Chrissian Residential Home Limited

Chrissian Residential Home is a residential care home providing personal care to up to 22 people. The service provides support mostly to older people, some living with dementia. The service is provided in one adapted building over two floors. At the time of our inspection there were 22 people using the service.

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

We found concerns at our last inspection and rated the home requires improvement in two key questions and overall. We also found breaches of the Health and Social Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we found that the provider had taken action to mitigate the risks to the health, safety and welfare of people living in the home. We were encouraged by the progress made and the provider was no longer in breach of the regulations. Improvements had been made and were ongoing to ensure the premises and equipment were maintained in a safe, comfortable and clean condition.

A new registered manager had been appointed and they worked closely with the provider. Both were visible in the home and effective governance systems to monitor and assess the quality and safety of the home were evident. This provided the oversight needed to drive improvement and support the continual development of the home.

People told us they felt safe and we observed they were comfortable and at ease in the company of the staff that cared for them. There were enough staff, safely recruited with the knowledge and skills to meet people’s needs and morale was good.

Risks to people were regularly monitored and assessed with appropriate management plans in place to mitigate. This included timely referrals to healthcare services. Processes were in place to learn lessons when things had gone wrong with actions taken to reduce future incidents happening.

Staff had received appropriate training to protect people from harm and followed the provider’s safeguarding policies and processes. Safe management of medicines was in place and the home was clean and hygienic with good infection control procedures carried out.

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.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 1 July 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of the regulations.

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.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led which contain those requirements.

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 requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chrissian Residential Home 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.

Chrissian Residential Home is a residential care home providing personal care to up to 22 people. The service provides support to older people, some living with dementia. The service is provided in one adapted building over two floors. At the time of our inspection there were 22 people using the service.

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

We identified concerns with the environment of the home, several areas posed a safety and infection control risk and required improvement. We have been given assurances that the provider is taking action to address this.

The systems in place to assess and mitigate risk were not robust. People‘s care records did not consistently reflect adequate assessment, planning and evaluation of their individual risks to protect them and keep them safe. Since our visits the provider has developed an action plan and is working with an external consultant and relevant stakeholders to rectify this.

We received mixed feedback about the staffing arrangements in the home. We were not assured that the deployment and organisation of staff on shift fully considered the needs of people and supported them to safely move around the home.

The governance systems were not robust enough to support the provider and management team to independently identify shortfalls and address them. Following our visits, the provider has been implementing their action plan. These improvements need to be sustained, maintained and fully embedded into the culture of the home.

The provider had risk assessments and policies relating to the COVID-19 pandemic. People were supported to have visitors. Overall, 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.

Staff were recruited safely, had received safeguarding training and knew how to protect people from potential harm. Safeguarding policies and processes were in place.

Safe management of medicines were in place.

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 2 May 2018).

Why we inspected

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.

We received concerns in relation to risk management, records, safe care and treatment and the management of the home. As a result, we undertook an unannounced focused inspection to review the key questions of safe and well-led.

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. We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chrissian Residential Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The service provides residential care in one adapted building for up to 22 older people, some of whom are living with dementia. There were 19 people living in the service when we inspected on 9 and 12 February 2018. This was an unannounced comprehensive inspection.

We last inspected this service on 9 January 2017 and rated the service as required improvement. During that inspection we found that the care plans did not always reflect people's current needs or risks associated with their care. This meant there was an increased risk of people receiving the wrong care or staff not taking correct actions to ensure people's needs were met.

This was a breach of Regulation 9 Person centred care, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found that the service was not adequately protecting people from risk associated with their care because records did not show adequate assessment, planning and evaluation of risk or actions staff should take to keep people safe. This was a breach of Regulation 12 Safe care and treatment, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe and Responsive to at least good.

During this inspection on 9 and 12 February 2018, we found that improvements had been made to meet the requirements to help ensure that people received a safe and responsive service.

Chrissian Residential Home Limited has 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.

The people who lived in the service told us that they felt safe and well cared for. There were systems in place that provided guidance for staff on how to safeguard the people who used the service from the potential risk of abuse. Staff understood their roles and responsibilities in keeping people safe.

There were processes in place to ensure the safety of the people who used the service. These included risk assessments, which identified how risks to people were minimised. Some radiator covers had been removed in preparation of them being updated. However, this left people at risk of being burnt, as they were very hot to touch. The manager immediately arranged to get the radiator covers replaced and took action, after developing risk assessments, to keep people safe.

There were sufficient numbers of trained and well supported staff to keep people safe and to meet their needs. Where people required assistance to take their medicines there were arrangements in place to provide this support safely, following best practice guidelines.

Both the manager and the staff understood their obligations under the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The manager knew how to make a referral if required. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

People were supported to eat and drink enough to maintain a balanced diet. They were also supported to maintain good health and access healthcare services.

There were arrangements in place to make sure the service was kept clean and hygienic. On our first day’s visit we found some minor examples of poor cleaning practices, but on our second day we saw that action had been taken to rectify the matter and the cleaning schedule had been amended to lessen the likelihood of this practice continuing.

We saw many examples of positive and caring interactions between the staff and people living in the service. People were able to express their views and staff listened to what they said and took action to ensure their decisions were acted on. Staff protected people’s privacy and dignity.

People received care that was personalised and responsive to their assessed needs. The service listened to people’s experiences, concerns and complaints. Staff took steps to investigate complaints and to make any changes needed.

People using the service, and the staff, told us that the registered manager had made positive changes in the service and that they were open and had good management skills. There were systems in place to monitor the quality of service offered people.

Further information is in the detailed findings below.

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.

The service can accommodate up to 22 people at any one time and provides residential care to older people. At the time of our inspection there were 21 people living at the service. .

At this inspection we found the new manager who was already familiar with the service was engaging well with people using the service and with staff. They had developed an action plan identifying what they needed to do in order to comply with the relevant standards. They told us that when they took over the management of the service, they had identified gaps and had not felt things were sufficiently robust. They were working towards bridging the gaps and ensuring records were up to date. Immediately following our inspection they sent us an action plan telling us how they would address the issues we raised which gave us some confidence in the ongoing management of the service.

We observed a caring, happy home in which staff appeared to get on well and were attentive to people’s needs. The home was relaxed and people were sufficiently engaged. The home was comfortably furnished and we found the home to be clean and smelling fresh. Prior to the inspection, we had concerns raised with us about poor infection control practices of staff. In addition we had identified some poor infection control practices at the last inspection but did not have any concerns at this inspection.

Staffing levels were adequate and people’s needs were reviewed to help establish if current staffing levels were adequate. However dependency assessment tools did not always identify changes in people’s needs. During the day there were catering staff employed to assist with breakfast and main meal at lunch time but in the evening care staff were expected to serve tea some of which might have been prepared earlier. This meant there was a reduction of staff at certain times of the day and this was likely to have an impact on the care and supervision provided. .

Risks to people’s safety were not always effectively managed. This is because we saw a number of incidents had occurred at the service and actions taken were not sufficiently robust and did not help ensure that an incident did not reoccur. For example falls risks assessments did not clearly show what actions had been considered and put in place before and, or following a fall. Records were not collated effectively and we found information difficult to follow in terms of actions.

We also found poor recording in relation to allegations of poor care which had not been referred to the safeguarding team and had not been fully investigated to show the outcomes and impact on people.

Medicines were managed effectively and people received their medicines as intended.

Staff received training and support for their role. Supervisions were being updated to ensure all staff had the opportunity to discuss their role and any training and, or support they needed. Induction for new staff was sufficiently robust and staff were being given the opportunity for further study.

Recruitment of new staff has been a concern in the past and the home has not always followed robust recruitment processes. We found on this occasion procedures were being followed but improvements could be made to the interviewing process.

Staff promoted people’s choice and had some understanding of the Mental Capacity Act 2005 and the Deprivation on Liberty safeguards. The MCA and DoLS ensure that, where people lack capacity to make decisions for themselves, decisions are made in their best interests according to a structured process.

People were supported to eat and drink in sufficient quantities for their needs. People’s weights were monitored but fluctuations in weight were not always sufficiently recorded in terms of actions taken.

People had their health care needs monitored and staff acted upon changes in people’s health but concerns were expressed about the responsiveness of one of the GP practices. This had an impact of the timeliness of medical intervention. We also found records did not always clearly reflect actions taken by staff.

People’s needs were documented and care plans told staff what people’s needs were and how these should be met. Staff knew people’s needs well but we were concerned that records did not always reflect the changes in people’s need or the impact of risk and how it could be reduced.

The home has undergone a number of changes in terms of its management but we were confident it is heading in the right direction but is not yet providing a safe and responsive service. However we consider the home is well managed and there are plans in place to improve upon the service delivery and the effectiveness of this.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what actions we told the provider to take at the back of the full version of this report.

There is a registered manager at the service but they have been on extended leave for about six months and no longer employed by 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.

During our inspection we were informed that the registered manager had put in their notice and the provider had recently appointed a new manager who had been in post for about three weeks. The provider was providing day to day management of the service. There were a number of senior staff, one allocated on each shift. Staffing on the day of our inspection appeared adequate but there were limited activities provided for people.

The provider did not have a dependency tool in use to determine how many staff they needed on each shift to ensure people’s needs were accurately met. However, through our observations staff worked well together and people’s physical care needs were met.

We did a detailed medication audit and looked at practices within the home. We were satisfied that there were adequate systems in place to ensure people received their medicines safely by staff who were trained to give medicines. However, we did identify a number of concerns which had not been identified by the providers own internal audits. These gave us concern that staff were not always following procedures and missed or changed medicines were not sufficiently recorded/reported which could put people at risk of not receiving their medicines as prescribed.

There were poor records and poor practices around staff recruitment which could and had resulted in staff appointments which were unsuccessful. This put people at risk of staff employed where the provider had not carried appropriate checks to ensure they were of good character.

Risks to people’s safety particularly in relation to falls and hydration/nutrition were documented and included actions staff should take to reduce the risks an ensure people’s needs were being met.

We identified some poor staff practice in relation to infection control which meant people were not adequately protected from the risk of cross infection.

Recent changes in the management of the service meant there were some gaps in service provision which had not been identified by the Director including some poor medication practices, poor recruitment practices and poor auditing of risks affecting people who use the service. We acknowledged that the provider had acted quickly to appoint a suitable manager and to address the concerns we had identified but this service has been in and out of compliance several times in the last couple of years which suggest the quality assurance management systems are not sufficiently robust.

The purpose of this inspection was to follow up on the warning notice we issued and to see if improvements had been made.

We considered all the evidence we had gathered under the outcome we inspected. We used the information we had gathered to answer questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

Following the issue of a warning notice the provider had implemented a safe staff recruitment and selection system.

Is the service effective?

Following concerns identified at our previous inspection the provider had implemented changes to their admissions and discharge policy. This ensured guidance for staff which would ensure the welfare and safety of people was protected when transferring from one service to another.

Is the service caring?

The provider had implemented changes to their procedural guidance for staff when transferring people from one service to another. This meant that staff had guidance to ensure people would be cared for in a safe and supportive manner.

Is the service responsive?

The provider had taken steps to ensure compliance with a warning notice issued following our concerns about the unsafe recruitment of staff.

Is the service well-led?

There were sufficient staff to meet people's needs.

During our inspection on 9 April 2014 we found that some improvements had been made.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information we had gathered to answer questions we always ask; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

We noted that improvements had been made to the environment since our last inspection. The provider had taken steps to ensure that people were cared for in a clean environment and to ensure the risk of infection was reduced. We found the environment to be clean and there were records relating to infection control audits and cleaning schedules were in place. This ensured that each area of the service was regularly cleaned.

As a result of the ongoing improvements to the premises we identified some immediate hazards to people's safety and sought assurances from the provider that these would be addressed. This included uncovered radiators, unrestricted windows and loose carpet tiles which the provider told us were being replaced with new carpeting. We have asked the provider to provide us with updated risk assessments with assurances that the ongoing building works would not compromise people's safety. Once electric works have been completed we have asked the provider to send us the electrical wiring certificate.

We observed there to be enough staff on duty to meet people's needs and we saw that people were regularly supervised for their safety.

Staff had recently attended training in understanding the Mental Capacity Acts (2005). The manager told us that there was no one currently living in the service who was subject to a Deprivation of Liberty Safeguard (DOLS).

Is the service effective?

People we spoke with told us their needs were met. We observed staff caring for people in an appropriate manner and offering them choices. The manager and staff spoken with and observed showed a good understanding of people's needs and acted in accordance with people's wishes. We looked at three care plans which told us about people's needs and how staff should meet them. People's needs were reviewed regularly. This supported staff in identifying and responding appropriately to the people's changing or unmet needs. Staff consulted with family members and other medical professionals when required and this was recorded.

Is the service caring?

Our observations indicated that people in the main were happy living at Chrissian Care Home. It was evident that the majority of people who used the service had a good relationship and rapport with the staff who supported them. Several people told us the staff were, 'Very kind' and, 'Could not do enough for you.'

Is the service responsive?

People's care records viewed showed us that their individual physical, mental and social care needs were assessed prior to admission to the service. Daily records evidenced that where concerns about the health and well-being of people had been identified appropriate action had been taken to ensure they were provided with the support they needed. This included access to health care professionals such as a doctor or district nurse.

We saw staff responding to people's requests. One person told us, 'The minute you press the alarm, staff respond.' We saw from a review of care plans that one person had requested that staff should not regularly monitor them throughout the night. This was recorded within the risk assessment and showed us that people's individual needs were met. We saw records in the kitchen which told us that people's dietary needs were known and people could have their meals at different times of the day and their individual dietary requests could be accommodated.

However, prior to our inspection we received information of concern which had been investigated by the local safeguarding authority. It was evident from the outcome of this investigation that a person assessed as physically frail and living with dementia had moved from Chrissian Care Home to another service without care staff support being provided. They had been left in the care of a taxi driver. We were therefore not satisfied that the provider had fulfilled their duty of care and taken steps to ensure people received safe coordinated care, treatment and support when transferring from one service to another.

Is the service well-led?

Following our last inspection we issued the provider with a fixed penalty notice for continued failure to provide a registered manager. The provider has since employed a manager who has been successful in their registration with the Care Quality Commission.

Our observation of records showed that following our last inspection the manager had implemented management quality monitoring systems. The records we viewed showed that the manager had regularly reviewed the cleanliness of the environment, care plans and monthly medication audits had been carried out.

We found that there were continued shortfalls in the management of staff recruitment. The provider continued not to protect the safety of people by failing to obtain satisfactory evidence of workers conduct in their most recent employment before they started working at the service. This meant that we could not be assured that only people suitable to work in a care setting were employed.

We spent some time in a communal lounge and observed the interaction between staff and people who used the service. We were unable to hold meaningful conversations with the majority of people who lived in Chrissian Residential Care due to their limited mental capacity. However, we spoke with three people who used the service. We also spoke with a relative of a person who used the service. One person told us, 'I have lived here a long time. I like it.' Another told us, 'Staff are nice to me, they know me very well.'

As part of our inspection we looked around the service. We found shortfalls in that people were not protected against the risk of cross infection because the hygiene and cleanliness of the service and the equipment used had not been fully maintained.

People told us that staff treated them with respect and kindness. One person said, 'Most of the staff are kind, some are better than others.'

We saw that staff tok their time with people and were attentive to people's needs and interacted with people in a caring, respectful manner. Care staff sought people's agreement before providing any support or assistance.

We looked at the care records of three people who used the service. Care plans and daily contact records recorded the care, treatment and support provided to people. We saw that changing health care needs were monitored and specialist advice sought when required.

We spoke with a visiting district nurse who told us that the provider responded appropriately and sought advice when individuals at risk of pressure ulcers were identified.

We found appropriate checks were undertaken before new staff began work at the service. There was a structured recruitment and selection process in place and we saw that relevant checks were carried out when staff were employed such as two written references and criminal records checks. However, we found shortfalls in the training provided for staff to ensure that staff were properly supported to provide safe care and treatment to people who used the service.

We spoke with three people who used the service who told us that they were happy living there. One person said, "Oh yes dear, I love living here." We chatted to two people about the cold weather and one person said, "We are nice and warm in here."

We looked at the care records of three people who used the service which showed that people experienced care, treatment and support that met their needs and protected their rights.