All inspections: Annabel House Care Centre

Annabel 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.

Annabel House is in a residential street in Weston Super Mare, close to local amenities and with onsite parking. Accommodation is offered over two floors and there is a mixture of single and double bedrooms. Communal spaces include two lounges and a kitchen-dining area, the garden is accessible and there is a decking area for people to use on the first floor.

The home is registered to provide nursing and personal care for up to 30 people.

During our inspection there were 23 people living in the home.

This inspection of Annabel House was carried out on the 10 July 2018 and was unannounced.

We last inspected Annabel House on the 7 and 8 July 2016 and during this inspection a breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) 2014.

The manager had made improvements to the service to ensure that the requirements of this regulation were met. Two activity coordinators were now working in the home and they had introduced meaningful and varied activities; people’s areas of interests were identified and activities designed with those in mind. Improvements made regarding the management of medicines and pressure care have been sustained.

The Care Quality Commission is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DOLs) and to report what we find. We saw that when people lacked capacity to make decisions for themselves that staff understood the requirement to work within the Act.

People were supported to ensure that they had enough to eat and drink. There was a choice of food available and people spoke positively about the food. When required, food and fluid intake was recorded accurately.

People received care and support from staff who were safely recruited and benefited from training and supervision to enable them to meet people’s needs.

Staff treated people with kindness, respect and ensured that people’s dignity was protected. Preferences, likes and dislikes were recorded and these were understood by staff.

People’s health and social care needs had been identified and risk assessments and care plans developed to guide staff in meeting these needs.

People, staff and relatives spoke positively about the manager and were well supported. Frequent team, staff and relative meetings were used to ensure that communication remained open and honest and contributed to positive outcomes for people.

The manager ensured that staffing levels were maintained at a safe level to ensure that people’s needs were met, this included managing the types of staff required e.g. nurse/care assistant in relation to the needs of people living at the service.

There was a programme of quality audits in place and these were used effectively by the manager to identify themes, create action plans and make changes.

Prior to our inspection, we looked at the service’s website to check that the most recent rating was being displayed. There was a link to the inspection report however the ratings were not displayed on the website.

This was a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20A.

The most recent inspection report was not being displayed in the service. We brought this to the attention of the manager. They informed us that they were unsure where the report was and that it had been displayed at some point.

Annabel House is registered to provide nursing and personal care for up to 32 people. Accommodation is provided in single rooms over two floors. Communal lounges and dining room are also on the ground floor. The gardens are easily accessible to people using the service. The home is situated in the town of Weston Super Mare and close to local amenities. There is a car park for visitors and staff. At the time of this inspection there were 18 people resident at the home.

We last visited Annabel House on the 11 and 13 January 2016. Breaches of legal requirements were found. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Regulations breached were Regulation 12 ,safeguarding service users from abuse and improper treatment. Regulation 13, Safe care and treatment. Regulation 19, Fit and proper persons employed. Regulation 18, staffing. Regulation 11, need for consent. Regulation 14, Nutrition and hydration. Regulation 9, person centred care. Regulation 17, Good governance.

This inspection of Annabel House was carried out on the 7 and 8 July 2016 and the first day was unannounced.

At this inspection, we found the new manager had taken action to improve consent to care, dignity and respect, training and supporting staff, care planning, pressure care, medicines management, making sure staff knew how to support people properly and quality assurance processes. However sustained improvements were needed to ensure the provider was fully compliant with regulations.

There was 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. However, the provider had appointed a new manager since the last inspection wo had started the Care Quality Commission process to be registered as the manager for the service. The current registered manager was in the position of deputy manager.

We found improvements had been made with the management of medicines and pressure care. Quality assurance systems had been introduced to support the manager to assess, monitor and mitigate the risks relating to the health, safety and welfare of people using the service and others.

Risk assessments relating to people’s care had improved and staff were familiar with the needs of people at risk of poor nutrition, falls, and pressure ulcers.

People received a balanced diet and special diets were catered for. The charts used to monitor people’s nutritional and hydration intake were being used effectively and this resulted in people having their nutritional needs consistently met. However, we did find some issues in recording of dietary needs.

Information sharing between staff had improved and we found records used by staff to review people’s needs were now completed.

There had been an increase in staffing levels and people using the service, relatives and staff told us this had been beneficial to them. People did not have to wait for assistance when they needed staff support.

Infection control within the service was good. The home was clean and odour free and there had been an increase in domestic hours to maintain cleanliness.

Training was being provided to support the staff to deliver safe and effective care and support. Staff training needs was being routinely assessed and planned for, and staff received regular supervision.

Staff we spoke with were aware of the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safe Guards (DoLS) and best interests decisions. The manager was familiar with the process to follow and had taken action to apply for DoLS following people’s capacity assessments and in their best interest.

People we spoke with considered staff were kind and caring. We observed people’s dignity and privacy was being respected and relatives commented they had seen a big improvement in the amount of individual attention people received. Staff were observed carrying out welfare checks to attend to people being cared for in bed.

People had a plan of care that covered all aspects of their daily lives and staff were familiar with these. These were complimented by an ‘All about Me’ information sheet that had been completed. These gave staff direction on how best to support people and to be mindful of what was important in people’s lives.

Communication between all staff was good when they discussed people’s care at the beginning and end of their shift. The manager had introduced a handover sheet detailing people’s individual needs, for example how many staff needed for mobilisation. This helped to ensure important information in relation to people’s care and support other staff would need to know was not missed.

Activities were still an area where improvements needed to be made. There was a dedicated new coordinator but they had access to very limited resources that were appropriate for people some of whom were living with dementia.

The complaints procedure was displayed in the home and we found processes were in place to record, investigate and respond to complaints. Complaints raised were taken seriously and action taken to bring about resolution.

Annabel House Care Centre provides accommodation for people who require nursing and personal care for up to 32 people. On the day of inspection there were 19 people living at the home. Most residents were living with dementia so were unable to express their views regarding the support they receive. The accommodation is arranged in one building over two floors. The main offices are located in the basement of the home and the nurses’ office is located between two living spaces.

At the last inspection, we found breaches in the home because staff were not receiving supervision in line with the provider’s policy and there was a shortfall in training. Staff had not read care plans and were not delivering care in line with what was in the plans. We found the home was not well led because there were gaps in the audit systems and they had not identified all the shortfalls we found. Since the last inspection, the provider and registered manager have been sharing changes they had made in the home. Although there had been some improvements, we found there were still concerns.

This inspection was unannounced and took place on the 11 and 13 January 2016

The home had been working towards the Butterfly Project in conjunction with Dementia Care Matters. This is an approach of working with people with dementia where you accept the world as they see it. Staff did not wear uniforms, they had name badges and positive interactions with people are encouraged. There are four lounges set up for different stages of dementia.

A clinical lead nurse supported the registered manager. A registered manager is a person who has been 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 but there were risks to their safety around pressure care, risk assessments, moving and handling and medicine management. Where staff had identified pressure related wounds, plans had not been put in place to manage them. Medication procedures were not always following best practice and this was putting people at risk. People who required support were not always transferred between chairs following best practice and their risk assessments were not detailed enough to tell staff what to do.

People had a choice of meals, snacks and drinks, which they told us they enjoyed. The chef provided alternative options if people did not want what was on the menu to ensure their preferences were met. However, there were times people’s weight was not being monitored and people were not receiving the correct food supplements.

Staff were receiving regular supervisions in line with the provider’s policies and there had been some improvements with the training staff received. However, the staff did not get all the training they needed to carry out their duties.

The staff were aware of their responsibility to protect people from avoidable harm or abuse and most staff had received training in safeguarding. Staff knew what action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to a senior person in the home and they knew whom to contact externally. The recruitment process did not always follow good practice, which meant people were put at risk from staff who had not had the correct checks from the provider.

The provider and senior management had an understanding about people who lacked capacity to make decisions for themselves. There had been some improvements into recording decisions made in a person’s best interest. However, care plans had not made the consultation process clear when people lacked capacity or had decision specific assessments. When they had decided to prevent people leaving the home for their safety the correct processes had been followed. But they had not always completed the correct process when bed rails were put in place to keep people safe. As a result, there were breaches of people's human rights.

The registered manager and provider had followed their legal obligations to notify CQC of other incidents. The registered manager and provider had regular meetings including one to review audits completed in the home. The audits were up to date and on occasions had been identifying shortfalls and recorded improvements. However, the systems were not identifying all shortfalls in the home or where some had been identified no actions had been taken. When we were told actions had been put in place to reduce the risks in relation to safeguarding these had not been completed.

The nurses and activities coordinator were in the process of updating and rewriting all the care plans. Where care plans had been updated there was evidence of people or relatives being involved. However, some people’s care plans were not complete or were not person specific. Not all the care plans had a person centred approach to them.This meant people were not central to their care and decisions they made for themselves or that were made for them. Staff had some knowledge about the care plans, but explained they had not had time to read them all.

Staff supported people to see a range of health and social care professionals to help with their care, but sometimes referrals were not been made in a timely manner. Staff supported and respected people’s choices and they knew how important this was.

People and their relatives thought the staff were kind and caring; we observed mainly positive interactions, but some were to fulfil tasks. The privacy and dignity of people was respected most of the time and people were encouraged to make choices throughout their day.

People knew how to complain and there were good systems in place to manage the complaints. The registered manager and provider demonstrated a good understanding of how to respond to complaints.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are currently considering the action we are taking.

Annabel House Care Centre provides accommodation for people who require nursing and personal care for up to 32 people. On the day of inspection there were 18 people living at the home; one of whom was receiving temporary respite. Most residents were living with dementia and were unable to effectively communicate with us. The accommodation is arranged in one building over two floors.

This inspection was unannounced and took place on the 15 and 17 July 2015

The home has signed up to the Butterfly Project in conjunction with Dementia Care Matters. This is an approach of working with people with dementia where you accept the world as they see it. Staff did not wear uniforms and positive interactions with the people are encouraged. There are four lounges set up for different stages of dementia.

There is a registered manager who is supported by a clinical lead nurse. A registered manager is a person who has been 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.

Although some people told us that they felt safe, there were risks to their safety. Since the last inspection there had been improvements with the hot water, radiator covers and the boiler was now in a cupboard. However, there were still concerns about environmental hazards such as wheelchairs and hoists being left insecure.

Most staff were aware of their responsibility to protect people from avoidable harm or abuse, but some had not received up to date training. Staff knew what action to take if they were concerned about the safety or welfare of an individual. They told us they would be confident reporting any concerns to a senior person in the home and they knew who to contact externally. However, most staff were unclear on what constituted a restraint or how to safely break away from a person.

The medication processes in the home were good and the recruitment process followed good practice. Generally the home was clean but there were some minor areas for improvement.

The staff received some training, but not all staff had received dementia training. There was limited understanding of how to support people who lacked capacity to make decisions for themselves. Staff supported people to see other professionals to help with their care. Staff supported and respected the choices made by the people.

People had a choice of meals, snacks and drinks, which they told us they enjoyed. The chef worked hard to ensure that they met people’s preferences. They provided alternative options if the people did not want what was on the menu.

People and their relatives thought the staff were kind and caring. We observed some positive interactions, but occasionally this was not the case. The privacy and dignity of most people was respected. People were encouraged to make choices throughout their day.

There were detailed care plans for all individuals but most of the staff had not read them. The needs of the people were not met when care was being delivered.

People knew how to complain and there were systems in place to manage the complaints.

Since the last inspection the registered manager had put some quality assurance procedures in place. The audits were not consistently completed or used by the registered manager to ensure the health and safety of people using the service. Care records were not stored appropriately.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are currently considering the action we will be taking.

We carried out this inspection over two days on the 23 and 29 January 2015. Our last inspection to the service was in May 2013. During the visit in May 2013, we identified that people were not being moved safely and the provider had not undertaken audits in relation to infection control. In September 2013, we followed up the shortfalls, which had previously identified. We did not re-visit the service as the provider supplied us with information to evidence that action had been taken to address the shortfalls. At this inspection, we found that all actions had not been implemented effectively.

Annabel House Care Centre provides accommodation to people who require nursing and personal care. Some people may have dementia or mental health needs. The home is registered to accommodate up to 32 people. On the day of our inspection, there were 26 people living at the home. Annabel House Care Centre has bedrooms on the ground and first floor. A passenger lift is available for people with mobility difficulties. There are four communal lounges of which three have a dining area. There is a shower room on the first floor and a bathroom with an adapted bath on the ground floor.

The manager has worked at the home for approximately five years but became the registered manager in 2014. 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 at a meeting when we arrived for the first day of our inspection. They returned after their meeting and were present for the remainder of the inspection. The provider visited the home on both days but was not involved in the full inspection process.

Whilst the registered manager confirmed staffing levels were satisfactory, there were concerns about the number of staff available to support people effectively. The lunch time meal was chaotic and people had to wait for staff assistance to eat. Some people walked around unsupported, looking anxious as if looking for something. There were incidents between people which impacted on safety but staff were not within the vicinity to intervene. There was no cook after 3pm, which meant this responsibility was transferred to the care staff. This impacted upon their ability to provide support, particularly at a time during the late afternoon when some people became anxious and unsettled.

Some people did not look well supported and had food debris on their clothing. At lunchtime some people used their fingers to eat their meal. This did not promote their dignity as the food was not considered “finger food.” Some people remained in the same position for most of the day and were not assisted to use the bathroom. This increased people’s risk of pressure ulceration. Staff did not consistently complete care charts to show the support they gave people. Some food charts showed people had refused meals or ate very little. There was no information to show further attempts or alternatives had been tried to encourage eating. One person staying in the home on a temporary basis did not have a plan of care in place, which increased the risk of inappropriate care. Other care plans were not person centred and did not reflect the support each individual required. Records detailing the management of wounds were not clearly organised. The information did not evidence the assessment, treatment and re-evaluation of the wounds.

The lunchtime meal looked colourful although there were some concerns from relatives about the nutritional content of the meals provided. There was a four weekly cycle of menus in place but these were not used. All meals were cooked according to the produce available on the day. People had a choice of two dishes for each meal, which they chose on the day. Staff were aware of people’s nutritional requirements although not everyone was supported to eat, in a way which met their needs. There was a large store cupboard, which contained basic food provisions.

There were systems in place to assess and monitor the quality of the service. However, these were not fully effective as shortfalls with the environment, fire safety and cleanliness had not been identified. Risks to people’s safety in terms of hot surfaces and hot water from hand wash basins had not been identified or recently reviewed. When discussed, the provider confirmed the potential risks associated with the radiators would be addressed without delay. The registered manager had identified the number of falls, incidents, complaints and safeguarding referrals. However, the control measures in place did not minimise further occurrences. This particularly applied to the high number of falls some people experienced.

Staff told us they felt supported in their role and enjoyed their work. However, supervision and appraisal systems where staff could formally discuss their work, performance and development were not consistently being undertaken. Records did not show that all staff were up to date with their training, to enable them to do their job effectively.

The home was taking part in the Butterfly Project which aimed to enhance the lives of people with dementia. The registered manager was passionate about the project and spoke about it with enthusiasm. They said improvements including more relaxed routines and a less clinical environment had been developed, as a result of the project. A kitchenette had also been installed. Doors to people’s bedrooms were being painted bright colours on the day of the inspection.

Staff spoke and interacted with people in a polite, caring and sensitive manner. They responded well when they identified people were anxious or upset. They gave reassurance, showed concern and gave people the time they needed. Staff enabled people to sit with them in the office if this is what they wanted. They used people’s preferred form of address and encouraged people to be involved in their care. This included informing a person about what was happening when being assisted to move using the hoist. Staff were clear about ways in which to promote people’s privacy and dignity. However, this was not always seen in practice.

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

From the evidence we have been provided we have found that the provider had addressed the areas of non compliance. Improvements had been made in the arrangements for infection control management and staff practice around moving and handling.

People we spoke with were positive about the care they received. People's representatives were involved in the care arrangements and had an opportunity to comment on the care people received. Practices in the home promoted people's rights and respected decisions people made.

Assessments of need and care planning identifying how need could be met had been completed. These provided staff with the necessary guidance to meet identified care needs. The provider had processes in place to make multi disciplinary best interest decisions. A moving and handling technique was being used which placed people's health at welfare at risk.

Staff had completed safeguarding training. They demonstrated a good knowledge of the nature of abuse and how to respond to any concerns about possible abuse.

Staff were very positive about the support they received and told us they found management approachable. Core skills training had been provided to all staff. There were good arrangements in place for the one to one supervision of staff.

We found that since our last inspection improvements had been made in the consistency and frequency of quality monitoring. However there remained some shortfalls in auditing arrangements.

On our last inspection on 29 August 2012 we found serious concerns regarding the management of medicines. We also found concerns regarding the home’s lack of effective monitoring systems for the management of medicines. We served a warning notice regarding the management of medicines and gave a compliance action for the monitoring of medicines. This was a follow up inspection to check compliance of the warning notice served.

We also checked some of the home’s newly implemented monitoring systems during this inspection. However, time is needed to judge if these systems are effective over a period of time. Therefore we will review their quality monitoring systems for medicines in the near future.

During our inspection we found the home was now complying with management of medicines.

It was not necessary to speak to people who used the service during this inspection.

During our inspection we found we had serious concerns regarding the management of medicines within the home.

We found staff felt supported and attended regular meetings to encourage good communication within the home. Staff showed a good understanding of how to protect vulnerable adults from abuse and what action they needed to take if they were concerned.

People who lived in the home told us they were very happy at Annabel House Care Centre. One person told us what they thought of the care staff. They said “the staff are quite good, they try to look after you”. One of the relatives we spoke with told us “mum’s totally happy here whenever I visit”.

During our visit we used the Short Observational Framework Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We carried out our observation in one of the lounges and observed four people. We found when staff interacted with people we saw that interactions with people were patient and kind. We saw staff on two occasions did not take the opportunity to interact and make conversation with people.

The purpose of this review was to check that improvements had been made to achieve compliance with outcome 20. During our visit to the service in November 2011 we found that the manager/ provider had not been reporting safeguarding incidents between people who lived in the home either to us or the local authority, and some staff were unware of the requirements and process for reporting this information.

During this review we did not visit the home , but we reviewed the information sent to us from the provider/ manager and we spoke to the local authority about information they had received.

We found Annabel House care centre to be compliant with this outcome

The purpose of this review was to check that improvements had been made to achieve compliance with this outcome. The service cared for older people, many of whom were in an advanced stage of dementia. On this occasion we did not speak to people who lived in the home. On our previous visit we spoke with them as far as they were able. At both this visit and our previous visit we observed care and support delivered to people and reviewed the information held about people and plans for their care and talked with members of staff.

We carried out this review to check that the concerns we had raised at our previous visit in August 2011 had been addressed. We did not speak with people who use the service as they are not all able to engage in conversation due to, dementia, Alzheimer's disease or other mental health condition.

We observed staff encouraging people and assisting them. Where people appeared unsure where they were going, staff took the time to ask what people wanted to do and direct and assist them as required.

We saw that people were having individual sessions with the activities co-ordinator and that during the afternoon staff joined in with singing in the lounge area. At this visit we spoke with four staff, all of whom told us they had received an update for manual handling from a member of the trained staff.

During our review of incident forms we noted that there were occasions when people who use the service had been involved in altercations and incidents with each other. We had concerns that these incidents had not been reported to the relevant authorities or CQC as required.

We found evidence that staff did not have access to information and guidance required to enable them to undertake some care assessments such as for risk of pressure sores.

The service cares for older people, many of whom are in an advanced stage of dementia. We were therefore not able to talk with people in any great depth about their care. We observed care and support delivered to people, reviewed the information held about people and plans for their care, and talked with members of staff. Relatives told us that generally they felt they were kept up to date with the care of their relative.

People who use the service told us they enjoyed their meals. We saw that people had been given a choice of hot meal at lunchtime and one person using the service was able to tell us what they were going to have to eat. People who use the service receive care and support from staff who undergo induction training and other relevant training.

People's needs are not always assessed and documented to reflect a change in the care and support they require. Administration of medicines is not always carried out in a safe way. There is no evidence of medication monitoring in place.

The provider has not provided us with sufficient evidence of the quality assurance and monitoring systems they use, to ensure the service meets people's needs.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Archived: Annabel House Care Centre

All Inspections

10 July 2018

During a routine inspection

7 July 2016

During a routine inspection

11 and 13 January 2016

During a routine inspection

15 and 17 July 2015

During a routine inspection

23 and 29 January 2015

During a routine inspection

During a check to make sure that the improvements required had been made

21 May 2013

During a routine inspection

18 October 2012

During an inspection looking at part of the service

29 August 2012

During a routine inspection

13 March 2012

During an inspection looking at part of the service

12 January 2012

During an inspection looking at part of the service

29 November 2011

During an inspection looking at part of the service

10 August 2011

During an inspection in response to concerns

Reports under our old system of regulation