The Larches - Tiverton

The Larches- Tiverton is a residential care home providing personal care to up to 20 people. The service provides support to people aged 65 and over with a physical disability or dementia. At the time of our inspection there were 17 people using the service.

The Larches is a large, detached property in the market town of Tiverton and located near the historic Grand Western canal. People’s bedrooms are on the ground and first floor, which people access using a lift.

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

Medicines were not always safely managed. Practices at the home were not in line with the providers medicines policy. Which meant people were at risk of not getting their medicines safely.

People had not always been protected from the risk of fire at the service. Improvements were made during the inspection regarding fire management.

Staff levels had been reduced by the provider. Staff said there had been poor communication about the changes and they did not feel there were enough staff to support people safely. Improvements were made during the inspection to increase staff levels. We have made a recommendation regarding staffing levels. Improvements were needed to ensure recruitment processes were more robust to ensure all documentation and checks were accessible.

People were kept safe from avoidable harm because the management team and the staff knew them well and understood how to protect them from abuse. People and their relatives were positive about the home and the way staff cared for people.

Audits were in place. However, they did not always identify risk. Where risk was identified, we could not see if action had been taken.

Improvements were needed in relation to infection control which were being implemented by the registered manager. We have signposted the provider to resources to develop their approach.

Accident and incident oversight was not robust. Staff completed incident and accident records on the providers computerised care system. However, there was not a system in place to analyse themes and trends.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and their relatives were not given the opportunity to attend meetings or complete surveys about their views of the service. However, it was a small service and people and relatives said staff knew people well. There was a suggestion box in the main entrance should visitors which to make any suggestions.

Monitoring systems had failed to identify all shortfalls found during the inspection process. In particular, medicines were not safely managed, unsafe fire risk management, managing staffing levels to meet people’s needs, infection control risks and oversight of accidents and incidents. This meant opportunities to drive improvements to quality and safety were missed.

Records were not available at the time of the inspection in relation to staff employment and staff training. When we did receive these, they were not comprehensive.

The provider and manager were receptive to the concerns found during the inspection and started processes to reduce the risk of harm to people living at the home. We were assured the provider and registered manager wanted to further improve their processes because they agreed to work with the local authority quality team.

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

Rating at last inspection

The last rating for this service was good (published 3 May 2018).

Why we inspected

We received concerns in relation to the management of the service and risks to people. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Larches-Tiverton on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

The registered manager had followed guidance on infection control procedures to safely support people living at the service during the pandemic.

People and staff had regularly been tested for COVID-19 and this process was monitored and kept under review by the registered manager.

All staff had received infection control training and had clear guidance around the home to remind them of the correct procedure for donning and doffing of Personal Protective Equipment (PPE). People told us that staff wore PPE and they felt safe.

Guidance had been implemented to allow, where possible, for relatives to continue to visit people safely. Checks were in place and carried out to reduce the risk of infection from visitors to the location. People told us their relatives were able to visit and they were kept informed by the registered manager of visiting guidance.

People had been supported to continue to access healthcare, this had included weekly visits and calls from the homes designated GP.

The home was clean and free from odours. Housekeeping staff completed cleaning schedules and frequent cleaning of regularly touched surfaces was implemented.

On arrival to work staff had a designated room for putting on their uniforms and PPE. Adequate supplies of PPE and hand hygiene products were available throughout the premises.

The provider had ensured that staff met vaccination requirements. They had a system to ensure

visiting professionals entering the home had been vaccinated.

People were admitted to the service safely.

The registered manager undertook infection control audits which included handwashing and safe use of PPE and actions had been taken where necessary to improve infection control measures. This included a new cleaning regime.

The provider’s infection control policy was in line with government guidance.

The Larches 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.

The Larches provides accommodation for up to 20 people requiring personal care. At the time of the inspection there were 18 people living at the service. There was 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.

People using the service, their family and professionals all said that The Larches provided a caring and safe service. Medicines were managed and stored safely. We found there were some gaps in medicine administration records but none of these omissions had resulted in harm to any individual.

People were protected from abuse by staff who had been trained to identify safeguarding concerns and knew how to act on them to keep people safe. Risks relating to the care of people living at the service were assessed and appropriate measures were put in place to minimise risks to people.

There were enough staff on duty to support people’s needs. Staff recruitment processes were robust and had ensured appropriate staff were employed. Staff turnover was low and staff morale was high. Staff received induction, training and the opportunity to undertake national qualifications.

The registered manager and staff had an understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). DoLS applications had been made as appropriate.

People received care from visiting health professionals as required who expressed confidence in the service. People were offered a varied and balanced diet.

People were supported by kind, caring staff who demonstrated warmth and compassion. People and their relatives praised the staff for their caring approach. One person said, “Nothing is too much trouble.”

Care plans were written to meet individual needs and in consultation with people and/or their relatives. Attention was given to specific communication needs.

People were offered a range of activities including outings for shopping and coffee. Different spiritual and religious needs were catered for in the service. Visitors were able to come and go at any time and praised the service for the warm and welcoming atmosphere. People knew how to raise a concern and felt confident these would be acted upon.

There was a range of systems in place to monitor the quality of the service.

There were 18 people living at the home. We spoke with six people living at the home, two relatives, three staff and the management team. We also spent time with people in communal areas of the home so we could make a judgement about how well people were cared for as some people were not able to comment directly on their care. The registered manager told us she had contacted families by phone to explain that she was leaving in October 2014. We also saw a notice on display in the home advising people she was leaving.

We looked at a selection of care records and staff communication records, as well as records relating to staffing levels, training and quality assurance.

Is the service safe?

We saw risks to people's health and well-being were monitored by caring staff but robust systems were not in in place to make sure that people's care and welfare was monitored and regularly assessed. This meant there was the potential for risks to people to be inconsistently managed. Assessments had not taken place to assess people who did not have mental capacity and therefore their rights were not protected. Staff did not receive appropriate training and knowledge to promote people's rights, safety and well-being. Staffing levels meant people were cared for in a safe environment where the atmosphere was calm. The home was clean and odour free, although improvements were needed in the style of the laundry to promote good infection control.

Is the service effective?

People were able to confirm they were happy with their care and they looked well cared for. Two visitors praised the care at the home, and a health professional said they had no concerns regarding the home. We saw people looked relaxed with staff and at ease in their surroundings. People's health and care needs were assessed, and staff knew when to seek external advice when people's care needs changed. However, risk management records and care planning did not clearly document what steps were being taken to provide effective care. Some aspects of the home's quality assurance systems did not support improvement, such as irregular supervision, gaps in training, and a lack of staff survey.

Is the service caring?

People were supported by friendly and caring staff. We saw that care workers showed patience and gave encouragement when supporting people. We saw that staff were attentive to people's needs, which people confirmed to us. People told us staff were 'kind' and this view was echoed in the feedback from quality assurance surveys. However, people were not always consulted about their care plans.

Is the service responsive?

We looked at people's care plans and we saw staff contacted health and social professionals appropriately when people's needs changed. However, care and risk management was not always recorded in a clear manner. Two relatives told us staff kept them informed of changes and said there was good communication between staff, the registered manager and families. A health professional said the district nursing team were contacted appropriately and in a timely manner. These views were also echoed in quality assurance surveys completed by people living at and visiting the home.

Is the service well-led?

Staff had a good understanding of the ethos of the home and their role in promoting good practice and reporting concerns. This helped to ensure that people received a good quality service. However, the quality of some of the care records was an area for further improvement. Staff did not benefit from regular supervision, comprehensive training and were not given the opportunity to influence the service through a staff survey.

There were 13 people living at the service. We met and spoke with four people and two visitors to the home. We spoke with four staff that were on duty at the time of the visit. We looked at care records for four people, we also reviewed records relevant to the management and administration of the service.

People told us they liked living in the home. One person told us 'The great thing about living here is that the staff are always so pleasant and helpful.' Another person said ' I like here it's very nice, I am very well looked after and well fed'

One relative we spoke with said 'We are very lucky to have mum here I can't speak highly enough of the place, I have been fully involved in her care and I have never been unhappy' They also went on to say how emotionally supportive the staff had been especially during the difficult period when their mum first moved. They felt the staff at the home had an open and receptive approach always willing to listen to any concerns.

Another visitor said 'The home is very welcoming I can visit any time, the staff are very pleasant and very obliging'

People told us they had plenty of activities to do. Two people particularly enjoyed trips out with the activities co-ordinator, others liked to play games, read books or the newspaper and watch the television. They were all confident that the staff had the skills to care for them.

We observed the serving of lunch in the dining room and drinks and snacks in people's rooms. People were provided with a choice of nutritious and appetising food and were well supported with their individual needs during the meal time.

On the day we visited the home was full; 17 people were at the home. Two other people were receiving care in a hospital. We saw all the people in the home and observed some people receiving care and support from staff working in the home. People living at the home were older people, and some people had a diagnosis of dementia. People we spoke with were positive about their experiences. Comments included 'the staff are very nice, they come to me when I need them' and 'I couldn't want for more.'

During the inspection we read a range of documents used to plan and evaluate care. We found that care and support was well planned, with people being involved in the process where possible. People told us they felt able to raise concerns within the home in order to improve services for them.

We checked the provider's employment records and found that newly appointed staff had undergone a robust recruitment process which helped keep people safe.