Archived: The Rock

People’s experience of using this service:

People told us they felt safe; however, we found people were not always protected from risks associated with their environment, medicines management and potential risks to people's health and welfare had not always been assessed.

People were not always protected by safe recruitment processes. The provider had not always obtained the necessary pre-employment checks before new staff started working at the service.

Systems and processes to monitor the service had either not been established or operated effectively to assess, monitor and mitigate the risks to people's health, safety and welfare. The provider’s quality assurance processes did not identify the issues we found at this inspection. These included concerns with the safety of the environment, risk management, recruitment and medicines management.

There was a risk that people's rights were not protected because staff did not always act in accordance with the Mental Capacity Act 2005 (MCA). Where people's capacity was in question MCA assessments were not always taking place and best interests decision processes had not always been followed.

Improvements were needed to ensure the service met the needs of people living with dementia. There was a lack of signage to help people living with dementia find their way around the home. People's bedrooms were not easily identifiable with nothing displayed on their doors. We made a recommendation to the provider about this.

People were supported by staff who had completed a range of training to meet their needs. Staff told us they felt well supported by the management team. The management team monitored staffs’ practice through regular observation but did not have a system of formal supervision meetings. We made a recommendation about this.

People received personalised care from staff who knew them well and understood how to meet their needs. Care plans contained information about individual preferences and what was important to people such as interests and activities. However, during the inspection we observed people were not engaged in meaningful activity and there was no information displayed within the home about activities on offer. We made a recommendation to the provider to review their activity provision at the service.

People and their relatives felt staff were kind, friendly, and attentive to their needs. We observed warm interactions and people were treated with kindness and care by staff. One person said, “I feel like one of the family. I am one of the family!” Another person said, “Staff look after us ever so well.”

People's privacy and dignity was respected, and their independence promoted.

People had access to healthcare professionals when required and were supported to maintain good healthcare. Health professionals we spoke with told us they were happy with the quality of care and engagement from the service.

Rating at last inspection: At the last inspection the service was rated Good (report published 18 October 2016).

Why we inspected: This was a planned inspection based on previous rating.

Enforcement: During this inspection we found four breaches of regulation. Action we told provider to take can be seen at the end of full report.

Follow up: We will carry out ongoing monitoring of the service and check the improvements have been made at our next inspection.

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

The Rock provides care and accommodation for up to 14 older people. People living at The Rock may also have mental health needs, including people living with Dementia. On the day of the inspection nine people were living in the home.

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

The systems in place for administering medicines did not comply with guidance from the Royal Pharmaceutical Society. Although we saw no evidence of harm to people, the provider had introduced a potential risk by dispensing medicines from their original packaging into a weekly dispenser purchased by the home. This practice is known as secondary dispensing. We discussed this with the provider and senior staff, and they agreed to discuss this issue with the supplying pharmacist to ensure their systems were safe and compliant with good practice. Following the inspection we spoke to the provider and pharmacist to confirm a meeting would be arranged between them to discuss the issues we had raised.

Medicines were stored safely and people received their medicines in a way they chose and preferred. Staff responded promptly to changes in people’s health and had good links with health and social care professionals. The food in the home was of a good quality and catered for people’s special dietary needs and preferences.

Throughout the inspection we found staff to be compassionate and caring. There was a calm, friendly and homely atmosphere. The interactions between people and staff were positive. People, relative’s and other agencies spoke very highly of the care and support provided at The Rock. People told us the staff were always kind and caring and they felt they mattered. A relative said they felt the care provided could not be any better. A person living in the home said, “The staff have been really lovely, I have felt really happy here”, and “They are always kind and respectful, I have no complaints about my care”. Feedback forms gathered by the provider included very positive comments, including, “I think the staff at The Rock give exemplary care, I cannot thank them enough for their outstanding care’, and “I think the level of care is high and personal and always caring”. The provider cared about people in the local community and offered day care and respite to support families when it was appropriate and they had rooms available. The registered manager said, “ We just want to help people because we care and know it can be difficult for families when there is no other support”.

Relatives and other agencies praised the home for their end of life care. Without exception, all expressed their gratitude for the loving care and kindness they and their relative had received during their final days at The Rock. Feedback we saw, which had been gathered by the service from the local District Nursing team included, ‘We don’t think you could have cared for […] with more love, care and attention. You all did a beautiful job. [….] always looked so clean, calm, and comfortable and settled”.

There was a positive culture within the service. The provider and senior staff provided strong leadership and led by example. There were clear visions, values and enthusiasm about how the service should be run and these were shared and understood by the whole staff team. Individualised care was central to the home's philosophy and staff were clear that spending time with people was as important as attending to daily care needs, such as washing and dressing. We saw staff sitting chatting with people, providing gentle reassurance when required and responding promptly when people became distressed or unwell.

There were sufficient numbers of staff to meet people’s needs and to keep them safe. Most of the staff team had worked in the home for many years and knew people well. All the staff we spoke with said they felt this consistency and their knowledge of people helped them provide good personalised care. The provider had effective recruitment and selection procedures in place and carried out all necessary checks when they employed new staff to help ensure they were fit and safe to work with vulnerable people. Staff had opportunities for training and said they were well supported by the management and their colleagues.

People told us they felt safe living in the home. All staff had undertaken training on safeguarding adults from abuse, and said they felt confident any incidents or allegations of abuse or poor practice would be taken seriously and dealt with appropriately.

When possible people and their relatives were involved in planning and reviewing their care. This meant their care was personalised and reflected the person’s current wishes and needs. Care and support focussed on each person’s individual needs, their likes, dislikes and routines important to them. Staff understood their role with regards to the Mental Capacity Act (2005) and the associated Deprivation of Liberty Safeguards (DoLS). Applications had been made and advice sought when necessary to help safeguard people and protect their human rights. When people were unable to consent to their care or support, discussions took place to help ensure decisions were made in their best interests.

Activities were planned to reflect people’s particular needs and interests. People had the opportunity to participate in community events and contact with family and friends was actively supported and encouraged. Relatives and friends said they were welcomed at all times and made to feel important in the home.

The provider promoted the ethos of honesty, learning from mistakes and admitted when things had gone wrong. This reflected the requirements of the duty of candour. The duty of candour is a legal obligation to act in an open and transparent way in relation to care and treatment.

There were effective quality assurance systems in place. Incidents were appropriately recorded and analysed so that any adjustments could be made in people’s support arrangements.

This inspection was carried out by an adult social care inspector. During the inspection the inspector looked at the evidence to answer five key questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

The Rock is a small home providing care and support for up to 14 older people, all of whom had some degree of dementia. We spoke with three people who lived at the home about their experiences there. We also spoke with two relatives, three members of staff and three members of the management team. We reviewed records relating to the management of the home which included 3 care plans and observed the care and support people received.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

We saw that the home was a caring and positive environment for people. We saw many examples of staff supporting people in a caring way, such as supporting them when walking or engaging in gentle and good humoured conversation. We saw staff sitting with people and their visitors, with everyone being included in their conversations. People repeatedly told us the home was a family style environment. One person told us 'It's a lovely place, not institutionalised at all. This room is just like someone's lounge. I love the cat too'.

We saw that several people visited one person whose Birthday it was on the day of the inspection. When visitors came they engaged with other people who lived at the home as well as the person they were visiting. We saw the home's staff celebrating with the person. This told us the home valued people's individuality and respected them.

We saw the staff's caring attitude was also demonstrated through the words used in the care plans. For example one plan we read said the person 'responds well if staff are cheerful with (them) and use a happy voice tone and never hurry (them). Take time to explain what you want (them)to do. It may take time and several attempts for (them) to understand'. We saw staff being positive when supporting people. This told us that staff took the time to understand and support people in the way they wanted and needed.

A relative we spoke with told us 'We just leave them to it. They know what they are doing and we can't praise them highly enough for what they do'.

Is the service responsive?

We saw that the home was responsive to changes in people's needs and to concerns identified to improve the operation of the home.

On our last inspection of the home in November 2013 we had identified that there were concerns over the training staff received. We saw that the home had responded to make improvements. Staff told us they received the training support they needed to carry out their role. One staff member we spoke with told us 'There is a good staff network here. I get good training, and I enjoy working here.' Another told us 'Working here is a lot of fun. I get well supported and lots of training. I want to do more and learn more'.

We also saw that improvements had been made to the record keeping and quality assurance systems as a result of the previous inspection. This told us the home responded to concerns.

We saw that care plans helped identify any deterioration in people's conditions and action was taken as a result.

Is the service safe?

We found the provider had taken action to make the home safe for people.

At our last inspection we had identified concerns in relation to the assessment and management of risks at the home. We found that action had been taken and the home's management could show us new risk assessments in relation to the operation of the home and management of the environment. We saw actions had been taken to address areas identified, such as the provision of new radiator covers. We saw assessments of risks for people who lived at the home had also improved and been regularly reviewed.

There were enough staff on duty to meet people's needs and the provider or another member of the management team was always on call in case of an emergency. This meant staff had access to more senior advice or support at all times.

We identified that the systems for managing medication did not comply fully with safe guidance from the Royal Pharmaceutical Society. However the provider had taken action to minimise any risks and was requesting a specialist inspection from the supplying pharmacy to ensure their systems were safe.

CQC is responsible for monitoring the deprivation of liberty safeguards which applies to care homes. No-one at the home was subject to an authorisation by the Court of Protection at the time of the inspection. The provider was however discussing the people at the home with the local authority and community psychiatric team to assess and prioritise applications due to a recent clarification of the law in this area. This told us that the provider understood the actions they needed to take to ensure that people's rights were protected and that where people were being deprived of their liberty this was in accordance with legislation.

Is the service effective?

We saw that the service was effective in supporting people with their health and wellbeing.

We saw effective systems for communication within the home. We saw the way information was handed over to staff between shifts and how staff duties were allocated each day. This helped to ensure everyone was clear about any changes in people's needs.

One visiting professional had completed a quality assurance questionnaire and had written the home 'would be good to use as an example of how residential homes should be run' and another had written 'There is a lovely warm, homely family atmosphere. The residents are well cared for and seem happy and content'. A relative had written 'I have witnessed my mother improve both physically and mentally, and I attribute this to the excellent care she has received'. This feedback told us the home was effective in meeting people's needs and supporting their wellbeing.

Is the service well led?

The provider and their family had operated the home for over 30 years as a family concern. They were still very much involved in the day to day operation of the home. For example we saw that there were daily meetings when people's needs were discussed and any new approaches identified. Staff told us they valued this time.

We saw feedback from families that told us how much they valued the ethos of the home and the care provided. One had said of the home 'How do I ever thank you'never doubt that you make a huge difference to all of the lives that you touch'.

We saw that the home had responded well to the previous inspection report and had introduced much more robust management systems.

We also found that some records, including those relating to risk and staff support systems were not being completed properly or updated regularly. Although staff we spoke with felt they were supported we did not see evidence of formal supervision, appraisal or training programmes in place. Some risks in the environment had not been assessed, or action plans to reduce risks put in place.

We saw people being supported by staff who were kind and caring, and knew people's needs well. The home offered a family run and homely small environment for people, many of whom were local to the town.

Prior to this inspection concerns were raised with us about the care and treatment for one person who lived at the home. We found that the home had acted appropriately and there was no evidence to support the concerns.

Although the manager had received training in the Mental Capacity Act 2005, staff did not demonstrate a good understanding of the Mental Capacity Act 2005 and how to apply this to their practice. There were no records that showed that decisions made on behalf of people were made in accordance with the Mental Capacity Act 2005.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

People told us they thought the staff were "wonderful". One relative told us that the staff were "lovely" and that there were always enough staff on duty when they visited.

We saw and heard evidence to show that there were a variety of methods of checking the quality of the services provided. However, the organisation had not brought all of the information together to carry out an overall review of the quality of the service on a regular basis.

We saw that people appeared well cared for, wearing appropriate clean clothing and footwear. Glasses and hearing aids were in place where needed. People in the home appeared to be warm, comfortable and pain free. People told us that they felt safe at the home.

During our visit we toured the communal areas of the home and looked at some of the bedrooms. We saw that people had been encouraged to bring in items from home that helped make their rooms personal and homely.

We looked at three staff files which included an employment contract, police checks and relevant qualifications. We saw that staff had not received any formal training since 2010. We also saw that there was no formal quality assurance process in place.

People were not protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.