Archived: West House

This is the second consecutive time the service has been rated 'Requires Improvement.'

West House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. West House provides accommodation and personal care for up to 26 older people. Some people also have dementia related needs. At the time of the inspection, there were 26 people living at West House.

Prior to the inspection the Care Quality Commission were notified of significant changes to the management team of West House. The registered provider and manager had notified us that they were no longer employed at West House. Following the inspection, the registered provider informed the Care Quality Commission they had applied to us to be formally de-registered as both the registered provider and manager of the service. An internal appointment was made in April 2018 whereby the team leader was successfully promoted to the post of deputy manager. At the time of this inspection the deputy manager was being supported by representatives from another organisation to manage the day-to-day running of the service. The representatives had been asked by West House’s shareholders to provide additional support at this time. Therefore, the service did not have 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 2008 and associated Regulations about how the service is run.

The registered provider had not made adequate and necessary improvements to comply with regulatory requirements or to achieve a better-quality rating since our last inspection to the service in October 2017. The quality assurance arrangements had failed to identify the issues we found during this inspection to help drive and make all the necessary improvements. Although the deputy manager was now in day-to-day charge of the service, they had received no formal induction to their role and were finding some aspects of this challenging. This referred specifically to dealing with matters relating to staff, such as persistent staff absence or poor performance, safeguarding concerns and complaints management. The deputy manager confirmed these matters had primarily been dealt with by the previous registered provider. The shareholders representatives advised us that support was being provided to the deputy manager to enable them to undertake their role and to ensure the safety and wellbeing of people using the service.

The arrangements for the safekeeping of people’s monies did not protect or safeguard their monetary arrangements. Where incidents had occurred which suggested potential abuse, these were not robustly investigated. The deployment of staff was not always suitable to meet people’s needs and this impacted on the quality of care some people received. Improvements were required to ensure staff adopted good infection control practices and minor improvements were required in relation to staff recruitment practices.

Not all staff had received up-to-date mandatory and specialist training; and not all training attained was embedded in staff’s everyday practice. Where staff had been appointed to a senior role, they had not received an induction and not all staff had received regular supervision or an appraisal of their overall performance. Improvements were required to ensure people received a more positive dining experience. This referred to them receiving their meals in a timely manner, receiving support that treated them with respect and dignity; and which enabled people to make informed meal choices.

Though some people and those acting on their behalf told us they received a good level of support and were treated with care and kindness, interactions by staff and the way they communicated with people required considerable improvement. Many exchanges were centred primarily on tasks and routines, rather than it being person-led and person-centred. Staff did not always listen to people or respond to non-verbal cues and there was an over reliance on the use of the television. Although a new member of staff had been appointed since our last inspection to undertake social activities and there was an expectation that care staff would also facilitate these, people did not routinely receive opportunities to engage in social activities.

Improvements were required to ensure that people’s care plan documentation reflected all their care and support needs and how the care was to be delivered by staff. Compliments and complaints were recorded; however, improvements were needed to show how decisions and outcomes had been reached.

People living at the service confirmed they were kept safe and had no concerns about their safety and wellbeing. Medication arrangements at the service ensured people received their prescribed medication as they should. The service worked together with other organisations to ensure people received coordinated and ‘joined-up’ care and support. People’s healthcare needs were well managed and people had their healthcare needs met. Information available showed that each person who used the service had had their capacity to make decisions assessed. Where people were deprived of their liberty, the registered provider had made appropriate applications to the Local Authority for DoLS assessments to be considered for approval.

We have made recommendations about infection control arrangements, reviewing Mental Capacity Act principles to ensure staff work within these guidelines, end of life care and leisure and social activities.

As a result of our concerns the Care Quality Commission took action in response to our findings by rating the service as ‘Inadequate’, placing the service into ‘Special Measures’ and amending the provider’s conditions of registration. This meant the provider had to send the Care Quality Commission a detailed written report each month as to how the necessary improvements were to be achieved and ensure timely assessment and planning of care for all new admissions to the service. At this inspection considerable progress had been made to meet regulatory requirements, however some further improvements were still required.

West House provides accommodation and personal care for up to 25 older people. Some people also have dementia related needs.

This inspection was completed on 2 and 3 October 2017 and there were 18 people living at the service when we inspected.

The registered provider was also 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.

Quality assurance checks and auditing processes carried out by the registered provider and the senior management team of the service were in place and completed at regular intervals in line with the registered provider’s schedule of completion. The registered provider and senior management team were able at this inspection to demonstrate a much better understanding and awareness of the importance of having good quality assurance processes and procedures in place. This was a significant improvement resulting in better outcomes for people using the service. Feedback from people and those acting on their behalf and staff were positive. This referred specifically to there now being confidence that the registered provider and senior management team were doing their utmost to make the required improvements. Nonetheless, some further improvements were still required as highlighted at this inspection.

Improvements were still required to ensure that people’s care plan documentation accurately reflected their care and support needs and how the care was to be delivered by staff. Suitable arrangements to mitigate risks or potential risk of harm for people using the service although improved still required further review and development as specific information associated with these risks were not recorded in sufficient detail. The registered manager and deputy manager confirmed following feedback at the time of the inspection that this would be addressed as a priority.

Staff spoken with at the time of the inspection described the management team as supportive and approachable. However, improvements were required to ensure information from the registered provider’s formal supervision arrangements were recorded in sufficient detail, including the actions to be taken and confirmation these had been completed. Staff had received refresher and updated training to ensure they remained knowledgeable and competent for their role. Induction procedures for staff had been reviewed and these were now robust.

People were now routinely asked to give their consent to their care, treatment and support and people’s capacity to make day-to-day decisions had been considered and assessed. Nonetheless, improvements were required to ensure more significant decisions which had been made by staff were in people’s best interests and clearly recorded the rationale for these decisions. Staffs’ understanding and knowledge of the Deprivation of Liberty Safeguards [DoLS] and the key requirements of the Mental Capacity Act [2005] required improvement, however it was acknowledged that further training in these areas was already planned and booked.

Suitable arrangements were in place to take action when abuse had been alleged or suspected. People were protected from abuse and avoidable harm and people living at the service confirmed they were kept safe and had no concerns about their safety. Safe recruitment practices were in place and being followed so as to keep people safe. We observed that staff followed safe procedures when giving people their medicines, medicines were stored safely and records showed that people were receiving their medicines as prescribed.

People were supported to have enough to eat and drink. Appropriate arrangements were in place to monitor and record people’s nutritional and hydration intake so as to identify at the earliest opportunity those people who were at risk. People were supported to maintain good healthcare and had access to healthcare services as and when required.

Staff knew the care needs of the people they supported and people told us that staff were kind and caring. Staff responded to people’s need for support and demonstrated appropriate concern for their wellbeing and people told us they were happy with the care and support provided by staff. People and their relatives told us that if they had any concern they would discuss these with the management team or staff on duty. People were confident that their complaints or concerns were listened to, taken seriously and acted upon.

Staff spoken with told us that the overall culture across the service was open and transparent and that they felt supported by the management team. Staff told us that communication between staff and the management team was good and that morale within the staff team had much improved since our last inspection in January 2017.

West House provides accommodation and personal care for up to 26 older people and older people living with dementia. The inspection was completed on 12, 13 and 16 January 2017 and was unannounced. There were 25 people living at the service when we inspected.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by the Care Quality Commission. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.

The provider was also 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.

There was a lack of provider and managerial oversight of the service. Quality assurance checks and audits carried out by the provider and Customer Services Manager were not robust, as they did not identify the issues we identified during our inspection and had not identified where people were placed at risk of harm or where their health and wellbeing was compromised.

Suitable control measures were not put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered and risk assessments had not been developed for all areas of identified risk.

Staff newly employed at the service had not received a robust induction. Suitable arrangements were still needed to ensure that all staff received regular formal supervision and an annual appraisal of their overall performance. Improvements were required in relation to the provider’s recruitment procedures so as to safeguard people using the service.

People and their relatives were not fully involved in the assessment and planning of people’s care.

Not all of a person’s care and support needs had been identified, documented or reviewed to ensure these were accurate and up-to-date. Improvements were required to ensure that the care plans for people who could be anxious or distressed, considered the reasons for people becoming anxious and the steps staff should take to comfort and reassure them. Improvements were needed in the way the service and staff supported people to lead meaningful lives and to participate in social activities of their choice and ability, particularly for people living with dementia.

Although staff had a good understanding of safeguarding procedures not all staff had received safeguarding training. Robust procedures and processes that make sure people and others are protected had not been considered and followed.

Improvements were needed to ensure people using the service were treated with respect and dignity. Not all people who used the service had had their capacity to make decisions assessed. Staff did not always understand the importance of giving people choices.

People were supported to have enough to eat and drink. People were supported to maintain good health and have access to healthcare services as and when required. Medication practices and processes were generally safe and much improved.

Arrangements were in place for staff to receive appropriate training opportunities for their role and area of responsibility. The majority of mandatory training for staff was up-to-date.

Staff knew the care needs of the people they supported and people told us that staff were kind and caring.

You can see what actions we told the provider to take at the back of the full version of the report.

The inspection was completed on 28 and 29 September 2016 and 6 October 2016 and was unannounced. There were 25 people living at the service when we inspected.

The service had 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 2008 and associated Regulations about how the service is run.

There was a lack of provider and managerial oversight of the service. Quality assurance checks and audits carried out by the provider were not robust, did not identify the issues we identified during our inspection and had not identified where people were put at risk of harm or where their health and wellbeing was compromised. The provider was unable to show us how they identified where improvements to the service were needed and lessons learned. However, by the third day of inspection the provider had started taking action to address the shortfalls in the service, including improvements to quality monitoring and staff training arrangements.

Suitable control measures were not put in place to mitigate risks or potential risk of harm for people using the service as steps to ensure people and others health and safety were not always considered. Risk assessments had not been developed for all areas of identified risk and pressure mattresses were not correctly set in relation to people’s weight. The management of medicines was not always safe and improvements were required to staff’s practices and procedures to ensure these were in line with current legislation and guidance.

Improvements were required to the provider’s recruitment procedures so as to safeguard people using the service. Robust systems were not in place for newly employed staff to receive a thorough induction. Although staff felt supported, suitable arrangements were required to ensure that formal supervision and appraisal measures were in place.

Although some relatives did not always think there were sufficient numbers of staff available to meet their member of family’s needs, our observations showed that staffing levels and the deployment of staff were suitable at the time of this inspection. However, the majority of interactions by staff were routine and task orientated and improvements were required. Whilst some staff’s interactions with people were positive and staff had a good rapport with the people they supported, this was in contrast to other observations. These showed that some staff’s practice when supporting people living with dementia required further improvement and development.

People’s care and support needs had not always been identified and documented as required and reflected in their care plans. Improvements were required to ensure that the care plans for people who could be anxious or distressed, considered the reasons for people becoming anxious and the steps staff should take to comfort and reassure them. Improvements were needed in the way the service and staff supported people to lead meaningful lives and to participate in social activities of their choice and ability. Assessments had been carried out where people living at the service were not able to make decisions for themselves, however the arrangements for the use of covert medication were poor and ‘best interest’ meetings to evidence decisions had not been considered.

The dining experience for people was positive and people had their nutrition and hydration needs met. People were supported to access appropriate services for their on-going healthcare needs. People knew how to make or raise a concern or complaint.

You can see what actions we told the provider to take at the back of the full version of the report.

We looked at seven people's care records. We also looked at the provider's arrangements for respecting and involving people who used services. In addition, we looked at the provider's arrangements for the planning and delivery of care, the management of medicines, records relating to staff induction and training, the provider's arrangements to monitor the quality of the service provided and the accuracy of records.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

People told us they felt safe living in the service. They also told us that they would feel able to speak up if they had concerns or worries and felt that they would be listened to.

CQC monitors the operation of the Deprivation of Liberty Safeguards [DoLS] which apply to care homes. At the time of our inspection no DoLS applications had been submitted or considered by the Local Authority.

We found that people who used the service were protected against the risks associated with the unsafe use and management of medicines. The records showed that people who used the service received their medicines as prescribed and in a timely manner.

We found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to records.

Is the service effective?

The provider was not able to demonstrate that they had an effective system in place to support staff so that they could carry out their roles and responsibilities. It was not possible to determine if newly employed staff had received a robust induction as there were no records available for some staff to evidence this had commenced and/or completed. In addition, improvement was still required for staff to receive both 'core' and specialist training. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting workers.

Our observations and discussions with the manager demonstrated that people who used the service received regular support and access from a variety of health and social care services and professionals as their conditions and circumstances required.

Is the service caring?

People told us that they were happy with the care and support they received. Staff were observed to respond to people's individual support needs.

Staff we spoke with were able to demonstrate a good understanding and knowledge of the people they supported. However, we found that staff did not know the needs of the newest person admitted to West House.

The majority of people who used the service had a care plan in place detailing their specific care needs and the support to be provided by staff. However, no care plan was completed for the newest person admitted to the service. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the carrying out of an assessment of the needs of people who use the service.

Our observations showed that people living at West House were treated with dignity and respect. People's relatives and friends were able to visit their member of family or friend without any restrictions.

Is the service responsive?

An effective system was in place to deal with comments and complaints received from people who used the service, those acting on their behalf and other third parties.

An activities co-ordinator had been newly employed at the service to provide meaningful social activities to people living at West House.

Is the service well-led?

The provider was able to demonstrate that improvements to assess and monitor the quality of the service provided had been implemented so as to comply with regulatory requirements and to improve the quality of care received by people living at West House. Our findings showed that lessons had been learned from previous inspections and a proactive approach was being taken to drive and maintain improvement.

We considered our inspection findings to answer questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found;

Is the service safe?

When we arrived at the service a senior member of staff checked our identification and asked us to sign in the visitor's book. This meant that the appropriate actions were taken to ensure that the people who used the service were protected from others who did not have the right to access their home.

People told us they felt safe living in the service. They also told us that they would feel able to speak up if they had concerns or worries and felt that they would be listened to.

We saw that the majority of staff were provided with training in safeguarding of vulnerable adults from abuse. Records also showed that some members of staff had received Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) training. This meant that staff were provided with the information that they needed to ensure that people were safeguarded.

We looked at the provider's arrangements for ensuring that the planning and delivery of care and, where appropriate, treatment met the needs of the people living in the service. We found that improvements were required to ensure that all of a person's care needs were recorded and that information included how risks were to be proactively managed. We also found that people's personal records were not always accurately maintained and provided conflicting information. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to protecting people against the risks of receiving care or treatment that is unsafe.

We found that appropriate arrangements were not in place to ensure that medicines were stored safely and securely for the protection of the people who used the service. Our observations showed that people who used the service were at risk of receiving medication too close together and there were a small number of discrepancies with the records viewed. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the risks associated with the unsafe use and management of medicines.

Is the service effective?

We spent time observing the dining service for people who used the service. We found that people who used the service were supported to have adequate nutrition and hydration. This meant that people's nutritional intake was effectively supported.

Our observations and discussions with the provider demonstrated that people who used the service received regular support and access from a variety of health and social care services and professionals as their conditions and circumstances required.

Records showed that minor improvements were required by the provider to ensure that staff received appropriate training for their role. In addition we found that improvements were required for staff to receive formal supervision and appraisal in line with the provider's policy. We asked the provider to tell us what they are going to do to meet the requirements of the law in relation to supporting staff.

Is the service caring?

People told us that they received the care they needed. People living in the service told us that they were happy living there. People told us that members of staff were always available when they needed them and responded promptly to any requests. Our observations showed on both days of the inspection that care and support was provided in a timely manner. Comments included, "It's not the same as living in your own home but it will do. The care is good and my needs are met." Another person told us, "Staff are very kind and considerate."

We found variable levels of engagement by some members of staff and limited evidence of good person centred care. The majority of interactions were seen to be routine and task orientated. However, where interactions were positive, staff were seen to have a very good rapport and relationship with the people who used the service. One person told us, "You can have a good laugh with some of the staff."

Our observations showed that people who used the service had their personal preferences respected and taken into account. Not all interactions between staff and the people who used the service were respectful or preserved their privacy and dignity. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to respecting and involving people who use services.

Is the service responsive?

People's preferences and diverse needs had been recorded in accordance with people's wishes.

Visitors confirmed that they were able to see people in private and that visiting times were flexible.

People told us that they knew how to make a complaint if they were unhappy and/or had any concerns. We saw that where people had raised concerns appropriate action had been taken to address them.

Is the service well-led?

The provider had some arrangements in place to assess and monitor the quality of the service provided. However systems were not in place, as detailed within this report in relation to the monitoring of care plans and personal records of people who used the service. Improvements were also required to ensure that shortfalls identified throughout this report, for example, medication practices and procedures were robust. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing and monitoring the quality of service provision.

The views of the people who used the service and those acting on their behalf had been sought. People's views about the service were noted to be very positive.

Notifications relating to the death of people who used the service and the development of pressure ulcers after admission to the service had not always been forwarded to the Care Quality Commission. This meant that the provider had failed to notify us of these incidents as required by regulation.

Our observations indicated that people living at the service were happy, that they felt safe and were well cared for. Comments included, "I've not been here long but it's fine. The staff are nice and they are very attentive. The food is great", "It's nice here and I am well looked after" and, "The staff are absolutely wonderful." It was evident that people who used the service had a good relationship and rapport with the staff who supported them.

People's health and personal care needs were assessed and there were detailed care plans in place for care staff to follow so as to ensure that people were supported safely and in accordance with people's individual preferences and wishes. Staff spoken with demonstrated a good understanding of people's health and personal care needs and how each person wished to be supported.

The provider was able to demonstrate that a robust staff recruitment policy and procedure was in place and followed to ensure that people living at the service were kept safe. We found that appropriate arrangements were in place to ensure that the premises were clean and infection control procedures followed. There was an effective complaints procedure in place.

We found that the dietary and nutritional needs of people were well managed and there were appropriate systems in place for people to receive their medicines safely.

Our findings showed that people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard. Staff working at the home were noted to have received appropriate opportunities for training so as to enable them to carry out their role. The provider was seen to have an effective system in place to regularly assess and monitor the quality of the service that people receive.