Archived: Overstone Retirement Home

The requirements of the provider's registration currently do not require a registered manager to be in post. However, the provider told us they had changed their legal entity to that of a limited company, and as such they planned to amend their registration with the Commission imminently, which would require the appointment of a registered manager. 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. We will monitor that the relevant applications are made to alter the provider's legal entity and we will ensure that this matter is addressed promptly.

We carried out this inspection to check whether improvements had been made since our last inspection in July 2016 at which multiple breaches of Regulations 12, 13, 17 and 20a of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 were identified. In response to our findings at that time, we took enforcement action against the provider. At this inspection we found that improvements had been made but some minor shortfalls remained. The provider had achieved compliance with all five of the regulations that were previously breached, but a new breach was identified.

People told us they felt safe and they had no concerns about how they were treated. They described staff as kind and caring and said they felt completely "at home". Previous failings with the management of safeguarding incidents and medicines had been addressed. Staff had been retrained since our last visit to the home and the provider was clear on their personal responsibility to report and progress matters of a safeguarding nature.

Improvements in how safely medicines were handled had been made and effective auditing of medicines processes and procedures had been undertaken.

Environmental risks had been addressed and window restrictors had been fitted throughout the home to help people remain safe. Water temperature checks had been undertaken to ensure they remained within safe limits to prevent the development of legionella bacteria in the water supplies within the home. General health and safety checks had been reviewed by an external company and personal emergency evacuation plans (PEEPs) were in place. Emergency planning had been considered and a file containing information for staff to refer to was being developed.

Accidents and incidents were managed well and people received the attention and support they needed to remain safe.

Staffing levels were consistently maintained. Staff training was carried out in key areas, such as medicines management and safeguarding, and also in areas specific to the needs of the people supported by the service, such as nutrition awareness. Staff supervisions were carried out and a new annual appraisal system had been introduced and had commenced.

People said that staff met their needs. The healthcare professional we spoke with reflected that any requests they received for support or input into people's care, were both proportionate and appropriate. People were supported to maintain their general health and wellbeing and attend appointments, for example, with their dentist and opticians. When people were ill, records evidenced that GP's were called.

CQC monitors the application of the Mental Capacity Act (2005) and deprivation of liberty. Applications to deprive people of their liberty lawfully had been made to prevent them from coming to any harm where they lacked capacity. The provider and senior care worker advised us that no best interests decision making had taken place in the service since our last visit in July 2016. They told us they routinely assessed people's capacity when their care commenced and on an on-going basis, and they would include people's families in decisions where relevant, and appropriately record any decisions made.

People were supported to eat and drink in sufficient amounts to remain healthy and although no person was being monitored for their food and fluid intake, tools were in place to facilitate this should it be necessary. People spoke highly of the quality and variety of home cooked food that they were served.

Staff and people enjoyed good relationships with each other. We observed staff treated people with respect and people told us that their dignity was maintained at all times. People were encouraged to be as independent as possible and they told us they made their own choices. Several people accessed the community on their own, or with friends and family. People pursued activities of their choosing. There were limited activities within the home but they were in line with people's needs. A large selection of films, games and books were available. People told us they enjoyed regular film nights put on by the provider.

Care records were person-centred and provided staff with information about people's dependencies, needs and the risks they faced in their daily lives. Care records were regularly reviewed. The care people received was individualised and specific to their needs. People and their relatives told us they had not had any reason to complain about the service and records reflected no complaints had been made. People told us they had choices about how they lived their lives and they were supported to be independent by staff.

Governance systems had been reviewed and staff meetings introduced which staff said they appreciated and found useful. Auditing was in place but in some areas such as infection control and health and safety, further developments were needed. The provider had also not identified through their own quality assurance systems the shortfalls that we identified with recruitment procedures. We have made a recommendation about this which states, "We recommend the provider continues to develop their quality assurance and governance systems and processes further, to ensure that any shortfalls or issues are identified and addressed promptly and that improvements within the service are sustained".

Recruitment processes were in place but we found shortfalls existed. Previous employment histories had not always been explored, the content and results of interviews were not recorded and the results of verification checks, such as references and Disclosure and Barring Service checks (DBS checks), had not always been received before staff started working for the service.

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely Regulation 19, Fit and proper persons employed. You can see what action we told the provider to take at the back of the full version of the report.

This inspection took place on the 7, 8 and 11 July 2016 and was unannounced. The inspection was carried out by one inspector. At this inspection we found some improvements had been made to records and recording, but there were continuing shortfalls in the management of medicines. In addition, the provider was found to be in breach of other regulations under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The provider's registration does not require a registered manager to be in post to manage the carrying on of the regulated activity, because the provider is an individual in day to day charge of the service. The registered provider is the ‘registered person’ under their registration with the Care Quality Commission. 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 told us they felt safe living at Overstone Retirement Home. They described a comfortable service where they were cared for by kind, patient and caring staff.

We found medicines management was not robust and we could not be sure that people received the medicines they needed at the right time. There were gaps in the recording of the administration of medicines and care planning around medicines had not been fully undertaken. People who were prescribed medicines to be taken "as and when required" did not have specific care plans in place to help staff identify when people may need these, for example, when they showed signs of pain. Controlled drugs were not always booked into the home correctly.

Staff had undertaken training in safeguarding but they did not always put this training into practice. Staff shared with us some safeguarding concerns and confirmed that they had not always reported these to the provider. In addition, we found some issues had been shared with the provider but she had not reported these matters of concern to the local authority safeguarding adults team. This showed that staff and the provider were not clear on their personal responsibilities to safeguard people from abuse and improper treatment.

Environmental risks within the service had not always been identified and mitigated against. For example, there were no window restrictors on the upper floor windows. Water temperature checks to prevent the development of legionella within the water supplies of the home had not been carried out in recent months. Emergency planning had not been undertaken although fire evacuation procedures were in place.

Accidents and incidents were managed well and people received the attention and support they needed.

Staffing levels were consistently maintained and recruitment procedures were thorough. Staff training was carried out in key areas, such as equality and diversity and moving and handling and in areas specific to the needs of the people who they supported, such as nutrition awareness. Staff supervisions were carried out but appraisals had not been completed.

People said that staff met their needs and relatives reflected they were happy with the care their family members received. Healthcare professionals spoke highly of the service and said that any requests they received for support or input into people's care, were both proportionate and appropriate. People were supported to maintain their general health and wellbeing and attend appointments, for example, with their dentist and opticians. Where people were ill records evidenced that GP's were called.

CQC monitors the application of the Mental Capacity Act (2005) and deprivation of liberty safeguards. Applications to deprive people of their liberty lawfully had not always been made to prevent them from coming to any harm where they lacked capacity. The provider and senior care worker told us they had assessed people’s capacity when their care commenced and on an on-going basis, when necessary. They advised that no best interest decision making had taken place in the service that they could recall, but that they included people's families in any larger care based decisions and they would continue to do that in the future, documenting decision making where necessary.

People were supported to eat and drink in sufficient quantities to remain healthy. Monitoring tools were available to ensure that where there were changes in people's health and wellbeing this was identified and actions were taken to prevent any deterioration in people's conditions.

Staff and people enjoyed good relationships with each other. We observed staff treated people with respect and people told us that their dignity was maintained at all times. People were encouraged to be as independent as possible and they told us they made their own choices. Several people accessed the community on their own, or with friends and family. People pursued activities of their choosing. Due to the nature of people's needs there were limited activities within the home but a large selection of films, games and books. People told us they enjoyed a film night.

Care records were person-centred and provided staff with information about people's dependencies, needs and the risks they faced in their daily lives. Care records were regularly reviewed. People and their relatives told us they had not had any reason to complain about the service and records reflected no complaints had been made.

The provider was not actively involved in the running of the service and did not effectively oversee the management aspects of the service, leaving this responsibility with a senior care worker. The provider confirmed she was not aware of relevant requirements and best practice guidance, for example, about health and safety in care homes. Auditing was limited and where shortfalls were found, for example in medicines, these were not always addressed.

The provider had not notified the Commission about other incidents that had occurred since our last inspection and they had not displayed the rating from their previous comprehensive inspection within the home, in line with legal requirements. The provider was not aware that the shortfalls we identified at this inspection existed and said staff had not shared some of these with her. She informed us that she did not carry out any audits at provider level, to measure the standards of the service delivered and to identify any shortfalls that needed to be addressed..

We identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely Regulations 12, 13, 17 and 20A. In addition, we identified one breach of the Care Quality Commission (Registration) Requirements 2009, namely Regulation 18. Full information about CQC’s regulatory response to any concerns found during this inspection will be added to the report after any representations and appeals have been concluded.

We considered all the evidence we had gathered under the regulations we inspected. We used the information to answer the five questions we always ask;

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

This is a summary of what we found.

Is the service caring?

We saw that people were supported by kind and attentive staff who displayed patience and gave encouragement when supporting people, for example by assisting them with mobility. Our observations confirmed that generally people were very independent and staff encouraged this, whilst ensuring that they offered assistance to people if required. People told us that they were happy with the care and support they received from the service. One person said, "They are all very nice here, I think we are looked after very well."

Staff were fully aware of people's care and support needs. Staff told us, and people confirmed that they pursued activities outside of the home regularly. This showed the provider promoted people's well-being.

Is the service responsive?

The provider had arrangements in place to review people's care records regularly and we saw that amendments were made to people's documentation as their needs changed, to ensure this remained accurate and any issues were promptly addressed.

Staff told us, and records showed that where people required input into their care from external healthcare professionals, such as district nurses or doctors they received this care.

People had a wide variety of foods available to them and confirmed that they were given choices. People's weights were monitored regularly and referrals had been made to dieticians where necessary, to ensure they received specialist input into their care to remain healthy.

Is the service safe?

People told us they felt safe and the care that we observed was delivered safely. Risks that people may be exposed to in their daily lives and in relation to their care needs had been considered. We saw that instructions had been drafted for staff to follow to ensure people remained as safe as possible in light of these identified risks.

We reviewed the arrangements in place for the management of infection and potential infection. We found that overall, these arrangements were appropriate. Staff were trained in infection control.

We found the building was well maintained and entry into the building was secure. People were accommodated in a safe environment.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We discussed the recent Supreme Court judgement handed down on 19 March 2014 in the case of 'P v Cheshire West and Chester Council and another' and 'P and Q v Surrey County Council', about what constitutes a deprivation of liberty. The senior carer seemed unaware of this ruling, but assured us that they would discuss this with the provider and liaise with their local authority safeguarding team for further advice on their responsibilities and the arrangements they now need to put in place, for people in their care.

Is the service effective?

People told us they were happy with the staff who cared for them and they met their needs. One person said, "It's a very relaxed relationship between us and the staff." Another person told us, "I think the staff are very good. They have been good to me anyway." It was evident from speaking with staff and through our own observations that staff had a good knowledge of the people they cared for and their needs.

Staff told us that although they understood their roles and responsibilities and felt supported by the provider, they did not get any supervisions or appraisals. We have set a compliance action and we have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting workers.

Is the service well-led?

The provider had policies and procedures in place which gave direction and instruction to staff. Questionnaires were used to gather the views of people and their relatives, but there were no other formal systems in place to gather the views of people or staff on a regular basis.

Meetings for staff and people who lived at the home were not held and only medication audits were carried out. We found that only a limited quality assurance system was in place. We have set a compliance action and we have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing and monitoring the quality of service provision.

We found people's needs were assessed and care was planned in line with their needs. One person told us, "I can get help if I need it." Another person told us, "I organise all my own health care." Care plans were recorded and these were regularly updated and contained clear information about individuals' care. People or their relatives had been involved.

We found the home was personalised, comfortable, well furnished, clean and well maintained.

At the time of this visit there were enough qualified, skilled and experienced staff available to meet people's needs. Staff responded promptly to requests for assistance. One person told us, "All of the staff are helpful and there when you need them."

People's personal records were accurate, fit for purpose and held securely. Staff records and maintenance checks were kept in an appropriate form.

There was evidence people were consulted about their care and their consent was sought about decisions that affected them.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. People told us they had confidence in the service. Comments included, 'I am very happy to be a resident in the loving, caring, homely atmosphere of Overstone." Relatives commented, "We feel very fortunate to find somewhere as good as Overstone for our mother" and "Just brilliant."

People said they were helped to fulfil their social needs within the home and community. People we spoke with said, "We have a good time and I enjoy the Sage and going to the local theatre."

We saw the home was well maintained and furnished to a good standard. We found there was a large outside area that people had easy access to. People told us their home was clean, comfortable and warm.

They said staff were kind and caring and there were sufficient staff available. People confirmed they were given the opportunity to comment on the service, change routine or raise complaints. They said their visitors were made to feel welcome and information sharing was good.