Two Acres Care Home

People’s experience of using this service:

This service has been in special measures. 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 time frame. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of special measures.

Some improvements were still required to records, quality monitoring systems and health and safety checks, however overall, we found significant improvements to the quality of the care provided.

The provider had implemented a number of wide-ranging changes across the service which had improved the quality of the care provided. These included changes to the management team, the introduction of an electronic care management system, an increase in staffing levels, a reduction in the use of agency staff, and changes to the quality monitoring processes in the home.

People using the service were safe. Risks to people were monitored and responded to. Systems to safeguard people were in place and concerns were reported appropriately.

Staffing levels in the home had been increased and people were supported by staff who knew them well.

Regular audits of medicines were made and improvements had been made regarding their management and administration.

Improvements in how people were supported at meal times had been made. People had choices in relation to the meals on offer and were more involved in discussions regarding food options.

Staff sought people’s consent regarding the care provided and their ability to make individual decisions was assessed and recorded.

Positive outcomes were achieved for people through staff working effectively with others.

There was good training and support for staff to help them understand and meet the individual needs of people using the service. This included regular competency checks and observations of staff practice.

The provider had implemented a programme of refurbishment across the home. Environmental improvements had been made. The design and decoration of the building met people’s needs.

Staff were kind, caring, and supported people’s dignity and independence.

Systems had been improved to ensure people and relatives were engaged and involved regarding decisions about their care and support.

Improvements had been made to people’s care plans and their involvement in them. The care provided met people’s individual preferences and needs, this included in relation to the provision of activities.

Positive comments were received regarding the manager, their openness, and their proactive approach. Improvements had been made to the involvement of people, relatives, and staff in the running of the service. People and relatives felt listened to and staff morale had improved.

Rating at last inspection: Inadequate; published 22 November 2018.

Why we inspected: This was a planned inspection based on the rating of the service at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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

Two Acres is a ‘care home’ providing nursing and residential care. 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.

The home is divided into four units. Three nursing units Rose, Lily and Iris and one residential, Fern unit. Rose and Fern units had shared bedrooms as well as single occupancy rooms. At the time of the inspection, there were 70 people receiving nursing care, and 13 receiving residential care.

The service 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 2008 and associated Regulations about how the service is run.’

At our last inspection on 5 and 6 September 2017, we rated the service overall requires improvement, with inadequate for the key question, well-led. We found breaches of regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Improvements were needed in relation to safe care and treatment, good governance practices and procedures and for sourcing consent from people living at the service.

Following this inspection, we took enforcement action and told the provider they had to send us monthly updates, linked to an improvement plan in relation to safe care and treatment. The required updates needed to cover nurse competency and implementation of training into practice, particularly in relation to medicines management and pressure care. Completion of four weekly audits of medicines management across the home were also required. Where concerns were identified as part of the provider’s medicine audit process, the conditions stipulated the need for the registered manager to implement management and contingency plans to mitigate risks.

During this inspection we identified repeated breaches of regulation and ongoing failings in the service's governance systems. We identified areas of concern in relation to staff competency in safe support of people experiencing dementia and complex physical health care conditions. There were significant shortfalls in the assessment and mitigation of risks to people using the service.

The service did not have robust governance processes in place for monitoring standards and quality of care provided. The registered manager and provider did not complete quality audits in areas such as documentation and equipment such as bed rails.

Staff were not consistently implementing training in the care and support of people living at the home. People’s records demonstrated a lack of consistent adherence to the Mental Capacity Act 2005. Concerns were identified around management of people’s food and fluid intake, with a lack of meal choices.

Low staffing levels impacted on people’s access to meaningful activities and care records lacked detail in relation to people’s hobbies and interests. There was not an up to date, daily activity timetable.

People were not consistently treated with care and compassion, and their privacy and dignity was not routinely protected. Staff did not consistently provide person-centred care to people living at the service.

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 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.

The home consists of four separate units, named Iris, Lily, Rose and Fern, set in landscaped grounds. At the time of our inspection Fern unit was closed for refurbishment and there were 69 people living in the home within the other units.

This comprehensive inspection included two visits to the home, which took place on 5 and 6 September 2017. The first visit was unannounced. The second visit was arranged with the registered manager to complete the inspection.

This home requires a registered manager as a condition of its registration. 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 home is run. There was a registered manager in post who had been in post since April 2017.

We had previously inspected this service on 1 and 10 August 2016. We found that the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of two of the regulations which were for staffing and good governance.

At this inspection we found that the provider had taken action to ensure there were enough staff to keep people safe and provide them with basic care, therefore they were no longer in breach of this regulation. However, we found that although there were enough staff to keep people safe, there were not always enough staff to provide people with individualised care.

The provider had not taken the necessary actions to meet the requirements of the regulation relating to good governance. They had not adhered to their action plan they had sent us since the last inspection and were still in breach of this regulation.

We also found that the provider was in breach of a further two regulations during our most recent inspection. These were in relation to mental capacity and safe care and treatment. We found that people’s mental capacity assessments (MCAs) had not always been fully completed detailing specific decisions. There were no records of best interests meetings having taken place with regards to people’s care when they lacked capacity. Mental capacity assessments and DoLS applications had not always been reviewed and the conditions of DoLS were not always met.

People’s risk of developing pressure ulcers and the subsequent treatment of these pressure ulcers was not adequately recorded, monitored and understood. The ongoing risk assessment process when people had a pressure ulcer was not always thorough.

The systems in place for monitoring the service in order to identify areas for improvement and take action were not effective. We saw that where audits had been carried out and identified concerns, no further action had been taken. The registered manager and the provider had insufficient oversight of the effectiveness of the service.

People did not always receive person-centred, individualised care. There were not always plans in place to fully guide staff on people’s individual needs and preferences, and staff did not always have time to deliver person centred care according to these needs.

We found that most people’s medicines had been administered as prescribed, however we found that not all medicines had been managed safely. We found that medicines errors or omissions had not always been reported, and that there were not effective systems in place for ensuring the correct stock counts were in place. There were no actions taken when concerns had been found.

We found that staff did not always record people’s fluid intake where they needed full assistance to have drink, so the registered manager could not be assured that people received enough to drink across the home. People received enough to eat and on most units, where people could choose, they were offered a choice of meals. In other cases, care staff knew people’s preferences and provided this with regards to their meals. Meals took a long time because most people required full support with them.

Staff were supported to undertake qualifications in health and social care and further training if they wished. They also had supervisions and appraisals where they could discuss their roles.

People were supported to access healthcare, and staff were responsive to emergencies and worked well as a team.

Staff were caring and compassionate, building positive relationships with people and their families. They respected people’s privacy and dignity, and where possible, encouraged people to maintain their independence.

People were supported to engage in a range of activities and follow their interests where possible. However some people were not always able to choose how they spent their time and did not always receive the level of care they preferred.

The staff team who worked well together and communicated well. They found the registered manager approachable and the registered manager maintained visibility throughout the home.

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

This comprehensive inspection included two visits to the home, which took place on 1 and 10 August 2016. The first visit was unannounced. The second visit was arranged with the registered manager to complete the visit and provide full feedback.

This home requires a registered manager as a condition of its registration. 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 home is run. There was no registered manager in post. The provider had appointed a manager who had been in post for two years. They were in the process of submitting an application to CQC to register as manager of Two Acres. The manager was on holiday during our first visit to the home.

Staff had undergone training and were competent to recognise and report any incidents of harm. Potential risks to people and to their health were assessed, recorded and managed so that people were kept as safe as possible. Medicines were managed safely so that people received their prescribed medicines.

The provider had followed a recruitment process that ensured that required checks had been undertaken before new staff started work. There were not enough staff on duty to ensure that people’s assessed needs were met.

Staff had undertaken a range of training courses and received support so that most staff were equipped with the knowledge and skills to do their job well.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS), which apply to care services. People’s capacity to make decisions for themselves had been assessed. Appropriate applications had been made to the relevant authority to ensure that people’s rights were protected if they lacked mental capacity to make decisions for themselves. DoLS authorisations were handled well.

People were supported to maintain good health and their healthcare needs were met by the involvement of a range of healthcare professionals. People were not always given sufficient amounts of food and drink and the nutritional needs of people who required special diets were not always met.

There was a range of quality in the care provided. Most staff showed that they cared about the people they were looking after and treated people with kindness, warmth and compassion. Some staff did not show respect for people and people’s privacy, dignity and confidentiality were not always upheld. Visitors were welcomed to the home at any time.

Care records included care plans which gave staff guidance on how to meet people’s needs. Care plans were not always personalised and had not always been updated to reflect each person’s current needs. Staff were not always able to fully meet each person’s needs as they did not have enough time.

People and their relatives knew how to complain and complaints were responded to in a timely manner. Some activities, outings and events were arranged for people but people did not always have enough to do to keep them occupied and stimulated.

People and their relatives were encouraged to share their views about the service being provided to them in a number of both formal and informal ways. Staff were also given opportunities to share their views about ways in which the service could continue to improve. Staff understood the provider’s whistleblowing policy.

Audits of aspects of the service were carried out but these had not always identified shortfalls in the quality of the service being provided. Records were not always maintained as required.

We found two breaches of the Health and Social Care Act 2008 (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.

Is the service caring?

Through observations, inspection of records and talking with staff and management we found the staff and managers knew the people living there well and had ensured the care offered was correct for the individual.

We listened to respectful discussions that showed staff were acting in the best interest of the person they were supporting. Explanations on what was happening were given slowly and people were given time to understand.

Comments from relatives were positive. They told us the home was caring and that they would not want their loved one living anywhere else.

Is the service responsive?

At the last inspection the provider produced an action plan showing how the environment was to be improved. During this visit the action plan had almost been completed.

In care records we noted individual support from health professionals was gained quickly when a concern was identified. For example, we read referrals to dieticians or continence advisers within 24 hours of a record stating a concern.

Is the service safe?

The home was split into four separate units. Due to the complex needs of the people living there outer doors had a key pad locking system. In some units, where the people were more mobile, sensor equipment was used to monitor when someone was up and out of bed or when they moved through their bedroom door. This could be turned off when not required. Risk assessments were completed to ensure these were managed correctly and safely according to the need of the individual person.

The home had recently needed to work with the local safeguarding team and quality monitoring officer in the local authority. We spoke with one of these professionals who assured us that the situation of concern had been fully investigated and that people concerned were safe.

Walking around the home we did not see any concerns regarding environmental safety. Staff told us they had health and safety checks carried out and any damage or building concerns would be dealt with. Fire officers had visited the building in January 2014 and a few changes to the property were required. Door strips had been put in place and rewiring in one area was planned.

Is the service effective?

The four buildings were of varying sizes and shapes. According to their individual needs people are placed in the most appropriate building. For example, one unit had a much bigger lounge and dining area that could accommodate people in wheelchairs and specialist chairs. One unit was smaller but had better areas for people who were mobile and preferred to walk.

We noted that staff interaction and the methods used were effective when a person did not understand or was unwilling. This ensured that people who may challenge the need for care and support received that support appropriately.

Clear records of assessment, care needs, outside professional support and risks were tailored to meet the individual needs of the person the plans of care belonged to. This ensured they had the correct and effective support required.

Is the service well led?

Staff told us that the home had improved in recent months and that the manager listened to what was said. The manager told us she worked shifts on the staff rota to observe the work taking place on the units. This ensured any concerns or issues could be addressed quickly.

We read the complaints system records and noted that action to address complaints or concerns were timely and appropriate.

We read the most recent questionnaire sent to families who praised the service. Where some concerns were highlighted the manager had started to act upon them.

We spoke with staff who were happy with their work and felt they were supported well with training, supervision and guidance.

Throughout the inspection the manager gave us information and an understanding that assured us she knew the people and staff in the home well. A night manager had been introduced recently to ensure the night shifts were supported by management as well as during the day. The manager explained how this leadership had helped with the 24 hour service provision.

Medicines were prescribed and given to people appropriately. We reviewed eight people's medication administration records, four people on Lily Unit and four people on Rose Unit. We saw that medication was appropriately documented and each dose signed for by a responsible member of staff.

During this inspection, we undertook a tour of the premises and noted that it was adequately maintained. All areas were clean and tidy and free from obstruction. Hand rails were available to support people who were able to walk around the building and appropriate signage was displayed to enable people to orientate themselves to the toilets and their own rooms.

Staff were able, from time to time, to obtain further relevant qualifications and records in relation to the running of the home were up to date, accurate and stored securely.

Visitors told us that they were happy with the care and support provided by the service and that people experienced a good range of meaningful activities. One person described the care as 'wonderful.' They said that the staff kept them "'up to date' with their relative's progress.