Archived: Margaret Clitherow House

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.

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 see how the home was operating.

Concerns about the management of risks to people at Margaret Clitherow House had been identified at an inspection in September 2014. In December 2014 we carried out another inspection and found that the required changes to management systems had not been made and that this amounted to a breach of legislation that corresponded to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Good Governance). 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.

We re-inspected the home on 6 January 2016. At the inspection on 6 January 2016 we identified concerns over a number of breaches of legislation including for safe care with regard to nutrition, 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 provider and registered manager needed to comply with the warning notices by 8 April 2016 (Regulation 12) and 27 May 2016 (Regulation 17). The home was rated as requires improvement overall but inadequate for the key question of well led.

This focussed inspection took place on the 22 June 2016. It was carried out to ensure the provider had met the requirements of the warning notices for Regulation 17 (Good Governance) and Regulation 12 (Safe Care and Treatment), and to follow up information we had received in relation to pressure ulcer prevention. Other areas for improvement identified during the inspection of 6 January 2016 remain part of the home’s ongoing action plan, and will be looked at on the next comprehensive inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Margaret Clitherow House care home on our website at www.cqc.org.uk.

At this inspection 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, and were not always providing safe, high quality care for people.

Some risks to people’s safety had not been properly assessed or actions taken to mitigate them, which meant that people could not be confident of receiving safe care. For example risks to people from tissue damage, poor nutrition or the management of long term health conditions were not always being identified or plans put in place to reduce them. Following the inspection we received information that told us that risks to people from pressure area care were being managed well by the home, in conjunction with the community nursing team.

Additional staff had been provided recently as the registered manager told us there had been an increase in people’s dependency levels. However this was not based on a systematic analysis of the changing needs of people at the home. We have recommended a tool be used to determine the safe level of staffing based on people’s needs.

The provider and registered manager were not operating effective systems to ensure people received consistent safe high quality care. Systems to audit and assess risks for example from medicines, the environment or poor infection control practices were not always thorough or accurate. Where risks had been identified there were not always clear actions in place to reduce risks to people from their care. We did however also see some developing good practice in this area. For example the service had recently taken prompt action to support a person accessing early support from the district nursing team.

Records, policies and procedures were still in many cases out of date or did not relate to the operation of the home. People’s care plans did not always reflect their needs, or risks associated with their care and how they should be supported.

The management committee were developing their skills and operating greater oversight over the home. However they had failed to take sufficient action to protect people or ensure high quality and safe care.

We found that sufficient changes had not been made to meet the warning notices or improve the previous rating of inadequate for the key question for well led. Other ratings areas identified on the 6th January 2016 have not been changed as a result of this inspection but will be updated at the next comprehensive inspection. A comprehensive inspection will take place to inspect all five questions relating to this service. These questions ask if a service is safe, effective, caring, responsive and well led. At the next inspection we will also check to ensure improvements made for this inspection have been sustained.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. This is because the ‘Inadequate’ rating for well led has not improved.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still 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 this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We found that Margaret Clitherow House was not a safe service as we found that the home was failing to meet people's medicine needs and people's individual choices.

We found care and treatment was not always planned and delivered in a way that ensured people's safety and welfare. For example, we saw some care plans without any assessment or detail on how people needed their care needs to be met. Many care plans did not hold relevant completed risk assessments for people's needs.

We found that there were not appropriate arrangements in place to manage medicines safely at the time of this inspection. People did not always receive their medicines as prescribed.

The people who lived in the home and the staff we spoke with said there was not sufficient care staff on duty to meet their needs. For example, when people rang the call bells it was taking too long to answer them and people's dignity was being affected as a result. One person said, 'I have to wait 20 minutes sometimes for my call bell to be answered'.

Is the service effective?

We found that Margaret Clitherow House was not always an effective service. They had not ensured people's care needs were being fully met and their care planning was insufficient to ensure it was personalised.

Care plans did not tell the staff how people's care needs were to be met. We discussed people's care needs with staff and not all staff were able to tell us about people's needs and how they liked all their care to be delivered. Some staff we spoke with were able to tell us what they did to support people and knew what to do for them if they needed any additional support. For example, staff told us about one person who was now bed bound and required regular repositioning to protect their skin integrity.

Is the service caring?

We found that the home was not always meeting its requirements as a caring service. People told us: "I wait too long for the call bell to be answered' and 'More like a nursing home, less personal, staff so rushed'. 'Many staff are very good; you get the odd one who could be short with you, because they are busy'.

We found that the staff were looking after people that had high needs including people with Dementia. The staff spoken with confirmed they had not had any Dementia training.

People we spoke with told us that the staff were kind and very caring. However many people said that the home was short of staff and that staff were, 'Run off their feet'.

During out observations and conversations we saw and heard examples of staff being respectful and treating people with dignity. One person told us 'The staff are very kind and patient with me, but they are always rushed'.

Is the service responsive?

Margaret Clitherow House was not always meeting the requirements of a responsive service. We found that they had not acted on concerns when they were raised by people living in the home.

We found that staff lacked the skills to meet people's individual complex needs. For example, someone with Dementia was seen left without staff intervention a lot of the time.

We saw that one person was upset and anxious about papers missing from their room. We also saw recorded in this person's daily records that they were anxious and upset about a visiting professional. The manager of the home was unaware of this person's anxiety.

We saw that staff paid respect to people's religion. For example, we saw that the home advertised the weekly religious services held within the home.

We saw that not all people's needs were assessed and care and treatment recorded in individual care plans. For example, we saw that some people did not have the help they required with their personal care recorded.

Not all care plans had been regularly reviewed and updated as people's needs changed.

Is the service well-led?

We found that Margaret Clitherow House was not always well led. The Manager had yet to be registered with the Care Quality Commission and had worked at the home for a few months. Many of the staff had worked at the home for some time.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Most staff that we spoke with told us that more care staff were needed. One staff commented, 'There is a lack of leadership, lack of staff and people (staff) not working as a team'.

We spoke with the Manager about the staffing levels. The manager said that usually there were five care staff on duty, with 37 people living in the home. However on the first and second day of our inspection we found four care staff on duty.

Many of the people living at the home that we spoke with told us that although staff were kind and caring they were always busy and never had time to stop and chat.

During this inspection, we identified shortfalls relating to care and welfare, management of medicines, and staffing. The provider's quality assurance systems had not picked up these issues. This told us there was not an effective quality assurance system in place.

We looked at eight care plans and found that peoples care needs were planned and reviewed regularly, and changes in their needs were documented and escalated to other health care professionals.

We spoke to three members of staff and people on work experience who told us that Margaret Clitheroe House is a nice place to work, and that they are supported by the management. One member of staff told us that they had worked in the home for a number of years and she had built up relationships with the people living there. This person said they had stayed at Margaret Clitherow House longer than the other places they had worked as the atmosphere was so nice.

We observed appropriate communication between staff and people living at Margaret Clitherow House. All staff addressed people by their title and surname and treated them with respect.

All the people and visitors we spoke with were positive about their experience of the care provided by the home. One person said 'If they give out medals I want her (the Manager) to have one. It's wonderful. Staff are so kind.' Another person said 'It couldn't be better. I've never been so happy. I don't want for anything. I can do my own thing.'

All the people and visitors we spoke with were positive about the staff. One person described the staff as 'nice and cheerful and helpful' and added 'It's good to have the girls (carers) here.'

One person told us there were 'more than enough staff' and added 'If you ask for something they'll rush to get it.' We asked if staff responded to their use of the call bell promptly and they said 'There's no complaints about using the call bell. It's fine.' Another person said 'Somehow they seem to know when I need help.

There was enough equipment to promote the independence and comfort of people who used the service. Appropriate arrangements were in place for the safe management of medicines.