Archived: Greengates

We undertook a full comprehensive inspection on the 15 and 16 February 2017. This inspection was prompted by the notification of a death, which indicated concerns. This incident is subject to a criminal investigation and as a result, this inspection did not examine the circumstances of the incident. However the information shared about the incident indicated potential concerns about the management of risk of insufficient staffing levels and the monitoring of people’s whereabouts. The inspection in February 2017 examined those risks.

During the inspection at Greengates Care Home in February 2017, we found the provider did not meet some of the legal requirements in the areas we looked at. After the inspection, the provider wrote to us with an action plan of improvements that would be made to meet the legal requirements in relation to the law.

Following the inspection in February we continued to receive concerns about the quality of care and support that was being provided. We met with the provider to discuss these concerns in July 2017. At this meeting the provider told us improvements at the service had been made and they were now meeting the legal requirements. After the meeting we continued to receive concerns about the service.

We undertook this inspection, on 26 and 27 July 2017, to review the improvements the provider had told us they would make. The first day of the inspection was unannounced. We found on this inspection the provider had not taken all the actions required to make the necessary improvements. After this inspection, there have been two allegations regarding potential abuse at the home. The local safeguarding team and the police were investigating the allegations. The Management had taken appropriate action in terms of staff suspension whilst the investigations were taking place.

Greengates Care Home is registered to provide accommodation which includes personal care for up to 54 older people, some of who are living with dementia. At the time of our visit 26 people were using the service. The service has capacity for up to 35 people in single occupancy rooms having changed some rooms which were double occupancy. The bedrooms were arranged over two floors, with only three bedrooms situated on the first floor. These bedrooms were not in use during this inspection. There were communal lounges with a dining area on the ground floor with a central kitchen and laundry.

A registered manager was no longer employed by the service. The service had recently appointed a new home manager who will be applying to become the registered manager. 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.

At our last inspection, training records confirmed staff received training on a range of subjects. However, the training information was not available during this inspection. Due to this, we could not confirm what training staff had undertaken. Not all staff we spoke with were knowledgeable about safeguarding vulnerable adults. Some staff were not able to tell us the actions they would take in protecting vulnerable people from the risk of harm or abuse or how they would report concerns.

At our last inspection staff had not received training on how to support people to manage distressed behaviour or how to physically restrain people. This training had been booked for 31 July 2017. New staff who had recently joined the service told us they had not received an induction or training to support them in their role.

Whilst the provider had systems in place to monitor the quality of service to ensure improvements were identified, these were still not effective. Audits that had been undertaken since our last inspection in February 2017 had not addressed the issues we had raised. They did not contain information on what it was that was being audited, specific findings during the audit and any outcomes or actions to be taken. During our inspection in July 2017, 17 people had body maps in place which identified unexplained bruising, marks or skin tears. The audits completed had not identified these incidents and action had not been taken to review these. The provider was unable to confirm if these incidents had been referred to the local safeguarding team.

The provider had not undertaken any spot checks at night. This is despite the incident in February 2017 and two allegations of abuse which had all occurred at night.

For people who needed an air flow mattress due to risk of pressure ulceration, the settings for these were not being monitored and audited. If mattresses are set at the wrong setting in relation to the person's weight this would increase the risk of the development of pressure ulceration.

During a meeting with the provider in July 2017, we raised concerns with regard to the fire safety arrangements on the first floor. The provider had not identified these issues in their audits.

People were not always protected by the prevention and control of infection. Seating and walls were damaged making them difficult to clean. Housekeeping staff were not aware of infection control protocols.

Improvements had been made to ensure risks to people’s safety had been assessed and plans put in place to minimise these risks. Risk assessments were now in place for those people at risk of choking and to support people to access the outside areas or their community. However, some areas of assessment still required improvement to ensure people’s care plans contained accurate and up to date information. Some of the assessments we reviewed contained contradictory information relating to the consistency of people’s food and fluids. Some of the risk assessments contained generic statements which were used in all of the assessments we looked at.

At our last inspection the service was not meeting the requirements of the Mental Capacity Act (2005). During this inspection we found some assessments to determine people’s capacity to make decisions had been started. We saw evidence that best interest discussions had taken place where people were assessed as lacking capacity. This still required improvement to ensure all people who required an assessment received one.

Some people’s care plans continued to lack important information in order to provide staff with guidance in how to meet people’s care and support needs. Some care plans contained contradictory and inconsistent information. Care plans were not always person centred and did not contain information on how people wished to receive care.

People and their relatives spoke positively about the food provided. However, we continued to observe that people did not always have drinks available close by. Where people required their food and fluid intake monitoring, records did not contain targets on how much fluid the person should be encouraged to drink each day. Where people had gaps in the recording of their food intake it was not recorded if the person had refused the food and if any alternatives were offered.

The storage and administering of medicines were managed safely. Improvements had been made around the management of covert medicines. However, some protocols for ‘as required’ (PRN) medicines still did not always give clear guidance to staff on when these medicines should be administered. People were supported to access appropriate healthcare professionals to ensure they received ongoing healthcare support.

Improvements were required to ensure staff knew how to protect people’s privacy and dignity. Staff were heard discussing people’s personal care needs in front of others. People and their relatives spoke positively about the staff. Staff continued to be knowledgeable about people’s care and support needs.

The service employed three activities co-ordinators who were responsible for providing daily activities. During our two day inspection we observed some people were not always engaged in meaningful activities and some people experienced little social interaction. Some people had accessed trips out to the local community since our last inspection.

During our last inspection we spoke with the registered manager regarding staffing levels and how these were met. They told us they did not use a formal dependency tool but assessed the staffing levels through observation and how care tasks were completed by staff. Since our last inspection the service had introduced a formal process for assessing the dependency of people to determine the level of staff required. As a result of this, staffing levels had been increased.

The staff records we looked at showed appropriate recruitment and selection processes had been carried out to make sure suitable staff were employed to care for people.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

For adult social ca

As a result of this incident appropriate disciplinary processes had been followed by the provider and registered manager. Following our inspection we wrote to the provider about what actions they had taken to address the areas of concern. They wrote to us with an action plan of improvements that would be made.

Greengates is registered to provide accommodation which includes personal care for up to 54 older people some of who are living with dementia. At the time of our visit 30 people were using the service. The service has capacity for up to 35 people in single occupancy rooms having changed some rooms which were double occupancy. The bedrooms were arranged over two floors, with only three bedrooms situated on the first floor. These bedrooms had not been in use during our previous inspection. There were communal lounges with a dining area on the ground floor with a central kitchen and laundry.

A registered manager was employed by the service who was present on the first day 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.

Whilst the storage and administering of medicines were managed safely recording when ‘as necessary’ (PRN) medicines were given was not done in line with the providers policy. Protocols did not always give clear guidance to staff on when these medicines should be administered. Some people who required PRN medicines did not have protocols in place. Medicines were stored and administered safely. People were supported to access appropriate healthcare professionals to ensure they received ongoing healthcare support.

We found that not all people using the service had risk assessments that identified areas of risk and guidance on the steps staff should follow to minimise incidents occurring. Risk assessments included guidance for staff that detailed the preventative actions to be taken to lessen the risks identified to people for areas such as falling, the safe moving and handling of people and supporting people when they showed distressed behaviour. However, there were no assessments in place to guide staff on how to reduce the risk of people choking or to support people to access the outside areas or their community.

During out our inspection we spoke with the registered manager regarding staffing levels and how these were met. They told us they did not use a formal dependency tool but assessed the staffing levels through observation and how care tasks were completed by staff. A lack of a formal dependency tool did not assess if staffing levels remained sufficient if people’s needs changed or numbers of people living at the service increased.

The service was not meeting the requirements of the Mental Capacity Act (2005). Not everyone had an assessment to determine their capacity to make decisions and best interest discussions had not always taken place where people were deemed as lacking capacity.

People told us they enjoyed the food. However, we observed that people did not always have drinks available close by and were not always offered a choice of what they wanted to drink. We saw in one person’s care plan it was recorded that they had lost weight over several months. This had not been identified in the monthly review and no action had been noted.

Staff were knowledgeable about people’s care and support needs. Whilst staff knew how to protect people’s privacy their dignity was not always respected. Staff were heard discussing people’s personal care needs in front of others. People and their relatives spoke positively about the staff.

We saw some people’s care plans lacked important information in order to provide staff with guidance in how to meet people’s care and support needs. For those people who were unable to verbally communicate care plans did not always include details of people’s preferences, likes or dislikes.

The registered manager told us about the different fundraising events which had been organised throughout the year. Money raised had been used to purchase an I-pad which was used to support people to look up places they had previously visited or listen to their favourite music. The service also had a sensory room for people to access. The service employed an activities co-ordinator who was not available during our inspection. During our two day inspection we observed people were not engaged in any meaningful activities and some people experienced little social interaction. Staff told us they did not have the time to sit and chat with people and we observed this did not happen during our inspection. People did not have access to any day trips out.

People’s needs were met by staff who were able to access most of the training needed to meet people’s needs. Training records we viewed confirmed staff received training on a range of subjects. However, staff had not received training on how to support people to manage distressed behaviour or how to physically restrain people.

The staff records we looked at showed appropriate recruitment and selection processes had been carried out to make sure suitable staff were employed to care for people. People were supported by staff who received up to date training which was regularly reviewed to ensure they had the skills and knowledge required to meet people’s individual needs. New staff received an induction which included a period of time working with experienced colleagues to ensure they had the skills and confidence to support people.

Staff received regular supervision and appraisal which gave them the opportunity to discuss their personal development and training. The service followed clear staff disciplinary procedures when it identified any poor practice in staff. Staff spoke positively about the support they received from both the registered manager and deputy manager.

Whilst the provider had systems in place to monitor the quality of service to ensure improvements were identified these were not always effective. Audits and checks had been completed but these had not been effective in identifying the shortfalls we found during the inspection.

Staff took appropriate action following accidents and incidents. These were recorded, investigated and reported to the Care Quality Commission when required. Records showed these were regularly audited by the registered manager and action taken to minimise the risk of them occurring again.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of the report. We are taking further action in relation to this provider and will report on this when it is completed.

The service provides accommodation and personal care for up to 54 older people. At the time of our inspection there were 28 people using the service. The service has capacity for up to 35 people in sole occupancy rooms having changed some rooms which were double occupancy. The service has a registered manager supported by a deputy manager. 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 and associated Regulations about how the service is run.

Greengates care home offers care and support to older people and those who have varying levels of dementia. People consistently told us about the excellent care they received. They told us the staff were ‘Wonderful’. People mattered, staff were patient, and they demonstrated empathy in their conversations with people and in how they spoke about them. The service had received numerous compliments. Comments from families and professionals ranged from ‘Excellent’, to ‘Absolutely fabulous and ten out of ten’ for the quality of care which people received. Staff developed exceptionally positive caring and compassionate relationships with people. The ethos of the home was that of an extended family. People were treated with dignity and respect and staff were caring and compassionate towards them.

People were fully supported in innovative ways to follow their interests and take part in social activities. The home had a wide range of activities suited to the individual needs of people and which brought positive outcomes and pleasure to their lives. Activities were designed to stimulate conversation, promote interaction with others, maintain manual dexterity and mobility and to have fun. People, families and staff had regular meetings to discuss what people would like to have in the home with regards to equipment, activities and daily routines. Everyone was encouraged to take part in fund-raising for the different projects people had chosen, including people, staff and families. The activities co-ordinator told us that most people involved themselves in fund-raising, such as making crafts to sell at the Easter or summer fete, painting and decorating boxes and then filling them with sweets and making and decorating peg holders.

People benefitted from their fund raising projects and to date this had provided an I-pad for people to use and a sensory room. People told us they enjoyed using these. The next project people had chosen was a sensory garden. People told us there was lots going on in the home and they enjoyed the activities and had fun taking part. People's wellbeing had improved because staff engaged with people in ways that prevented them becoming isolated.

People, families and professionals consistently gave us positive feedback about how the service was personalised to meet people's individual needs. Staff knew each person as an individual, their preferences and interests.

People experienced effective care and support that promoted their health and wellbeing from staff that had the knowledge and skills needed to carry out their role. People were supported by enough skilled staff so their care and support could be provided at a time and pace convenient for them. Each person's needs were assessed and care records had personalised information about how to meet them. Care was focused on people's wishes and preferences and people were supported to remain active and independent. Care staff felt the information available to them enable them to offer care in the way each person wanted.

People told us the food was “wonderful” and they really enjoyed meal times. There was a varied diet and choices available according to people’s likes and dislikes.

Health and social care professionals gave very positive feedback about the personalised approach of staff towards people and how well people were cared for.

People were cared for by a motivated and well trained staff team. The manager’s and the provider offered strong and effective leadership to the service and regular residents meetings ensured people were involved in the running of the home.

The provider has taken steps to provide care in an environment that was suitably designed and adequately maintained. We saw the home was in good decorative order and clean throughout. Everyone had their own bedroom and we were invited to look at several peoples bedrooms and could see they provided a comfortable environment. The rooms had been furnished with their own belongings, family pictures and various ornaments.

All successful job applicants were offered a post subject to satisfactory references and successful completion of a three month probationary period. During this time staff had monthly supervision and observed practice to track their progress and development, and we saw records to confirm this. The manager also received feedback from existing staff on the new staff member's suitability and recorded this in the supervision notes.

When we spoke with relatives, they told us they were happy with the numbers of staff in the home. They thought their training and experience levels were sufficient to meet the needs of the people living in the home. One relative told us 'all the staff here are so caring, and my wife is well looked after by them all'. Another said 'I have been coming here weekly for over a year now and have never seen it short staffed'.

The manager told us she encouraged relatives and people living in the home to raise issues with them directly or their deputy if they were not happy with any aspects of their care and support. Each month either the manager and/or her deputy would attend the residents and relatives meeting, held in the home to answer any questions or deal with concerns.

A GP visited the home every week. A person said 'You always see a doctor quick if you need to'. Care plans showed how people's needs were to be met. We saw care being given in line with care plan guidance.

All staff received annual refresher training about recognising signs of possible abuse and their responsibilities to act on any concern. We saw how a concern had been acted on to keep people safe.

All staff undertook dementia care training. Staff supervision and training were planned for the year ahead.

A person who lived in the home told us 'We're always being asked if we are happy. In some places people would be afraid to complain, not here. You can talk to any of the staff and they listen.' There were regular meetings to involve people in the home and staff in how the home was run. A member of staff told us 'It's very open management, a clear structure and they are always available.'