Albany House - Tisbury

Albany House - Tisbury is a residential care home providing accommodation and personal care to 15 people aged 65 and over at the time of the inspection. The service can support up to 19 people.

People had bedrooms with private bathroom facilities on the ground and first floor of the home. There were shared lounge, dining and conservatory areas. People had access to the garden.

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

Since the previous inspection there were some areas where further improvements were needed. There continued to be some shortfalls in ensuring the safe management of medicines. Also, some monitoring systems needed time to embed into practice. However, there were many areas of improvement found at this inspection. The previous deputy manager was working as the home manager. The manager was leading positive changes in the quality of care people received and how their care needs were documented.

People were supported by staff who knew them well. We observed kind, caring and respectful care interactions. People told us they liked the staff who cared for them.

People’s needs and preferences were assessed. People told us they had recently had reviews of their care, where they could give feedback about any changes they wished to have made. Care plans were in the process of being developed into a more modernised format. This would enable staff to have access to important information with ease.

At meal times people were offered a choice, from a recently introduced seasonal menu. People also had a choice of drinks and snacks throughout the day.

There was good community engagement. The service regularly held events where people from the community could visit and spend time with people in the home. The visiting priest told us how the home was an important part of the local village.

People liked the location of the home and different people told us they liked how from their bedroom they had good views.

There were meetings for people and staff to attend and share their views about the home. The meeting minutes showed people discussed the food, events, and their suggestions for the service.

The staff team had been through some changes and there had been a period of using agency staff. This had reduced and there was an improved culture of working together as a team with new staff joining the service.

The home was clean, tidy and free from bad odours throughout. People praised the standard of the laundry service.

The manager had plans for networking and broadening their understanding of how the service could continue to improve. They were supported by a recently appointed senior carer. People and staff spoke positively about how the management team led the home.

People’s mental capacity regarding decisions about their care was assessed. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 21 May 2019).

At the last inspection the service was in breach of regulations 12, 17, 18 and 19. The provider had completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since 1 April 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will request a monthly action plan from the provider to identify what they will do to improve their rating to at least good. We will work alongside the provider and local authority to monitor progress until we return to visit. If we receive any concerning information we may inspect sooner.

People’s experience of using this service:

At our previous inspection of Albany House – Tisbury, the service was rated as Requires Improvement. There were four breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were because people’s needs were not assessed when they were admitted to the home. Care plans were not developed in a timely manner. The care plans did not include enough information regarding people’s preferences, risk assessments and risk related records, and medicines administration. People had not been consulted with about their care, to gain their informed consent. Mental capacity assessments were not always completed where required. Also, staff training, and supervision meetings were not up to date.

At this inspection we found that there were some continued shortfalls at the service, as well as identifying other concerns. There was a failure to take timely and appropriate action to address concerns raised at previous inspections and to ensure that there was a managerial oversight monitoring the improvements. Because of this, the service is now rated as Inadequate for Safe and Well-Led, and this makes the service Inadequate overall.

The registered manager had a vision for the future of the service, however did not have a plan on how to achieve this. The lack of planning had resulted in continued areas for improvement, which had not been addressed. The registered manager felt they had been working in an insular manner and that they needed some peer support to understand how to better manage the service. The registered manager did not take accountability for their legal responsibility to lead improvements at the service. They shifted blame to staff and to the nominated individual. However, they had not discussed with staff or the nominated individual a plan of action and who should be accountable for what.

There were quality assurance systems in place to monitor different areas of the service, however these were not being used at all or utilised effectively. The registered manager had a quality assurance system to monitor the whole home. They informed us they had read the information however we saw that the audits involved had not been completed or followed up.

There were records of accidents at the home. However, a monitoring system to identify patterns and trends was only implemented after this was raised with the registered manager on day one of the inspection. One incident was not recorded in the accident log, and this meant that any overview would not give an entirely accurate picture of the service.

Medicine administration records contained gaps in records, without reasons for this recorded. Medicine audits were in place but were not being completed consistently. This meant that previously identified shortfalls had continued, and improvements were not always sustained.

The medicines fridge was not locked. The medicines policy and CQC guidance states that this should be locked and stored in a locked room. The room was accessed by staff who are not responsible for medicines administration. There was potential for people living with dementia who may not understand the risks associated with medicines stored in the fridge. We saw that the room was unlocked and open at times where no staff were present. The fridge temperatures were not consistently recorded daily to ensure creams and insulin were stored at safe temperatures.

Staff continued to not receive supervision meetings with their senior or the registered manager in a timely manner. The registered manager told us they aim for each staff member to have six supervision meetings per year. Supervision meeting records evidenced that this was not being achieved and some staff did not receive more than one supervision meeting per year.

Risks were not always identified and assessed. Records showed that water temperatures in people’s bedrooms were routinely above 50 degrees Celsius (°C). The Health and Safety Executive guidance recommends that water temperatures in older people’s care services should not exceed 43°C. This meant there was a risk of scalding in bathrooms and bedrooms that had not been identified. One person smoked and was prescribed paraffin-based creams, which are highly flammable. The risks had not been discussed with the person. There was no risk assessment in place.

At this inspection, there were some improvements in the care plans, however further work was needed to ensure these included all important information about the person and their needs.

Additional improvements included that where people lacked the mental capacity to consent to specific decisions, a mental capacity assessment and best interest decision had been completed. Deprivation of Liberty Safeguard (DoLS) applications were made to the local authority for authorisation. Records were kept of correspondence with the local authority to monitor the DoLS application process for each person.

We also saw that a new training system had been implemented and staff were getting accustomed to accessing the online training resources. Records showed that staff had completed their required training. The training system allowed the registered manager to monitor when staff had accessed and completed training.

People chose where they wanted to spend their time. We saw people spending time in the garden, enjoying the good weather. At lunch, people sat with their friends.

People told us staff were kind and caring. We saw people and staff interacting and conversing with one another in a respectful and friendly manner.

The home was clean and free from odours throughout.

The service continued to be rated as Requires Improvement overall and for Safe, Effective, Responsive and Well-Led. The service continued to be rated as Good for Caring. More information is in the full report.

Rating at last inspection: The home was rated as Requires Improvement at the two previous inspections. This is the third consecutive time the home has been rated as Requires Improvement.

Why we inspected: This was a scheduled comprehensive inspection, based on the rating at the previous inspection.

Enforcement and follow up: This is the third time the service has failed to achieve a rating of Good. In line with our published guidance, we met with the provider. We asked the provider to supply an action plan to tell us how they would improve. We also asked for regular updates about their progress. This service will be monitored and inspected again within six months.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The inspection took place on 4 May 2016 and was unannounced. We returned on 5 May 2016 to complete the inspection.

The service had a registered manager who was responsible for the day to day running of the home. 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 service did not follow the requirements set out in the Mental Capacity Act 2005 when people lacked the ability to give consent to living and receiving care at Albany House.

Staff did not receive sufficient appraisal and supervision to support them to carry out their work as effectively as possible.

Staff members said they felt sufficiently trained. However the registered manager did not have a training record in place, which meant some staff training had not been updated.

People’s care plans did not always contain the most up to date information to enable staff to be responsive to people’s needs. Information within care plans was sometimes contradictory and associated risk assessments had not always been completed.

The registered manager of the service worked as part of the care team on a daily basis but this left little time for managerial duties. The service did not have fully effective systems in place to evaluate and improve the quality of the service.

People and their relatives spoke highly of the care at Albany House. Comments included “We like everything about this place” and “We are blessed. The staff are always lovely.”

People and/or their relatives said they were able to speak with staff or management if they had any concerns or a complaint. They were confident their concerns would be listened to and appropriate action taken.

People were protected from the risk of harm and abuse by trained staff who knew how to recognise abuse and what actions to take, to keep people safe.

People’s medicines were managed and administered safely. Medicines were securely stored in line with current regulations and guidance. We found prescribed creams and lotions were not always recorded, when applied.

Staff were genuinely concerned about people’s well-being. Staff knew the people they were caring for including their preferences and personal histories. People were supported to follow their preferred routines.

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

Albany House supports up to 21 older people and some of whom were living with dementia. At the time of the inspection there were 19 people living at the service.

This inspection was unannounced and took place on 8 and 9 November 2017.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Medicines administration systems were not safe. Procedures were not in place for medicines to be taken “when required” (PRN). Medicine Administration Records(MAR) showed people were having PRN medicines. Medicine care plans for some people included people’s preferences on how they liked their medicines to be administered. Medicine administration records (MAR) charts were signed by staff to indicate the medicines administered.

Risks were not always identified and there was no guidance to staff on how to minimise potential harm to people or to help them take risks safely. Risk management procedures were not up to date. The risk assessments were not updated for people who fell frequently and there was no action taken to prevent further falls for example, referrals for specialist support such as falls clinic. Where people were refusing food and fluid there were no formal systems to assess their deteriorating health. We found monitoring charts were not consistently completed or analysed and risk assessments were not developed on supporting these individuals with hydration.

Formal arrangements to assess and monitor service delivery were not in place. Quality assurance systems were not in place. Records were not up to date and staff acknowledged that the recording of information needed to be improved. Policies and procedures were outdated and were based on legislation that had been replaced. Accidents and incidents were documented but not analysed to identify trends to help staff prevent a reoccurrence of the accident.

Where people had cognitive impairments their capacity for care and treatment was not assessed. Relatives and friends without Lasting Power of Attorney (LPA) had consented to care and treatment. Where it was documented that LPA was in place the type was not identified. Covert medicines were being administered without the appropriate framework being in place. The staff knew the day to day decisions people were able to make.

People’s needs were not assessed before their admission to the home. Care plans were not developed on how to meet people’s needs and lacked person centred approach. We saw where staff had documented they were supporting people with personal care but care plans were not developed. People were not supported to develop plans about their future wishes for their end of life journey.

The staff knew the types of abuse and the expectations placed on them to report abuse. However, the training certificates showed only two staff had attended safeguarding training.

Staffing levels were well maintained but there were staff vacancies which meant agency staff were being used.

Arrangements were in place to maintain a clean environment and we found the home was free from unpleasant odours. We saw housekeeping staff maintaining the environment.

We saw good interaction between people and staff. The feedback from people and their relatives was complimentary. Staff knew how to respect the rights of people.

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

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.

We spoke to staff who were confident in their knowledge of people's needs. We observed the care described was in line with people's plans of care.

The provider had implemented a new system for recording essential patient information staff needed to be aware of. For example changes in a patient's health or specific care instructions. This ensured staff were responsive to changes in people's care and were able to implement guidance provided by other healthcare providers such as GP's.

We observed and were told people were involved in decisions about their care. We were also told consent was obtained before care was given. Staff worked in the best interests of people with diminished capacity in line with guidance from the Mental Capacity Act 2005.

People we spoke with told us they were satisfied with their care. One person said " it's wonderful. They're very willing to help. They're very good." We observed staff who were patient and caring. They were knowledgeable about the people they looked after.

We found all areas of the home were clean. People we spoke with were satisfied with the cleanlines of their rooms. Staff wore clean neat uniforms and appropriate personal protective equipment as necessary.

We saw the provider had an effective system to ensure people received appropriate support and care provided by other health care services.

We found people did not have plans of care which reflected their identified needs. The care records did not provide sufficient detail to enable staff not familiar with people to provide safe effective support. We found specific assessment of risk for example risk of pressure ulcer development had not been reviewed regularly for people identified as high risk.