Underhill House Residential Home

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

People told us they felt safe, relatives said they felt happy their relatives were being well supported and cared for. Where risks had presented themselves these had been assessed, reviewed, and appropriate action was being taken to mitigate them. The building was checked regularly in terms of fire and other environmental factors.

There were enough staff to meet the needs of people at different times of the day. These staff were recruited safely, using a robust process. People and relatives told us the service was always very clean and smelled fresh.

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 had choices over what they ate and drank, where they sat, and how they spent their time. The service arranged for local entertainers to come in but also catered for quieter tastes.

Staff were kind and caring and the service had a homely feel. People were treated with dignity and respect and their families welcomed whenever they visited.

People accessed healthcare services where needed and professionals we spoke with had a positive view of the service. There was an emphasis on putting people first and making sure they were happy and well. Care plans included information about people’s life histories and what care and support they needed from staff.

The service was well-led. Aspects of the running of the service were regularly audited and there was a good understanding of regulatory requirements, including the need to be open and honest when things went wrong. There was an open culture where staff felt supported through supervisions, training, and the open-door policy of the management team.

We made one recommendation that signage in the service was reviewed to ensure it met the needs of people living in the service.

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 August 2017).

Why we inspected

This was a planned inspection based on the previous rating.

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

Follow up

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

Underhill House Residential Home provides care without nursing for up to 28 older people who may be living with dementia. At the time of our inspection there were 27 people living at the service.

The provider was the 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.

At our last inspection on 15 and16 March 2016 we asked the provider to make improvements to ensure people were protected from risks associated with their care and the environment, that people’s medicine were managed safely and to ensure people’s human rights were protected by the Mental Capacity Act 2005 (MCA). We also asked then to make improvements to how people's complaints were managed, and to how they assessed, monitored and improved the ongoing quality of the service. Following our inspection, the provider sent us an action plan telling us how they intended to meet the associated regulations. During this inspection we looked to see if improvements had been made and we found action had been taken.

People told us they felt safe living at the service. People were protected from abuse because staff understood what action to take if they suspected someone was being abused, mistreated or neglected. People were cared for by staff who, had been recruited safely to ensure they were suitable to work with vulnerable people. People were supported by suitable numbers of staff. People were supported by staff who had received training to be able to meet their needs.

People who had risks associated with their care had these managed appropriately to help ensure their ongoing safety. Accidents and incidents were recorded and assessed for themes and trends to help protect people and reduce the likelihood of re-occurrence.

People lived in an environment which had been assessed for risks. Fire tests were carried out and equipment was serviced in line with manufactures requirements. In some bathrooms, there was an unpleasant odour, this was because clinical waste bags had not been emptied. The provider told us they would take action and review how often bins were emptied.

People’s medicines were managed safely, and the provider’s processes followed best practice guidelines as set out by the National Institute for Clinical Excellence (NICE). However, people’s topical medicines (creams or gels) were not always dated upon opening, which meant there was a risk that they may be used past their expiry date. The provider explained they had spoken with staff about this, but told us they would re-look at their auditing processes to ensure medicines were dated appropriately. Staff at lunch time, were observed to not always be vigilant in ensuring when people had been given their medicines in their medicine pot that they had taken them. The provider told us she would speak with staff about the importance of observing medicines had been taken before medicine administration records (MARs) had been signed. Staff responsible for medicine administration, including night staff had received training and action was being taken to ensure staffs ongoing competence was assessed.

People's consent to care was sought and their human rights were protected. People had access to external health and social care professionals which helped to promote their ongoing health and wellbeing.

People told us they liked the meals and that there was always enough to eat. People were supported to eat and drink when necessary.

The provider had taken some action to ensure people living with dementia were supported and empowered by their environment, for example there was pictorial signage in place for the dining room, however not for all other areas. This meant people living with dementia may find it difficult to ordinate to their environment. We recommend that the provider takes account of dementia research to help create a more dementia friendly environment.

People and their relatives all, expressed how caring staff were, describing the service as being “Full of love”. Relatives told us it was a “Home from home”.

Staff knew people well, and spoke to people by their preferred name. Staff demonstrated a calm and patient approach and spoke fondly of the people they cared for.

People’s privacy and dignity was respected. People and their relatives felt involved in decisions relating to their care. Relatives were kept informed of any changes, and told us they had total trust in the staff to look after their loved one. People and their relatives were confident about who they would speak with if they had a complaint or issue.

Prior to moving into the service, people had a pre-assessment to help ensure the service could meet their needs. People received personalised care, and had care plans in place which were reflective of their individual needs. Care plans had been re-designed to help ensure staff had accurate information about how to meet people’s needs.

People could participate in social and wellbeing activities, including listening to musicians that visited on a regular basis, have manicures and go on trips out. The provider ensured the service remained in the heart of the community by inviting local schools into sing.

People’s religion was respected. The Catholic Church visited and other local churches had been asked to be part of the service.

The provider had introduced a new schedule of audits to help assess and monitor the ongoing quality of the service, and to help highlight when improvements were necessary.

People, their loved ones and staff told us, the people, were at the heart of the service. Staff told us the provider had high standards of which were adhered to.

People, and their loved ones views were gathered by the completion of satisfaction questionnaires to help ensure the service was run in line with people’s wishes and preferences.

The service was managed by the provider, as well as by a deputy manager who supported the day to running of the service. The provider was available and visible throughout the inspection.

People were protected by the provider's policies and procedures which had been updated to reflect changes to best practice guidelines. There was a whistle blowing policy which protected staff should they disclose poor practice and staff told us they would feel confident to speak with the provider if they had any concerns.

The provider demonstrated an open and transparent approach throughout our inspection this demonstrated their understanding and recognition of the Duty of Candour. The Duty of Candour means that a service must act in an open and transparent way in relation to care and treatment provided when things go wrong. The provider had not displayed their latest rating in line with legislation, but took immediate action to rectify this by the end of our inspection.

The provider worked in partnership with external professionals in order to continually improve the service.

Underhill House provides residential care without nursing for up to 28 older people who may be living with dementia. Twenty eight people were living at the service when we visited.

A registered manager was employed at the service. 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 registered manager, who is also one of the providers, was on holiday when the inspection took place. The deputy manager was the person in charge in the absence of the registered manager and they were present during the inspection.

Prior to the inspection we received information of concern about people’s care at Underhill House from different sources. This included concerns about care not being personalised, people receiving medicines which then made them sleepy, personal care not always completed to a high standard, food portions were described as “small” and staff were not following choking risk assessments. We were also told people’s care at their end of life was not well planned and medicines to alleviate pain at this time were not readily available. We were also told the service had strict routines in place and people who could not consent to care due to their level of dementia were having routines decided for them. We were also told the water people had access to was “scalding”. We checked these concerns as part of the inspection. We found concerns during the inspection which are summarised below but can be reviewed in the full report.

People’s medicines were not always managed safely. For example, staff trained in the safe administration of medicines were not on duty overnight. This meant people had to wait to be administered pain relief from an on call member of staff. Gaps between the administration of some medicines were not sufficiently spaced. For example, antibiotics were given over a shorter timescale than recommended. Storage of some medicines was not in line with current guidance and temperatures of medicines were not being recorded. Staff who were administering medicines were suitably trained but were not having their competency checked.

People’s medicine administration records were completed. People were happy with how their medicines were administered. There were clear systems of ordering and returning unused medicines. A medicines audit was in place to check systems were being followed.

People were not having their ability to consent to their own care and treatment assessed, as required by the Mental Capacity Act 2005 (MCA). When people could not make decisions about their care and treatment due to their living with a condition which may have affected their ability to consent this had not been assessed. Best interest decisions had not been recorded. People who were having their medicines given without their consent had not been assessed in line with the MCA. However, staff were observed asking for consent when offering care and applications had been made to seek an assessment of people who may be deprived of their liberty to keep them safe.

Staff demonstrated they knew people well and how to meet people’s needs. However, people’s care was not recorded in a personalised way which reflected their needs and how they wanted their care to be given. For example, care plans showed no evidence of having been planned with people or their family or representative as required. People’s preferences were not recorded. For example, what time people wanted to get up or go to bed. Staff recordings in daily records were inconsistent and often made it difficult to establish whether an identified need had been met. People’s end of life care was not routinely discussed with them or their family. Family members were complimentary about staff’s ability to support both the person and their family when someone was dying or had died. One of the GPs we spoke with was happy with how the staff were looking after people at their end of life.

Prior to the inspection, we were told there were strict routines in place which people had to adhere to. We found people were being supported to get up for breakfast at 8am. Some people told us they did not want to get out of bed that early. Also, staff confirmed some people were being supported to get ready for bed at 5.30-6pm. Staff said the early rising and getting ready for bed reflected people’s preferences but these were not recorded. Staff had also had not ensured this was in the person’s best interest when they lacked capacity to consent. Staff advised they would review this area of their practice.

Risk assessments did not always reflect people’s current needs and where not always updated as required. Individual risk assessments were not always available to ensure all risks people may be exposed to while living at the service were then mitigated. For example, choking risk assessments were not completed for people cared for in bed or who could be at risk due to identified swallowing concerns.

Action had not been taken to ensure water temperatures placed people at a lower risk of accidental scalding. A plumber was called to the service during the inspection to start putting this right. Up to date Personal Emergency Evacuation Plans and evacuation equipment were not available. We have advised the fire service of our concerns.

Prior to the inspection we were made aware that complaints and concerns had been raised by relatives, or via safeguarding concerns, but these had not been reviewed in line with the complaints policy. The service had a complaints policy in place however, we found complaints that had been made had not been investigated. This meant lessons learnt or patterns had not been reviewed to see if there were positive changes which could be made to the service to improve everyone’s experience.

The registered manager did not have robust systems in place to ensure the quality of the service. Audits, other than in relation to medicines, were not taking place to check practice was safe. For example, there was no audit of infection control, care plans or staff recordings. There was also no falls audit to check if amendments could be made to keep people safe. People and staff felt the registered manager and deputy manager were approachable. The registered manager had systems in place to ensure the building and equipment were safely maintained.

People were positive about staff and staff spoke fondly about the people they cared for. People confirmed staff treated them with respect and dignity. We observed positive interactions between people and staff. Relatives told us they were always welcomed and kept up to date about their loved one’s care.

People and their relatives said Underhill House was a safe place to live. People were looked after by staff who understood how to identify abuse and what action to take if they had any concern. People were supported by a sufficient number of competent, trained staff, who were recruited safely. Staff felt the management would take action on any safeguarding and staffing issues to keep the service running safely.

People had their need for an adequate diet and enough to drink met. Action was taken to address any concerns. People were complimentary about the food and felt the portions they were served were large enough. People were offered extra servings in the dining room at lunch time. People also had their health needs met. People said staff always responded quickly to ensure any health needs were met. Records showed people’s GPs were contacted as required. The GPs we spoke with were positive about staff member’s ability to contact them appropriately and give them current information on people’s needs.

We found breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

As part of the inspection we spoke with five people who lived at the home, four relatives, three care staff, the deputy manager and the registered manager, who was also the provider. We reviewed policies and records relating to the management of the home which included, six care plans, daily care records and six staff files. There were 27 people living at the home when we visited. Everyone who lived at the home had some degree of memory loss or dementia.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service safe?

We found that people were cared for in a fresh and clean environment and that the home was well maintained.

People told us they felt safe at the home. One person said, 'I'm unsteady on my feet and when I was at home I kept thinking I might fall over. Here I know there is always someone around who can help'.

One of the relatives we spoke with said, 'It's such a relief to me to know that (my relative) is secure here'. Another person told us that a 'safe and sound environment' was one of the essential requirements for them in making the decision for their relative to move in. Another commented, 'Safety was a real issue before my relative came here'.

We spoke with four relatives who all commented that one of the greatest considerations had been their relative's safety prior to their arrival at the home. One relative said, 'I now have peace of mind that my relative is safe".

There were systems, policies and procedures in place which ensured risks to people were reduced and that the service was safe. Risk assessments had been undertaken and helped ensure people received care safely. People were given choice and remained in control of decisions about their care and daily lives.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We were told there was one application to the DoLS which was in process. We noted that the home followed procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and took advice and guidance from medical professionals.

Is the service effective?

We spoke with five people who lived at the home who told us they were happy with the care they received. They felt their individual needs were understood by staff and were met. One person said, 'The girls are very good and kind. They are always around'.

One of the relatives we spoke with said 'Communication here is very good, especially with the manager'. Another said, 'We can talk to any of the staff, everyone seems to be in touch with what's going on'.

We met a person, who had arrived at the home a week earlier and their relatives. One of the relatives said, 'I can't believe what a difference there is (in my relative). In one week they have become more relaxed, they have put on weight and have had their toe nails cut by the visiting chiropodist'.

People's health and care needs were assessed and care plans developed which ensured appropriate care and support was provided.

Is the service caring?

The home is run as a family home. The registered manager was fully involved in all aspects of the home and the care provided.

Relatives told us, 'Staff are brilliant, it feels like home and we couldn't wish for anything better'. We were told the service was 'consistently compassionate' and run as a 'family home'.

People were supported by kind and caring staff. People commented, 'The staff are always around', 'the girls are very kind'. We observed that staff knew people they cared for well and were gentle and reassuring in their communication with them.

Is the service responsive?

We spoke with four relatives who all commented on the responsiveness of the home to people's needs. One person told us about their relatives' recent hospital admission where staff had been proactive in ensuring immediate action had been taken. Another relative told us how quickly the home had responded to a request for an emergency admission to the home. They said, 'We don't know how we would have managed without the immediate response from the home'.

We noticed staff promptly and appropriately responded to a person who had fallen on the day of the inspection and how staff gave caring support and reassurance throughout the incident.

We saw that call bells were installed in people's rooms and people told us these were always responded to promptly.

Is the service well led?

The registered manager was also the provider of the home. The ownership and management of the home had been under the same provider and registered manager for 25 years. The registered manager was actively involved in all aspects of the day to day operation of the home and knew everyone who lived and worked at the home well.

The registered manager was supported by a deputy manager who had recently been appointed. We were told that an administrator was in the process of being appointed to assist with the organisation and maintenance of records and documentation required at the home.

We found that there were formal and informal systems and mechanisms in place to monitor the service provided and to provide training and support for staff. However some of the systems for receiving feedback, involving people in decisions about the home and for supporting and training staff were not in operation at the time of our inspection. We found there were shortfalls in staff training and support systems which could mean that staff were not always up to date with working practice or changes in legislation which could affect their ability to appropriately perform their duty of care to people at the home.

We were told that the appointment of new staff would help to ensure that all formal systems could be re-introduced and records kept up to date.

We asked the home to produce an action plan be show how they were going to address the concerns raised. We were told that the home would have addressed the concerns by the end of September 2013. We contacted the registered manger and asked they provide us with the evidence that they have made the necessary changes and that the concerns have been addressed.

We have reviewed the information provided and felt that the home was now addressed the areas we were concerned about.

We found that those people who were able to communicate with us felt their care was delivered with respect and dignity.

For those person's less able to communicate their needs due to a diagnosis of dementia, we found that assessments around their capacity to make decisions had not been completed.

We found that the care plans ensured that people's needs were understood and was delivered in line with need as the care plan was clearly written. However not all care plans were able to show that the care was being delivered with the person's consent. People or their representative's views had not been documented.

We found the cleanliness and hygiene of the home was generally very good with strong policies and training in place to support its delivery. However we found that the way the commodes were cleaned did not ensure cross contamination was managed. We also found other communal used items such as bath hoists were not routinely cleaned.

Staff received a good level of training that was regularly updated and they felt supported in their role.

We found that the home had a good system of quality assurance in place and utilised the services of an external auditor to ensure that there was independent oversight.