Two Gates House

We found the following examples of good practice.

The provider maintained good levels of personal protective equipment (PPE) and staff were observed wearing PPE correctly.

The service was clean and effective systems were in place.

There was a booking in system for visits from family and friends, this helped monitor the number of people at the home. The registered manager had alternative methods to keep in contact with family and friends if they could not visit.

The provider stated there had been no impact on the care people received due to workforce challenges in the sector and when needed agency staff provided support to ensure staffing levels were appropriate.

Two Gates House is a residential care home that was providing personal care to 30 older people at the time of the inspection.

People’s experience of using this service:

People were supported by staff who knew how to manage risks and report any concerns they may have. There were sufficient numbers of staff to support people and medicines were managed in a safe way. There were effective infection control practices in place.

People’s rights were upheld in line with the Mental Capacity Act and were supported to access healthcare services where required. People’s dietary needs had been met. People were supported by staff who had received training and support.

Staff had developed friendly and kind relationships with people. People were supported to be involved in their care and had been treated with dignity and respect.

Records held personalised information about people and staff knew people well. Activities were available that met people’s individual interests. Complaints made were investigated and resolved.

The management team had a visible presence in the home and had friendly relationships with people. There were systems in place to monitor the quality of the service and people had opportunity to feedback on the quality of the service.

Rating at last inspection:

Requires Improvement. (Report Published 03 May 2018)

Why we inspected:

This was a planned comprehensive inspection which took place on 31 May 2019.

Follow up:

We will continue to monitor intelligence we receive about the service until we inspect again as part of our inspection programme. If any concerning information is received, we may inspect again sooner.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

During this inspection improvements have been made and the service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

This inspection took place on 8 and 12 February 2018 and was unannounced. Two Gates House can accommodate up to 32 older people who may have dementia in one adapted building. At the time of the inspection there were 24 people living at the home.

Two Gates House 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.

There was a registered manager in post who was also the provider. 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.

Improvements in the way risks to people’s safety were assessed and managed meant that people now had the support they needed. Staff moving and handling practices had improved and people were being supported in a safe way. There were processes in place to ensure the premises and equipment were regularly checked and to manage the prevention and control of infection. The registered manager reviewed accidents and falls to ensure people had the right support to keep them safe. Medicine practices had improved and we saw checks were in place to ensure people's medicines were managed safely and administered correctly. There were enough staff to support people’s needs and the provider followed safe recruitment practices. People told us they felt safe and staff knew how to report concerns about people's safety.

People's needs were assessed and people and their relatives told us they were happy with the care they received. People were supported by staff who had regular training to provide effective care for people. People were happy with the choice and quality of the meals provided and staff understood how to support people to eat and drink sufficient amounts to maintain their health. Staff communicated effectively between themselves and with other organisations so that people were supported to live healthier lives and have access to other professionals to meet their needs. The premises were suitable to meet the needs of the people who used the service. People are supported to have maximum choice and control of their lives and staff supports them in the least restrictive way possible; the policies and systems in the service support this practice.

People described the staff as caring and attentive and told us they enjoyed the fact that staff spent time with them. People's privacy and dignity was protected by staff and people were encouraged to maintain their independence. People were supported on a daily basis to express their views.

People were involved in the planning of their care and staff had knowledge of people's preferences so that people’s care was personalised. People told us staff responded to them without delay when they needed support. People enjoyed a variety of regular activities and events of their choosing. People and their relatives told us they were confident that if they had any concerns or complaints they would be listened to. Where complaints had been received they had been investigated and people had a written response to their concern with the outcome. The provider had linked with other organisations to source training and the development of care practices to support people approaching the end of their life, this showed a compassionate response to people's needs.

People and their relatives spoke positively about the management of the home and felt they could voice their opinions on the service. People told us there had been improvements in the way the home was run. The registered manager and provider had improved their systems to monitor the quality and safety of the service and had further developed aspects of the service to provide better outcomes for people. External professionals told us they recognised improvements in the way people’s care was managed and organised and that the provider had worked well with them to improve the standard of care for people. Whilst the systems in place now support the delivery of safe care to people the provider must ensure they can sustain these improvements and ensure the service is consistently well-led.

At our last inspection of the service in July 2016 we found that the provider was meeting regulatory requirements and the overall rating for this service was Good.

Two Gates House provides accommodation for up to 32 older people some of whom have a diagnosis of dementia. At the time of our inspection 29 people lived at the home. The home had 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 and associated Regulations about how the service is run.

The use of unsafe equipment had placed people at risk of harm. Risks to people's health and safety were evident due to trip hazards which potentially could cause people to fall. Worn equipment had not been checked sufficiently to ensure it was safe for use. Risks were not consistently assessed or managed which meant some people were at risk from avoidable harm. People’s care plans and risk assessments had not always been reviewed or updated and action had not always been taken to mitigate the risk of future events. People’s medicines were not managed safely or always administered at the intervals needed. People told us they felt safe and staff knew how to report concerns about people’s safety. Dependency levels had increased but there were sufficient staff to meet people’s needs. Recruitment practices required improvement to ensure references and health declarations were obtained.

The provider had not identified a number of areas of the service provision that were not meeting the requirements of the law. The systems used to monitor the quality of the service had not been fully effective in identifying concerns to people’s safety and people continued to be placed at risk of harm. Risks or changes to people’s needs were not always escalated and there were delays in the registered manager taking action to mitigate risks to people’s safety. The provider had a history of ineffective monitoring and audit processes previously in June 2014. This improved in 2016 but we found at this inspection they had been unable to sustain good governance arrangements or the progress they had made.

Action had not been taken in line with the expectations in place to comply with the regulations related to the Duty of Candour. This regulation requires providers to be open and transparent with people who use their service and other relevant people. It sets out specific requirements that providers must follow when things go wrong with people’s care or treatment. We identified shortfalls with how the Duty of Candour regulation was applied to a specific incident within the home.

Staff were supported in their roles through induction and training. Some training gaps were identified which the provider had plans to address. Staff did not always use their training effectively so people had been moved in way that increased the risk of injury to them. People enjoyed the meals provided and had positive support and encouragement. Staff sought consent from people and had some knowledge of the Mental Capacity Act (MCA) (2005). However staff struggled to ensure a balance in protecting people’s basic rights and taking action where people’s decisions put them at risk of harm. Where deprivations to people's liberty had been identified the relevant applications had been made.

People described staff as kind and caring. We saw staff were attentive and interacted with people and were respectful towards them. People’s dignity had been compromised by practices in the home which had not been recognised as an issue of dignity. People were supported to maintain their independence and visiting times were flexible to enable people to have regular contact with their family and friends.

People's care plans reflected their preferences and the way in which they preferred their care to be delivered. Some further detail was needed to ensure people’s specific needs were planned for. People were supported to take part in a range of activities they enjoyed. People’s views about the service were sought and the provider had acted on their feedback. The provider had a system in place to respond to people’s complaints and whilst some people told us they were confident these would be addressed, there was some inconsistency in resolving people's concerns.

The provider was working with a number of agencies in order to rectify the shortfalls identified. The provider had also agreed restrictions on admissions until such time the service was safe.

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

This was our first inspection of this provider using the new methodology introduced for inspections to provide a rating for the service under the Care Act 2014.

At our last inspection in June 2014 we found the provider was not compliant with our Essential Standard outcomes that we assessed at that time. People were not always safe because risks to their safety had not been fully identified or managed consistently. Learning from events such as accidents and incidents was not fully established to help reduce the risks to people. The quality assurance system and management overview was not effective in identifying shortfalls. The provider sent us an action plan and at this inspection we found that the provider had made the improvements needed.

Two Gates House provides accommodation for up to 32 older people some of whom have a diagnosis of dementia. At the time of our inspection 32 people lived at the home.

There was a registered manager in post who was also one of the providers. 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 who used the service and their relatives told us that they felt they received safe care. Staff had been trained to recognise harm or abuse and systems were in place for reporting these. Staff were able to describe in detail the needs of people they supported and how to promote people's safety. Risks to people's safety had been identified, assessed and were regularly reviewed. People told us they had their medicines when they needed them and the arrangements in place for managing people's medicines were safe.

People were satisfied with the numbers of staff on duty. People and their relatives had no concerns about staffing levels and described the staff as friendly and caring.

Staff had an induction into their role and support and training to ensure they had the skills to meet people's needs.

The Deprivation of Liberty Safeguards (DoLS) had been considered as part of people's care planning to protect their legal and civil rights. People's consent was actively sought before care was delivered.

People told us they enjoyed the meals provided and we saw they had the support they needed to eat and drink enough. People were supported to have their routine health care needs met and medical advice was sought to keep people safe and well.

We observed positive interaction between staff and people who lived at the home. People told us staff were kind, patient, respected their need for privacy and protected their dignity.

People were actively involved in planning all aspects of their care. Personalised care plans were in place and staff understood and followed people's preferences regarding how they wished their care to be delivered. People were actively supported to follow their interests and take part in social activities.

People, staff and relatives were encouraged to share their opinions about the quality of the service. We saw that the provider had a system in place for dealing with people's concerns and complaints. The providers systems to monitor the quality of the service were effective in ensuring the home was well-led.

We had been made aware of concerns prior to this inspection about delays in seeking medical attention following accidents people had. As a result we looked at records in the home and how the home monitored the quality of service to people.

Below is a summary of what we found. The summary is based on our observations during the inspection. We spoke with the eight of the 31 people who used the service, five care staff, three visitors, the provider, manager and deputy manager.

We found that the provider had improved how they involved people who use services in planning their care. We also found improvements in the way people's care was provided and how staff were supported to deliver care. However the way care was provided to people needed further improvement to ensure people's needs were met.

Is the service safe?

People we spoke with told us they were happy that staff met their care and support needs and they felt safe when staff supported them. A relative said, 'They are fantastic, very pleasant and always around. They are respectful and able to tell me about my (relative) as soon as I walk in'. Another relative told us how pleased they were that staff sought health care treatments when needed. We found that people were happy with the care they received.

Risks to people's health and welfare were identified and staff said they received updates when people's needs changed. Staff we spoke with were aware and able to identify the risks people faced such as fragile skin, risk of falls or not eating enough. We saw people had the equipment and support they needed to manage such risks. However this information was not fully reflected in people's care plans.

Care plans did not show how to support those people who got agitated or people who had specific health needs. Care plans did not provide enough guidance to staff as to how to support people, minimise identified risks and ensure a consistent approach to managing their needs.

There were a number of examples where information was either not recorded, or inaccurately recorded. Information was not always shared properly with other parties. The lack of precision in recording especially where information needs to be shared could result in delays to people having appropriate care and or follow up from external health care professionals.

Some improvements had been made to the procedures staff followed to ensure that people were safe. These included the process following a person falling. This was to ensure people did not have delays in getting medical help when they needed it.

There was a system for recording accidents. Records failed to show where people had refused treatment and did not show people had been seen by a doctor. There was evidence that learning from events such as accidents and incidents was not fully established to help reduce the risks to people.

Policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) were in place. This is legislation that makes provision relating to persons who lack capacity, and how decisions should be made in their best interests when they do so. At the time of our inspection no applications had needed to be made. Staff understood the requirements and what to do if a person needed protection.

Is the service effective?

We found that people had a care plan which set out their care needs such as any equipment, mobility aids and specialist dietary requirements they had. Improvements had been made in involving people in reviewing their care plans and identifying their routines and preferences. This was intended to ensure that people's individual care needs were met.

We found there was insufficient information in people's records about how to plan for and manage risks to their safety, for example people who expressed behaviour that was challenging. This meant that information was not always available to staff to allow them to offer consistent and effective support to meet people's needs.

The service was not always effective in communicating and engaging with people in a meaningful way. We saw that people who had dementia received less staff contact and stimulation than people who did not.

People had access to a range of health care professionals. People told us that staff contacted healthcare professionals when they needed it. It was not always clear from the entries in records that people's health needs were shared or reported effectively which could cause confusion.

Is the service caring?

People shared their opinions about the staff that supported them. One person told us: "I have always been satisfied with the care'. A visitor told us, 'The care is good and staff always show an interest because they update me with changes'. Another relative said, 'I think they could spend more time on helping and doing things with some people, there doesn't seem to be a lot happening in activities'.

We found staff were not always aware of the needs of people with dementia, and were not always aware of the need to plan for people's needs. There was a tendency to react to situations rather than look to meet the needs of the individual.

Is the service responsive?

The results of surveys (collated by provider) showed that the majority of people were satisfied with the care and support they received. People's comments had led to some improvements such as the continued refurbishment of the premises. We saw people had identified that improvements were needed in providing dignity for people, communication with service users and families, and further efforts in the provision of activities. The provider had an action plan to address these areas.

We saw that improvements had been made to the formal supervision of staff. Staff were receiving the training they needed to respond to people's care needs. The provider was aware that more direction to staff and observation of their practice was needed to ensure staff had structured support.

The provider had not taken into account people's concerns regarding the conduct of staff which could compromise people's safety.

Is the service well-led?

The service worked with other agencies and services to make sure people received the care they needed.

The quality assurance system and management overview was not effective in identifying shortfalls.

The assessment of risks and planning for them to keep people safe was not well managed. The provider and manger informed us they recognised the overview and management of the service was not working effectively and assured us improvements would be made to ensure that people receive a good quality service at all times.

We saw people and their representatives were involved in making decisions about their care, but care plans did not always capture all aspects of a person's routines or choices. We saw occasions where staff did not engage with people to help them understand the routines in the home.

We found that staff understood the importance of getting consent from people before they delivered care. We saw arrangements were in place to protect people who were unable to give their consent.

Care plans did not fully reflect the changing health conditions that people had. Information for staff about how they should support people was not in care plans and we saw some people's needs had not been met.

One relative told us they, 'Worried that things got missed', and that staff; 'Did not always appear to know the needs of people'. There was no evidence that staff competency and skill was monitored regularly to ensure they had the skills to do their job.

We found people had clean, comfortable and spacious accommodation. Appropriate arrangements were in place to ensure the safety of the premises.

We saw positive interactions between people living there and the staff team, staff spoke with people regularly, and we saw people responded to this. The atmosphere was friendly and relaxed.

Staff we spoke with presented as skilled and knowledgeable. They understood people's needs and knew how to support people with specific needs, such as eating and drinking enough.

People had care plans in place which are detailed and show how risks to people's health are met.

We found that staff had the support; guidance and training they needed to ensure people's needs were being met.

Systems are in place to monitor the quality of the service provided, and people who live there are involved in this process.

People told us their views and complaints are listened to and resolved. People's care records are held securely and their confidentiality is respected.