Archived: Haverholme House

At the last inspection in October 2016 the service was rated requires improvement in four domains; safe, effective, responsive and well-led. This gave the service the rating of requires improvement overall. We found no breaches of regulation. This rating was awarded in the four domains because we had to make sure positive improvements that had been made were maintained over time since the inspection in February 2016. At that time we had found the provider was in breach of ten regulations. These were in relation to person centred care, need for consent, safe care and treatment (including management of risk, medicines and infection prevention and control), safeguarding people from abuse, premises, complaints, staffing (numbers, support and training), good governance, fit and proper person's employed and non-notification of incidents. In February 2016 the service had been rated 'inadequate' and it was placed in special measures. During this inspection we found improvements in all of these areas had been maintained.

The inspection was completed on 1 and 7 November 2017, by one adult social care inspector. No breaches of regulation were found.

The service did not have a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. A manager had been appointed and they were going to make a registered managers application to the CQC. Therefore the domain 'well-led' cannot be rated higher than requires improvement.

We found staff understood how to identify signs of possible abuse and knew how to report this to help to protect people from harm and abuse. Staff recruitment procedures were robust. Infection prevention and control measures were in place. Staff had good knowledge and understanding about risks present to people’s wellbeing. People who used the service told us they felt safe living there. There were sufficient numbers of competent staff provided to meet people’s needs.

Accidents and incidents were monitored and there were plans in place to inform staff of the action they must take in the event of an emergency. This helped to protect people’s health and safety. General maintenance of the premises was undertaken.

People received their medicine as prescribed and staff were appropriately trained with the skills required to carry out their role effectively. Minor issues regarding people’s prescribed creams were dealt with immediately by the manager to protect people’s wellbeing.

Staff received supervision and an annual appraisal was being planned for staff who still required this.

People’s independence was promoted even if there were risks attached to this. The service gained permission to share relevant information with health care professionals so that people’s wellbeing could be promoted.

The environment had been enhanced with reminiscence areas for example, an old fashioned post office and a 1950’s lounge. Gardens had level access and were inviting. There was a wide variety of activities provided in house and links with the community were being enhanced.

People’s capacity was assessed and care and support was provided in line with the Mental Capacity Act 2005, which helped to protect people’s rights.

People were treated with respect. Staff were kind and patient in their approach to people and respected their diversity. People’s confidentiality was maintained and care records were stored securely, in line with data protection legislation. Advocates were provided to people if this was required, to help them raise their views.

People were offered choices of food and drinks and individual dietary needs were catered for and monitored in line with their care plan. People had access to health services when required and the service responded quickly when they needed advice or guidance from other professionals.

The service had a complaints policy and welcomed feedback from people living at the service, relatives and staff. Issues raised were investigated and this information was used to enhance the service provided to people.

People who used the service had personalised care plans in place and their individual’s preferences were documented. Risk assessments were in place along with life history, medical conditions and professional contact records. People’s communication needs were recorded and staff were aware of this, which ensured people were able to let staff know their needs.

Family and friends were welcome to visit the service and people living at the service were encouraged to maintain their family contact.

There was an effective management team at the service who were open and transparent. They were supporting a new manager who had recently been appointed. The service's visions and values were known by the manager and all parties were working to maintain or improve the service provided for people.

At the last inspection on 18, 19 and 22 February 2016 we found the registered provider was in breach of ten of the regulations we assessed. These were in relation to person centred care, need for consent, safe care and treatment (including management of risk, medicines and infection prevention and control), safeguarding people from abuse, premises, complaints, staffing (numbers, support and training), good governance, fit and proper person’s employed and non- notification of incidents. Due to these shortfalls we rated the service overall as ‘inadequate’ and it was placed in special measures. The registered provider agreed to put in place a voluntary suspension on admissions to give them time to correct the issues we found. We followed our enforcement policy.

This inspection was undertaken on 4, 5 and 24 October 2016, and was unannounced. We found significant improvements had been made driven by a service improvement plan. Increased management support had been provided and we found the registered provider to be no longer in breach of any regulations. This means the service is no longer in special measures.

During this follow up comprehensive inspection we found improvements had been made in all areas. We have rated the individual domain for ‘Caring’ as good; we have changed the rating from Inadequate to Requires Improvement in ‘Safe’, ‘Effective’, ‘Responsive’ and ‘Well-led’. We have changed the rating of the service overall to ‘Requires Improvement’. This is because we want to monitor the improvements further to be sure they are sustained over a period of time.

There was no registered manager at the service, a new acting manager had been appointed in June 2016, they confirmed they were in the process of submitting their application for 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 time of the inspection there were 20 people residing at Haverholme House. They were all accommodated in Grove Court. Following the inspection in February 2016 the registered provider had taken the decision to close Pine Tree Court unit, in the short term, to enable corrective action to be taken. Each person had been consulted and had been supported to move where they had agreed with this decision.

We found significant improvements in the way the service was managed. The quality monitoring system had been reviewed and strengthened. There was closer scrutiny of governance systems by the registered provider. Where incidents had occurred, we saw evidence of clear preventative measures being put in place to help keep people safe. Staff and management were clear about their role in reporting and investigating incidents.

People and their relatives provided only positive feedback about the service. Each person we spoke with considered there had been a lot of improvements at the service especially with the environment, staffing levels and attitude of staff, care support and quality of the meals.

We found people were protected from the risk of abuse or harm. Staff were more aware of how to use the policies and procedures to safeguard people and when to make referrals to the local safeguarding team.

Improvements had been made to the medicine management systems. However, documentation relating to prescribed creams needed to be more robust.

Improvements had been made to the standards of cleaning and hygiene throughout Grove Court unit. We also found areas of the home had undergone redecoration, refurbishment and renewal with consideration to providing adaptations for people living with dementia.

We found risk assessments were completed and updated when people’s needs changed. This enabled staff to monitor risk and provided them with accurate and up to date information in order to protect people and minimise risk.

We found staff were recruited safely and there were sufficient numbers of staff with different skills and experience on duty day and night. Staff received training, supervision and appraisal in order for them to feel supported and confident when caring for people.

We found people’s health and nutritional needs were met. People were able to see their GP or other health professionals, such as dieticians when required. Menus had been updated including the provision of a larger range of fortified diets. The meal time experience for people was much more positive.

We found staff supported people to make their own decisions on a day to day basis; they held meetings to discuss options when people lacked capacity to do this by themselves. If people were deprived of their liberty to protect their safety, staff had ensured this was done in the least restrictive way and in line with current legislation. We saw staff provided information and explanations to people before carrying out tasks for them such as giving them medicines, assisting with meals or helping them transfer into wheelchairs.

People were treated with dignity and respect, and care was planned and delivered in a person-centred way. We observed staff interacted well with people, knew their likes and dislikes and demonstrated a caring and attentive approach.

We saw people were encouraged to participate in a range of activities within the service and local community. They were supported to maintain their independence where possible. Relatives told us they could visit at any time and we saw staff supported people who used the service to maintain relationships with their family.

The registered provider had a complaints procedure on display. Relatives told us they felt more reassured with the new management in place that concerns they raised would be looked into and dealt with effectively.

The service did not have a registered manager in post. An acting manager had been in post for 10 months and had submitted their application for registration, however during the inspection they resigned from their position and left the service. 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. A support manager had been employed at the service for two weeks prior to the inspection to help the acting manager develop their performance to the required standard to enable them to continue to run the service. Following the acting manager's resignation the support manager was appointed by the registered provider to take over the day-to-day management of the service.

This inspection was unannounced and took place over three days on the 18, 19 and 22 February 2016. The previous inspection of the service took place on 12 and 13 March 2015 and was found to be compliant with all of the regulations inspected. During the inspection there were 32 people using the service, two of whom had been admitted to hospital.

We found the registered provider was in breach of eight regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person-centred care, safe care, safeguarding people from abuse, staffing levels, training and supervision, obtaining consent and working within the requirements of the Mental Capacity Act 2005 (MCA), maintenance of the premises, complaints, and assessing and monitoring the quality of service provision. We also found a breach of Regulations 18 of the Care Quality Commission (Registration) Regulations 2009 for non-notification of serious incidents that occurred in the service. The majority of these breaches were assessed by CQC as high, as the seriousness of the concerns placed a risk of significant harm on the lives, health or well-being of the people who used the service. We followed our enforcement policy.

We found risk to people such as falls, leaving the building, pressure damage, weight loss and the use of bedrails had not been assessed or managed properly. Measures had not been put in place to minimise risks and incidents and accidents had not been recorded and analysed to help find ways to reduce them.

Some people had not received health professional advice and treatment in a timely way and their changing health care needs were not known and understood by the staff. People were at risk of harm because the service failed to respond promptly and appropriately to new care needs.

Staff had not provided people with person-centred care that met their needs. Care plans contained some preferences for care but did not describe people’s needs properly so staff did not have clear guidance in how to manage them. Communication regarding people’s care was not effective to ensure staff were kept up to date with people’s needs.

Whilst people told us they enjoyed the meals served to them at Haverholme House the service did not have a robust way of monitoring people’s nutritional and fluid intake. Some people had lost weight but this had not always been recognised and followed up.

Safe staffing levels had not always been maintained and staff recruitment processes were insufficient. We observed routines were busy and disorganised at times and people experienced delays with care support.

Staff were not adequately supported to undertake their role effectively. We found many staff had not received appropriate supervision, appraisal and training to ensure they were confident, safe and competent to provide people with effective and safe care.

People who used the service and their relatives told us staff were kind and caring. We saw some positive interactions with staff and management treating people well, with dignity and respect. However, we found interactions were mostly task focused and there was a lack of stimulation and activities provided for people, especially those living with dementia.

There had been a failure to protect people from harm and to recognise and report when people had been put at risk or had been subject to harmful situations. There had been unacceptable delays in the provision of information to the local authority safeguarding team when requested and also delays in the completion of investigations into safeguarding concerns.

Safe systems were not in place regarding the ordering, administration, recording, stock control and return of medicines. The systems were inadequate and placed people at risk of harm.

We found people who used the service were subject to restrictive practices which had not been identified or managed in line with the MCA and the Deprivation of Liberty Safeguards (DoLS).

Although information about complaints was displayed around the service and available to people, we found effective systems to manage people’s complaints were not always in place.

We found many parts of the environment required attention to make sure they were hygienic and maintained. There was no renewal programme in place.

We found serious concerns with how the service was managed overall by the acting manager and how well it was governed by the registered provider. There was no effective system in place to monitor the quality of the service people received. Although there was evidence of regular visits to the service by the regional operations manager, quality manager and CEO (Chief Executive Officer), there were few records to show how the acting manager was supported in their role or how the registered provider monitored the acting manager’s practice to ensure they had the competence, skills and experience to manage the service.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff who supported them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Staff did not always follow the risk assessments in people's care plans with regard to safe moving and handling practices. This meant people were being put at risk or harm.

People told us 'We get our medicine on time and when we need it', but we found that appropriate arrangements were not in place in relation to recording, handling and safely administering medicines to people who used the service.

The system in place to make sure that the manager and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations was not effective. This meant that people were not benefitting from a service that had taken on board lessons learnt from recent events.

We have asked the provider to tell us how they will make improvements and meet the requirements of the law in relation to risk management, medicine management and learning from incidents and events.

Is the service effective?

People's health and care needs had been assessed and care plans were in place. However, some of the care plans were not up to date, were not written in a person centred way and the staff reviews of the care plans were poorly recorded. Risk assessments completed for individuals were not detailed / robust, especially for residential individuals. Some people who did not have dementia also told us that staff had not spoken with them about their care needs. Care plans were therefore not able to support staff consistently to meet people's needs.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the planning and delivery of effective, safe and appropriate care that meets people's needs and protects their rights.

Is the service caring?

From our observations of the service and from talking with people who used the service it was clear that some individuals experienced an inconsistent level of care and support, but they were able to make choices and decisions about their care. For example, one person said 'The care can be very good, but sometimes it is poor. It depends on which staff are on duty.' A second person said 'The staff are very good to me, I have no concerns about my care' and the third person told us 'The staff are okay. They are around when you need them.'

Our observations of people who used the service found that they were comfortable, clean and had received support when needed on the day of our inspection. We saw that staff were friendly and attentive to the people who used the service.

People's preferences, interests, aspirations and diverse needs had not always been recorded. Because of this care and support could not always be provided in accordance with people's wishes. We saw that one person's care file contained brief notes, but did not have any care plans or risk assessments within it. We asked this person if staff had spoken to them about their care and they said 'No one has asked me about myself so far. I am stuck in this room and I feel a bit lonely and isolated.'

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to involving people in planning their care.

Is the service responsive?

People and relatives said that they could make a complaint if they wanted to, but they were not always satisfied with the way in which their complaints were handled. During our inspection we found that action had been taken to address people's concerns and meetings with families had eventually been held but the manager's approach could have been more open and effective.

Is the service well led?

The service had a quality assurance system, but records seen by us showed that some areas of risk had not been identified or managed appropriately. Where shortfalls had been identified there was a lack of evidence to show how these had been addressed.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance

People's comments about their care included, 'The care and treatment here is all right," and 'The general care is very good and I like the friendliness of the place; you only need to ring the bell if you don't feel up to it, and they are there.' A relative told us, 'I think this is a lovely place, it is like a home from home. I think the care is excellent.'

People said about staff: 'The staff do their best for me,' and 'All the staff really look after you.' A relative commented, 'The staff are very friendly and helpful. If you are worried about anything they will explain things to you; they are very professional.'

Meetings for residents and relatives were held and one person told us, 'I attended the residents' meeting yesterday and I thought it was a good meeting; we were all listened to.' A relative said, 'We went to the residents' meeting yesterday and they took everything on board.' People also completed surveys.

People knew how to make a complaint. One person told us, 'I should ask staff if I had a complaint but I haven't had any complaints.' A relative said, 'If I had a complaint I would go to the manager and express my view, although there is nothing I am worried about.'