Archived: Neilston Residential Care Home

We have shared our concerns with commissioners and the safeguarding team. Following this, with the agreement of the provider, health professionals visited the home to assess people's safety and wellbeing. Some people's care needs are currently being reviewed by the local authority commissioners. In addition, the local authority quality monitoring team are working with the provider and staff to support them to bring about improvements.

Neilston Residential Care Home is registered to provide personal care and support to 22 people who may be living with dementia. The registered manager was also the provider of the service but they did not have day to day responsibility for the running of the service. They are referred to in this report as the registered provider. The registered manager who did have day to day responsibility for the service left in January 2017. Another manager had been appointed and had been working at the home for four weeks at the time of our inspection.

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.

People were not safe and were placed at risk of harm. Risks to people's physical health were not identified and managed. The management of falls, choking, skin and pressure area care, medicines, and moving and handling was unsafe. Poor monitoring and management of people's eating and drinking put some people at risk. Care plans were not clear and up-to-date, which meant staff did not have current information on how to meet people's needs. This meant people were at risk of receiving inconsistent care and not receiving the care and support they needed. Staff did not always make referrals to other healthcare professionals to ensure people's care and treatment remained safe.

The provider did not operate safe and robust recruitment procedures. Checks required by law had not been carried out before staff started work at the home. This exposed people to unnecessary risk.

People did not benefit from enough staff to give them the care they needed. At various times throughout the inspection, we observed people sitting in the lounge with no staff present. Some of these people were unable to mobilise independently and had no way of calling for assistance if they needed it. The care and support we saw staff giving in the lounge was largely task based. For example, supporting people with moving and handling transfers and offering drinks or food. There was little meaningful communication between staff and people in the lounge area throughout the inspection. This meant people's social needs were not being met and there was a lack of consideration for their wellbeing.

People did not receive support from staff who had appropriate training and supervision to ensure they had the skills and knowledge to meet their needs. Although some dementia training had been completed, we observed not all staff understood how to meet the needs of people living with dementia. Most interactions between staff and people were poor. We observed staff did not always listen to people or support them to express their views. For example, one person asked to go to the toilet and was ignored, despite there being a strong smell of urine. People were not treated with respect at all times. For example, we observed staff telling one person they were a ‘good girl’ and another person was told they were ‘being naughty’.

People did not benefit from meaningful activities. People had not been supported to follow their individual interests. We saw people who sat in the main lounge spent most of the time dozing or looking round the room. The television was on but not many people were watching it. The manager told us organised activities took place for two hours on a Tuesday and Friday. There was little attempt to engage any of the people with any form of activity or conversation.

There were restrictions to people’s movements around the home and these had not been assessed as being the least restrictive option to keep people safe. For example, people’s bedroom doors were alarmed and stairgates were in place. The environment was not suitably adapted to meet the needs of people living with dementia. We had made a recommendation at our inspection in April 2015 in relation to the environment but there had been little progress since then in meeting people’s needs.

Risks to people within the environment were not assessed or managed. In people’s bedrooms and communal areas we observed items that people living with dementia may misuse or swallow. People were not protected by the prevention and control of infection. The environment was dirty and dusty. The premises were not free from offensive odours. Odours of urine were noted at different places and different points of the inspection. Infection control practices were poor. We identified concerns in relation to the safety of the electrical installation and hot water temperatures. We asked the provider for more evidence so that we could judge whether people were safe but we did not receive this.

Weak leadership and a lack of oversight of the service had allowed poor practice and inconsistent care to be delivered. When the registered manager who had day to day responsibility for the service left in January 2017, another manager was appointed. Following our inspection, we were informed this manager had resigned from their post. The previous manager then returned to cover three hours a day each afternoon, from Monday to Friday. The provider told us they were unaware of events relating to the care of people living in the home. The provider had not developed the staff team to ensure they displayed the right values and behaviours towards people. At times, this resulted in poor outcomes for people who lived in the home.

Management systems were not effective as they had not identified and addressed the risks and issues we found during our inspection. There had not been any recent audits at the time of our inspection. Where the registered manager had identified issues previously, these had not been actioned within the timescale given. The local authority quality monitoring team had completed a report with recommendations, following a visit to the home in October 2016. We identified the same issues during this inspection. Records relating to the care and treatment for each person were not accurate, up-to-date or easily accessible. This showed the provider had not taken action to ensure improvements were made.

During the inspection, we identified a number of concerns about the care, safety and welfare of people who lived at Neilston Residential Care Home. We found nine breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

After that inspection we received concerns that people’s medicines were not being managed safely; that the service had not sought advice from healthcare professionals in a timely manner; the home was not following dietary guidance for people who required a soft or pureed diet and that there were insufficient staff on duty to meet people’s needs.

As a result we undertook a focused inspection on the 22 August 2016. We inspected the service against one of the five questions we ask about services: is the service safe? At our previous inspection we rated this key question as requires improvement. This report only covers our findings in relation to those concerns. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for residential care home on our website at www.cqc.org.uk”.

We found there were not always enough staff on duty to meet people's needs. The management team had recognised this and were attempted to recruit additional staff. Some records were not always well maintained, clear or up to date, although the manager took immediate action to remedy this. We did not find evidence to support the other concerns and have asked the manager to keep these under review.

The home 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.

People told us they felt safe and well cared for at Neilston. People told us they thought there could be more staff on duty so they did not have to “wait for someone to come”. Relatives told us they were happy with the care provided by the home and said people were well looked after. However they also said the home could do with more staff. Staff told us there were enough staff. They said they needed at least one more person during the day, especially in the morning, when people needed more assistance. During our inspection we saw people were left unsupervised for long periods of time while staff were attending to people’s needs in their bedrooms. Staff interacted with people in a friendly and caring manner and people seemed comfortable in their presence. However many of these interactions were task related. Although staff did not appear rushed, some people did have to wait for their needs to be met. We raised these concerns with the registered manager who told us they had already identified the need to increase staffing levels and had a clear plan in place to address this. They planned to increase staffing during the day from two care staff and one senior to three care staff and one senior. We saw a new senior had recently been appointed, adverts had been placed to recruit more care staff and interviews were planned for the following week to appoint an activities co-ordinator.

We received information that one person had fallen and the home had not sought advice from an appropriate health care professional. We looked at the care records of this person and found the incident had been appropriately managed and documented. However not all records relating to this person were accurate, clear or up to date. The manager addressed this immediately.

People received their prescribed medicines on time, in a safe way, and were given the time and encouragement to take their medicines at their pace. There was a safe system in place to monitor the receipt and stock of medicines held by the home. Medicines were disposed of safely. Staff had received training in the safe administration of medicines.

People’s care records contained food and fluid intake charts, nutrition, hydration and swallowing assessments, which were reviewed and updated regularly. We observed lunch and saw; where people required a soft or pureed diet this was being provided.

We found a breach 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 the report.

The home had a registered manager who was no longer in post but was yet to deregister with the Care Quality Commission (CQC). A new manager, who was in post at the home, registered with the CQC following this inspection. 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 a 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 a previous unannounced comprehensive inspection of this service on 21 April 2015. Breaches of legal requirements were found in relation to people not always being treated with dignity and respect; risks to people not always being assessed or mitigated; premises posing risks to people; people being deprived of their liberty without lawful authority; systems not protecting people from abuse; people’s nutritional needs not being monitored; people not receiving dietary supplements as required and effective systems not being in place to assess and monitor the safety and quality of the service.

Breaches of legal requirements were also found in relation to the Care Quality Commission not being notified of incidents relating to the management of the service and incidents of safeguarding concerns as required by law.

Following the inspection in April 2015 Neilston Residential Care Home was rated as inadequate and was placed in special measures.

The provider sent us an action plan which detailed what they were going to do to meet the regulations. Actions had been taken to address the concerns identified at our last inspection, however, there were still some areas of concern identified. .

This inspection took place on 13 January 2016 and was unannounced. At the time of our inspection there were 11 people using the service. People had a range of needs with some people being independent and others requiring more support with their mobility and care needs. Many people who lived in the home were living with a form of dementia.

Some people were being deprived of their liberty for their own safety. The registered manager had made the appropriate Deprivation of Liberty Safeguards (DoLS) applications to the local authority and the majority of these were still awaiting approval. Where one application had been approved, staff did not have a clear understanding of the implications of this on the person’s care. Clear guidance relating to this DoLS was not reflected in the person’s care plan. This could pose a risk of these restrictions not always being followed appropriately.

In one bathroom we found items such as deodorants, anti-bacterial hand wash and vinyl gloves left out. These items could pose a risk to people if ingested. We also found one fire exit which was not clearly sign posted and one fire extinguisher which was out of date. These issues could pose risks to people in the event of a fire.

Although improvements had been made to the environment and there were further plans in place, at the time of the inspection the environment was not suitable for people living with dementia. There was a lack of clear signage and items around the house for people to pick up and handle.

A new registered manager had recently taken over the management of the home and was making a number of changes in order to improve on people’s day to day lives. They had made changes to people’s care plans in order to make them more person centred, had organised training for staff, had undertaken maintenance work and had plans in place to undertake further improvements.

An activities coordinator had been recruited in order to provide people with meaningful activities which met people’s individual interests. People took part in group activities and staff spent time individually with people. We saw people enjoyed the activities they were involved in.

Staff treated people with kindness and respect. People enjoyed pleasant and affectionate interactions with staff which demonstrated people felt comfortable with the staff. People were cared for by staff who knew their histories, preferences, likes and dislikes. This ensured people were cared for by staff who knew them well and cared for them in ways that met their preferences.

Staff received training that related to the needs of the people who lived at Neilston Residential Care Home. Staff could tell us what care people required and how they ensured they supported them in the way they needed. Staff had undertaken further training since the new registered manager had been in post and best practice and guidance had been sought from healthcare professionals. There were still some gaps in staff training but these were being responded to.

Each person’s needs had been assessed and new care plans had been put in place to meet those needs. Care plans had been developed to meet people’s needs in a person centred way. Where people’s needs had changed, these had been updated and staff had taken action to ensure people received the care they needed.

Where people were not able to make decisions for themselves staff involved people’s relatives and appropriate professionals to make sure people received care that was in their best interests. People were supported to be involved in making as many decisions as possible for themselves and were always asked for their consent before care was delivered. Staff understood the principles of the Mental Capacity Act 2005 and how to apply these.

There were sufficient staff on duty to meet each person’s needs. Staff spent time chatting with people individually and helping people take part in group activities. Staff supported each person in the way they required and were not rushed.

People were helped to eat and drink enough to maintain good health. People were seated at the tables in the dining room for a long time before their meals were served. This time was mainly spent in silence as staff did not encourage interaction during that time. Once all the meals were served staff chatted with people and made the mealtime into a social experience. People were offered choices of foods they wanted to eat and were given alternatives if they did not want the options on the menu. People were provided with drinks and snacks throughout the day and where people required their food and fluid intake monitored this was recorded, detailed and analysed.

People’s relatives told us they were comfortable sharing their feedback with the registered manager, including raising concerns. Relatives felt involved in people’s care and told us they were kept regularly informed about their relations’ care and health.

People were protected from the risks associated with medicines because the provider had appropriate systems in place to manage these. Staff had received training in relation to the storing, administering and disposal of medicines.

People’s needs and abilities had been assessed and risk assessments had been put in place to guide staff on how to protect people. Plans and risk assessments included specific guidance for staff to follow in order to reduce risks to people.

Staff had sought advice from healthcare professionals such as GPs, physiotherapists, district nurses and chiropodists. This advice had been used to update people’s care plans and staff guidance on how to best care for each person. This minimised risks to people and staff.

Where accidents and incidents had taken place, these had been reviewed and action had been taken to ensure the risk to people was minimised.

The premises and equipment were maintained to ensure people were kept safe. Maintenance work had been undertaken and further plans were in place in relation to renovating and changing the décor of the home. There were arrangements in place to deal with foreseeable emergencies and each person had a personal emergency evacuation plan in place.

People were protected by staff who knew how to recognise possible signs of abuse. Staff told us what signs they would look out for and the procedures they would follow to report these. Where safeguarding concerns had been raised in the past the provider had taken action, had learned lessons and had involved people in the process.

Recruitment procedures were in place to ensure only people of good character were employed by the home. Potential staff underwent Disclosure and Barring Service (police record) checks to ensure they were suitable to work with vulnerable adults.

There were systems in place to assess, monitor and improve the quality and safety of care at the service. These had not picked up on some areas, but when discussed with the registered manager they took actions to address these areas. The registered manager undertook a number of checks and audits to ensure people’s care needs were being met. They looked at accidents and incidents, food and fluid charts, care provided, medicine management and the environment. They regularly conducted staff observations and had implemented a new supervision and appraisal system which checked whether staff were displaying the home’s philosophy of care. The home’s philosophy of care was to treat each person as an individual, to involve people and offer them as many choices as possible.

Due to the early hour of the inspection, 5.50am, we did not speak to people who used the service on this occasion.

The information we had received related to the times people were woken up in the mornings, the times people were made to go to bed at night, people’s food being restricted, staff speaking foreign languages in the presence of service users and staff not receiving induction or appropriate training.

We found people were able to wake up in the mornings at whatever time they preferred and people went to bed whenever they wanted.

People were provided with a varied choice of foods and were not restricted in their eating.

Staff spoke clear English and management had systems in place to manage and discipline staff should they be observed speaking a foreign language in the presence of service users.

We found each member of staff had undergone induction and had received appropriate training.

We reviewed records which identified that people were assessed when they arrived at the home and a care plan devised to ensure their welfare and safety. We also spoke with health professionals who visited the home who told us that staff contacted them for specialist advice when necessary.

The home had an emergency plan which identified what they would do in the event of an emergency.

The home was clean and well maintained. Adjustments had been made, including the provision of lockable stair gates to ensure safety and reduce the likelihood of accidents. However, staff did ensure that people living there were supported to go between their bedroom and the open access areas downstairs, whenever they wanted to.

We reviewed rotas which showed that there that there were sufficient, experienced staff on duty during the day and at night. We talked with staff who told us that they were supported to gain further qualifications.

We found the home had systems for recording and safekeeping of records relating to people using the service, staff and the premises.

On the day of inspection 18 people were living at the home and receiving care from the service. We spoke with six people, the provider (owner), the manager, three care workers, one relative and a visiting trainer. We spent time observing care and looked at three care plans. We checked how people were looked after at each stage of their care.

The home had made obvious improvements since the last inspections. Due to people's conditions we (the CQC) were not able to discuss their experience in detail. However all made positive comments. One person said 'We couldn't be looked after any better.' A relative described staff as 'very, very kind' and 'right on top of everything'.

There were appropriate arrangements in place for the safe management of medicines. Effective recruitment and selection processes were in place and suitable arrangements were in place to support staff. All the staff we spoke with were positive about the training they had received. There were systems in place to monitor the quality of the service and manage risk.