Archived: The Priory Residential Care Home

Following our inspection in May 2016, we served two warning notices, relating to staffing and good governance. In August 2016, we re-visited the home due to concerns regarding people’s safety and found the staffing warning notice had not been met. During our current inspection, we found a new breach and four on-going breaches of the Health and Social Care Act 2008 and associated Regulations and a new breach of the Act; this included the warning notices for staffing and good governance which still have not been fully met. The service was part of a whole home safeguarding process and was being visited by a range of health and social care professionals. They were also being supported by the local authority’s quality assurance and improvement team.

There was 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 is also one of the directors of the registered provider. Throughout this report we have referred to the registered manager. There are also two deputy managers who the registered manager has delegated some managerial duties to.

The service lacked effective leadership and the management style was often reactive rather than proactive. There was not an effective system to regularly monitor and assess the quality of the service and the risks to the people living there. This meant improvement had not been made in some areas of care and new areas of concern had not been addressed or identified.

Previous inspections by CQC had highlighted concerns regarding staffing levels and the registered manager had not effectively monitored if staffing arrangements kept people safe and met people’s physical and mental health needs. We identified concerns about staffing levels in the evening at this inspection. People did not always receive care at a time convenient for them and lacked adequate supervision in communal areas.

People were supported to see, when needed, health care professionals. Care staff recognised changes to people’s physical well-being and knew to share this. However, some aspects of medication administration, storage and recording were poorly managed.

Safety checks were carried out but some areas of the home were potentially unsafe to people living with dementia. Aspects of infection control practice did not protect people from the risk of cross infection. The reporting of safeguarding issues by the management team had improved. However, some staff did not have the knowledge and confidence to identify safeguarding concerns and act on these to keep people safe.

Applications had been made for Deprivation of Liberty Safeguards (DoLS) assessments for people living at the home. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Discussions between the registered manager and deputy managers highlighted there was a lack of clarity whether the applications were appropriate for all of the people living in the home. However, people’s consent for day to day care and treatment was sought by staff.

In one aspect of the recruitment process, there had been improvement to make it a safer process, but there were still gaps in recruitment information. This meant potentially people unsuitable to work with vulnerable people had not been identified. People living at the home were cared for by staff who had not been appropriately supported through induction and training. However, throughout our inspection we saw people were supported in a kind and caring manner by staff who knew them well. Staff spoke about people in a compassionate and caring manner. Staff showed a strong sense of loyalty towards the people living at the home. Most people said they felt safe and comfortable.

People were positive about the quality and range of food at the home. They said the food was well cooked and they enjoyed their meals. People were supported to ensure that they had enough food and fluid to support their health needs. However, recording was not consistent to help manage the risks to people’s health.

There was an effective complaints system to address people’s concerns. Activities to motivate people and promote a positive well-being were available, but there was not a system in place to ensure activities happened regularly to meet people’s individual interests.

During the inspection we identified four continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk of harm because the provider’s actions did not sufficiently address the on-going failings. There has been on-going evidence of the provider’s failure to sustain full compliance since 2014. We have made these failings clear to the provider and they have had sufficient time to address them.

We are taking further action against this provider and will report on this when it is completed. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

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. Following the inspection, we shared our concerns with the local authority safeguarding team and commissioners.

We undertook this focussed inspection on 10 and 18 August 2016 to check they had followed their plan and to confirm they now met legal requirements. We had also received concerns regarding the safety of people at the home. This report only covers our findings in relation to the staffing levels and the safety of people living at the home. You can read the report from our last comprehensive inspection by selecting the all reports link for the Priory Residential Home on our website at www.cqc.org.uk.

The Priory Residential Care Home provides accommodation and 24 hour care for up to 21 older people, some of whom have dementia and some who have physical frailties. At the time of this inspection there were 15 people living at the home.

The home is located in Ottery St Mary, a small town in East Devon. The Priory had been adapted from a large three storey house set around a small courtyard with bedrooms on all three floors. Communal areas include two sitting rooms and a dining room were located on the ground floor. A day service for six people is also provided in the home by three staff who use one of the lounges and the dining room for activities. These staff also support people who live at The Priory if they wish to join in the activities.

The home has a registered manager, who is also the provider. 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 supported by two assistant managers who oversaw the work of three shift leader care workers. Shift leader care workers were responsible for managing the work of the care workers who were on duty.

We found on the first day of inspection that there were insufficient staff to keep people safe and meet their needs during the evening. We also found that staff did not ensure they prioritised their work to ensure vulnerable people were kept safe while in communal areas. Staff had not undertaken all the checks they were supposed to do, for example on pressure mats and door alarms. This had meant that incidents, such as a person falling or leaving their bedroom, which staff had not been immediately alerted to.

By the second day of inspection, rotas showed additional staff were on duty during the evening. We spoke to staff who confirmed that there were now three members of staff on duty between 19:00 and 21:30 each evening.

Risk assessments and care plans had not been updated after incidents had occurred. For example where people had shown aggression to other people, there was no evidence that staff had updated care plans to reduce the risks of reoccurrence. Safeguarding referrals had not been made where there had been altercations between people who lived at the home. The deployment of staff had not been arranged to ensure people at risk were observed in order to ensure harm to themselves or others was prevented.

By the second day of the inspections, there had been some improvements but there were still times where people were not observed by staff.

We found breaches of the Health and Social Care Act (2008) Regulations 2014. CQC is now considering the appropriate regulatory response to resolve the problems we found.

The home was previously inspected in July 2015. At this comprehensive, unannounced inspection, the home was rated as requiring improvement.

The Priory Residential Care Home provides accommodation and 24 hour care for up to 21 older people, some of whom have dementia and some who have physical frailties. There were 20 people living at the home on the first day of inspection and 19 people on the second day of inspection.

The home is located in Ottery St Mary, a small town in East Devon. The Priory had been adapted from a large three storey house set around a small courtyard with bedrooms on all three floors. Communal areas include two sitting rooms and a dining room. A day service for six people is also provided in the home by three staff who use one of the lounges and the dining room for activities. These staff also support people who live at The Priory if they wish to join in the activities.

The home has a registered manager, who is also the provider. 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 supported by two assistant managers who oversaw the work of three shift leader care workers. Shift leader care workers were responsible for managing the work of the care workers who were on duty.

The registered manager had not ensured that there were sufficient staff at all times. They said they had not used a dependency tool to identify how many staff were required, but were able to assess this based upon their knowledge of people’s needs. However, we found there were times when there were not enough staff to meet people’s needs. Staff had raised concerns about the lack of staff but the registered manager had not taken action to address these concerns. This meant that at times, people were distressed and unhappy with staff not being present to respond. One person was at risk of developing pressure sores because staff did not ensure they were supported to go to the toilet sufficiently often. Health professionals expressed concern about the care provided, which, they said, had led them to visiting the home more often than they would have expected to.

Staff had not always been recruited safely as we found the provider had not always completed checks on the new member of staff before they started work. Staff had not completed all the training and supervision required to ensure they had the skills and knowledge to carry out their role effectively. Senior staff said that due to the staffing pressures they were aware that they had fallen behind with the supervisions they had planned to complete.

Although senior staff were aware of the types of abuse that people should be protected from, they had not taken appropriate action, such as reporting allegations to the local authority.

The home was generally well maintained, clean and odour-free, although there were some areas, such as the laundry which posed an infection risk. Following the inspection, we received information from the provider that the laundry was being redecorated and repainted. We also identified that the home had not been adapted to suit the needs of people with dementia.

People had been risk assessed when they were first admitted to the home and care plans developed which provided detailed information about the person and their needs. Care plans also had information about the person’s history and family. However, some care plans had not been updated as people’s needs had changed. For example one person’s mobility was not described accurately in their care plan. This would mean that new staff may not be aware of the person’s needs.

The registered manager and staff understood their responsibilities under the Mental Capacity Act (2005). Applications had been made for Deprivation of Liberty Safeguards (DoLS) authorisations where needed.

Although there was some governance and quality assurance processes in place, these had not always identified issues. For example, care record checks had not identified or addressed issues such as charts recording weight and food/drink not being completed fully. The registered manager relied upon senior staff to do some of the quality assurance checks. However there was no evidence that, when these had not been completed, actions to address the shortfalls had occurred. Following the inspection, we received information from the provider that audits systems had been modified to address these concerns.

People were supported to receive their medicines safely and access health and social care professionals such as their GP, dentist and district nurses. Specialist advisors such as speech and language therapists and mental health teams had also been consulted when necessary.

Staff were generally very caring and supported people with compassion. Staff clearly knew people and their families well. People, relatives and visiting professionals said they thought staff were very good. However there had been some instances where people were not treated with dignity and respect. For example they were referred to by staff, using inappropriate language. The home had a complaints policy and people and their relatives were aware of how to make a complaint. There was evidence that when complaints were received, these were dealt with appropriately.

People were generally positive about the meals at The Priory. However, fluid and food charts for people who had been assessed at risk of not eating or drinking enough were not always fully completed. This could place people at risk of not receiving enough food or hydration to maintain good health.

Group activities, both in and out of the home were offered to people. These included music sessions, quizzes, games, visits to the seaside and theatre, arts and craft. However, people who did not want to take part in group activities were not well supported to do individual activities of their choice.

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

The Priory is a historic building in the centre of Ottery St Mary, overlooking the church and church yard. The communal areas were large and comfortably furnished. People's bedrooms were also of a good size.

From talking with the staff it was clear that their focus of work was on providing a good service to those who lived at the home. The home could benefit from paying closer attention to their administration in order to better demonstrate their good practice.

We looked at some key records, including care assessments, risk assessments and care plans. We also looked to see how the service ensured that staff were competent to manage complaints and safeguarding issues.

All the outcomes areas that we inspected were compliant. We saw that people's dignity and respect was maintained, and their health and wellbeing was assessed and care provided in a way that suited their individual needs. Staff knew their duty to report safeguarding concerns. Staffing levels helped ensure that people's individual needs were met and the atmosphere was positive and welcoming. There was a complaints system in place and people living at the home, and visiting the home, were confident that concerns and complaints would be addressed promptly.