OSJCT Chestnut Court

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

The service had clear infection control processes in place and looked clean. Staff were wearing appropriate PPE and following recognised guidance. People and their relatives were kept informed of any changes and spoke positively of the communication they had received from staff during the Covid-19 pandemic.

The service had adopted a whole home approach to activities and engagement. Activity and care staff spoke positively about the engagement they provided people and that people now benefitted from access to more activities which promoted people’s wellbeing.

People were supported with a range of activities which were tailored to their individual needs and preferences. The service had outdoor areas which provided green spaces, in which people could take part in gardening activities.

The activity staff, care staff and domestic staff had kept records of the support people had been provided with to support their wellbeing. Changes in people’s abilities and needs had been identified and appropriate care and support provided.

Staff spoke positively about the consistent leadership provided in the home and how they now felt supported and valued. This was also reflected in feedback the service had received from people and their relatives. This consistency had led to improvements within the home, which were having a positive impact on the caring culture of the staff team.

The registered manager, deputy manager and provider had implemented robust governance systems to monitor the quality of care people received. There were systems in place focusing on the clinical care needs of people, including tissue viability, falls and weights to ensure people’s health needs were met.

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 Requires Improvement (report published 28 November 2019) and we identified two breaches of the regulations. This included a breach of regulation 17 (Good Governance) and regulation 9 (Person Centred Care). We issued a warning notice to the provider in relation to regulation 9 to be met by the 31 January 2020.

We found significant improvements had been implemented and sustained at this inspection and the provider and registered manager were now meeting all of the relevant regulations.

Why we inspected

We undertook this focused inspection to identify if the service had improved and to confirm they now met the legal requirements. We also looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

As part of CQC's response to care homes with outbreaks of coronavirus, we are conducting reviews to ensure that the Infection Prevention and Control practice was safe, and the service was compliant with IPC measures. This was a targeted inspection looking at the IPC practices the provider has in place.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.

Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for OSJCT Chestnut Court on our website at www.cqc.org.uk.

Follow up

We will return to visit as per our inspection programme. If we receive any concerning information we may inspect sooner.

OSJCT Chestnut Court is a residential and nursing home which provides personal care to 80 older people and people living with dementia. The home consists of a home contains four individual units, a range of communal areas, including lounges, dining rooms and a reception area. At the time of our inspection 75 people were living in OSJCT Chestnut Court. The home is based in Quedgeley, next to amenities such as a medical centre and local shops.

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

Since our last inspection the management of the service had changed. The manager, deputy manager and representatives of the provider had identified a number of the concerns we had found prior to our inspection. However, actions at the time of our inspection were still ongoing and had not been fully implemented and evaluated to ensure people would always receive care which was person-centred to their needs. The provider and deputy manager were implementing systems, including a new dependency tool to help drive improvements.

At this inspection we found that people were still not receiving person centred care. Staff told us they did not have the time to spend with people and promote their wellbeing. People did not always receive access to a stimulating life which promoted their wellbeing and social needs. This was a repeated breach from our last two inspections.

People and their relatives told us the staff were caring, kind and ensured their healthcare needs were met. There were enough staff deployed to keep people safe. People received their medicines as prescribed and were safe living at OSJCT Chestnut Court. The provider ensured the home was safe, well maintained, clean and free from infection.

People received care and support from staff who had the training, skills and support they required. The provider was taking action to ensure all staff received effective line management and support to develop. Staff spoke positively about the training they were receiving and how this impacted on their work.

People, their relatives and staff spoke positively about improvements which had been made to the home, including a new twilight work shift and changes to the décor of the home. People, relative and staff were hoping the improvements were embedded and sustained and spoke positively about the impact of the management team.

The manager and provider ensured people’s views were sought and listened to. Complaints were acknowledged and responded to in accordance with providers expectations.

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

Rating at last inspection

The last rating for this service was requires improvement (published 4 April 2019) and we identified two breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, we found that improvements had not been sustained and the provider was still in breach of these regulations as well as other regulations. We have used the previous ratings of the service and enforcement action taken to inform our planning and decisions about the rating at this inspection. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about the service from healthcare professionals and people’s relatives. These concerns related to the quality of care people received, staffing skills and communication from staff at the service. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. Please see the ‘Is the service Safe?’; ‘Is the service Effective?’; ‘Is the service Responsive?’ and ‘Is the service Well-led?’ key question sections of this full report.

Enforcement

We identified that people did not receive care and support which was tailored to their individual needs. People did not always receive meaningful engagement.

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.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will meet with and work alongside the provider to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We inspected OSJCT – Chestnut Court on the 6 and 7 November 2018. OSJCT is registered to provide accommodation and nursing care to 80 older people and people living with dementia. The inspection was unannounced.

OSJCT – Chestnut Court 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.

At the time of our inspection, 77 people were living at Chestnut Court. The care home has two floors with four separate units, each of which has their own communal spaces. Two of the units provide care for people living with dementia. The home has secure gardens which people can access as well as an internal courtyard.

We last inspected in April 2018. At the inspection in April 2018 we found the provider was not meeting a number of the regulations. We found people did not consistently receive safe care and treatment, because staff had not always assessed their risks or ensured concerns and risks were responded to appropriately. Additionally, staff did not have access to training and support. People did not have access to person centred care and stimulation which would benefit their wellbeing. The provider did not always have effective systems to monitor and improve the quality of service people received.

Following our inspection in April 2018, we issued the provider with a warning notice in relation to people’s safe care and treatment. We also met with the provider during the inspection and asked them to provide us with weekly action plans regarding how they planned to improve the service people received. We rated the service as “Requires Improvement” and ‘Is the service well led?’ as “Inadequate” due to the inspection history of Chestnut Court that showed ongoing concerns over a period of time.

At this inspection on 6 and 7 November 2018 we found improvements had been made, however further work was still required to ensure the service was safe, effective, responsive and well led. Following this inspection, we rated the service as “Requires Improvement”.

At this inspection on the 6 and 7 November 2018 there was not a registered manager in post. The manager was completing the registration process at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Building and maintenance checks were completed. We found risks to people had been identified and were being managed however, care staff did not always have clear guidance regarding the needs of people whose behaviours could challenge.

There were systems and processes in place for the safe storage of medicines but people were not always receiving their medicines as prescribed. Whilst the provider was implementing systems to ensure people received their medicines as prescribed, further time and work was required to ensure this system was fully embedded and followed by care and nursing staff.

Care staff responded to people's changing needs and worked closely with healthcare professionals including people's GPs. There were enough staff deployed to ensure people's health needs were met. The provider and manager had carried out consultation work with staff to ensure they were effectively deployed to reduce agency use, ensuring people received continuity of care from familiar staff.

People's privacy and dignity was respected and protected. Visitors to the service said staff were caring. Care staff supported people in a caring and compassionate way and people’s needs and choices were respected. People’s care and treatment was being delivered in line with current legislation. People were supported to maintain a balanced and varied diet in accordance with their individual needs.

Staff had most of the skills they needed to meet people's needs, however staff had not always received training in relation to dementia care. Not all staff had yet received effective line management support or one to one supervision (a regular meeting with their line manager). The manager and provider were aware of these shortfalls and was taking action to address these.

People we spoke with told us the culture within the home was improving and staff said they felt able to approach the management team. People who use the service along with family members and healthcare professionals told us they felt involved with the service.

The management team and the provider were working on an action plan to address any shortfalls we found at our previous inspection and those they had identified through their own quality assurance processes. The management action plan was not always effective in driving improvements to ensure people would always receive safe and effective personalised care. Following our inspection, the area manager and registered manager provided us with a list of actions they were planning to implement to drive improvements.

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

We last inspected the home on 5 and 19 April 2017. At the April 2017 inspection we rated the service as “Requires Improvement”. We found the provider was not meeting all of the requirements of the regulations at that time. People were not always protected from the risks associated with their care, such as the risk of choking. Additionally not all staff understood their responsibilities to raise safeguarding concerns. The provider had sent us an action plan and told us they would meet the required regulations by 31 December 2017.

During our April 2018 this inspection, we found all the required improvements had not been made. Staff understood their responsibilities to raise safeguarding concerns; however people were still not always being protected from the risks associated with their care. We also found new concerns in relation to people not always receiving personalised care, care records were not always complete, staff did not receive sufficient support and the provider’s quality monitoring systems had not always been effective in driving improvements. We again rated the service ‘Requires Improvement’ overall.

We have also rated the key question ‘Is the service well-led?’ as 'Inadequate' as the provider had failed to meet the regulations over three consecutive comprehensive inspections. The provider had therefore not demonstrated that they were able to consistently meet the requirements of their registration and operate effective systems to ensure that OSJCT Chestnut Court met the requirements of the Health and Social Care Regulations and people were not placed at risk of receiving inappropriate care.

A registered manager was not in position at the service; the service had not had a registered manager since October 2015. An Area Operations Manager and Area Operations Director for the service informed us that recruitment for a new manager who would register with CQC was ongoing with interviews being held. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were not always protected from the risks associated with their care. People could not always be assured that care and nursing staff would take prompt, effective action to ensure people’s risks were reduced. Care and nursing staff did not always follow up or report on concerns. People’s care plans did not always document their risks and the support they required from staff, at times this could have an impact on people’s safety and wellbeing.

People did not always receive personalised and dignified care. We observed some interactions between staff and people which were not personalised to the person’s needs and did not respect their wellbeing or dignity. However, we witnessed many examples of caring and compassionate interactions between staff and people. People sometime went long periods of time without engagement and their requests were not always responded to in a timely manner. People’s preferences and wellbeing needs and decisions had not always been recorded; meaning people sometimes received care and support which was not in accordance with their preferences.

People had access to diets which met their nutritional needs. People also enjoyed a range of activities, arranged by a dedicated activities team. The activity co-ordinators had built strong links within the community and provided activities which were tailored to people’s needs and interests.

There were enough staff deployed to meet people’s needs. The service was currently in the process of recruiting to a number of care and nursing hours and was reliant on agency staff to ensure there were suitable staffing numbers to meet people’s needs. While staff received communication, this was not always effective and there was not always firm direction and leadership on the individual units.

Management support was being provided by the provider, and an interim manager was in place supporting a newly employed deputy manager. Area Operations and HR managers were providing daily support to the service. A range of systems were being implemented to improve the quality of care and support people received, however a number of these systems had only recently been implemented. The provider had implemented a detailed action plan for the service.

People, their relatives and staff stated the service needed continuity and stability. Representatives of the provider agreed with these views. Staff felt they did not always have the support they needed, however felt they could see improvements being made to the service. Staff told us they had the training they needed, however did not feel confident they could ask for additional training due to previous requests not being acted upon.

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

Chestnut Court provides nursing, residential, and respite care for up to 80 people in four households Two households cared for people living with dementia. At the time of our inspection 75 people were living there. The home is purpose built over two floors.

There had been no registered manager in post for 18 months. 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. An interim manager was currently managing the service and had recently decided to apply to CQC to be the registered manager.

There were four breaches of legal requirements at the last inspection in December 2015. Following this inspection the provider sent us an action plan detailing how they would address the shortfalls that had been identified. At our comprehensive inspection on 11 and 12 April 2017 the provider had followed their action plan which they told us would be completed on 31 August 2016 with regard to the use of the Mental Capacity Act to protect people, improving their quality assurance systems although further improvements were needed, providing sufficient training for staff and ensuring there were adequate staff to protect and care for people.

At this inspection we found that people were not always protected against the risks associated with abuse and improper moving and handling. We could not always be assured that care staff understood their duty to raise safeguarding concerns as part of the providers ‘whistle blowing’ policy.

People were not always protected against the risks associated with the unsafe management of medicines. There were errors and inconsistencies in some medicine records and medicine was not always available on time.

People were not always protected against the risks of falling. Risks were not always reviewed and measures recorded to prevent further accidents.

People were not always protected against the risks associated with meeting their nutritional needs. Some records were inaccurate when assessing people’s nutritional risk and one person was at risk from choking due in part to the support plan not being followed..

There were varying opinions about staffing levels from staff, people and relatives but the provider had assessed people’s dependency levels every six months and provided some additional staff hours. Additional hours for activity staff had been implemented since the last inspection. As a result there was an improvement for people in the activities they joined in with six days of the week. We have made a recommendation to continually monitor people’s dependency levels to provide sufficient staff to support and care for people safely.

In view of the shortfalls in this report it was evident that the quality assurance systems had not been fully effective. We have made a recommendation the systems for assessing the quality of the service be more robust and continually reviewed by the provider and the manager to ensure safe care and treatment for people.

People were able to make some choices and decisions and staff supported them to do this. Healthcare professionals visited when required and clear records were kept of the visits. There was evidence of communication from the mental health team and palliative care team and their guidance was followed. People were supported by staff that were well trained and had access to training to develop their knowledge.

People were treated with kindness and compassion. We observed staff engaged with people in a positive way and they were caring when they supported them. Relatives felt welcomed in the home and told us the staff were kind. People had a range of activities to choose from which included cookery, quizzes, ball games, arts and crafts and musical entertainment. Community links included people visiting the local church and shops nearby.

Staff meetings and resident/relative meetings were held and they were able to contribute to the running of the home.

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

Chestnut Court provides nursing, residential, and respite care for up to 80 people in four separate units. Some people were living with dementia. At the time of our inspection the home was full. The home is purpose built over two floors and has secure gardens.

There was no registered manager but the home manager had already applied to become registered with us. 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 were no breaches of legal requirements at the last inspection in September 2014.

People were not always supported by sufficient staff. Two relatives, staff and a health care professional commented on the shortfall. This has required improvement.

According to the training records, which were incomplete, staff had not completed regular training updates to ensure they had sufficient knowledge to carry out their roles. Staff supervision had not been completed regularly to identify staff training needs. This has required improvement.

Staff generally lacked knowledge about the Mental Capacity Act 2005 and records were inconsistent and did not protect people with regard to consent. This has required improvement.

Quality monitoring procedures used to improve the service for people were not effective. Care plans were not always personalised and audited regularly to ensure the information was relevant. Six monthly care plan reviews usually recorded what people or their relatives said about their progress and the service but their views were unknown by the manager. This has required improvement.

The provider’s area operations manager looked at various aspects of the service during the monthly review and monitored the action taken. Residents/relative meeting were held to include them in developing and improving the service. The provider also relied on comments posted on the Carehomes internet website to monitor the service

People were kept safe by staff trained to recognise signs of potential abuse and they knew what to do to safeguard people. People told us they felt safe and were very comfortable, they said, ”If I stay in my room staff check if I am ok”. Relatives and friends also felt that the service had a safe environment and told us, “I have been impressed by the staff and their care” and “I have only seen kindness, they [staff] are wonderful”. A relative told us they felt mum was very safe in Chestnut Court.

People had access to health and social care professionals to support them when required.

People’s medicines were managed safely and regular checks were made to monitor staff practice. People’s medicine was reviewed by their GP or a nurse practitioner from the surgery as part of an annual review.

People were supported to have a well balanced diet that met their individual needs. We observed a variation in people’s experience at mealtimes in the units. Mealtimes were relaxed but did not always engage people. There were no accessible visual menus that could be used to help people living with dementia know what meals were available.

We observed engagement between people and staff was mostly caring and kind. People appeared to be comfortable in staff presence. People indicated they were happy living in the home and with the staff that supported them. One person said, “Staff go above and beyond what their role is”. Relatives were complimentary about how the staff responded to people and the relationships they had built with them. One relative described the staff as being “Kind and caring”.

The new manager had been in post for just under three months when we completed the inspection visit and was well thought of by relatives and friends. They told us the new manager was very good and listened to any concerns they had. Relatives were confident their voice was heard and felt the new manager was approachable and responded well to them.

.There were good links with the local community to include the schools and the church. The service had a ‘Memory Café’ where people in the local community came to listen to talks about dementia and their questions were answered by the providers specialist dementia nurse. The local superstore provided refreshments for the café.

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

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

Is the service caring?

We saw people being supported by polite and attentive staff. We saw staff sitting with people whilst assisting them with their meals. We observed people holding two way conversations with staff. As we walked past one person, he stopped us, and pointed to the member of staff nearby saying 'this one deserves extra points.' One person told us "they are very good" whilst a relative told us 'they are kind to him."

We saw that care workers were patient and gave encouragement when supporting people. We heard one staff saying to a person using the service "do you want me to put your TV on? Is that better? I'll put your bell near you" A person told us 'it's very nice here, they treat you well."

We observed staff knocking on people's bedroom doors before entering and then keeping the door closed whilst providing personal care.

Is the service responsive?

The care files confirmed people's preferences, interests and individual needs had been recorded and the support provided met people's wishes. One person told us 'staff treat me very well. I choose my own meals.'

To help staff get to know people as individuals there was 'All about me' or 'my life story' information at the front of care folders. One person said she liked singing and regularly sang with staff.

Relatives were involved in contributing towards people's annual care review and their views were taken into consideration. In several reviews, the relatives made significant contributions and signed the review. One relative said "I got involved when we arrived at the home."

We saw that the service worked well with other healthcare professionals. There were several letters in people's care records from health professionals suggesting changes to a person's care or treatment.

People could make choices. We regularly heard staff asking people to make a choice. We heard staff asking a person "if you need anything just ring, so I can get it for you." A person told us 'I pick my own clothes and choose when to go to bed.'

Is the service safe?

We found the home safe at the point of entry. To enter the home we had to ring, wait for the door to be opened, we signed in and signed out. People were cared for in an environment that was safe, clean and hygienic. We found the environment in good decorative order and staff had the equipment needed for moving and lifting people safely.

We saw from the completed records that equipment at the home had been well maintained, serviced regularly and therefore safe for people to use. People told us that staff looked after them well, one person said 'they look after me, when moving me.'

Staff we spoke with were able to tell us what action they would take if they saw abuse taking place and where to find the correct contact information and procedures. One staff told us "I treat people here like I would like to be treated myself."

The staff carried out a range of health and safety checks to ensure people were kept safe. Records showed that fire drills were carried out and that people had their personal evacuation plans.

People ate food which had been safely supplied and prepared. The catering facilities had been assessed by an environmental health officer in 2014 and were given the top star rating.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards which apply to care homes. The Deprivation of Liberty Safeguards are in place to protect people's human rights. The records showed that some people's mental capacity has been assessed and best interest meetings held.

Is the service effective?

Relatives told us that they were happy with the care they saw and felt people's needs had been met. One relative told us "staff are friendly and we can make our own drinks when we want' whilst a person using the service told us 'I told the staff I was not happy about something and it was dealt with immediately.'

Staff told us that communication was good in the home, issues relating to individuals were discussed at handovers. From viewing the care records we saw that sudden changes to a person's health were added to the care plans as an extra information sheet. Staff also told us that their views were heard and taken into consideration.

We viewed the letter sent to relatives summarising their comments made about the service at the relative's meetings. Where it was relevant the letter also had details of the actions taken by the service in response to the relative's comments.

Is the service well-led?

The manager was registered with the Care Quality Commission as the registered manager for the service. One person told us "if I had a concern I know he would do something about it" whilst another relative said "it's lovely here."

We viewed several training records to confirm that the staff had received regular training to meet the needs of the people living at the home. The service had a training coordinator to help ensure staff regularly updated their training. Staff told us there were prompts in place to remind them when training updates were due.

The home had a range of quality control processes in place. The records needed for the safe and smooth running of the home were in good order and up to date.

People's relatives were included in how the home was run by being asked for their feedback on the service. Relative's views had been listened to and we saw changes had been made where required. One person using the service told us 'they try very hard to please' whilst a relative told us 'it's an easy going sort of place, so I've no complaints.' Staff told us their views were heard and changes could be made to how the service was run.

We found the home was well equipped. The staff were observed using electrical hoists and the bathrooms offered a range of facilities to meet people's needs.

At our last inspection we found gaps in the assessment records and six monthly reviews. We checked these files again and found that all risk assessments had been updated. We found that people had received their reviews of care in conjunction with their families. We checked two additional monitoring charts and found them to have been completed in line with the person's care plan.

During our visit we saw that staff asked the permission of people who used the service before supporting them. We saw inconsistent practice in the way staff supported people who used the service. Some of this was excellent, however some was not. We also found that some people who had been assessed as high risk for developing pressure ulcers and malnutrition had not received regular assessments. This put them at increased risk of receiving poor or unsafe care. We found the home to be clean although in some parts of the home we did notice an odour. Medicines were stored correctly and administered by trained staff. We looked at the complaints register which confirmed two complaints had been received since January 2013. Both had been investigated thoroughly and action taken where necessary.

We spoke to three people who used the service. They told us 'it's not home, but I have realised I need people to help me, and they do that very well here'. 'I am happy here'. 'The staff are very good and the food is good too'. 'It's a very good home and the staff look after me really well'.

We looked at the care files for eight people who used the service. All the care files we saw contained personal plans and life stories for each individual. The daily notes were always signed and contained appropriate information linked to their care plans. The care plans had been reviewed regularly and reflected each person's individual needs. Risk assessments were reviewed each month

We spoke with two people who used the service and two relatives. One person told us 'I have been here 10 months and it's absolutely brilliant. The food is very good and the staff are excellent'. Another person told us 'the staff are excellent and very supportive'. The two relatives we had spoken to both told us how the staff always kept them informed of what was happening.