Archived: Richmond

Richmond is located in Bexhill-on-Sea and provides accommodation and personal care for up to 58 older people who live with dementia and live with long term healthcare needs such as Parkinson's. The home is set out over two floors, Richmond and Heatherbank. Heatherbank was on the ground floor and supported people who lived specifically with dementia and who had additional health problems such as decreased mobility. Richmond supported people with health needs and general frailty. There is lift access between the ground floor and upper level.

We found the following examples of good practice.

The registered manager had followed current guidance in relation to infection prevention and control. Measures had been implemented to ensure people entering the home did so following current guidance regarding PPE and social distancing. This included staff temperatures being taken on arrival for work and once more during the day along with recording oxygen levels. Temperatures on arrival at the home were also measured for essential health professional visits. The provider was not currently taking new admissions.

Staff told us how they kept people in touch with their loved ones at this time. This included face timing, telephone calls, letters and emails. Staff had ensured that peoples’ mental health was promoted as much as possible during the pandemic and the home being closed to visitors. There is a music therapist that spends time with people on a one to one basis whilst maintaining social distancing. People spoke of staff taking time for pampering sessions and of staff sitting and talking to them.

People who lived at Richmond were monitored closely by staff to ensure they were well and not displaying symptoms of Covid19. This included twice daily temperature and oxygen checks.

Visiting for relatives was by appointment only. Safe measures had been implemented to support safe visiting for each person’s designated relative. However, at this time due to a COVID19 outbreak, Richmond is closed to visitors unless it’s exceptional circumstances such as to spend time with a relative in receipt of end of life care.

The premises allows for the units to be isolated and there is a dedicated unit for COVID19 positive people should it be required.

There were adequate personal protective equipment (PPE) supplies in the service, this was located at designated points around the home to ensure staff had access to required PPE at all times. Outside each person’s room there was a wipeable unit with PPE equipment and pedal bins. Staff used PPE appropriately. House keeping staff followed a cleaning schedule which had been extended and developed during the pandemic. All staff ensured regular disinfection of frequently touched surfaces of the home for example, handrails and bannisters. Laundry facilities now ensured all peoples personal laundry was washed and dried separately and immediately returned to the person. Social distancing rules were being followed where appropriate.

Regular Covid-19 testing was taking place regularly for people and staff. Staff had access to guidance and policies regarding Covid-19 and infection prevention and control. The registered manager carried out checks and audits in relation to infection prevention and control and implemented any actions identified.

Further information is in the detailed findings below.

Richmond is located in Bexhill-on-Sea and provides accommodation and personal care for up to 58 older people who live with dementia, and live with long term healthcare needs such as Parkinson's. The home is set out over two floors, Richmond and Heatherbank. Heatherbank was on the ground floor and supported people who lived specifically with dementia and who had additional health problems such as decreased mobility. Richmond supported people with health needs and general frailty. There is lift access between the ground floor and upper level. At the time of our inspection there were 36 people living at the home.

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

At the last comprehensive inspection in November 2018, we told the provider they needed to improve the oversight and governance of the service and to ensure people received safe care and treatment. The manager and provider had made significant improvements to the governance and oversight arrangements, implementation of systems and processes to safely assess and manage risks to people, including their medicines. However, there were some areas of documentation that needed to be further developed to ensure people received safe and consistent care. There were also improvements needed to ensure people consistently received care that met their individual needs. Activities reflected people’s preferences and interests. However, the activity programme has been impacted on by staff sickness. One person told us, “I enjoy the activities, but they are in a bit of a doldrums now.” There were plans to allocate care staff to cover the programme so that people received the social interaction they needed and wished for. At the time of the inspection, it was clear that there was some instability within the staff teams, we received mixed feedback about the management of the service and staff feeling unsupported. The atmosphere of the home was subdued, and if not managed had the potential to impact on the people who lived there.

People received safe care and support from staff who had been appropriately recruited, trained to recognise signs of abuse or risk, and understood what to do to safely support people. People said, “I do feel safe, I am happy here, I like the food and I don’t need more,” and “I like it here genuinely, I’m very safe, I feel this is my home.” People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible. Medicines were given safely to people by competent and knowledgeable staff, who had received appropriate training. There were enough staff to meet people's needs. The provider used a dependency tool to determine staffing levels. Staffing levels were reviewed following falls or changes in a person's health condition. Staff were deployed in a planned way, with the correct training, skills and experience to meet people’s needs. Agency staff used, received an induction to the service and worked alongside regular staff.

Staff told us that they had received the training they needed to meet people’s needs safely and effectively. The training matrix tracked staff training and this had ensured all staff received the training and updates needed to provide safe consistent care. A plan of supervision to support staff was available and this also included competency sessions on training received. One staff member said, “Supervision is every couple of months, but we are encouraged to speak up if we need support.” People’s nutritional and health needs were consistently met with involvement from health and social care professionals.

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.

Everyone we spoke to was consistent in their views that staff were kind, caring and supportive. People were relaxed and comfortable in the company of staff and were treated with respect. People’s independence was considered important by all staff and their privacy and dignity was also promoted.

People were encouraged to go out and meet family and friends. Technology was used to keep families in contact by skype and email. Staff knew people’s communication needs well and staff communicated with people in an effective way.

Care delivery was based on people's preferences and wishes. People were involved in their care planning as much as they could be. One person said, “I am very involved in my care plan because I know what I want.” End of life care planning and documentation guided staff in providing care at this important stage of people’s lives.

People, their relatives and health care professionals had the opportunity to share their views about the service. Complaints made by people or their relatives were taken seriously and thoroughly investigated. One visitor said, “I speak to the manager if I have any concerns.” The provider and manager were committed to continuously improve, and had developed structures and plans to develop and consistently drive improvement within the service to deliver sustainable good care.

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 13 December 2018)

The overall rating for the service has remained Requires Improvement. This is based on the findings at this inspection.

Why we inspected:

This was a planned inspection based on the previous rating.

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.

Richmond 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. Richmond is located in Bexhill-on-Sea and provides accommodation and personal care for up to 58 older people requiring support with a dementia type illness and who are at risk of falls and live with long term healthcare needs such as Parkinson's. The home is set out over two floors. There is lift access between the ground floor and upper level. At the time of our inspection there were 49 people living at the home.

Following our inspection in March 2017 a number of breaches were identified and the service was rated requires improvement with the well led domain rated as inadequate. We served a number of Requirement Notices in relation to meeting people’s preferences, providing support in line with the Mental Capacity Act, unsafe medicine procedures, not reporting possible abuse effectively, inadequate systems for assessing and monitoring the service and insufficient staff levels. The provider sent us an action plan that told us how they would address these. We inspected again in September 2017 to check the provider had made improvements and to confirm legal requirements had been met. We found improvements had been made in several areas but in relation to the management of ‘as required’ medicines and the overall assessment of staff levels there were still shortfalls that needed to be addressed to fully meet the regulations.

This inspection found that whilst improvements seen in September 2017 had not deteriorated, there had not been the necessary improvements to change overall the rating to Good.

This is the third consecutive time the service had been rated as Requires Improvement.

Whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. This included updating care plans when an identified need or directive of care changed. For example, a deterioration in health and nutritional needs.

Not all care plans had been reviewed and updated to ensure they reflected people’s current needs and associated risks. For example, when a person’s skin integrity changed and the equipment used to manage the risks to their skin, such as pressure reliving mattresses.

We have made a recommendation about the management of some medicines and in how staff administered medicines.

There was a registered manager in post. 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 associated Regulations about how the service is run.

People spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made.

Most care plans reflected people’s assessed level of care needs and care delivery was person specific, holistic and based on people's preferences. Risk assessments included falls, skin damage, behaviours that distress, swallowing problems and risk of choking, and moving and handling. The care plans also highlighted health risks such as diabetes and leg ulcers. People said they felt comfortable and at ease with staff and relatives felt people were safe.

Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people when they needed assistance. The provider was actively seeking new staff to ensure there was a sufficient number with the right skills when people moved into the home. Pre-employment checks for staff were completed, which meant only suitable staff were working in the home.

All staff had attended safeguarding training. They demonstrated a clear understanding of abuse; they said they would talk to the management or external bodies immediately if they had any concerns. Staff had a clear understanding of making referrals to the local authority and CQC.

The manager and staff had completed training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. They had assessed some restrictions were required to keep people safe for example, doors were locked and, where assessed as appropriate bed rails and mat sensors were used for people’s safety. Where this was the case referrals had been made to the local authority for authorisations.

People had access to healthcare professionals when they needed it. This included GP’s, dentists, community nurses, and opticians. Staff received regular support from management which made them feel supported and valued. They were encouraged to develop their skills and take on additional responsibilities. Staff spoke positively about the changes made to the running of the home and the way the home was managed.

Staff were kind and caring, they had developed good relationships with people. They treated them with kindness, compassion and understanding. Staff supported people to enable them to remain as independent as possible. They communicated clearly with people in a caring and supportive manner. We received positive feedback from relatives and visiting professionals about the care provided.

Activities were provided and were seen to be enjoyed by people who lived at Richmond. Staff told us they were constantly reviewing activities and ensuring that they reflected people’s interests. Staff had received training in end of life care and were supported by the Local Hospice team. The service worked well with allied health professionals.

A number of audits had been developed, including those for accidents and incidents, care plans, medicines and health and safety. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Staff said they were encouraged to suggest improvements to the service.

Richmond was inspected in March 2017. A number of breaches were identified and the service was rated requires improvement with the well led domain rated as inadequate. We served a number of Requirement Notices in relation to meeting people’s preferences, providing support in line with the Mental Capacity Act, unsafe medicine procedures, not reporting possible abuse effectively, inadequate systems for assessing and monitoring the service and insufficient staff levels. Following our inspection the provider sent us an action plan telling us how they would make improvements. This inspection found improvements had been made in several areas but in relation to the management of ‘as required medicines and the overall assessment of staff levels there were still shortfalls that needed to be addressed to fully meet the regulations. We acknowledge the management structure had changed following the last inspection and there had been difficulty in staff recruitment.

There was no registered manager in post. 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 associated Regulations about how the service is run. A manager had been appointed and was in the process of submitting their application for registration. Since our inspection we have received this application and it is currently being processed.

There have been a number of changes to the management of the home in the past two years. In recent months CQC have received a number of concerns about the service and where appropriate, these have been sent to the local safeguarding team for investigation. During our inspection we received concerns from two whistle blowers (WB). Immediately following our inspection a third WB contacted us. Concerns included poor record keeping, a lack of availability of some prescribed creams and poor care. We looked at some of the concerns raised and asked the provider to carry out an investigation. We found some of the concerns were substantiated. However, a number of concerns were historical and actions had already been taken to address these areas.

The management team confirmed staff turnover had been high and in a number of cases disciplinary actions had been taken. This had led to low staff morale. The management team had responded robustly to this and to the impact this had on the running of the home and the care and support people received. Feedback from staff, visitors and people confirmed significant improvements had been made in relation to the running of the home.

Whilst we found improvements had been made we also found there were areas where improvements were needed. For example in relation to the management of medicines prescribed on an ‘as required basis,’ in relation to monitoring of mattress settings to ensure people’s skin integrity, and in consideration of risks when caring for people whose behaviour can challenge.

There were particular times of the day when calls bells were busy and this had an impact on people and staff. Whilst there were systems to monitor this, they needed to be implemented more frequently to ensure people’s needs were met safely and if necessary to revise staff levels. Systems for monitoring staff levels also needed to take account the overall impact of a high use of agency staff and a high number of falls.

Despite the above concerns we found staff understood what they needed to do to protect people from the risk of abuse. Appropriate checks had taken place before staff were employed to ensure they were able to work safely with people at the home.

The manager and staff had completed training on the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. They had assessed some restrictions were required to keep people safe for example, doors were locked and, where assessed as appropriate bed rails and mat sensors were used for people’s safety. Where this was the case referrals had been made to the local authority for authorisations.

People had access to healthcare professionals when they needed it. This included GP’s, dentists, community nurses, and opticians.

People were asked for their permission before staff assisted them with care or support. Staff received regular support from management which made them feel supported and valued. They were encouraged to develop their skills and take on additional responsibilities. Staff spoke positively about the changes made to the running of the home and the way the home was managed.

Staff were kind and caring, they had developed good relationships with people. They treated them with kindness, compassion and understanding. Staff supported people to enable them to remain as independent as possible. They communicated clearly with people in a caring and supportive manner. We received positive feedback from relatives and visiting professionals about the care provided.

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

Richmond is located in Bexhill-on-Sea and provides accommodation and personal care for up to 58 older people requiring support with dementia type illness and who are at risk of falls and long term healthcare needs such as Parkinson’s. The home is set out over two floors. There is lift access between the ground floor and upper level. At the time of our inspection there were 50 people living at the home.

A registered manager was in post. 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 and associated Regulations about how the service is run.

People living on the first floor of the service were not consistently responded to in a timely manner due to insufficient numbers and deployment of staff. Throughout our inspection we heard call bells ringing for extended periods; staff told us their responsiveness was impacted by the provider’s high use of agency staff.

We found two occasions where the providers own safeguarding procedures had not been consistently adhered to in regard to notifying appropriate external authorities in a timely manner.

The shortfalls in the recording of PRN (as required) Medicines we found at our last inspection had continued and additional concerns were identified in the administration and disposal of medicines.

Staff told us their morale was low and that they did not always feel listened to by senior staff. We found staff knowledge and understanding in areas such as the Mental Capacity Act 2015 (MCA) and behaviours that challenge required improvement. The provider had not ensured that staff completing MCA assessments had a clear understanding of how to capture and record people’s capacity in line with legislation. MCA assessments did not evidence how staff had arrived at decisions related to people’s capacity via best interest meetings and discussions.

Although we saw kind and caring interactions between people and staff we also found instances when there had been shortfalls in the staff approach in regard to confidentially, dignity and respect.

The provider had not ensured people’s care was consistently responsive to their support needs. Care plans did not always reflect people’s individual care and support needs and were not consistently person centred. The provider’s reliance on care agency for an extended period meant that the continuity of care people received was variable. We found there were occasions during our inspection where there was a lack of provision for people in respect to social activities and interaction with staff.

Some of the established quality assurance systems had failed to provide senior staff with clear oversight of the service. Audits related to care plans and call bells had not identified the concerns we found during our inspection. Effective leadership was not evident on the floor and the issues which had impacted on low staff morale had not been addressed.

Appropriate checks had been completed when new staff were recruited to ensure they were safe and suitable to work within a care environment. There were systems and processes in place to routinely check all equipment including those related to fire safety and health and safety.

People had a choice as to where they ate and they and their relatives were positive about the food provided. People told us they felt listened to in regard to their comments and suggestions about food and mealtimes.

People and their relatives were positive about the physical environment and aspects of the care they received such as their rooms and the support they received to dress the way they chose.

The provider had established an organisational system whereby the registered manager was provided with practical support and guidance from area and regional managers along with head office support in regard to areas such as HR.

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

When we inspected this service on 3 September 2013 we found that people were not receiving holistic care on one of the units; and some practices did not show that people were involved in decisions about the care provided. Staff spoken with said they did not feel supported by the management, and there were inconsistencies in the way that records were kept.

Following our inspection we received an action plan from the provider that told us that processes were in place that ensured people and their relatives were involved in decisions about the care they received. A holistic approach to care had been developed, staff were supported to provide this and record keeping was appropriate. The provider said the service was compliant. This inspection was carried out to check that the home had complied with the compliance actions made at our previous visit.

People told us they were quite comfortable living at the home. One person told us, 'You'd find it hard to get a better home than this, and the food is excellent, 5*. You can make suggestions to the chef and he will get it for you.' Another person said, 'They are very kind to me and I do appreciate it.' A relative told us, 'The care is very good. Staff know how to support people who have dementia, and we would not be able to find anywhere better.'

We found that staff provided appropriate care and support for people in each unit at the home. We looked at six care plans and found that people, and if appropriate their relatives, were involved in planning and reviewing the care they received.

Staff spoken with said the management were very supportive and they felt able to provide holistic care for people.

The records we viewed were up to date and relevant to the services provided.

We found that there were differences in the way that services were provided on the two units. We looked at the processes in place to gain consent. We found that some practices did not show that people were involved in their care decisions. We observed that people did not receive holistic care on one of the units.

We looked at the processes for the administration of medicines.

We spoke with eight staff and the two peripatetic managers. There had been some improvements to staffing levels in the three weeks prior to our visit and the rotas showed that future staffing levels reflected the increased numbers. There had been temporary management arrangements in place since June.

Although there was a comprehensive programme of training in place we found that learning had not always been transferred into practice. Overall, staff felt unsupported.

We looked at eight care plans and four staff files and found that there were inconsistencies in the way that records were kept.

We asked the acting manager to provide additional evidence. This was not available at the time the draft report was produced.

Although the two units at Richmond were run separately there were a number of joint activities that took place and brought people and staff together. For example, a summer garden party was held in the grounds for all people using the service their family and friends. Weekly church services were held in the communal lounge for everyone. The singing activity we observed that took place on the Heatherbank unit was attended by people from the Richmond unit too.

People told us that they were well cared for and that the staff met their needs and they received the care and treatment they expected to have. One person told us 'Its very nice here, I can't fault it'. Another person told us, 'Staff are very kind and helpful from the managers down'.