This inspection took place on the 23 March 2016 and was un-announced.
We last inspected this service on 21 and 29 October 2014 and found it was not meeting some of the standards required and the location was rated as Requires Improvement overall. We carried out a further inspection on 5 August 2015. We rated the service overall as Inadequate as it had not made progress against the breaches identified at the last inspection and people were not a experiencing a good quality of care. The service was placed into special measures, which means the service was providing inadequate care and was given an initial six months but no longer than a year in which to improve. In addition to this we served a warning notice relating to the providers failure to comply with Regulation 18 HSCA (RA) Regulations 2014. Staffing. As we identified insufficient numbers of staff with the right skills, qualifications and experience to deliver effective care. The timescale to comply with the warning notice was 28 days. We re-inspected the service on the 5 November 2015 and only looked at one area of concern relating to the breach around staffing and whether people were receiving safe care. The service had made some improvement in this area and had partially met the requirements of the warning notice but it remained in special measures.
The service has four separate units and can accommodate up to 91 older people who require residential or nursing care and may have a diagnosis of dementia.
There is 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.
During the inspection in March 2016 we found the service was slowly improving. We found that a high staff turnover in recent months had destabilised the service and impacted on the ability to make the improvements required at a faster pace. The manager was not able to manage the service effectively as there was no support from either a clinical lead or deputy manager although we were advised during the inspection that one of these posts had been recruited too. There were also a number of nursing vacancies across the service. We observed that people experienced differential levels of care across the various units.
Care staff vacancies had been reduced to a minimum and there had been a dramatic decline in the use of agency staff which meant people felt that the continuity of care had improved. Staffing rotas and dependency tools to determine how many staffing hours were required to meet people’s needs would suggest staffing levels were adequate but people’s experiences and our observation identified this was not always the case. People’s care was compromised at times due to ineffective deployment of staff.
People felt safe and risks to people’s health and safety were well documented and steps were being taken to reduce risks to people. However staffing levels could potentially impact on people’s safety particularly in relation to staff’s response to call bells.
Staff understood their responsibilities to monitor people’s health and safety and to reduce risk and report any concerns they might have about people’s safety. Some staff felt the manager was not always approachable which could act as a barrier for them raising concerns.
There were safe systems in relation to medication practices and we were confident that people were receiving their medicines as and when they needed them by staff who were sufficiently competent and trained to administer medication.
The service was clean and organised and systems were in place to audit the cleanliness of the service.
Staff received support and training to enable them to perform their role. The induction process was robust. Training received by staff was good and induction covered how to meet people’s personal care needs. People raised concerns in relation to the language skills of some of the staff which made communication difficult. Staff were being supported to develop enhanced skills and receive training around people’s individual needs.
There were processes in place to support people with their hydration and ensure the risks from unplanned weight loss were effectively managed. However the dining experience for some people was poor as people did not receive adequate support around their individual needs and some people reported poor quality and choice of food. In advance of the inspection we had received a number of concerns about people becoming dehydrated, we found on the day that the service had improved how they manage people’s food and fluid intake.
People’s health care needs were clearly documented and showed us how staff were meeting people’s needs. However concerns were expressed by relatives and people using the service about some staff not being familiar with people’s needs which increased the risks of people not getting their needs adequately met.
Staff had a good understanding of legislation relating to the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberties Safeguards (DoLS). The MCA ensures that, where people have been assessed as lacking capacity to make decisions for themselves, decisions are made in their best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation.
Overwhelmingly people were complimentary about the care and support they received from staff and staff expressed frustration at not being able to spend more time with people. The service worked inclusively with family members, visitors and other health care professionals. They also engaged with volunteers to help ensure people’s emotional and spiritual needs were met.
Staff tried to deliver care according to people’s assessed needs and wishes but this was sometimes compromised due to staffing levels. However care observed was compassionate and delivered in a calm, engaging way. They was a great deal of laughter from people and staff at the service and people appreciated being supported by cheerful staff.
People were involved and consulted about their care but it was recognised that some people found it hard to engage in care planning and it was not always clear how their views were taken into account.
There was an established complaints procedure which was understood by people and there was evidence that complaints/ comments were acted upon in a timely way to improve the service.
The service tried to meet people’s individual needs and provided lots of different activities. However some people were not engaged throughout the day and there did not appear to be sufficient opportunities for everyone to have activities that were appropriate to their needs.
Care plans were mostly up to date and showed people’s needs once assessed were regularly updated to ensure the plan of care remained relevant to their needs.
The service was well managed but we identified gaps in service provision due to vacancies and change in staffing and not having an effective management team in place.
Communication was improving and we found records reflected people’s needs with sufficient management oversight.
Audits were regularly completed to assess the quality and effectiveness of the care provided but we felt these need to be strengthened to ensure everyone experienced a good standard of care and pockets of good practice are the norm across the whole service.
We found breaches of the Health and Social Care Act 2008(Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.