "My X tells me that the food is good and that they never feel hungry."

We saw that a 4-week menu was in place and this provided a varied and nutritious diet for the people accommodated. We found ample food stocks in the home to meet the nutritional needs of the people accommodated. Care records provided evidence that people who had been assessed as at risk of weight loss were consistently being monitored. Appropriate referrals had been made for dietary advice where necessary and dietcian's guidance was being followed in providing food supplements to people at risk.

We found inaccurate recording of a nutritional risk assessment and food and fluid intake charts relating to two people living in the home.

The people we spoke with told us that they had no concerns about the care they received and would speak to the Registered Manager if they had any concerns.

The people we spoke with told us they did not have any concerns about the number of staff at the home. The relative of a person who uses the service told us they thought it would be better if a member of staff was always present in one of the lounge areas.