This inspection took place on 19 and 24 April 2017. Day one was unannounced and day two was announced. At the three previous inspections in June 2015, March and August 2016 we rated theservice as inadequate. At the inspection in August 2016 we found the provider was in breach of six regulations which related to safe care and treatment, staffing, person centred care, governance, consent to care and nutrition.
At this inspection we found the provider had improved the service sufficiently to meet three of the regulations. They needed to make further improvements to ensure the service was consistently safe, effective, caring, responsive and well-led. The provider was still in breach of three regulations relating to safe care and treatment, consent to care and good governance.
Donisthorpe Hall is registered to provide residential and nursing care for a maximum of 189 people. Care was provided in four units. The management team told us there were 83 people using the service when we inspected. The home has a longstanding association with the Jewish community in Leeds and also offers care to people of other faiths or beliefs.
At the time of the inspection the service did not have a registered manager although the home manager had submitted an application and this was being assessed. 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 this inspection we found medicines were better organised and the provider had reintroduced a paper based system which staff found easier to use, however, medicines were still not being managed safely. Staffing arrangements had improved; there was a more regular team of workers and a big reduction in agency workers which meant people received care from staff they knew. The provider told us they were actively looking at reviewing the staffing levels and increasing where possible. Risks to people were identified, assessed and usually managed although we found some examples where management of risk was not effective. People lived in a safe, comfortable, clean and pleasant environment.
Systems for assisting people to make decisions in line with the requirements of the Mental Capacity Act 2005 had improved but not sufficiently to meet regulation. Consent records and care plans did not consistently evidence people or their representatives were in agreement. We found the process for managing Deprivation of Liberty Safeguards was not effective.
Staff told us they received more opportunities to receive training and better support, including regular supervision. Staff told us the quality of training was good and it had helped them understand how to do their job well. We observed meal times and observed people had a pleasant experience. People told us they enjoyed the food and were offered a varied menu. People received appropriate support to make sure their health needs were met.
During the inspection we saw many examples of good care practice. Staff were observed to be caring and kind in their interactions with people. Stakeholders told us the service was caring. People who used the service and visitors were complimentary about staff. People looked well cared for, with hair styled and clean clothes. Although feedback was positive we received some comments from people that further improvements were required, for example around support at meal times.
We saw staff worked as a team. They communicated with each other and checked who had eaten and who needed assistance. Staff knew the people they were supporting and referred to them by name. When we looked around the service we saw there was information available which helped to keep people informed. For example, there were leaflets and notices around promoting dignity, data protection, safeguarding and hygiene.
The provider had improved their care planning system. A standard format was used which helped staff understand the process and aided access to information wherever they worked within the service. Care plans were written for a range of needs, however, the quality of information varied. This included details around people’s preferences, likes and dislikes, and guidance for staff to follow. Some lacked person centred information. People were encouraged to engage in different group and individual activity sessions.
People who used the service, their relatives, staff and stakeholders told us the service had improved. The provider continued to develop the service, however, they had failed to establish and operate effectively systems and processes to assess, monitor and improve the service or assess, monitor and mitigate risk. Further changes in management had impacted on the service delivery. Information was gathered around incidents and complaints but the provider did not have effective systems to identify trends or how they could learn lessons and prevent repeat events. Opportunities for people who used the service to share views were limited although more regular meetings were held with staff which had improved communication so they felt better informed.
We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014. These related to management of medicines, how people consented to care and governance arrangements. You can see the action we have told the provider to take at the end of this report.
The overall rating for this service is ‘Requires improvement’. However, the service will remain in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.
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.