Troutbeck Care Home

Troutbeck Care Home is a nursing home providing personal and nursing care to up to 52 people. The service provides support to older people, some of whom were living with dementia. At the time of our inspection there were 38 people using the service.

People’s experience of the service and what we found:

Staff delivered poor care and treatment to people, which put them at risk of significant harm. The service did not always properly assess and plan for risks, which meant measures were not in place to reduce or minimise them.

Staff were not always aware of people’s care needs. This meant we could not be assured people were receiving appropriate care which was safe for them.

Staff did not support people to have enough to eat and drink. At the time of our inspection 20 people had suffered unintentional weight loss in the service at the time of our inspection. The service had not addressed this robustly to protect people from malnutrition and dehydration.

Staff did not take action, where safeguarding concerns were evident. They failed to protect people from incidents where people were repeatedly assaulted by another person using the service and had accepted this as the norm.

The building was not safely maintained, and the provider had failed to take prompt action to address fire safety concerns, which meant people were at risk of harm in the event of a fire.

People did not receive support from staff in a timely way and people made negative comments about the time it took for staff to respond to their needs.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People’s dignity and respect was compromised in the service and people were not provided with person centred care. There was a poor culture among the staff team at all levels, with some staff displaying a disregard for people’s health and welfare.

People were at risk of social isolation, boredom and disengagement because the service did not ensure that they had sufficient sources of meaningful engagement or stimulation.

The provider has failed to operate the service in a way which is safe, effective, caring, responsive and well-led over a period of 9 years. The service has only been compliant with fundamental standards and regulations at one of 9 inspections since 2014.

Quality assurance systems had been ineffective in taking prompt action in response to shortfalls identified. This meant people had continued to receive poor care and be put at risk of harm.

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 Good (published 3 September 2019).

Why we inspected

The inspection was prompted in part due to concerns received about nutrition, sexual safety, wound care and staffing levels. A decision was made for us to inspect and examine those risks.

You can see what action we have asked the provider to take at the end of this full report. Please see the safe, effective, caring, responsive and well-led sections of this full report.

Enforcement and Recommendations

We have identified breaches in relation to person centred care, dignity and respect, consent to care and treatment, premises and equipment, safe care and treatment, nutrition and hydration, safeguarding, staffing and good governance.

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 request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We found the following examples of good practice.

The environment had been arranged to minimise the risk of infection. The designated area is a separate self-contained unit and could accommodate up to ten people. Individual rooms were comfortable and spacious with en suite toilet facilities. Equipment was in place specifically for use in the designated area. This included profiling beds and a hoist. An iPad was available to support people to keep in touch with their friends and families.

Arrangements were in place for a cohort of staff to work on the designated unit. They were able to access the unit from a separate entrance. There were facilities on the unit for staff to shower, change their uniforms and take their breaks.

Tests for COVID-19 were carried out weekly for staff and monthly for people living at the service. We observed staff wearing personal protective equipment (PPE) in line with government guidelines.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Further information is in the detailed findings below.

Troutbeck is a residential nursing home situated in Ilkley. The home provides accommodation and personal care for up to 54 older people and people living with dementia. At the time of the inspection there were 34 people living at the home.

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

People and relatives told us the service was caring and safe. However, we found at key parts of the day staff were rushed and sometimes people had to wait for support. The system to assess and monitor staffing levels needed reviewing to ensure the registered manager was able to identify and act on any staffing issues promptly.

We have made a recommendation about monitoring and reviewing staff levels.

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 supported this process.

People’s care needs were assessed, and they received good quality person centred care from staff who knew them very well. Staff were caring and compassionate. There were inclusive and person-centred activities available for people.

Medicines were generally managed safely. People’s health and dietary needs were met and there were close links with health professionals and other agencies.

The home and the grounds were accessible and well maintained. There were a range of communal areas which were spacious, light and homely.

Staff were knowledgeable about people and the topics we asked them about. They received a range of training, supervision and appraisal.

The registered manager provided the home with strong leadership and promoted a positive team culture. They maintained good oversight through communication with people and the team and a detailed scheduled of audits. They were passionate about continuing to improve the quality of the service. The atmosphere in the home was warm and inclusive.

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 25 August 2018) and there was a breach 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Troutbeck Nursing Home is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can accommodate up to 54 older people and older people living with dementia in one adapted building. Accommodation is provided over two floors. At the time of our inspection, 29 people lived at the service.

At this inspection we found some improvements had been made to the administration, recording and storage of medicines. This meant the service was no longer in breach of Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. However, further improvements were needed to the documentation of prescribed creams.

The registered manager had recently left the service and a new manager had been in position for three weeks at the time of our inspection. They were planning to register with the Commission. 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.

Staff were being recruited safely and there were generally enough staff to take care of people. However, we have recommended that the manager reviews staffing levels and deployment of staff. Staff were receiving appropriate training and they told us the training was good and relevant to their role. Staff were supported by the manager and were receiving formal supervision where they could discuss their ongoing development needs.

People who used the service and their relatives told us staff were helpful, attentive and caring. We saw people were treated with respect and compassion.

Care plans were generally up to date and detailed what care and support people wanted and needed. Risk assessments were in place and showed what action had been taken to mitigate any risks which had been identified. People felt safe at the home and appropriate referrals were being made to the safeguarding team when this had been necessary.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s healthcare needs were being met and medicines were mostly being stored and managed safely.

Staff knew about people’s dietary needs and preferences. People told us there was a good choice of meals and said the food was very good. There were plenty of drinks and snacks available for people in between meals. The completion of food and fluid charts needed to be improved.

Activities were on offer to keep people occupied both on a group and individual basis. Visitors were made to feel welcome and could have refreshments at the home if they wished.

The home was spacious, well decorated, generally clean and tidy. All of the bedrooms were single occupancy with en-suite toilets.

The complaints procedure was displayed. Records showed most complaints received had been dealt with appropriately.

Everyone spoke highly of the manager and said they were approachable and supportive. The provider had systems in place to monitor the quality of care provided. However, these needed to be more effective to ensure where issues were identified, actions to make improvements were done within a reasonable time frame..

We identified one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to good governance and have made one recommendation in relation to deployment of staff. You can see what action we told the provider to take at the back of the full version of the report.

Troutbeck Care Home is situated in Ilkley, West Yorkshire and provides nursing or residential care for up to 54 people. At the time of our inspection there were 28 people living at the home. A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following the last inspection, we met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key questions of 'is the service safe, effective, caring, responsive and well led' to at least 'good'. At this inspection, we saw steps had been taken to address these questions although the service was still on an improvement pathway and had not yet reached the standards of a 'good' service.

People told us they felt safe living at the service. Staff understood how to keep people safe and had received training in how to recognise and report signs of abuse. Appropriate safeguarding referrals had been as well as incidents and accidents recorded. Risk assessments were in place and plans of care formulated to mitigate risks to their safety.

Staff who administered medicines had received training in the safe administration of medicines and their competency checked. We found some shortfalls in the safe administration, recording and storage of medicines. For example, the room which contained boxed medicines was left open on a number of occasions with the medicines cupboard unlocked.

We looked round the premises and found it reasonably well maintained with equipment serviced and in working order.

Staff were safely recruited and there were sufficient staff deployed to offer safe care. The registered manager told us they would increase the staffing levels as the service's occupancy rose. Training was up to date or booked and regular supervisions took place. The registered manager had not yet commenced appraisals but had plans in place to do so.

The service was acting within the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) although a more robust system for recording some best interest decisions such as for covert medicines needed to be put in place and consent forms were not always signed.

People were generally complimentary about the food and a healthy and nutritious diet was provided. People at nutritional risk were referred to the GP or dietician although people's fluid amounts did not always reach the level requested by the GP.

Most staff appeared caring and supportive and there was a positive atmosphere, with people treated with dignity and respect. However, some staff appeared disinterested when interacting or providing support to people. People were supported to maintain independence where possible.

Some people's care records contained good information although improvements were required in others, such as detailing information about how to support some people's moving and handling and medication needs and updating plans with the most relevant information.

Complaints were treated seriously and investigated, with outcomes communicated to all relevant parties. These were analysed with actions put in place to drive service improvements.

A range of activities were on offer and the activities co-ordinator was enthusiastic about their role. Activities were conducted on a group and a one to one basis, according to people's wishes.

Relatives told us the service had improved over the last few months and were complementary about staff and the registered manager. Staff felt supported by the management team and morale was good. Regular meetings were held to discuss concerns, issues and updates with staff, relatives and people living at the home. Annual satisfaction surveys were conducted although none had been sent out since our last inspection.

A range of quality audits were in place to monitor and drive service improvements. These had improved since the last inspection although further improvements were required to help ensure a consistent and high quality service.

During the inspection the registered manager was open and honest and we had confidence they would continue to improve the service.

We found one repeated breach of regulations in regards to the safe administration, recording and storage of medicines. You can see what action we told the provider to take at the back of the full version of the report.

At our last inspection in July 2016 the service was found to have made some improvements from the previous inspection. We rated it 'Requires Improvement' overall, with identified breaches regarding dignity and respect, good governance and staffing. The service was deemed to have made sufficient improvements for it to be taken out of 'special measures'.

This inspection took place in response to a number of safeguarding issues raised and concerns from relatives of people living at the service about care and support. We found these concerns were now beginning to be addressed through the increased management support and the actions of the acting manager.

Troutbeck Care Home is situated in Ilkley, West Yorkshire, and provides nursing or residential care for up to 54 people. At the time of our inspection there were 29 people living at the service. Of these, 22 people required nursing care and 7 people required residential care.

The service should have a registered manager in place. 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 had recently left the service and there was an acting manager in place who was intending to apply for the post of registered manager. The home was also being supported by the provider's Clinical Skills Development Manager, Senior Operations Manager, Quality Assurance Manager and Regional Director.

Staff were suitably trained in the safe administration of medicines. However, we found some shortfalls with staff administering medicines safely and providing an accurate record of their actions.

People told us they felt safe at the service, staff understood how to recognise and report signs of abuse and appropriate safeguarding referrals had been made. Incidents and accidents were documented, people's needs were assessed and plans put in place to mitigate risks to their safety.

The premises was reasonably well maintained although we saw some areas required some refreshing. Equipment was regularly serviced although two pieces of equipment to assist with the safe moving of people were out of service and awaiting parts.

There were sufficient staff deployed to offer people safe care and support although we were concerned about plans to reduce these numbers. A robust recruitment process was in place and staff training was up to date or booked, with all staff currently undergoing a refresher induction training programme. We saw the acting manager had a plan for staff supervision and appraisal.

The service was acting within the legal requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). However we found staff had limited knowledge of this.

People were largely supported to consume a nutritious and varied diet although some food was served when it was not warm.

Plans of care were developed from initial needs assessments and these were reviewed regularly. However, these needed to be more person centred and care did not always follow these plans. Some charts relating to people's care were not always completed. Although care records were reviewed regularly, we saw little evidence of people or their relatives being involved in these.

We saw consent sought for care wherever possible, such as signed consent forms for care and support in people's care records and staff asking for people's consent before providing care. People's preferences were respected, such as where they wanted to spend their time, where they wanted to sit and what they wanted to eat or drink.

People's health care needs were largely met although there were some concerns from relatives about communication of some people's care and support needs.

We saw staff interaction with people was largely task focussed and some staff had a limited knowledge of people and their care and support needs. However we did see some caring interactions using verbal and non-verbal techniques and people looked smartly dressed and well groomed.

A plan of activities was in place depending on people's preferences. People's relatives and friends were actively encouraged to visit and were warmly welcomed.

Complaints were documented although these were not robustly recorded, analysed or followed up.

Staff morale was variable. We found people, staff and relatives were concerned about the lack of sustained management and provider support and the impact this had on the service.

Some issues we found at inspection had not been highlighted by the quality assurance process. This shows processes were not currently effective in addressing issues and driving improvements within the service.

A service improvement plan was in place; the acting manager was open and honest in their approach and determined to address the issues found at inspection.

We found the service to be in breach of a number of Regulations regarding providing personalised care, safe care and treatment and good governance. You can see what action we told the provider to take at the back of the full version of the report.

The inspection took place on 28 July 2016 and was unannounced. The last inspection was in December 2015. At that time we found the provider was in breach of four regulations and the home was placed in special measures. The breaches of regulation were in regard to safe care and treatment, privacy and dignity, person centred care and good governance. Following the inspection we received an action plan from the provider detailing how improvements would be made including timescales. At this inspection we found the provider had made sufficient improvement to take the home out of special measures.

The home 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 home had a safeguarding policy in place which made staff aware of their roles and responsibilities. We found staff knew and understood how to protect people from abuse and harm and what might constitute abuse.

We found the service was meeting the requirements of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).This legislation is used to protect people who might not be able to make informed decisions on their own.

We saw staff were caring courteous toward the people they supported and received appropriate levels of training and supervision to carry out their roles effectively. However, we had concerns there were at times insufficient staff on duty to meet people’s needs and staff needed to be more vigilant and attentive when assisting people with their personal care.

We saw arrangements were in place that made sure people's health needs were met. For example, people had access to the full range of NHS services. This included GPs, hospital consultants, community health nurses, opticians, chiropodists and dentists.

We found the nursing staff responsible for administering medication received appropriate training and people received their medicines safely. However, poorly completed documentation meant we could not be certain creams/lotions were being applied as prescribed.

We found people’s needs were assessed and care plans had been put in place to meet their assessed needs although they did not always reflect the care and treatment people actually received. The majority of people we spoke with told us they were involved in planning their own care and treatment however this was not always evidenced in the care plans and supporting documentation we looked at.

We saw there was a complaints procedure available which enabled people to raise any concerns or complaints about the care, support or treatment they received.

We found although some improvements had been made to the quality assurance monitoring systems further improvements were required. The audit systems were not robust and had not identified the shortfalls in the service highlighted above and in the body of this report.

We identified three 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.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five key questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

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

Is the service safe-

Each person's care file had risk assessments which covered areas of potential risk such as pressure ulcers, falls and nutrition. When people were identified as being at risk, their plans showed the actions required to manage these risks.

We found appropriate arrangements were in place for obtaining medicines and discontinued medicines were disposed of appropriately and stored safely. This helped to prevent mishandling and misuse.

We spoke with six people who used the service and they told us they were pleased with the standard of care and facilities provided by the service. One person said '"I enjoy living at Troutbeck and although the home has had a few problems I have always been well cared for." Another person said "I chose to live at Troutbeck and have never regretted my decision."

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The operations manager told us they were familiar with the requirements of the Mental Capacity Act 2005 (MCA) and was aware of the recent Supreme Court judgment on the Deprivation of Liberty Safeguards.

Effective -

People had an individual care plan which set out their care needs. We saw wherever possible people had been involved in the assessment of their health and care needs and had contributed to developing their care plan.

The home had a good working relationship with other health care professionals and followed their guidance and advice. The input of other health care professionals involved in people's care and treatment was clearly recorded in their care plan.

Caring '

People who used the service and their relatives told us they were happy with the care and facilities provided at Troutbeck Care Home. One relative said "The home had hit rock bottom but is now moving in the right direction.' Another relative told us the standards at the home had fallen but over recent months they had seen signs of improvements being made. They put this down to the interim management arrangements put in place by the provider.

We found the staff we spoke with demonstrated a good knowledge of people's needs and were able to explain how individuals preferred their care and support to be delivered. They felt confident the service provided to people who lived at the home was good. They told us they encouraged people to remain as independence as possible within a risk management framework.

We found the atmosphere within the home was friendly and welcoming. We saw staff approached individual people in a way which showed they knew the person well and knew how best to assist them.

Responsive '

People's needs were assessed and care and support was planned and delivered in line with their care plan. Care records contained good information about how care and support should be delivered.

Wherever possible people who used the service and/or their relatives were involved in discussions about their care and the risk factors associated with this. Individual choices and decisions were documented in the care plans and reviewed on a regular basis.

People knew how to make a complaint if they were unhappy and were confident if they made a complaint it would be investigated thoroughly and action taken if appropriate. There was evidence that learning from incidents/investigations took place and appropriate changes were implemented.

Well led '

The staff we spoke with confirmed they were well supported by the operations manager and said they could contact them at any time if they had concerns. They also told us communication between management and staff had improved in recent months. This ensured the needs of people who used the service were met in line with their agreed support plan.

However, we found that although the service had a quality assurance monitoring system in place it was not used effectively to ensure compliance with the essential standards of quality and safety. We were also concerned records and reports relating to people's care and welfare did not always provide accurate and up to date information.

We have asked the provider to tell us what action they intend to take to address these shortfalls in the service.

When we inspected the service in November 2013 we were concerned care and treatment was not always planned and delivered in a way that ensured people's safety and welfare. In addition, we were not confident people who used the service were protected from the risk of inadequate nutrition and dehydration or that there were sufficient staff on duty to meet people's assessed needs.

On this inspection we found the provider had taken steps to ensure people's dietary needs were met and there were sufficient staff on duty to meet people's needs. However, we were still concerned care and treatment was not planned and delivered in a way that ensured people's safety and welfare or there were suitable systems in place for the storage and administration of medicines.

We spoke with the relatives of three people who used the service and they told us they had been concerned about the standards of care but had found the care and treatment people had received had improved recently. However two relatives told us the care and attention people received was inconsistent and depended upon which floor of the building their bedrooms were located on.

The new manager who was appointed in July 2013 was on leave at the time of the inspection and therefore information about the service was provided by the deputy manager and the quality assurance manager employed by the organisation.

We used a number of different methods to help us understand the experiences of people who used the service. This was because some of the people who used the service had complex needs which meant they were not able to tell us their experiences. For example, we observed care practices and talked to people's relatives and staff. People who were able to tell us of their experience of living at Troutbeck told us they were generally happy living at the home.

However, we were concerned care and treatment was not always planned and delivered in a way that ensured people's safety and welfare. In addition, we were not confident everyone who used the service were protected from the risk of inadequate nutrition and dehydration and there was sufficient staff on duty to meet people's needs during peak periods of activity, which included mealtimes.