Garlands Residential Care Home Limited

Garlands is a residential care home providing personal care to 20 people aged 65 and over at the time of the inspection. The service can support up a maximum of 20 people. Garlands is a converted property with communal areas on the ground floor and bedrooms on both the ground and first floor.

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

People were protected from abuse and avoidable harm. Risks identified at our previous inspection relating to fire safety, safety of equipment and premises and cleanliness had been addressed. Staff were recruited safely and there were enough staff on duty to meet people’s needs. The administration of people’s medicines was safe.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. Where people lacked capacity to make decisions, we saw evidence of capacity assessments and best interests decision making.

New staff were supported through training and induction. There was a programme of ongoing training and regular management supervision for existing staff. People were supported to eat and drink. We saw staff involved other healthcare professionals as required. There was a system in place to ensure relevant information was communicated within the staff team.

People were treated with dignity and respect. Privacy was respected and staff encouraged people to maintain their independence. People were offered choices and were encouraged to be involved in decisions regarding their care and support.

An accurate, complete and contemporaneous record of each person’s care and support was not always maintained. Nutritional supplements were not always record on people’s fluid intake charts. Staff did not always complete people’s fluid records in a timely manner. We saw improvements had been made to the content and accuracy of peoples care plans. People were supported to participate in a range of activities. No formal complaints had been received since our previous inspection.

People, relatives and staff told us the home was well led. A number of improvements had been made since the last inspection including more regular audits. However, we found these audits had not identified or addressed the shortfalls we found with, for example, peoples records. Regular meetings were held with people, relatives and staff. The registered provider and registered manager had worked closely with the local authority and had attended good practice events to learn and improve the quality of care they provided for people.

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 8 February 2019.

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 significant improvements had been made however, further improvement was needed. The provider was still in breach of a regulation.

This service has been in Special Measures since 17 December 2018. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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

Garlands Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Garlands Residential Care Home accommodates a maximum of 20 people; there are communal areas located on the ground floor with bedrooms situated on both the ground and first floor. The home provides care and support to people who are assessed as having personal care and support needs. There were 18 people living at the home at the time of the inspection.

The service had a registered manager in place. 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.

People were not adequately protected from the risk of fire. We saw gaps in the ceilings, in the event of a fire this would enable the fire to spread quickly throughout the home. The stair lift had not been tested to ensure it met with current safety legislation and we saw a wheelchair which was not safe to use. Some areas of the home were visibly dirty. We also identified some mattresses and cushions which were soiled inside their covers and needed to be replaced.

Risk assessments were not always sufficiently detailed or reflective of people’s current needs.

We saw people’s medicines were not always administered safely. There was a lack of guidance for staff regarding the administration of ‘as and when’ required medicines.

There were systems in place to reduce the risk of employing unsuitable staff. There were sufficient staff on duty to meet people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However, records did not evidence lawful consent was consistently provided.

The staff team communicated with each other and shared relevant information. People were supported to access external health care professionals when their health needs changed.

When people had lost weight, appropriate referrals were made to the dietician. Where nutritional supplements were prescribed, records did not evidence these were provided in line with the prescriber’s instructions. The care records we reviewed did not always include sufficient detail to ensure people’s care needs were met. The content of some care records was conflicting. Care records did not include information regarding people’s end of life wishes. We have made a recommendation about end of life care planning.

Relatives told us the staff were caring and kind. Staff clearly knew people well and spoke about people in a caring way. We saw evidence people’s individual beliefs were respected but we also saw examples of staff not treating people with dignity and respect.

Verbal complaints were not recorded and had not been an opportunity to review the quality of the service people received and or make any improvements.

The registered provider and the registered manager were present in the home daily. Everyone we spoke with told us they were friendly, approachable and caring.

During our inspection we identified numerous concerns. These demonstrated that systems of governance were ineffective in assessing and monitoring the quality of the service. Audits on some aspects of the service were not sufficiently robust and audits on some aspects of the service were not completed at all.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

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 act 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.”

During this inspection, we found breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014, related with dignity, consent, safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Garlands Residential Care Home, known as Garlands to the people who live there, their relatives and staff, provides personal care for up to 20 older people, some of whom are living with dementia. Accommodation is in single and double bedrooms. On the day of our inspection there were 17 people living in the home.

The service did not have a registered manager. 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. The current manager of the home had commenced their application to register with CQC but their application had not been finalised at the time of this inspection. The nominated individual was also applying to register as joint registered manager.

Robust emergency plans were not in place in the event of a fire because fire drills had not been regularly completed to reduce risks to people, and staff gave us inconsistent information about action they should take in the event of a fire.

We found improvements needed to be made to the registered provider’s system of water temperature checks to ensure people were not at risk of scalding, as recommended by the Health and Safety Executive.

People told us they felt safe. Staff had a good understanding of how to safeguard adults from abuse and who to contact if they suspected any abuse.

Risks assessments were individual to people’s needs and minimised risk whilst promoting people’s independence.

Effective recruitment and selection processes were in place. Two staff members had recently commenced employment without a reference from their most recent employer; however alternative checks and safeguards had been put in place until references were received.

We found improvements had been made in the management of medicines, although some minor discrepancies were found during our inspection.

Staff told us they felt supported. Records showed they had received an induction and role specific training; however we saw staff supervision was minimal. This meant staff were not always supported to fulfil their role effectively.

People were supported 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 practice, although some best interest processes had not been evidenced; for example, when consenting to the bedroom door being locked during the day. We made a recommendation about good practice where people may lack mental capacity to consent to certain decisions.

People told us they enjoyed their meals. People’s nutritional needs were met and they had access to a range of health professionals to maintain their health and well-being.

The home had begun a building programme to extend the facilities and upgrade the environment to be more suitable for people with a physical disability. The environment had been adapted to be more suitable for people living with dementia, although the décor in some areas was in need of refreshing.

Staff were caring and supported people in a way that maintained their dignity, privacy and diverse needs. Relatives told us staff were caring and we observed staff interacting with people in a caring, friendly manner. Observation of the staff showed that they knew people well and could anticipate their needs.

Individual needs were assessed and met through the development of detailed personalised care plans. People’s needs were reviewed as soon as their situation changed.

An activity coordinator had been employed at the service, which meant improvements had been made in the provision of activities.

Systems were in place to ensure complaints were encouraged, explored and responded to in good time and people told us staff were always approachable.

The registered provider and manager were available in the home to provide support and had an overview of the service. There were gaps in the auditing and overview of the service, which meant some of the issues we found had not been identified or addressed.

The manager and registered provider knew the needs of people who used the service and people and staff were positive about their input in to the service. People told us they liked the family atmosphere of the home.

The manager had taken some action to improve the quality of the service during the months prior to this inspection.

People who used the service and their relatives were asked for their views about the service and these were acted on.

We found breaches of the health and social Care Act (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Garlands Residential Care Home provides personal care for up to 20 older people, some of whom are living with dementia. On the day of our inspection there were 18 people living in the home most of who were living with advanced dementia. Accommodation is in single and double bedrooms.

There was a registered manager in place who had been registered. 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.

Staff had received training in how to keep people safe. All the staff we spoke with demonstrated they understood how to ensure people were safeguarded against abuse and they knew the procedure to follow to report any safeguarding incidents.

Risk in some areas was well recorded such as for nutrition and skin integrity. Risks around the use of assistive equipment such as use of the stairlift, wheelchairs, and bathing equipment was not recorded to ensure identified risks were reduced to the lowest possible level to keep people safe.

We found examples of poor practice with the storage and administration of some medicines particularly those which were not administered through the monitored dosage system. This breached Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 around safe care and treatment.

Staff had received training to enable them to develop knowledge and skills to develop in their caring role. They also received regular supervision.

People were provided with nutritious meals and frequent drinks which meant people’s nutritional and hydration needs were met, although this was not always recorded in detail in people’s care records. However, the service was in the process of making improvements in this area of recording and the local authority had provided additional training on record keeping in general.

The service sought the assistance of health and social care professionals to ensure people were provided with appropriate and effective solutions to any health and social care issues.

The environment and decor in some areas was in need of refreshing and updating to be suitable for people living with dementia and/or physical disability. The home was to undergo a building programme to extend the facilities which will upgrade the environment to be more suited to people with a physical disability and those living with dementia and they are awaiting a start date from their chosen builder.

We found all the staff to be caring in their approach to the people who lived there and treated people with dignity and respect. We observed staff to be kind and compassionate throughout our inspection.

The service was not providing meaningful activities for all the people living there and there was little activity for those people who were difficult to engage to ensure their mental wellbeing. We found this was a breach in Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 around person centred care.

The management team were visible in the service and ensured there was cover in the absence of the registered manager who was not present on the first day of inspection. They knew the people who lived there well. They were passionate about the home and staff said they felt supported and listened to by the management team and told us they could make suggestions for change to improve the service.

Systems to assess and monitor the quality of the service were not robust enough to ensure the standards of care were effectively audited to drive up the quality of the service and although the home was proactive in following suggestions for improvements, they did not have a system in place to monitor and measure the service against good practice guidelines and regulations.

You can see what action we told the provider to take at the back of the full version of the report.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key 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. The summary describes what we observed, the records we looked at and what people who lived at the home and the staff told us.

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

Is the service safe?

People were cared for in an environment that was clean and hygienic. There were enough staff on duty to meet the needs of the people who lived at the home. One person living at the home told us, 'They seem to have plenty of staff around and they're always friendly.'

Is the service effective?

We looked at three people's care files we saw their individual needs were assessed thoroughly and care and support was developed from an assessment of their needs.

People were provided with a healthy nutritionally balanced diet to support their health, this protected people from the risks of inadequate nutrition and dehydration.

Is the service caring?

People were supported by kind and attentive staff who obviously knew people well. We saw that care assistants were patient and encouraging when supporting people.

The provider told us, 'The care here is 100%, All the staff do their best for people.'

The three people we spoke with all told us they were very happy with the care provided at the home. The care assistants we spoke with told us they felt confident the service provided to people who lived at the home was good and they had a good staff team. When we looked around the home we saw people's bedrooms had been personalised and contained personal items such as family photographs.

Is the service responsive?

We saw from the care records that people's needs had been assessed before they moved into the home. Records confirmed people's preferences, interests and life histories had been recorded. The care, treatment and support provided at the home met their individual needs. People had access to appropriate activities and were supported to maintain relationships with their friends and relatives.

Is the service well-led?

Staff we spoke with told us they felt well-supported by the home manager and the provider. One of them said, 'The manager is really lovely; very approachable and encouraging.'