Blenheim Care Home

Blenheim Care Home is registered to provide accommodation with personal care for up to 57 older people in one adapted building, including care and support for those living with dementia. There were 17 people living at the service at the time of the inspection

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

The service was inspected in March 2020 and was found to have significant failings. The service was placed in special measures. A new manager was appointed and formerly registered with CQC on 17 September 2020. A focused inspection was carried out in September 2020 to check the provider had followed their action plan and to confirm they now met legal requirements. At the inspection in September 2020 whilst some improvements were noted we still identified breaches in relation to safe care and treatment, responding to complaints and ineffective governance arrangements. At this inspection further improvements were seen

Staff knew how to keep people safe and received training for safeguarding and how to reduce the risks of harm from occurring. However, whilst a concern had been investigated by the registered manager it had not been referred appropriately to the local authority. People were supported with their medicines in a safe way. Risks to people had been adequately identified and measures put in place with guidance for staff to mitigate the risk of harm. Infection control procedures were followed by staff. People were able to have visitors, following the latest government guidance.

The service knew how to support people to access health services when required. It was noted advice from a speech and language therapists was not recorded for two people identified with specialist diets. The registered manager and staff had a good knowledge of people’s health conditions and needs and what support would be needed to manage these effectively.

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.

Staff told us training and supervision was arranged to ensure staff

had the skills to carry out their role. Areas of the environment where people were living were found to have improved. The provider had further planned improvements for other areas of the service that would be undertaken before being used by people for care and support.

People and relatives told us staff were caring and they had choices about their care and support.

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 inadequate (published 07 May 2020) and there were multiple breaches 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. A focused inspection was carried out in September 2020 some improvements were found but there were still breaches of the regulations for safe care and treatment, receiving and acting on complaints and governance.

This service has been in Special Measures since 20 November 2018. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last 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 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 undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions of safe, effective, caring and well led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Blenheim Care Home is registered to provide accommodation with personal care for up to 57 older people in one adapted building, including care and support for those living with dementia. There were 18 people living at the service at the time of the inspection.

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

The service was inspected in March 2020 prior to the official lockdown period due to the coronavirus pandemic. Six months prior to the pandemic CQC and the local authority had significant concerns about the lack of systems and leadership in the service. The lack of leadership, oversight and scrutiny by the registered persons failed to identify poor care practice and significant shortfalls in the management of the service. These failings placed people using the service at risk of harm, and significant exposure to the risk of harm. When the pandemic came, the service was ill prepared to manage the outbreak, resulting in significant consequences for the service, people and staff.

The registered manger resigned after the March inspection. A new manager was appointed in April 2020, and formally registered with CQC on 17 September 2020. Whilst the registered manager had worked hard to improve and stabilise the service over the last few months, the providers systems for identifying, capturing and managing organisational risks and issues still require improvement.

The provider had appointed a governance team with specific roles and accountabilities with regards to oversight and development of the service. However, we found their processes for implementing and monitoring improvements required improvement. Where audits have been completed, these lacked details and did not reliably identify where improvements were needed, such as risks to people choking and medicines being out of stock. Where improvements had been identified to improve fire safety and the environment, action plans did not contain measurable timescales for the required improvements to be made. The lack of effective provider oversight has resulted in continued breaches of regulatory requirements relating to safe care and treatment and good governance. A further regulatory breach has been cited in relation to the providers lack of transparency in response to complaints.

The area manager and registered manager were confident the service was moving in the right direction but acknowledged there was still more to do. Further improvements were needed to ensure risks to people were identified, and all reasonably practicable measures are taken to reduce that risk. This relates to medicines management, evacuation plans in the event of fire and choking due to swallowing difficulties. People’s care records needed further information to guide staff on how to meet people’s specific needs, including where they have had a stroke, have a diagnosis of dementia and behavioural needs associated with dementia.

The 18 people currently residing in the service, are all accommodated on the ground floor. Before the provider considers opening the first and second floor to new admissions, they need to have a planned programme of refurbishment to ensure the premises are fit for their intended purpose and consider national best practice in relation to dementia settings.

People’s medicines were generally managed well, however staff failed to follow the providers medicines policy and procedure to check medicines for expiry dates, and report to the registered manager, GP or pharmacists where people repeatedly refused their prescribed medicines.

We have made a recommendation about managing medicines.

Infection control and prevention had improved, and we were assured the service now had systems in place to respond to coronavirus and other infection outbreaks effectively. Staff were clear of safeguarding process, when and how to raise concerns.

The registered manager had successfully recruited a new staff team. There were enough staff employed to meet the needs of the eighteen people currently residing in the service.

Feedback from people’s relatives and staff is that the culture in the service has improved under the direction of the registered manager. Staff felt supported, had direction and leadership, and had received training that gave them the skills and knowledge they needed to carry out their roles effectively.

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 inadequate (published 07 May 2020) and there were multiple breaches 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, not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 03 and 04 March 2020. Breaches of legal requirements were found. These breaches related to a lack of governance and managerial oversight of the service. The failure to have good oversight and leadership had resulted in people not being treated with dignity and respect, being placed at risk of harm, because staff had not understood, or followed arrangements to safeguard people from the risk of abuse. Infection control arrangements were poor. Equipment and the premises had not been safe or suitable for the people who lived there which placed them at risk of harm. There had been insufficient staff deployed across the service. Staff had lacked the competency, skills and experienced to carry out their roles.

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. Although safe and well led domains have improved to requires improvement, the overall rating for the service remained inadequate. This is based on the findings at this inspection.

We also 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 coronavirus and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Blenheim Care Home 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 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.

We have identified breaches in relation to safe care and treatment, responding to complaints and ineffective governance arrangements at this inspection.

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

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.

Special measures

The overall rating for this service is ‘Inadequate’ and the service remains 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 the 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.

Blenheim Care Home is registered to provide accommodation with personal care for up to 57 older people in one adapted building, including care and support for those living with dementia. There were 37 people living at the service at the time of the inspection.

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

The lack of oversight and scrutiny by the registered persons has failed to identify poor care practice and significant shortfalls in the management of the service, which has placed people using the service at risk of harm. There was a lack of leadership on the floor to guide staff and ensure risks and regulatory requirements were understood and managed.

Quality monitoring systems were not being used effectively to identify, capture and mitigate risks to the health, safety and welfare of people using the service. These failed to identify significant concerns relating to the standard of care, unsafe use of equipment, cleanliness and infection control, fire safety, poor state of the premises including loose and damaged wires, poor bedding and the impact of too few staff, specifically around provision of personal care and mealtimes.

Safety concerns and risks to people, such as unidentified bruising and choking were not consistently identified or addressed quickly enough to keep people safe. People were at risk of harm because staff did follow current national guidance and standards in relation to moving and handling and infection control. Safeguarding policies and procedures were not fully imbedded into practice. Staff were not clear of safeguarding process, when and how to raise concerns, which meant there were times when people’s safety had not been protected.

Risk management was poor. Systems in place for assessing and managing risk had failed to identify two people occupying beds, with incompatible bedrails and mattresses which placed them at risk of entrapment. Assessments in people’s care records contained limited information to guide staff on what they needed to do to mitigate risks associated with pressure wounds and choking. People’s individual fire evacuation assessments had not considered all factors that may affect a safe evacuation in the event of an emergency.

The facilities and premises were not designed to enhance the wellbeing of people living with dementia. The environment needed maintenance throughout to ensure they were in good repair and safe. Infection control, including the practice for disinfecting equipment, such as commodes was poorly managed, which placed people at risk of acquiring infections. Cleaning schedules were not specific to ensure the premises was deep cleaned on regular basis to prevent the spread of infection.

Although the provider had a training programme in place, this did not ensure all staff had the skills and knowledge to carry out their roles effectively and keep people safe. Staff had a limited or no understanding of how dementia affected people in their day to day living. There were no systems in place to test staff understanding of training delivered and minimal testing of their competence to ensure they delivered safe and effective care.

The service had insufficient staff employed to ensure staff had time to provide the support people needed, including mealtimes and make them feel that they mattered. Although staff were observed to treat people kindly, care was delivered intuitively and not driven by best practice. The culture in the service was poor, the registered manager and staff failed to recognise the impact on people being got up early in the morning and left seated in lounges all day, with little or no interaction or stimulation. Agency staff had been recruited by an agency on behalf of the provider and living on site. The registered manager lacked understanding of their legal responsibilities for checking agency staff were trained, skilled and competent before working with people in the service.

The requirements of the Accessible Information Standards were not being met. There was minimal information available to support the communication needs of people with a disability or sensory loss. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We have made a recommendation about consent to care and treatment being sought in line with the Mental Capacity Act 2005.

People had good access to health services which ensured their healthcare needs were being met. However, care plans needed to improve to ensure they accurately reflected people's needs and provided guidance to staff on how to meet those needs. Further work was needed to ensure people's care plans contained information about their preferences at the end of their life. People’s medicines were generally managed well, however further work was needed to ensure protocols were in place to guide staff when to administer medicines on an as required basis, particularly medicines to relieve anxiety, pain and constipation.

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 03 November 2017).

Why we inspected

This was a planned inspection based on the previous rating.

The inspection was prompted in part due to concerns received about poor care, unsuitable moving and handling equipment, poor training, poor culture in the service and lack of understanding about dementia care. A decision was made to bring our scheduled inspection forward for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well led sections of this full report.

Enforcement

We have identified breaches in relation a lack of leadership, management and governance at this inspection. Failure to have good governance arrangements has failed to identify poor care, people not being treated with dignity and respect, poor risk management, inadequate systems for checking the premises and equipment were safe, insufficient staff to provide care to people when they needed it, and infection control poorly managed to prevent the spread of infection.

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.

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.

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 the 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.

re-ablement following a time in hospital. This was an unannounced inspection.

At the last inspection, the service was rated good and at this inspection we found that although some improvements were needed the service remained good overall.

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.

There was a positive, open and inclusive culture in the service and the atmosphere was warm and welcoming .

There were sufficient numbers of well trained staff to meet people’s needs. Recruitment processes checked the suitability of staff to work in the service.

People presented as relaxed and at ease in their surroundings and told us that they felt safe. Procedures were in place which safeguarded the people who used the service from the potential risk of abuse. People knew how to raise concerns and were confident that any concerns would be listened and responded to.

People were complimentary about the way staff interacted with them. Independence, privacy and dignity was promoted and respected. Staff understood the importance of gaining people’s consent and were compassionate, attentive and caring in their interactions with people. They understood people’s preferred routines, likes and dislikes and what mattered to them.

Care plans were written in a person centred manner and reflected the care and support each person required and preferred to meet their assessed physical needs. More information was needed to guide staff how to support people’s social needs.

For some people there was a lack of opportunity to engage in meaningful activity throughout the day. The management team were already aware of the shortfalls with regard to activity provision and a lifestyle co-ordinator had recently been employed. Plans were in place to improve this aspect of the service.

The mealtime experience was not a positive one for many. Staff were not deployed appropriately to ensure that people had the assistance they required with their meals and choices were limited. We discussed our concerns with the management team who took immediate action to make changes to improve this aspect of the service provision.

People’s nutritional needs were assessed and professional advice and support was obtained for people when needed. They were supported to maintain good health and had access to appropriate services which ensured they received ongoing healthcare support.

The management team and staff understood their responsibility to comply with the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Our observations told us that staff sought people’s consent and acted in accordance with their wishes. However, additional work was needed to ensure people were always supported to make their own decisions wherever possible.

People were provided with their medicines in a safe manner. They were prompted, encouraged and reassured as they took their medicines and given the time they needed.

The service had a quality assurance system in place which was used to identify shortfalls and to drive improvement. However, these were not always effective as they had not identified some of the shortfalls we found during our inspection. A new auditing tool was in the process of being implemented to enable the management team to make improvements to quality monitoring. The management team were open and transparent throughout the inspection and sought feedback to further improve the service provided.

During our inspection we saw that people received good care. Relatives who completed surveys as part of the home's quality monitoring processes were complimentary about the standard of care their relatives received. One relative stated: 'Overall we are very satisfied with the care that X is receiving.'

We saw that people were comfortable with staff and others living in the home and there was a relaxed atmosphere. Relatives made positive comments about the staff including: 'The staff are all very caring.' Someone living in the home who preferred to maintain their independence said: 'Staff offer help when I ask. They do not interfere.'

The home was well managed and relatives commented on this in the quality monitoring surveys. Comments included: 'I feel that the manager is doing a great job', 'We feel that the manager has gone out of her way to be really helpful and we are very grateful' and 'The home is improving a lot since the new manager has taken over.'