We carried out this unannounced inspection of Kernow House on 17 and 19 May 2017. At the last comprehensive inspection in August 2016 we asked the provider to take action to make improvements and the service was rated as Requires Improvement. At the focused inspection in November, while we found the necessary improvements had been made, we did not review the rating of the service which remained as Requires Improvement. Kernow House is part of the Barchester Healthcare group of homes. It provides personal and nursing care to a maximum of 98 people within five specialist units. There were two units for people with Huntington’s Disease and three dementia units, one of which provided care for people who could become agitated and required more intensive staff support. At the time of our inspection there were 70 people living at the service.
There was a registered manager in post who was responsible for the day-to-day running of the service. 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.
Before this inspection we received concerns about staffing levels at night. We found these concerns related to one unit where the level of night staff had been reduced. However, the reason for the reduction in staffing was because the needs of the people living in that unit were lower. Also night staff were shared between this unit and an adjoining unit because the two units had joined together.
A recent review of staffing numbers, across all the units, had resulted in staffing levels being reduced, although the review also took into account that fewer people were living at the service. A dependency tool was used to determine the staff numbers in each unit, which assessed each person across a range of different needs. While we found the numbers of staff on duty in each unit were in line with the recorded assessments of people’s needs there were delays in people’s needs being met. For example, on the first day of the inspection all of the units were busy and lunch time took over two hours to complete. In one unit staff finished serving breakfast only 45 minutes before lunch started.
A review of how staff were deployed between the five units had also taken place. This meant staff were sometimes moved from their usual unit to work in another unit where the needs of people’s were the highest. Staff told us they did not always feel confident to support people in units they didn’t normally work in as they were not familiar with their needs.
From our observations and feedback from people and staff we judged that the dependency tool used had not sufficiently taken into account the level of staffing needed to meet some people’s needs. In addition we found staffing levels were not adjusted as people’s needs fluctuated or to take into account staff who may be new to the unit and therefore not so familiar with people’s needs. For example, on the first day of the inspection people’s needs were not being met in a timely manner. However, on the second day, with the same number of staff, people’s needs were being responded to more promptly.
Staff supported people to maintain a balanced diet in line with their dietary needs and preferences. During the inspection staff told us people no longer had access to snacks such as crisps, chocolate and frizzy drinks and some people enjoyed these snacks. We found while these items of food were not stored in the kitchens in each unit they were still available for staff to access from the main kitchen. The management told us a decision had been taken across the service to encourage people to eat healthier snacks, such as yoghurts and fruit. However, this decision had not been effectively communicated to staff as they were not accessing these snacks from the main kitchen. There was also no evidence that people had been consulted about the decision the service had taken to encourage people to eat healthier snacks.
We found staff morale in the service was very low. Staff’s perception of the recent changes to staffing levels, how staff were deployed and the decision to reduce the availability of certain snacks were extremely negative. Every member of staff we spoke with expressed their concerns about the changes. Comments from staff included, “There is no continuity moving around the units and it’s unsafe”, “They’ve cut staff. I have been sent home four times because they have changed the rota on my day off and not told me”, “They have taken crisps and chocolate away and people can only have one glass of juice in the morning” and “Nine times out of 10 there are not enough staff and we can’t take people out.” We judged that there had been poor communication and support for staff around the organisational changes.
Most people living at the service were unable to tell us their views of the staffing levels. One person did tell us, “The place hasn’t got enough staff.”
Management and staff applied the principles of the Mental Capacity Act 2005 (MCA) in the way they cared for people. Although, we found records did not clearly state on what legal authority staff were providing care for one person. Where people’s liberty was restricted in their best interests, authorisation for these restrictions had been sought from the local authority. For some people conditions had been applied to their Deprivation of Liberty Safeguards (DoLS) authorisation. Records to show that these conditions had been complied with were not being kept.
People’s care files included risk assessments which identified risks and the control measures in place to minimise risk. However, we found insufficient action had been taken to mitigate the risk of harm for one person because a long lead used to operate the bed in their room had not been removed. Once we alerted the registered manager to this omission the lead was immediately taken away.
Care records were personalised to the individual and detailed how people wished to be supported. They provided clear information to enable staff to provide appropriate and effective care and support. Any changes to people’s needs were recorded as part of the monthly review process. However, for some people these changes had not been updated in their main care plan which meant information about some people’s current needs was not easily available for staff to follow. We have made a recommendation about the recording of people’s care needs.
While most people were unable to tell us about their experiences we observed they were relaxed and at ease with staff. People had good and meaningful relationships with staff and staff interacted with people in a caring and respectful manner. People who were able to tell us about their experiences said, “It’s nice here. I’d rather be here than out in the rain” and “Everything’s OK. It’s tickety boo.” A relative told us, “Staff are responsive to my requests and don’t skive off when I want my son moved from chair to bed.”
People received their medicines on time. Medicines administration records were kept appropriately and medicines were stored and managed to a good standard.
The service worked closely with healthcare professionals such as dementia liaison nurses, psychiatrists, speech and language therapists and GPs to help ensure people’s individual needs were met. Incidents and accidents were recorded in each unit. An overview for the whole service was collated and analysed by the registered manager.
Staff had received training in how to recognise and report abuse. Staff told us if they had any concerns they would report them to management and were confident they would be followed up appropriately.
Staff completed a thorough recruitment process to ensure they had the appropriate skills and knowledge. Staff received appropriate training and supervision. New employees completed a thorough induction which incorporated the care certificate, which is an industry recognised induction that replaced the Common Induction Standards in April 2015.
People and their families were given information about how to complain. There were effective quality assurance systems in place to make sure that any areas for improvement were identified and addressed.
We found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.