Archived: Margaret Clitherow House

Updated 22 December 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 23 November 2016 and was unannounced. The inspection was carried out by two adult social care inspectors and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service, in this instance Adult Social Care Services.

We looked at the information we held about the home before the inspection visit. We looked at information the provider had sent us in a provider information return (PIR), and information that we had received about the home since the last inspection. We contacted other agencies such as the local authority business and quality improvement team who were supporting the home to make improvements. At the time of the inspection the home was not having placements made by the local authority, as they were considered to be in default of their commissioning arrangements. Following the inspection the nominated individual and registered manager sent us additional information we had requested, and updated us on actions they had taken.

We spent time observing the care and support people received, including staff supporting people with their general care needs. The majority of people living at the home were able to share their views with us about their experience of care at Margaret Clitherow House. On the inspection we spoke with or spent time with 11 of the 26 people who lived at the home, 2 visitors, the registered manager, the nominated individual and chair of the management committee, a visiting health care support worker and 7 members of both day and night staff.

We looked at the care plans, records and daily notes for five people with a range of needs, and looked at other policies and procedures in relation to the operation of the home, such as the safeguarding and complaints policies. We looked at two staff files to check that the home was operating a full recruitment procedure, and also looked at their training and supervision records. We looked at the accommodation provided for people and risk assessments for the premises, as well as for individuals receiving care and staff providing it.

Updated 22 December 2016

This inspection was carried out on the 23 November 2016 and was unannounced. It started at 07:30am to allow us to meet with the night staff going off duty, and observe staff being organised for the day ahead.

Margaret Clitherow House is a care home without nursing, registered to provide accommodation for up to 41 people needing personal care. On the day of this inspection there were 26 older people living there. The home has strong links to the local Catholic Church and is physically joined to the church building. However the home welcomes people and staff of all faiths or none to live and work there.

The home had a registered manager. A registered manager is a person who has registered with the 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. The registered manager was overseen by a management committee who met at the home regularly and carried out visits to monitor how the home was operating.

Concerns about the management of risks to people at Margaret Clitherow House had been identified at inspections in September and December 2014 The home was rated as "Requires Improvement". The provider sent us an action plan, and later wrote and told us they had carried out the changes needed.

On 6 January 2016 we re-inspected the home. We found concerns over people’s nutrition, complaints, person centred care and people’s capacity to consent, pressure ulcers, records, medicines, and a lack of audit and management oversight. Following that inspection we issued the provider and registered manager with warning notices in relation to Regulation 17 of the Health and Social Care Act (Regulated Activities) Regulations 2014 (Good Governance) and Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014 (Safe Care and Treatment). The home was rated as requires improvement overall but inadequate for the key question of well led.

On 22 June 2016 we carried out an unannounced focussed inspection to follow up on the warning notices. We found that although some improvements had been made the provider and registered

manager had not taken sufficient action to meet the requirements of the warning notices. The home was rated as inadequate and placed in ‘special measures’. We re-issued the warning notices and met with the provider and registered manager to ensure they were clear about the actions that needed to be taken. We contacted the registered manager regularly to discuss progress being made, and regularly reviewed progress with the local Care Trust who were supporting the home to improve.

On this inspection we found improvements had continued, and although some areas of development were still needed they did not have a significant impact on safety or well-being of the people living at Margaret Clitherow House. We received feedback from the local Care Trust that improvements were continuing and they were continuing to assist the provider with the development of the home.

The improvements mean the home has come out of ‘special measures’ and is now rated as ‘requires improvement’.

People lived in a comfortable clean and well-maintained environment, which was adapted to meet their needs. Risks to people’s health and well-being, for example from the environment were assessed. Where additional concerns were identified during the inspection the registered manager took immediate action to address them. We found for example that there were two large, heavy and unstable items of furniture that could present risks if someone fell against them. The service had carried out an assessment of risks from furnishings following the previous inspection and had ensured where unstable furnishings were securely fixed to the walls. However these had not been included in the risk assessment.

Some other risks to people were not always being well managed. For example, people were placed at potential risk of poor health outcomes because risks from poor hydration were not always being identified.

People told us and we saw staff had the skills, knowledge and experience to support people effectively. Staff told us they were well supported, and worked well as a team. We saw staff care and support practices were good and were well understood by staff. However these were not always linked to the home’s policies and procedures which were in some instances inaccurate or incomplete. This meant effective policies were not always available to guide staff on actions to take in the absence of other information, for example with regard to managing infection control issues.

People were protected from the risks associated with staff recruitment. A full recruitment procedure was followed for new staff and there were enough staff on duty both day and night to meet people’s needs. We saw staff being able to respond to people’s needs in a timely way. One person told us staff took a long time to respond to their calling for assistance, but other people told us staff responded quickly to any requests for support. The home had a new staffing tool which identified there were sufficient staff on duty to meet people’s needs.

People were being protected from abuse because staff understood the correct processes to be followed if abuse were suspected. Staff had a good understanding of people’s wishes, lifestyle choices and the support they needed. People could be confident concerns and complaints would be investigated and responded to. The system for the management of complaints ensured these were recorded and any concerns appropriately escalated to the management committee or other agencies.

People could expect to receive their medicines as they had been prescribed because safe systems were in place for the management of medicines. Staff received training in the safe administration of medicines and appropriate records were being completed. Medicines were being stored safely.

People’s rights were respected, and the home was following the best interest’s framework of the Mental Capacity Act 2005. People’s choices were respected and we saw staff asking people for their consent before delivering care. All care was delivered in private. Signs were available for people’s room doors to ensure people did not knock while they were receiving personal care.

People experienced good medical and community healthcare support. We saw people had access to support from community nurses, GPs and other support services. People were supported to attend hospital appointments if they needed this, and we saw evidence of other services being provided such as podiatry, optical and dental. People’s nutritional needs were assessed to make sure they received a diet that met their needs and wishes. Some people were not happy with the quality of some of the food and the home’s management were working to improve this.

People were able to influence change at the home as they were consulted about their views on how the service could be improved. This included through questionnaires and attendance at residents meetings. Members of the management committee met with people on their visits to help assess the quality of their experiences. People’s needs and wishes regarding their care were understood by staff who ensured they were followed and respected.

People benefitted because they were able to exercise their religious beliefs and live amongst ‘like-minded people’. Visitors were welcome at any time, and family members were being encouraged to take part in providing more person centred activities. We saw staff addressed and related to people in a friendly and positive manner, however people told us sometimes staff were a bit abrupt. We saw staff respecting people’s individuality and respect. When they spoke or wrote about people’s needs this was done respectfully and with a caring attitude. Staff told us they felt the home was caring and they were proud of the improvements that had been made.

People benefitted because staff were aware of the risks of social isolation and made efforts to engage with people throughout the day. New activities were being developed in accordance with people’s interests, as some people had said they had not previously enjoyed the activities on offer. This included relatives and other visitors being encouraged to develop groups. For example we saw one relative was setting up an art class for people the day after the inspection. We spoke with the registered manager who told us this had been well supported and would be repeated at people’s request.

The management committee had undertaken training and were presenting a more visible presence in the home. This meant they were in a better position to exercise effective governance over the service. Changes had been put into place following the last inspection to make improvements and meet legislation, for example more regular audits had been implemented. The home had been working with the local Care Trust on a service improvement plan, and took advice following this inspection on changes to be made to the home’s infection control policy.

We identified a breach of legislation during this inspection.

You can see what action we told the provider to take at the back of the full version of the report.’ Please note that the summary section will be used to populate the CQC website. Providers will be asked to share this section with the people who use their service and the staff that work at there.