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Inspection carried out on 6 August 2019

During a routine inspection

About the service

Alde House is a residential care home providing personal care up to 17 older adults. At the time of the inspection 16 people lived at the home. The care home is located within the Chiltern area of outstanding natural beauty. People had access to a lounge, dining area, sun lounge and could freely access a garden area.

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

The service did not routinely ensure all the required pre-employment checks were completed for new staff. People were supported by enough staff who were deployed to meet their needs. Staff were skilled in recognising potential abuse and knew what to do to protect people from harm.

People were not routinely supported to have maximum choice and control of their lives and staff did not routinely support them in the least restrictive way possible and in their best interests. This was because the service did not fully adopt best practice for assessing people’s mental capacity to make informed decisions.

People, relatives and staff told us the service was well-led. We found the provider and registered manager failed to notify us of all reportable events. Record management within the service required improvement.

We observed people were supported by staff who demonstrated kindness and a caring approach. People were treated with dignity and respect by staff. People and their relatives described the care home as ‘Homely’ and felt part of a ‘Family’.

People told us they received a personalised service from staff and were supported to engage in meaningful activities. People were supported to practise their chosen faith.

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 requires improvement (published 15 August 2018).

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 some improvement had been made. However, we found the provider was still in breach of regulations.

This is the second consecutive time the service has been rated requires improvement.

Why we inspected

This was a planned inspection based on the previous rating.

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

Enforcement

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We identified one breach of the Care Quality Commission (Regulation) Regulations 2009.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Inspection carried out on 5 March 2018

During a routine inspection

Our inspection took place on 5 March 2018 and was unannounced.

Alde House is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection.

Alde House can accommodate 17 people across two floors, each of which has separate adapted facilities. The service cares for older adults, including people living with early stages of dementia. The premises are a converted building, set on acreage. People live in their own bedrooms and have access to communal facilities such as a dining room, lounges and bathrooms. At the time of our inspection, there were 15 people living at the service.

The provider is required to have a registered manager as part of their conditions of 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 our inspection, there was a registered manager in post.

People safety was not always adequately protected. There were risks from fire and Legionella which were not satisfactorily assessed and mitigated. However, people were protected from the risks of abuse, neglect, discrimination, injuries and accidents. People’s risk assessments and the support they received from staff ensured their safety. There were sufficient staff deployed to meet people’s needs. People were protected from the risk of infections. The service was clean and well-maintained. The management of people’s medicines was robust. We made a recommendation about incident and accident reviews.

The service was compliant with the requirements of the Mental Capacity Act 2005 (MCA) and associated codes of practice. People were assisted to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practise.

Staff training, supervision and performance appraisals ensured workers had the necessary knowledge and skills to effectively support people. We made a recommendation about staff induction. People’s care preferences, likes and dislikes were assessed, recorded and respected. We found there was appropriate access to other community healthcare professionals. People were supported to maintain a healthy lifestyle. People had adequate nutrition and hydration to ensure their wellbeing.

There was complimentary feedback from most people who used the service and their families. They said staff were kind, friendly and committed. People told us they were able to participate in care planning and reviews and there was evidence that the service promoted people’s independence. People’s privacy and dignity was respected when care was provided to them. People’s care records and confidential operational information was appropriately secured away.

The service provided person-centred care. Care plans were suitable and contained information of how to support people in the best possible way. We saw there was an appropriate complaints system in place. The complaints policy and signage required updates. People and their families had a say in the everyday decision-making and operation of the service.

The provider had failed to notify us, without delay, of certain events that were related to people’s care. This meant between our inspections, we could not effectively monitor the governance of the service. The service and provider had a clear and credible strategy that included person-centred aims and objectives for the operation of Alde House. There was positive feedback about the registered manager from people who used the service, staff, relatives and community agencies. A small number of a

Inspection carried out on 20 & 21 July 2015

During a routine inspection

This inspection took place on the 20 & 21 July 2015 and was unannounced.

Alde House is a care home providing accommodation and care for up to 16 older people. At the time of this inspection 15 people were living at Alde House.

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.

We found people were very well cared for. People we spoke with, who either lived in the home or were relatives of people who did were extremely positive about the standard of care and the way the staff and management supported people. "They are all exceptional" was one typical comment.

A number of relatives told us they selected the home following recommendation from people who knew it and its reputation. They told us it was "like a family" and particularly liked it’s scale and ‘homely’ feel. "It is as good as it gets" was how one person put it.

People were able to be actively involved with the local community. This included churches and social activities in the village and wider afield. Families told us they could visit at any time and were able to go out with their relatives for short or more extended trips. One person told us they hoped to be able to go on a holiday with their family, with care support provided by a member of staff who would accompany them.

The home operated with a settled team of staff and management, many of whom had worked at the home for a number of years. "I wouldn’t work anywhere else" one person said. This meant people received consistent care and support from a familiar staff team.

Throughout our visits and in talking with people after them, we were given a picture of a friendly, warm and caring home. We saw staff knew the people they cared for and had relaxed and unhurried conversations with them. The registered manager confirmed they received effective support from the trustees who were responsible for the overall management of the home.

We spoke with health and social care professionals who were familiar with the home who told us they felt it met people’s needs effectively. They said it represented a welcome alternative to larger scale services, whilst maintaining a high standard of care.

Whilst care and other records were adequate and in some cases very full, there were instances where they could be improved. The system based care record system had the capacity to provide very effective recording of people’s care and support. Where staff were able to use it to its full potential, it provided them with the details and information they required to meet people’s needs effectively.

Inspection carried out on 8 May 2014

During a routine inspection

This visit was carried out by one inspector. We spoke with seven people who lived in Alde House. We spoke with three members of the care staff team and with the home's manager. We observed the interaction between staff and people who lived in Alde House and looked at some key care records. We considered the evidence we had gathered under the outcomes we inspected. We used this information to answer the 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 very positive and complimentary about the quality of the staff and the care and support they experienced. We spoke with staff as part of our visit. They knew the individual needs of people and how their safety could be assured. We saw staffing rotas were maintained which ensured people's care needs were met throughout the day and at night.

CQC monitors the operation of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. The manager told us they had not needed to submit any applications to deprive people of their liberty. However, the provider may find it useful to note there were no recorded mental capacity assessments in the care plan records we saw, to support this judgement. When we spoke with staff, they told us they had been trained to understand when an application should be made, and how to submit one. This ensured there were proper safeguards in place.

We looked at three paper care plans and also at computer based care notes. Basic information about people was available on one or other format. For example, pre-admission assessments which established people's basic needs and how they were to be met together with assessments of risks and how these were to be eliminated or managed. Risks assessed included falls, nutrition and moving and handling. This confirmed care and support was planned and delivered in a way that was intended to ensure people’s safety and welfare.

When we looked at the storage, administration and recording of medication we found people were not protected against the risks associated with medicines because the provider had not put in place or maintained appropriate arrangements to manage medicines. We asked the provider to tell us what they are going to do to meet the requirements of the law in relation to medication.

Is the service effective?

Care plans had been put in place for each person. These were either as hard copies or on a computer based system. These outlined the care and support people needed to meet their needs. Staff had reviewed information, to make sure it was up to date, relevant and continued to meet people's needs. However, there was very little detailed or useful personal history and some key records, for example a full history of weight gain or loss, appeared to be split between the two systems. This meant staff found it hard to access all the information they needed in one place. The provider may find it useful to note this made the process of, for example reviews of people's care, harder to maintain effectively as some information was in one system and some in another.

People had access to external healthcare professionals and specialist advice, such as GPs, community nurses, tissue viability nurses and stoma care nurses. Records were kept of any visits or appointments. This helped maintain people's health and welfare.

Is the service caring?

We observed the routines of the home and staff interaction with people who lived there. We saw staff gave people choices. For example about what they ate and where they wanted to sit. People told us "Staff are very willing and helpful." The interaction we observed between staff and the people they provided support to was respectful and relaxed. People appeared to be at ease with staff and staff provided support without obviously 'rushing'.

Is the service responsive?

People were aware of the complaints system. We saw a copy was displayed along with other information about the service. The We found detailed records were kept where anyone had raised issues about standards of care. In each case, action taken in response had been recorded.

Is the service well-led?

The provider had an semi-structured, informal system in place to regularly assess and monitor the quality of service that people received. This had been through meetings and informal feedback together with more detailed provider visits and reports. We were told whilst there were no structured surveys currently carried out, these were planned to take place in June or July 2014 and at least annually thereafter. These would include health and social care professionals involved with Alde House as well as people who lived in the home and those who were responsible for them.

The provider showed us a recent contract monitoring report carried out by Buckinghamshire County Council in April 2014. They detailed the actions they had already taken or were taking to meet any identified shortfalls. This showed both that Alde House was subject to external scrutiny by the local authority and also that they responded in a timely manner where any minor concerns were raised. The report did not identify any significant problems with the standard of care provided by Alde House.

Inspection carried out on 26 April 2013

During a routine inspection

We spoke with four people who lived at Alde House. They said that staff looked after them well and said that they were comfortable and happy with the care they received. For example one person said "“staff are all very kind; they couldn’t do anymore than what they already do". Another person told us "the care really is very good... I feel very lucky."

We found there were systems in place to gain consent to care from people. We saw care plans and risk assessments were signed by the person receiving care and or a family member. People told us that care staff asked them how they liked to be supported. We found risks relating to the person had been identified and assessed. Risk assessments had been written for risks such as, falling, moving and handling, showering and challenging behaviour.

People told us that they felt safe living at Alde House. Comments included "I feel very safe here", "I have no reason not to feel safe" and "Oh yes I feel safe both in the home and when I go out in the community."

We found appropriate checks were undertaken before staff began work. Each file had evidence of enhanced Criminal Records Bureau disclosures, written evidence of references obtained and proof of identification.

People we spoke with did not have any complaints about their care. There was a system in place to listen to any complaints people had.

During a check to make sure that the improvements required had been made

The provider informed us that since our visit in April 2012 a new electronic care planning system had been established in the service. Most information on people using the service was now on that system. The provider said that some information, including notes made by GPs and risk assessments, was maintained in paper records for each person. The provider said the new system had rationalised the practice of care planning. A review of each person’s care plan was now carried out each month. Risk assessments for each person were reviewed every three months. Reviews were carried out earlier where required. The introduction of the electronic system, together with regular reviews of care plans and risk assessments, supported action to ensure that care plans were up to date and relevant to the needs of people using the service.

The provider informed us that monthly meetings were now being held with people. Since April five meetings had taken place. The provider said that as a result of such meetings a new staff call system had been installed and the service had changed its supplier of some materials.

The provider informed us that care plans were now routinely audited. Since April three audits had been completed. The results of the audits were discussed with staff. The audits, combined with monthly care plan reviews and quarterly reviews of risk assessments, supported action to achieve consistent standards of staff practice in meeting people’s needs.

Inspection carried out on 26 April 2012

During a routine inspection

We heard a mix of views on the service from people.

One person using the service told us that the staff were all “very nice”. The staff had given the person all the information they needed on moving into the home. The person told us they had a good relationship with staff and they provided all the care and support the person needed.

A carer (relative) told us that it was a friendly home, that in many respects it felt like a big family. They found the staff to be caring and patient with people, even at times when “…they were rushed off their feet”.

The carer said that around the time of admission the managers had been very willing to make some changes to the environment to ensure that the home was comfortable and met the needs of the person moving there.

Two other people we spoke with expressed concerns about some aspects of their care. They said that they didn’t think there were enough staff to provide help and support in an emergency. We asked if they had discussed their concerns with the managers and they told us that managers had not yet given them the opportunity.

Reports under our old system of regulation (including those from before CQC was created)