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Wiltshire Heights Care Home Outstanding


Inspection carried out on 23 January 2019

During a routine inspection

About the service:

Wiltshire Heights is a care home which provides accommodation and nursing care for up to 63 older people, including people living with dementia. The home is arranged over three floors, Robin, Willow and Poppy. At the time of our inspection 54 people were living at the home.

People’s experience of using this service:

People received an outstanding leisure and wellness service which catered to individual interests and abilities. People had a comprehensive and varied menu of activities to choose from and were involved in the development of clubs and programmes for the home.

People received outstanding end of life care which was compassionate, holistic and sensitive. Families were generously and respectfully supported during this time and were able to stay with their relative or visit around the clock.

People received an outstanding caring service. People told us they received very kind and respectful support from staff who promoted their abilities. Staff promoted people’s privacy and dignity and enabled them to make choices and have as much control and independence as possible

The registered manager had made improvements since the last inspection to ensure people always received safe care and treatment. People told us they felt safe.

People benefited from the development of closer links to their local community which included intergenerational events.

People were cared for by well trained and skilled staff who knew their needs and how they liked to be supported. The whole staff group worked as a team to support people in a person centred way.

People had access to plenty of food and drink throughout the day and were served by a hostess. People told us the food was very good and there was plenty of choice. Meals were appetising and served in a calm and organised manner.

The service was well-led. The provider’s quality assurance processes were effective and there was a focus on continuous improvement. The registered manager provided good support for staff to be able to do their job effectively.

More information is in Detailed Findings below.

Rating at last inspection:

Good overall, Requires Improvement in Safe (report published 6 July 2016).

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Follow up:

We will monitor all intelligence received about the service to inform when the next inspection should take place.

Inspection carried out on 16 May 2016

During a routine inspection

Wiltshire Heights is a care home which provides accommodation and nursing care for up to 63 older people, including people living with dementia. At the time of our inspection 40 people were resident at the home.

This inspection took place on 16 May 2016 and was unannounced. We returned on 17 May 2016 to complete the inspection.

At the last comprehensive inspection in August 2015 we identified that the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not always managed safely, staff did not always take action to safely manage risks people faced, some nursing staff did not have the necessary skills to provide care that met people’s specific needs, the home had not followed the principles of the Mental Capacity Act 2005, people were not always given the help they needed to eat and drink, people’s private information was not securely stored, care records were not accurate and the service was not well managed. We served a warning notice to the provider as a result of the concerns we identified and the service was placed into 'special measures'. We completed a focussed inspection in December 2015 and found that the provider had taken the immediate action necessary to improve the service. During this inspection we found that the provider had sustained and built upon these improvements. The home was providing a good service, but some action was needed to ensure the support staff provided to keep people safe was always recorded accurately. As a result of the improvements made, the service has been removed from 'special measures'.

Medicines people had been prescribed were available and were safely managed. People received support to take their medicines but further work was needed to ensure staff recorded when they had supported people with topical creams.

Risks relating to malnutrition were well managed and people were supported to take nutritional supplements and fortify their meals where needed to minimise risks. Further work was needed to ensure staff always recorded the nutritional risk assessments accurately.

People told us they felt safe living at Wiltshire Heights. Comments included, “Of course, I’ve only got to press my button and they are there for me, no waiting, and they can’t do enough for me” and “I’m as safe as houses living here”. We observed people interacting with staff in a confident way and people appeared comfortable in the presence of staff.

There were enough staff, with the right skills, available to meet people’s needs. Comments included, “There are always enough staff available. They come quickly if you use the call bell” and “There are sufficient staff and they have the right skills”. During our observations we saw that staff were available to provide support to people when needed, including support for people to eat, drink and move around the home safely. Call bells were answered promptly and staff responded to verbal requests for assistance from people.

Staff understood their responsibilities under the Mental Capacity Act 2005 and had taken appropriate action where people did not have capacity to consent to their care. Staff were well supported and received training that was relevant to their role.

People who use the service, their relatives and visiting professionals were complimentary about the caring nature of staff. Comments included, “They always treat us well. They ask me what I can / want to do and how much help I need. They always encourage me to be as independent as possible”, “I had pneumonia but I have got better, you are so well cared for here you can’t help but get better” and “Staff are very kind and provide all the care and help I need”.

People had been supported to develop care plans which were personal to them and told us staff provided care in line with their plan. People were confident any concerns or complaints they raised would be responded to and action would be

Inspection carried out on 2 December 2015

During an inspection to make sure that the improvements required had been made

At the comprehensive inspection of this service in August 2015 we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued the provider with one warning notice stating that they must take action. We shared our concerns with the local authority safeguarding and commissioning teams.

This inspection was carried out to assess whether the provider had taken action to meet the warning notice we issued. This report only covers our findings in relation to the warning notice we issued and we have not changed the ratings since the inspection in August 2015. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Wiltshire Heights Care home on our website at

We will carry out a further unannounced comprehensive inspection to assess whether the actions taken in relation to the warning notice have been sustained, to assess

whether action has been taken in relation to the remaining breaches, and to review the rating for the service.

At this inspection we found the provider had taken action to either fully address the issues highlighted in the warning notice or to make sufficient progress. Nursing

staff had the required core skills to be able to offer individualised care safely. There was a training programme in place to ensure competency in these core

skills and the training for the safe administration of medicines. There was a clear structure in place for clinical direction and supervision of nursing staff.

Improvements had been made to record keeping, in the level of detail care plans included and the guidance to staff on how to support people with behaviours which

may challenge. Staff were receiving training on managing behaviours in a positive way and in dementia awareness. Risk assessments clearly identified the possible triggers people may display prior to an incident, thereby enabling staff to take more preventative measures. Monitoring charts contained more information and were being more closely reviewed, however, there was still room for improvement in this area.

People had access to their call bells at all times. Care plans and risk assessments identified the location of where equipment should be placed such as sensor mats.

Staff were clear as to why equipment was used and how it should be used in order to protect people. The recording of medicines had improved, however, there

were still areas for further improvement around ensuring recording was accurate and complete. New systems were being put into place for the organisation and ordering of medicines.

Inspection carried out on 07 and 10 August 2015

During a routine inspection

This inspection took place on 07 and 10 August 2015 and was unannounced. At the time of the inspection the service did not 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 and associated Regulations about how the service is run.Wiltshire Heights care home provides accommodation and nursing care for up to 63 adults, some of whom are living with dementia.

People were not protected against the risk of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. There was a lack of information and guidance for staff on how to support people safely and consistently. Medicines were not organised and administered in a safe and competent manner. There were errors in the recording of medicines and a Registered Nurse on duty told us that one person had run out of their medicine. Staff who administered the medicines did not adhere to safe practices. The manager could not find the stock ordering sheet for the medicines as the staff member who carried out the ordering was on holiday.

People sometimes did not have access to the equipment they needed. Not all staff were knowledgeable about the equipment in place and staff did not monitor if the equipment was being used appropriately.

Staff had not received training relevant to the people they cared for. Not all of the nursing staff had competence in the core skills of: taking blood, using a syringe driver and catheterisation. The nursing staff relied upon the availability of the district nursing team to carry out certain procedures or to supervise the nursing staff to perform them. Some people who lived at Wiltshire Heights care home had different types of behaviours which may challenge others. None of the staff had received training in how to manage these behaviours and to keep themselves, the person and other people safe.

We reviewed the care records of twelve people on the dementia and the nursing floor. We found that mental capacity assessments had not been completed for some people who were unable to consent to moving into the home or their care and treatment. Where capacity assessments had been completed they were not specific to the reason for the assessment.

The standard of record keeping was poor with missing information and records which had not been completed fully. The care records did not accurately reflect the care being provided or required.

The nursing floor did not have a clinical lead and there was a lack of leadership and support to the Registered Nurses.

People told us they enjoyed the food however, some of the food was cold. Not everyone received appropriate support to eat and drink and some people did not have specialist crockery to support them to eat independently. People had access to food and drink throughout the day and the chef went out of their way to ensure that people had the treats they liked.

The systems in place used to assess, monitor and improve the quality, safety and welfare of people were not fully effective. Some audits did not identify where standards were not met.

Staff received supervision and training and the new care certificate had been introduced. The home was in the process of setting up dates for appraisals.

The home was purpose built on three levels and the building was fully wheelchair accessible. Communal areas were bright and hallways were wide and straight which meant that people could walk unsupervised.

Staff were caring, kind and respectful towards people and we saw that people and staff had developed positive relationships. However not all staff waited to be invited into the person’s room when they knocked.

There were safeguarding and whistleblowing policies and procedures in place which provided guidance on the agencies to report concerns to. Staff had received training in safeguarding and whistleblowing to protect people from abuse and training records confirmed this.

The provider had audits in place in relation to the safety of the buildings and fire safety.

We found a number of breaches 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.

The overall rating for this provider is ‘Inadequate’. This means that this service 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.

Inspection carried out on 17, 18 July and 13 August 2014

During a routine inspection

We carried out the inspection over three days. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask.

� 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?

People were treated with respect and dignity by staff. People told us that staff treated them well. People were cared for by staff who were aware of the risks to their safety and health and staff knew how to support them in a safe way. People told us "I feel safe at night" and �carers are respectful and they are my friends� and �I have no complaints�.

Staff we spoke with told us that they had attended safeguarding training and knew how to recognise and report abuse. They demonstrated their understanding of safeguarding issues and their responsibilities in reporting concerns.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The registered manager had submitted a recent application and had been trained to understand when an application should be made. This meant that people were kept safe from harm. There were effective systems in place where people did not have capacity and best interest decisions were made through a multiagency approach.

Is the service effective?

People we spoke with told us that they were generally happy with the care they received and their care needs were met. It was clear from observations and from speaking with staff that they had a good understanding of people's care and treatment.

A visitor told us that care staff were �mostly� knowledgeable and understood their relative�s needs. We were told �all care staff are delightful, very nice and helpful, and do their best� and the nurses were �good�. However they said that when care staff were new they did not always know how to support their relative in a consistent way.

The service had gone through a period when several staff had left, leaving agency workers to cover vacant shifts. Comments people made about the staffing included �you never know who�s going to be here today, that is the problem here� and �wasn�t like that six months ago, has gradually happened�. Some staff told us �everyone is under pressure, staff leave and at times we have not been fully staffed.� Another member of staff told us staffing had improved recently with more cover organised. We found the lack of continuity of a regular staff team had resulted in a low staff morale. Recruitment processes had begun to fill vacancies.

The records of care that staff provided to people were not always accurate. There were gaps in records relating to people's fluid and nutrition intake and the support they received to reposition to prevent pressure damage. This increased the risk that people would receive inappropriate or unsafe care and treatment.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. They demonstrated their knowledge about the people they cared for and understood their preferences in consenting to how they liked things to be done.

We saw people were receiving care in a sensitive way. We observed people being supported in making choices about their daily routines and the activities they would like to do.

Is the service responsive?

We found evidence there had not always been good communication in the management of people's care between the provider and external professionals. Healthcare professionals had concerns about staff having a lack of knowledge and that local resources such as district nurses had been called in to support staff in setting up equipment to meet people�s needs and support people with nursing. This showed us that when the home admitted some people they had not always made sure there were suitable arrangements in place to meet individual needs, prior to admission. We found that the provider had not always ensured that there were sufficient staff on duty who had been trained to meet people�s needs.

Is the service well-led?

The registered manager has left and the service was being managed in the interim by the regional manager.

Quality assurance processes had not always helped to make improvements to the quality of the service where they were needed. Actions was recorded but had not always been followed up at regular intervals.

We found there the service had not always been well led. This was because there had been a lack of regular staff supervision taking place, staffing vacancies unfilled and communication that had not always been managed well leading to a lack of staff morale and cohesion among the staff teams.