Richard House Care Home

About the service

Richard House is a residential care home providing personal care to up to 33 people. The service provides support to people aged over 65 in one adapted building. At the time of our inspection there were 19 people using the service.

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

Medicines were not always managed safely which placed people at risk of harm. Safe recruitment procedures had not always been followed to check staff were safe to work with people who may be vulnerable. Environmental safety checks had not always been carried out.

People’s nutrition and hydration needs were met. 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.

The provider had not ensured sufficient oversight of effective auditing and the delivery of safe care. Audits completed had not always identified the concerns we found on inspection. We identified multiple and repeated breaches of regulations. The deputy manager was helpful and quick to act when we fed back our findings during the inspection. The registered manager had good links with other organisations and built relationships with key people such as the local authority and health teams.

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 (published 28 April 2020) and there were 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 the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement overall for the last three consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We 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 COVID-19 and other infection outbreaks effectively.

We last carried out an unannounced comprehensive inspection of this service on 10 and 11 March 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, staffing and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe recruitment, safe management and administration of medicines and governance of the service.

Please see the action we have told the provider to take at the end of this report.

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 meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

About the service

Richard House is a residential care home providing personal and nursing care to 18 people aged 65 and over at the time of the inspection. The service can support up to 33 people in one extended and adapted building.

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

Medicines were not always managed and administered safely. We found several medication errors where people had been placed at the risk of harm. Sufficient staff training, supervision and oversight of staff competency was not in place. Staff had not always received training in mandatory subjects. People did not have assessments in place for safe moving and handling. As a result of these findings we raised a safeguarding alert with the local authority for everyone in the home.

The service ensured people’s nutritional needs were assessed and dietary requirements were met. People told us they were happy with the food and were able to make choices. People were supported to have access to health professionals, such as GPs and community nursing.

People told us staff treated them with care and respect. We observed very kind and caring interactions between people and staff and established relationships were evident. People felt they were treated with dignity and respect and had their independence promoted.

Care plans were inclusive and person-centred and written with full involvement of people and those important to them. An activities co-ordinator organised a variety of events at the home.

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.

There had been a lack of provider and managerial oversight of the operations of the service and this had led to the concerns identified in this inspection. The registered manager was keen to make improvements to the service and was responsive throughout the inspection.

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 (published 15 March 2019) and there were 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 enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to the safe administration and management of medicines, providing good governance of the service and the training and supervision of staff at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

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

Richard House offers accommodation for up to 29 people who require assistance with personal care and support. The home is a two-storey building with bedrooms and bathrooms on both floors and secure garden areas. At the time of the inspection 18 people were using the service and one person was in hospital.

At our previous inspection conducted in May 2017 the service was given an overall rating of Good and there was a breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question of Well-Led to at least Good, which we received. At this inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance and safe care and treatment. We also made a recommendation about activities.

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

Richard 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.

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.

Accurate records to demonstrate the safe management of people’s medicines were not always present and the provider was unable to demonstrate sufficient time was being maintained between medicines. Medicines were brought from the upper floor of the building to downstairs to give to people which is potentially unsafe practice.

Records regarding PRN (when required) medicines were not always accurate.

We found gaps in some people’s medicines administration records (MAR’s). MAR charts were not always easy to read for some people. Three MAR’s we looked at were missing a picture of the person and one MAR had no name of the person on it.

Some MAR’s did not have any specialist instructions for people with swallowing difficulties and how this may affect their ability to take their medicines.

When people were identified as having dietary needs either due to swallowing difficulties or weight loss, care plans had not been updated to reflect this need and monitoring charts had not been implemented to demonstrate people’s needs were being met.

One person had been in residence at the home since September 2018, however no risk assessments had yet been undertaken.

The arrangements for assessing quality and safety required further improvements to ensure they were effective and robust in identifying concerns; audits undertaken had not identified the concerns we found during this inspection regarding the safe management of medicines and the absence of up to date records.

Activities provided to people were limited and we have made a recommendation about providing activities in relation to people’s identified preferences and choices.

Any accidents or incidents had been recorded and acted upon.

People who used the service and their relatives told us they felt safe living at Richard House and there was an appropriate safeguarding policy in place.

People told us they felt there were enough staff on duty to meet their needs and the home assessed people’s dependency levels to ensure there were sufficient staff on duty.

We observed many good interactions between staff and people who used the service; people and their relatives told us staff were kind and caring.

The registered manager was aware of their responsibilities of how to apply for any best interest decisions under the Mental Capacity Act (2005) and followed the correct procedures. Staff had knowledge of Mental Capacity Act (2005) and no-one was unlawfully deprived of their liberty.

There was a business continuity plan in place which provided staff with guidance on what to do in case of an unexpected event. People had personal emergency evacuation plans in place which provided staff with guidance on how to safely evacuate each person, if necessary.

Equipment used by the home was maintained and serviced at regular intervals.

There was evidence of robust staff recruitment procedures.

All areas of the service were clean and there were no malodours in any of the communal areas or bedrooms we checked.

People had access to and were supported by staff to see healthcare professionals and the service was adapted to support people with additional mobility needs.

People had personalised their bedrooms with individual items such as family photographs, bedding and personal objects.

Formal meetings with staff were not held regularly and meetings with people who used the service and their relatives were also not regularly undertaken, which lessoned the opportunities for people and staff to contribute their views about the service provided.

At the last inspection on 19, 20 and 21 September 2016 the overall rating for the service was requires improvement, with the well led section found to be inadequate. At that inspection we identified multiple regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014, which related to medication administration, premises and equipment, receiving and acting on complaints, fit and proper person’s employed, safe care, staffing and good governance.

Following the inspection the provider sent us an action plan detailing how the identified breaches would be addressed. This inspection was to check improvements had been made and to review the ratings.

Richard House Care Home is located in the Cale Green area of Stockport and is registered to provide accommodation for up to 29 people who require assistance with personal care and support.

Accommodation is provided on two floors, which are accessible by a passenger lift. There are twenty five bedrooms, four of which have the capacity to be used as shared rooms. However at the time of this inspection all of the rooms occupied were single occupancy. Six bedrooms have en-suite facilities.

The home has three lounges, a sun room, a porch seating area and two dining rooms as well as garden space and parking to the rear of the property.

At the time of our inspection there were 22 people living at Richard house Care Home.

The home had a manager registered with the Care Quality Commission (CQC), who was currently on sick leave and not present throughout the three days of inspection. CQC had been appropriately notified of this sick leave. The acting manager was present for the first two days of the inspection and a senior carer was present for the third day of the inspection. A registered manager is a person who has registered with CQC 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 and associated regulations about how the service is run.

During this inspection, we found significant improvements had been made; the acting manager and senior care staff we spoke with were responsive to our feedback and were committed to further improving the service delivered to people living at Richard House Care Home. At this inspection we identified a breach of one regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to good governance.

We observed people receiving person-centred care and staff were able to describe the individual care needs of people, but we found some shortfalls in the written plans of care. This was because some parts of the plans of care were pre-printed and staff used a tick box approach to identify if the care need related to the person. This meant that some parts of the plans of care were vague and did not include details of exactly what assistance the person required to meet their assessed care needs.

As stated above during the inspection we found significant improvements had been made since the last inspection. However we found that robust systems had not yet been implemented to monitor all aspects of the quality and safety of the service being provided.

We observed staff giving kind and caring support to people. We saw that people’s privacy and dignity was respected and people were relaxed in the company of staff.

Improvements had been made to medication administration and we saw medicines were managed safely and people were receiving their medicines in line with the prescriber’s instructions.

Since the last inspection the recruitment processes had been improved to ensure only suitable staff were employed to work in the service.

From looking at the training record and speaking with staff, we found improvements had been made to ensure staff were properly trained and future training had been planned.

Since the last inspection staff had received on-going supervision and an annual appraisal. This meant that staff were being appropriately guided and supported to fulfil their job role effectively.

Staff spoken with understood the need to obtain verbal consent from people using the service before a task or care was undertaken and staff were seen to obtain consent prior to providing care or support.

The home was clean and we saw staff had access to personal protective equipment (PPE) to help reduce the risk of cross infection.

Staff understood how to recognise and report abuse which helped make sure people were protected. People living at Richard House Care Home, the staff, the visiting relatives and the healthcare professional spoken with all said they thought safe care and treatment was provided.

People had access to healthcare services and we saw specialist advice was sought in a timely manner, for example from the district nurse, dentist, optician and chiropodist. People were supported to attend hospital appointments as required.

Attention was paid to people’s diet and people were supported to eat and drink in a way that met their needs. People living at Richard House Care Home were complimentary about the food provided and said there was plenty of it.

A notice informing people how to make a complaint was displayed in the main entrance of the home and in the dining room. Details of how to make a complaint were also detailed in the home’s statement of purpose and service user guide. There was a system in place for receiving, handling and responding to concerns and complaints. The people living at Richard House Care Home who we asked and all of the visiting relatives we spoke with told us they had never raised a complaint but thought the manager would be responsive if they did.

The visiting healthcare professional we spoke with told us they had no concerns for the people living at Richard House Care Home and told us staff were knowledgeable and proactive in their care delivery.

We last inspected Richard House Care Home on 11 December 2013. At that inspection we found the service was meeting the regulations we assessed.

Richard House Care Home is located in the Cale Green area of Stockport and offers accommodation to 29 people who require assistance with personal care and support.

Accommodation is provided on two floors, which are accessible by a passenger lift. There are twenty five bedrooms four of which have the capacity to be used as shared rooms. However at the time of this inspection all of the rooms occupied were single occupancy. Six bedrooms have en-suite faculties.

The home has three lounges, a sun room and two dining rooms as well as parking and outside garden space to the rear of the property.

On the first day of our inspection twenty two people were living at the home, however one person was later discharged home so twenty one people were accommodated at the home for the remainder of the inspection.

A Registered Manager was in post although they were not available during this inspection as they were on annual leave. 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.

During this inspection we identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Full information about Care Quality Commission's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Some medicines were not managed safely. We found there were not always clear, detailed written directions for the use of medicines to enable staff to apply topical prescribed creams for example doublebase cream and fenbid gel as intended by the person’s doctor. This meant there was a risk that prescribed creams may not have been applied when required, which could have resulted in unnecessary discomfort for the person.

We had concerns in relation to staff supervision because staff were not receiving supervision on a regular, ongoing basis. This meant that staff were not being appropriately guided and supported to fulfil their job role effectively.

Some of the routine safety checks had not been undertaken, for example, checks of window restrictors, water temperature delivery testing and the nurse call system. This meant the provider could not be sure people using the service were supported to remain as safe as possible at all times.

Recruitment processes required improvements to ensure only suitable staff were employed to work with vulnerable people.

We saw that some people’s identified care needs did not have a corresponding plan of care to direct care staff on how to meet the person’s individual care need, for example, the use of topical creams or if a person had a chest or urine infection. This meant there was risk that people could receive unsafe and inappropriate care.

Staff training records viewed indicated there were gaps in staff training. This meant some staff were not being appropriately trained and skilled to meet the needs of the people living at the home.

We found that robust systems had not been implemented to monitor the quality and safety of service people received.

People were supported by a stable staff team who had worked together for a number of years and knew the people living at Richard House very well. However we found there was not a systematic approach to determine the number of staff and range of skills required to meet the needs of the people who used the service. This meant the registered provider could not be sure that the staffing levels and skill mix of staff were sufficient to meet the assessed needs of people living at Richard House Care Home. We made a recommendation that they implement the use of a staffing tool.

We recommended that the service considers reviewing people’s plans of care to ensure where possible they are developed in partnership with the person using the service and are designed to meet their specific individual needs and personal preferences.

We recommended that the service further develops the pre admission assessment form to ensure they can fully meet all of the person’s individual care needs.

We recommended that individual assessments of people’s hobbies and interests were undertaken and recorded to ensure that the activities provided were in accordance with people’s personal preferences.

The visitors we spoke with told us they thought Richard House Care Home was a homely, friendly care home and they were happy their relative was well looked after.

There was a complaint notice on display in the main entrance hall of the home although we found the complaint policy to be out of date and there was not a clear system in place for receiving, handling and responding to concerns and complaints.

Staff spoken with understood the need to obtain verbal consent from people using the service before a task or care was undertaken and staff were seen to obtain consent prior to providing care or support.

From our observations of staff interactions and conversation with people we saw staff had good relationships with the people they were caring for and the atmosphere felt friendly and relaxed.

Attention was paid to people’s diet and people were supported to eat and drink in a way that met their needs. All of the people living at Richard house Care Home who we spoke with were full of praise for the cook and the meals provided. We were told that the food was all homemade, very tasty and there was more than enough food and drink provided.

The healthcare professional we spoke with told us they had no concerns for the people living at Richard House Care Home and they told us they thought the staff were exceptional and very caring.

We found evidence that there were procedures in place to assess the capacity of people to

consent to their care and treatment. We found that people's decisions about how they wished their support to be provided were respected.

We saw that care plans clearly identified the needs of the person and had been reviewed on a regular basis. One person told us, "The care I receive is excellent. I always get what I need when I need it."

We looked around the premises and found it was clean and welcoming. People's bedroom's were individualised with their personal items and people could choose where to spend their time.

We observed support staff were friendly towards people and enabled them to be as independent as possible.

We found evidence that there were systems in place for the safe administration of medicines.

We saw evidence that there were effective recruitment procedures in place to ensure that people who used the service were protected from inappropriate staff.

We found that suitable arrangements were in place to manage an effective complaints process for identifying, receiving and handling complaints for people living at Richard House.

People said 'this is a lovely place to live and I can go in to any room or stay in my bedroom.' 'I have not been here long and the staff are good they do talk to me about my care plan,' 'there are activities but I don't take part you can choose if you want to join in.' 'Another said 'we play board games and really have a good laugh.'

People said they felt well cared for by the staff that supported them. Everyone we chatted to was positive about the support provided.

People told us that they felt safe and have no concerns about the care and treatment they receive from staff. People said they could talk to the manager at any time and she would sort anything out. They said she spoke to them each day and that all of the staff would listen if they had any concerns.

Relatives spoken with were happy with the care their relative received.

Comments such as 'the staff are marvellous;' a great team of girls' 'the staff are second to none' 'the staff treat me very well and we have a good laugh' were made.

People we spoke with said that the staff asked for their views on the routines at the home and they have meetings with the manager to discuss anything they wanted to.