Archived: Western Rise

This inspection took place on 4 February 2016. We brought a planned inspection forward because we had received concerns about people’s health and welfare.

The service was last inspected on 9 January 2015, when it was rated as ‘Good’. Prior to this, the home had a history of not being able to maintain the standard of care provided to people.

This inspection took place as a result of concerns CQC received relating to the staff attitude, cleanliness and the care and welfare of people living at the service.

The registered manager for Western Rise had recently left. As a consequence there was no manager registered for the service. It is a condition of the registration for the service that a manager is 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.

Alternative management arrangements had been made. These arrangements were not robust and risks and quality issues identified during this inspection had not been identified by the management team. Action had not been taken to ensure people received a safe, effective, responsive and caring service. Although staff were well intentioned, they were working without clear leadership, direction or co-ordination. Staff talked about tasks that needed to be done and kept records relating to these. However, no one staff member had overarching responsibility for ensuring that people’s needs were met, and met in a personalised way.

The majority of staff were not trained in safeguarding people and did not understand whistleblowing procedures. Staff had not escalated concerns to the registered provider when action had not been taken to ensure people were safe. Recruitment of staff was not robust enough to ensure people of good character were employed.

Risks to people’s physical and mental health were not assessed or understood. As a consequence people were at risk of developing pressure sores, of becoming unwell because staff did not know about risks associated with their fluid intake, and at risk of not getting their medicines. Some people had mental health issues which were distressing to the person, and this distress was not managed. This was also distressing for others around them, and this was not managed.

There were sufficient staff on duty during the day, although we have asked the registered provider to review the staffing between 0630 and 0800am. However, staff did not receive the training or support they needed to meet their responsibilities, and to support people effectively.

The home was not clean and not well maintained. There was a strong smell of urine throughout the home and some toilets were dirty. Carpets were stained and many had significant burn marks. Parts of the home smelt of smoke. Some people were smoking in their room. One of these people had been assessed as not being safe to smoke without supervision. However, this person was smoking on their own. Fire checks had not been carried out since October 2015 and some fire doors did not close. We have shared this information with the local fire authority.

People did not always have their choice promoted. Many people were deprived of their liberty but staff did not know who had legal authorisations in place, and who didn’t. The front door, porch door, door to the kitchen and door to the lower floor had key pad locks on them. Only staff knew the numbers to these doors. All staff carried a master key which they could use to go into all the bedrooms. Staff had a poor understanding of the Mental Capacity Act (2005) and when making decisions for people, were not doing this in accordance with this law.

Staff made referrals to health care professionals. However, they did not always follow the recommendations provided. For example, one person had been prescribed nutritional supplements and staff were not monitoring to ensure this person took these. This person was losing weight.

People did not always have their privacy and dignity promoted. We sat that one person was calling out whilst being hoisted in the middle of a busy lounge. Staff did not respond to this person’s distress, or make attempts to protect their dignity. Distressed people, or people making requests, were sometimes ignored. People were not supported to maintain their independence or to develop new skills, and were not involved in planning their care. They spent much of their time sitting in the home. Many people said they would like to go out or do something, but there were no opportunities for this. There was a card making activity during our inspection, but people living at Western Rise said this type of activity was unusual.

Care plans did not contain information for staff on how to prevent behaviours which might challenge, or any specific information on what might help a person to be reassured or engaged. Some people told us about the small things that made them happy, but that these weren’t available to them. These included going for a walk .

People’s monies were well managed and kept safely.

We found ten breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and one breach of the Care Quality Commission (Registration) Regulations 2009 (Part 4). We have also recommended the registered provider keep the staffing levels under review.

We have shared our concerns with commissioners, with the safeguarding team and with the local fire authority. People’s care needs are currently being reviewed by the local authority commissioners.

We are taking further action in relation to this provider and will report on this when it is completed. The overall rating for this provider is ‘Inadequate’. This means that it 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.

• Services placed in special measures will be inspected again within six months.

• The service will be kept under review and if needed could be escalated to urgent enforcement action.

Is the service safe?

This inspection was carried out to assess what the provider had done in response to the action we had told them to take following our last inspection. This was in relation to the safe management of medicines.

This is a summary of what we found-

Is the service safe?

We found that there had been improvements made to the way medicines were managed and handled in the home. There were systems in place to manage medicines safely.

We met with the provider and new manager to discuss our concerns. We also liaised closely with the local authority and fire service.

This inspection was completed to ensure the concerns had been addressed. We found that improvements had been made.

The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

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 spoke to seven people who used the service and they said they were all happy with the care provided. They said they were treated with respect and dignity by the staff. There were enough staff on duty to meet the needs of the people who received care at the home. However not all staff had been suitably trained to meet the needs of people in the home. One person said 'I appreciate their (the staff) kindness and help ' they provide me with food, respect my privacy and dignity'.

We saw many of the areas within the home had been made safe, for example door locks had been removed or changed to enable people to leave their rooms safely. Areas of the home required further improvement as there were still strong odour in parts of the home despite the deep cleaning which had occurred.

Two workers from the local authority were working alongside Western Rise staff to monitor the improvement. They told us that since we had issued warning notices, staff had made considerable changes to their practice to care for people safely and well.

Is the service effective?

People's health and care needs were now being assessed with them where possible. The staff we spoke with had a clear understanding of the care and support needs of the people living in the home. We saw that people had outside support from their GP and other service such as from dieticians.

We discussed people's care needs with staff and they told us about people's needs and how they liked their care to be delivered. We saw that staff were visible and available to support people to meet their needs. We saw people were offered choices regularly. For example, where they wanted to sit and what drink they would like.

We also saw that the home had active Mental Capacity Act 2005 (MCA) applications in place for people who lacked the ability to consent to their own care.

Is the service caring?

During our observations and conversations we saw and heard examples of staff being respectful and treating people with dignity. They spoke kindly to people, were patient and when we spoke to staff they knew and understood people's individual needs. One person told us 'Staff are kind, they gave me lipstick, eye shadow and some playing cards'.

We saw that people responded positively to staff and the staff had the skills to communicate with people with a range of needs. We observed staff talking to people kindly and supporting people throughout the day. Care was given in an unhurried manner.

Is the service responsive?

Western Rise had undergone a lot of change since our initial inspection in June 2014. We found that they had addressed many of the concerns following our inspection. Further improvements were required but the provider had plans in place to carry these improvements out.

We saw people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. For example, we saw that where people had been reassessed it was recorded what help people needed with their personal care. There was written information and evidence in people's daily records that this help had been given.

We saw evidence that the care plans had been updated to ensure they were appropriate to people's current needs with further updates planned. The home was now responding to changes in people's needs. For example, care plans and assessments were reviewed regularly when changes in people's condition occurred.

Is the service well-led?

We spoke with the Registered Provider and Manager for the home. They showed us how they had made improvements following the serving of the warning notices. We found that the concerns were being addressed and changes made that ensured people were being protected from unsafe and inappropriate care.

There was not a Registered Manager in place. The previous manager had deregistered with CQC prior to this inspection process being completed. The newly appointed manager, who had yet to register with the Care Quality Commission, had made many improvements in the home. This included employing suitable experienced staff and in sufficient number to meet the needs of people living in the home. Staff were aware of the needs of the people living at the home and were able to meet them.

We saw the Manager of the home was experienced and knowledgeable. One person living in the home told us, 'There are enough staff, really it is none of my business but I am never short of help.'

The home currently had two workers from the local authority working alongside Western Rise staff to monitor the improvements. They told us, 'There has been a 70% improvement, it was worse than jail before but staff are now more relaxed, they work well together, people are more relaxed, they are less aggressive.' This told us that external agencies were confident improvements were being made.

Is the service safe?

This inspection was carried out to assess how medicines were handled and managed in the home. This was to follow up on some issues that were found at a previous inspection.

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.

This is a summary of what we found-

Is the service safe?

We found that there were not appropriate arrangements in place to manage medicines safely at the time of this inspection. We saw that the management of medicines was being improved in the home, but we found that these improvements were not yet completed.

We also reviewed concerns from our previous inspection on the 4 December 2013 due to concerns about people with reduced capacity not having their mental capacity assessed and consent sought.

Two inspectors completed this inspection. We carried out this inspection by speaking to people who live in the home; speaking to professionals with knowledge of the home and by observing how care was given to people. We also reviewed records held about people's care (called care plans) and other information provided by the home.

We read eight care plans and spoke with nine staff and those in management roles. We visited all the people in the home and spoke to them. Two people chose not to talk to us and this was respected.

When we inspect we gather evidence to answer the questions below:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Below is a summary of the inspection and what we found.

Is the service safe?

We found Western Rise was not a safe service as we found that the home was failing to meet people's basic needs and people's individual choices. Many people living at the home did not have the ability to consent and the home had not ensured they were lawfully protected.

People told us: 'I find it a terrible place, this place; it's a diabolical place. It stinks' and 'I pray for company.'

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), and to report what we find. The DoLS apply to care homes and hospitals. We found that people's records did not include an assessment of their mental capacity or referenced whether the DoLS were relevant. We found that it had become common practice in the home that people were being deprived of their liberty illegally.

Staff told us it was common practice to lock people within their rooms to respect their privacy without ensuring they had the means or ability to call for assistance, support and help. Some people lacked capacity and/or others did not have a call ball or means to contact staff to seek help. When people rang the call bells it was taking too long to answer them and people's dignity was being affected as a result.

There was insufficient staff in both number and who were suitably trained and equipped to meet people's needs.

We requested the fire service attend the home as we were concerned about the safety of people in the event of a fire. They found serious failings in the home and acted in line with their own legislation.

We found the condition of the building to be poor and infection control policies and practices were not being followed. People were being placed at risk of infection as a result.

Is the service effective?

We found that Western Rise was not an effective service. They had not ensured people's care needs were being fully met and their care planning was sufficient to ensure this was personalised.

We found three of the first few people we saw required a GP appointment as the carers had not identified they were poorly or responded to requests for support and help.

We saw that staff were rarely visible in the communal areas so it was difficult to assess if people's consent was being sought on each occasion as expected.

People were not supported to take part in activities. We found that people were isolated socially from others. We found that people's rooms, the way they were dressed, how often they were bathed and how their records were written were completed in a way that did not respect the individual needs, wants and desires of that person.

Is the service caring?

We found that the home was not meeting its requirements as a caring service.

People told us: 'I like it here but there is no one to have a conversation with; I just come up here (to my room) and read a book'; 'I am looked after as good as can be'; 'The staff are very good; you get the odd one but you can't help that' and 'One thing this house needs is something to do. After lunch I just go back to my room'.

We found that the staff were looking after people that had high needs. Staff told us they were under pressure when working night duty to get 10 service users up regardless of whether they wanted to. This was to support the day staff. We saw one person had been awoken, washed and dressed and placed in their chair by 6.30am on the second day of the inspection. They told us this was not their choice. They had their breakfast much later and as they were diabetic there was a risk of a direct impact on their health and welfare. For many of the people who were up early we were told they were given two breakfasts as there was such a long time between their getting up and lunch time.

The professionals we spoke with told us they called the GP often and in a timely way and the district nurse told us the home was 'better than it used to be' and 'the staff are very good, obliging and seem to have a good rapport' with people.

Is the service responsive?

Western Rise was not 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 saw that people's adverse behaviour was not seen as a form of communication. Instead of exploring the behaviour we heard people referred to by their diagnosis. For example, they were only acting like that because they have mental health issues.

We found that staff lacked the skills to meet people's individual complex needs. There were situations that the inspectors had to intervene in to support people in the home having their needs met and ensure they were safe.

We were told 'Staff sometimes come. Sometimes I have to shout when I use the call bell'. When we rang the call bell on both days to follow up people's concerns we found that the bells took a long time to answer. People told us they soiled themselves as staff took so long. This meant people's dignity and respect were affected as a result.

We found that external agencies were not brought in readily enough to ensure people's needs were being correctly assessed. We found two people who required urgent assessment to ensure the equipment and methods used to move them were meeting their needs and keeping them safe.

Is the service well led?

We found that the home was not well led and serious concerns arose about both the Registered Manager and Provider. On the first day we met with both of these and were introduced to a new member of staff who was identified as the new Deputy Manager. There was also the Area Manager, who was the manager of another home owned by the same Registered Provider.

We were shown a number of immediate steps the Area Manager had taken on hearing of the concerns CQC was made aware of that instigated our inspection.

We found that the Registered Provider had not ensured learning had been transferred from their other home to this one. The Registered Manager and Provider had failed to act to prevent the situation we found when we carried out our inspection.

We found the home lacked structure, routines and people's individual care needs were not met. No one had audited the physical appearance of the building and acted to ensure this was safe.

Visiting professionals gave a previously positive picture of the Registered Manager and the home's ability to meet people's needs.

We spent time observing care and looked at six care plans in detail. On the day of our inspection we were told that 25 people were living at the home.

Some people who lived at the home were deemed not to have the mental capacity to make decisions. We found that best interest assessments had not been completed for some decisions made on behalf of people who did not have capacity. We found that assessments of people's capacity had not been completed in line with the principles of the Mental Capacity Act 2005.

One person said 'They (the staff) are brilliant. It is really good here'. Another person said 'They really do a good job'.

Care plans showed that healthcare professionals were involved as necessary in people's care.

The premises was safe and suitable for people who lived there.

Staff told us they felt supported by the manager. We saw from records that staff had received training and supervision.

Every person we talked with described the staff as kind. We observed positive interactions between staff and people. We saw that people appeared relaxed and happy.

Records were stored securely and kept for the appropriate time period. There was a system in place for securely destroying records when appropriate to do so.

We, the CQC, spoke with the manager and three care staff. We asked care staff if they had received supervision, appraisal and training. They said they had received supervision and appraisal however we found that training had not been completed. One member of staff said 'Oh yes, training is something that we really do need'.

Staff were knowledgeable about how to deliver safe and effective care and could answer our questions about safeguarding, manual handling and supporting people with their personal care needs.

We looked at staff records. We saw that the home had started to make improvements with completing supervisions and appraisal however we saw that most staff had not received up to date training. This meant that people were at risk of receiving care and treatment that was inappropriate or unsafe.

The manager was open with us and told us that the home had not made any improvements with regards to training since our last inspection. We expressed our concern at staff not having received current training and the potential negative impact that this could have on the quality of care given to people who lived at the home.

The manager gave an assurance that, as a priority, staff would be updated on mandatory training.

We (the Care Quality Commission) spoke with five people, the provider (owner), manager and three carers. We also spent time observing care and lunch time and looked at four care plans in detail. On the day of our inspection we were told that 26 people were living at the home and receiving care from the service.

One person said 'Yeah they look after me well here'. Another said 'Yeah I like it here. The staff are all brilliant.'

Care plans showed that healthcare professionals were involved as necessary in people's care, although record keeping did not always make this obvious. The provider agreed to act promptly to address the strong offensive odour in several people's rooms.

Medicines were being managed safely and equipment had been tested as needed.

Staff were not receiving appropriate training and supervision.

All the people we spoke with described the staff as kind. Quality assurance processes were reasonable and the provider described the improved quality assurance survey to be carried out in January 2013. The provider and manager said that statutory notifications were being made to CQC as required.