Elephant Care Ltd

Beechwood House Rest Home is a residential care home providing personal care to nine people aged 65 and over at the time of the inspection. The service can accommodate up to 13 people in one adapted building.

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

Quality had deteriorated. The provider had not had close oversight. They had not satisfactorily addressed the issues identified at the last inspection. Their quality assurance had not identified the shortcomings found at this inspection. Records were incomplete and lacked detail. Legal requirements for displaying the inspection rating were not met. We have made a recommendation about understanding the requirement to notify CQC of changes in the management of the service.

People were not protected from avoidable harm. Checks on volunteers and staff were incomplete. There were reports of unkind staff. Incidents were not always reported or addressed. Risk assessments were incomplete or missing. Some environmental risks were not addressed, and there were shortfalls in cleanliness. Medicines were not managed safely.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support least restrictive practice. One person was unduly restricted, and we raised a safeguarding adults referral concerning this.

Staff did not all have the necessary skills to work safely. They did not always seek timely medical advice when people showed signs of being unwell. Assessments and care plans lacked detail regarding people’s care needs. Care was often task-focused rather than centred on people’s individual needs and wishes.

Most people said they liked the staff and we observed some respectful, gentle interactions. Care was offered discreetly. However, people’s preferences were not always respected. People had little involvement in planning their care.

People mostly said they liked the food. However, there was not usually a choice of main meal. People were not always offered alternatives if they did not want what was offered. We have made a recommendation regarding ensuring people always have enough to drink.

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 inadequate (published 22 November 2018); there were multiple breaches of regulation and the service was placed into special measures. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection improvements had not been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We carried out an unannounced comprehensive inspection of this service on 28 September, 2 October and 10 October 2018. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, safeguarding service users from abuse and improper treatment, good governance and notifications.

At this inspection we checked they now met legal requirements.

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

Enforcement

We have identified breaches in relation to safe care and treatment, safeguarding people from abuse and improper treatment, good governance, person-centred care, and the requirement to display ratings.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will meet the provider to advise them of the proposed regulatory action and to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special measures

The overall rating for this service is inadequate and the service remains in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of the 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.

The older people living in Beechwood House Rest Home have care and support needs associated with their physical and mental health.

The inspection visits took place on the 28 September and 2 October 2018. The initial visit was unannounced. We continued to gather evidence form professionals until 11 October 2018.

The service had a registered manager who had been running the home for many years. 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.

We carried out this inspection in response to information of concern we received alleging that people were receiving unsafe and poor care. We planned to undertake a focused inspection to answer the key questions “Is the service safe?”, “Is the service effective?” and “Is the service well-led?” Following our visits, we continued to receive information of concern from professionals and whilst analysing our evidence we determined that a comprehensive inspection was necessary.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

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.”

At this inspection, we found that risk management was not sufficient to ensure people received safe care and treatment. Risks related to skin damage, mobility and eating and drinking were not being managed effectively and staff did not always have accurate information about these risks. Risks related to the environment had not been picked up and fire safety checks had not been carried out. This was a breach of the regulations.

Allegations of abuse had not been appropriately responded to. Allegations had been brought to the attention of the registered manager but appropriate agencies had not been notified. This was a breach of the regulations.

Staff followed safe procedures and this ensured that people received their medicines as prescribed.

People were supported to have choice and control of their lives. However, the assessment and documentation systems in the home did not support the embedding of the Mental Capacity Act 2005 and we have made a recommendation about this. We have also made a recommendation about the development and documentation of comprehensive assessments of people’s needs.

People’s communication needs were not assessed, recorded and shared in line with the Accessible Information Standard. We have made a recommendation about this.

Notifications had not been made to the Care Quality Commission where required due to allegations of abuse and people developing pressure areas. This was a breach of the regulations.

Staff had been recruited safely and were able to respond to people when they wanted help. They had received training but this had not been sufficient to ensure people were helped to move safely. This was a breach of the regulations.

The menu offered a variety of main meals and snacks and catered for individual likes, dislikes, allergies and special diets. We have made a recommendation about developing the range of foods available to people on special diets.

Care staff were kind, patient and friendly throughout and people’s privacy and dignity were usually respected.

People told us they had access to GP’s and dentists when they needed them.

People and staff described the manager and staff as approachable. They knew how to raise concerns and felt they would be listened to and any actions needed would be taken. Complaints were not always investigated in a way that ensured learning and where they included allegations of abuse these were not addressed appropriately.

There were shortfalls in the oversight of the service, risk management, the management of safeguarding, staff training, failure to comply with statutory responsibilities and quality assurance in the home.

The service was previously inspected on 29 November 2016 when it was found to require improvement. This was because medicines had not been stored and dispensed in accordance with current guidance and notifications had not been submitted to the CQC. We made recommendations as a result of these findings.

At this inspection we found people’s medicines were managed safely and people told us, “I get my medicine on time.” We found medicines were now dispensed, administered and stored appropriately in accordance with current guidelines. Medicines administration records had been fully completed and regularly audited to ensure their accuracy.

Beechwood House accommodates up to 13 older people with care and support needs. At the time of our inspection 13 people were living at the service. The service consists of a detached house set within its own gardens and there was a passenger lift to enable people with limited mobility to access rooms on the first floor.

The service had 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 registered manager was also the registered provider. The registered manager lived on site and was available to support people and staff at all times if required.

People were relaxed and at ease in the service and told us, “I am very happy here, I was surprised how nice it was” and “The staff are very kind, they are very good.” Relatives comments included, “The atmosphere is very warm and friendly. All of the staff are very caring and nothing is any trouble” and “I can’t praise it enough, I want to go there when I get to that age.” People were comfortable requesting support which staff provided promptly and with compassion.

Staff had received safeguarding training and understood their responsibilities in relation to protecting people from abuse, harm and all forms of discrimination. They told us, “I think people are safe” while professionals commented, “This is a very safe and caring service, definitely one of the best I know.”

The well-established staff team were sufficiently skilled to meet people’s needs and were guided and supported by the registered manager who led by example. People told us, “[The registered manager] is very nice, very, very hands on. You know you can always talk to her about anything.” It was clear that the registered manager was fully committed to ensuring people’s needs were met. We found both the registered and deputy managers knew people well and had a detailed understanding of their individual care and support needs. Staff told us they were well supported and commented, “The registered manager is really good, very helpful and always there if you need her.” Health and social care professionals were also constantly complimentary of the manager’s approach saying, “[The] management of the service is excellent.”

People told us they would report any complaints to the registered manager but said this had not been necessary. Records showed people and their relative’s regularly complimented the service on the quality of care and support provided and recently completed feedback questionnaires had also been complimentary.

The service was well maintained and decorated in a homely style. People’s bedrooms had been personalised with ornaments, furniture and paintings. There were systems in place to monitor the standard of the environment and two people’s bedrooms were in the process of being redecorated. Fire detection equipment and utilities had been regularly tested by appropriately skilled contractors. The servicing of firefighting equipment was not up to date but this issue was immediately addressed by the registered manager when we brought it to their attention.

Care plans included risk assessments and guidance for staff on how to protect people from identified risks in relation to both the environment and the persons specific care needs. Where accidents or incidents occurred these had been investigated by the registered manager to identify any further actions that could be taken to improve people’s safety.

The service was fully staffed and people told us, “There are enough staff around to meet my needs”, and “They come straight away if you ring the bell.” There were appropriate recruitment procedures in place for new staff and all necessary pre-employment checks had been completed.

Detailed assessments of people’s needs were completed before they moved into the service. This was done to ensure the service could meet the person’s needs and that they would be happy living there. The assessments process included visits to the person’s home. Professionals praised the deputy manager for the support she had provided to one person who had felt anxious about moving into the service. People’s initial care plans were based on information gathered during the assessment process combined with background information from commissioners and relatives.

Care plans were sufficiently detailed and staff had a thorough understanding of each person’s individual needs. Staff told us, “I think there is enough information [in the care plans]” Information about people’s life history and background was documented as well as details of the care and support they required. These records had been regularly reviewed and updated where any changes in care needs had been identified.

The registered manager was in the process of introducing a new care planning format designed to directly link with the service’s assessment processes. We reviewed one updated care plan and found it included more detailed guidance for staff on the person’s specific needs. Changes were also planned in relation to daily care records and staff told us, “We are changing the daily record system to improve detail.”

People were able to choose how to spend their time and to access the community when they wished. During our inspection one person chose to spend the day away from the service so staff had prepared them a packed lunch. People and their relative’s told us there was enough to do at Beechwood House. Their comments included, “We do quizzes and things. Puzzles, bingo at times and I can play bowls on the television” and “There is plenty for people to do.” Informal activities were normally arranged by staff in the afternoon and there were regular visits by external entertainers.

Information was stored securely and there were systems in place to monitor the service’s performance, gather feedback from people and their relatives and identify where improvements could be made.

Management and staff had a good understanding of the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DoLS). People told us, “They ask me what I want and what I don’t want” and we saw staff consistently respected people’s decisions and choices. The service’s policy was that people were free to leave the service if they wished and the registered manager recognised this meant the service was unable to meet the needs of individuals who lacked capacity.

Beechwood House is a residential care home for older people. The service is registered to provide care for up to 13 people and was fully occupied. Each person had their own bedroom and with the exception of one have en-suite toilet and wash hand basin. A lift provided access to the first floor. There is a specialist bathroom, a lounge and communal dining room and on site laundry and kitchen facilities.

There is 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.

Statutory notifications had not been made to CQC which meant that we had not received information to support our monitoring of the service. Audits were being completed in most areas but did not include care and support plans or identify that medicines were not being administered in line with best practice. This was an area that the registered manager was aware of and at the time of our inspection an audit schedule was being implemented. People had provided feedback about the service in a quality assurance survey in October 2015. Any issues raised had been addressed in a timely and appropriate way. Feedback has been extended in the next survey to include staff and people’s relatives. A complaints procedure was in place and people felt if they needed to use it they would be listened to and actions taken to put things right.

People’s medicine was not stored and administered in line with best practice guidance which increased the risk of people not receiving their medicines correctly. Staff had been trained to safely administer medicine and had their competencies regularly checked. People received their medicine as prescribed and staff were aware of how to report an error.

People were supported by staff who had received training in how to recognise abuse and the actions they would need to take if they felt a person was at risk. Staff had been recruited safely which included checks with the disclosure and baring service to ensure they were suitable to work with vulnerable people. There were enough staff with the right skill mix to meet people’s needs. Staff received regular supervision and were supported to carry out their roles effectively.

Risks to people were assessed and staff understood their role in minimising risk whilst ensuring people’s choices and freedoms were respected. Personal evacuation plans were in place to ensure people would receive the support they needed in an emergency.

People were involved in decisions about their care. When they were unable to do this the principles of the mental capacity act were being followed. Where people had a power of attorney staff understood the scope of decisions they could make for a person.

Staff understood people’s dietary needs including allergies and special diets. Food was freshly cooked and available at any time of the day. Specialist crockery, beakers and plate guards were used to support people to enjoy their meals independently.

People had access to a range of health care which included chiropodists, opticians, GP’s and community nurses.

Staff were caring and had warm friendly relationships with the people they supported. Staff attitudes were positive and they were described as respectful, open and friendly. People’s communication needs were understood by staff and included appropriate use of body language. This enabled people to be involved in decisions about their day. Staff had a good understanding of people’s interests, likes and dislikes which meant they could have meaningful conversations with people. People’s dignity and privacy was respected and staff encouraged and supported people to be as independent as possible.

People had been involved in assessments of their care needs prior to moving to the service. Staff understood people’s care needs and how they liked to be supported. Daily records were completed by staff that reflected the care and support plan and provided information for when care and support plans were reviewed.

People had opportunities to maintain links with family, friends and the community. Activities were organised within the home and the wider community which were linked to people’s interests.

The service had an open, friendly atmosphere and staff were positive about the organisation, their roles and the teamwork. Staff felt informed and appreciated and described communication as good.

One person told us that they were "well looked after" and another said the "food was very good".

We found that before people received any care or treatment, they were asked for their consent and the provider acted in accordance with their wishes.

People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. This was because the provider worked in co-operation with others.

People were protected from unsafe or unsuitable equipment.

We found that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

We found there was an effective complaints system available. One of the relatives we spoke with said she felt "the manager was very approachable and would deal with any complaints appropriately".

We found that the provider had complied with the compliance action issued, which required the service to have an effective system to regularly assess and monitor the quality of service that people received. We also found the provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others.

People living at Beechwood House Rest Home were positive about their experience of living at the home. No one had any complaints or concerns about how the home was run and managed.

People told us that they had good relationships with the staff, who were described as 'kind and respectful'. They told us that the home was kept clean and warm. People said there were activities to keep them occupied.

People who lived at Beechwood House Rest Home benefited from processes and procedures being followed when new staff were recruited, which meant they were protected from harm.

Medicines were prescribed and given to people appropriately.

We found the home did not have adequate quality assurance systems in place to ensure standards in the home were maintained.