Challoner House

Challoner House is a residential care home that was providing personal and nursing care for up to 49 older people. Some of the people using the service lived with dementia. At the time of the inspection there were 44 people using the service when we inspected.

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

Relatives felt their loved ones were safe living at Challoner House and they were very much at the heart of the service. We received consistent positive feedback from relatives and a professional.

People were supported to stay safe, protected from abuse and risks were assessed and well managed. There were sufficient numbers of qualified, skilled and experienced staff deployed to meet people’s needs. The provider operated safe and effective recruitment procedures.

Medicines were stored and administered safely. Clear and accurate medicines records were maintained.

Systems were in place to ensure risks associated with infection control were managed. Staff were following national guidance in relation to COVID-19. Cleaning schedules were in place and the service appeared clean and was free of malodour.

The culture of the service was open, transparent and progressive. All the staff were committed to continuous improvement of the service and individual care. People using the service, their relatives and the staff felt valued.

People were cared for by a motivated staff team, who always put people first. Staff received regular support and felt valued and listened to by management.

Regular audits were carried out to assess and monitor the quality of the service. There were appropriate management arrangements in place and relatives were positive about the management in the home.

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 requires improvement (published 17 April 2019).

Why we inspected

This was an inspection based on the previous rating. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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 found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to good. 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 Challoner House 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.

During our previous inspection in August 2018 we identified five breaches of regulations. We took enforcement action and imposed a condition on their registration. This was to ensure effective systems were operated to ensure compliance with regulations and to monitor and improve the quality of the service provided. At this inspection we found improvements had been made; however, there was a need to sustain the improvements made and to make further improvements. The service has been rated as requires improvement as it met the characteristics for this rating in most key questions. More information is in the full report.

People’s experience of using this service:

Overall, improvements had been made to the staffing arrangements but these needed to be further embedded to ensure that people were consistently having their needs met in a timely manner.

Improvements were still needed to ensure people received person centred care which was responsive to their individual needs.

Staff received more frequent support and one to one sessions or supervision to discuss areas of development. They completed more training and felt it supported them in their job role.

People were supported with their nutritional needs when required. People received varied meals including a choice of fresh food and drinks. Staff were aware of people’s likes and dislikes.

Medication administration records (MAR) confirmed people had received their medicines as prescribed.

People were treated with kindness and compassion. Staff were able to identify and discuss the importance of maintaining people’s respect and privacy at all times.

There were plans in place for foreseeable emergencies. Staff were able to tell us how to keep people safe.

Where people could not consent to their care, staff had sought appropriate guidance and followed legislation designed to protect people’s rights and freedom.

There was a system in place to allow people to express any concerns or complaints they may have.

The provider’s quality assurance system helped the management team implement improvements that would benefit people. Action had been taken to become compliant with most of the breaches of regulation identified at the previous inspection.

Rating at last inspection: At the last inspection the service was rated as Inadequate. (Report published 04 January 2019).

This service has been in special measures. Services that are in special measures are kept under review and inspected again within six months. We expect providers to make significant improvements within this time frame. During this inspection the provider demonstrated to us that improvements had been made and the service is no longer rated inadequate overall or in any key questions, therefore, this service is now out of Special Measures.

Why we inspected: At our last inspection in August 2018, we rated the service as ‘Inadequate’ and placed them in special measures. This inspection was carried out as part of our enforcement process to check for improvements and to review the ratings. We found the provider had made improvements although there remained breaches of the Regulations in relation to staffing and person-centred care. There were also other areas requiring improvement noted. This meant the service was not yet consistently providing good care.

Follow up: We will continue to monitor the service to ensure the improvements we found are maintained.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

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. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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 carried out a responsive unannounced inspection of this home on the 02 and 03 August 2018 following concerns which had been raised by the local authority about the safety and welfare of people. At our last inspection of this home we had rated it Good. At this inspection we found concerns for the safety and welfare of people. The registered provider had failed to be compliant with all of the required Regulations.

Challoner House is a ‘care home’ and is registered to accommodate up to 49 people. 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. At the time of the inspection 42 people were accommodated at the home.

The registered manager had just left the service the week before our inspection but was currently still registered with the Care Quality 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.

We found peoples safety was compromised in some areas. There were inadequate numbers of permanent staff and the home was reliant on agency staff especially at night. The provider had been running the services with inadequate staffing levels which staff felt was unsafe and that they could not meet people’s needs safely.

Relevant recruitment checks were conducted before staff started working at the service to make sure staff were of good character and had the necessary skills. However, there were unexplained gaps in staff employment histories.

Staff understood safeguarding procedures to keep people safe. However, systems were not in place to monitor these

Environmental risks were not managed effectively; fire alarm tests were not up to date as recommend by fire safety regulations. People did not have individual personal evacuation plans to support staff in the event of an emergency. A legionnaires water risk assessment had needed to be reassessed since 2015. Infection control procedures needed to be more robust.

Risks associated with people’s care had not always been identified and assessments made to reduce these risks for people. Emergency call bells were not always available to people in the case of an emergency to call for help. Improvements were required for the safe management of medicines.

Staff did not receive regular support and one to one sessions or supervision to discuss areas of development and to enable them to carry out their roles effectively. Staff completed a range of training but felt it didn’t always support them. Dementia training was not always available to all staff.

People’s rights were not always protected because staff did not always understand and work within the principles of the Mental Capacity Act 2005 or Deprivation of liberty safeguards. These were in the process of being reviewed.

People care plans provided information to guide staff in how to support them. However, we found some contained inaccuracies and missing information. There were concerns with missing entries and gaps in charts to monitor people’s food and fluid and skin integrity.

People and their relatives told us staff treated them with kindness but people were not always treated with dignity and respect. People did not always receive care that was person centred and individual to their needs. People received varied meals including a choice of fresh food and drinks.

There were not meaningful activities and interactions in the home for people cared for in bed to reduce the risk of social isolation for people. People and staff told us people were lonely.

During our inspection we found there was a lack of effective management and leadership in the home. Staff felt unsupported and let down by management and morale was low amongst staff. Areas of concern we had identified during our inspection had not always been identified by the governance processes in the home. We could not be assured complaints were always responded to appropriately.

Records were not always accurate. The provider did not send in all notifications to CQC as required by law of all significant events.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

Challoner House is a modern purpose built nursing home for older people. They are registered to provide care for up to 49 people. At the time of the inspection there were 39 people living at the service.

The home had 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.

All staff had a good understanding of abuse and how to identify this. They knew what actions to take to keep people safe. There were processes to minimise risks to people's safety. These included procedures to manage identified risks with people's care and for managing people's medicines safely.

There were sufficient numbers of qualified nurses and care staff to meet people's needs. Recruitment processes included a number of checks to make sure staff were suitable to work with people who used the service. New staff completed an induction programme when they commenced employment. Staff received training and

had regular supervision and appraisal meetings in which their performance and development was discussed.

Medicines were stored and secured appropriately. People told us that they received their medicines on time.

The registered manager understood their responsibilities in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff respected people's decisions and gained people's consent. People's care needs were well known by the staff we spoke with including people's likes and dislikes.

People were asked for their permission prior to receiving care and support so people were able to give their consent. Best interest decisions were in place where people were unable to make an informed decision on their own.

Staff were supported by the management and received training to ensure they had the skills and knowledge necessary to care for people. Staff were able to attend meetings where they were able to voice their opinions.

People's healthcare needs were monitored and health professionals were consulted in order to maintain people's well-being. People told us they liked the food available and confirmed a choice was available to them.

Staff told us they enjoyed their work and liked the management team. People and their relatives were confident any complaints made would be listened to and responded to.

Systems were in place to monitor the service as a means to improve the quality of care and support people received. Complaints policies and procedures were in place and were available to people and visitors.

There were 36 people who used the service at the time of our inspection. We used a number of different methods to help us understand their views and experiences. We observed the care provided and looked at supporting documentation. We talked with 11 people who used the service, five relatives, 11 care and nursing staff, the chef, two activity staff, a visiting hairdresser and the manager.

This inspection was carried out over three days. On the first day there were three inspectors and one inspector on the two subsequent days. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

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

Is the service safe?

Generally people were protected against the risks associated with medicines because staff followed correct recording procedures. However, people were not protected against the risks associated with the application of prescribed topical medicines.

Care plans and risk management plans had not been developed to accurately inform staff how to meet people's needs and records in general needed to be improved to ensure people's safety.

Is the service effective?

People told us they did not always receive their care in a timely way. Staff, relatives and people who used the service told us there were not enough staff to meet people's needs. Our own observations confirmed this. People who required the support of two care staff were most affected by the lack of staff.

Is the service caring?

People generally praised the attitude and commitment of staff. Comments included, 'Staff are caring but over worked'. 'They are polite', I trust them and they know what they are doing'. 'They are lovely, carers', and 'Very good'. Our own observations were that staff were kind, considerate and caring.

However we found care had not always been planned and delivered in a way that met people's individual needs. Although people's needs had changed they had not always been regularly or accurately reviewed. Several care plans provided conflicting and out of date information.

Is the service responsive?

People had been provided with information on how to make a complaint and most people knew about their rights. People were less than satisfied with the action taken to address their concerns. They told us improvements did not last long.

Is the service well-led?

We saw evidence the provider had systems in place to assess the quality of the service provided to people. However we found these were not always effective.

Assessments and care plans were completed in a way that was person-centred and reflected the person's preferences and interests. There were plans in place in relation to people's specific health care needs. A person who used the service told us 'The staff are quite good. I can tell them what I think and they listen to me. They come when I call them'. Another person said 'We have been made very welcome here'. A relative told us the care was 'Absolutely brilliant'. They told us the service was meeting their expectations and what was important to them, in that their relative was 'Pain free, comfortable and clean'.

However, whilst steps had been taken to improve the planning and delivery of care to ensure people's welfare and safety, this had not been achieved for everybody using the service. We also found that people were not protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were not maintained.

People were provided with a choice of suitable and nutritious food and drink; and were supported to be able to eat and drink sufficient amounts to meet their needs. A person who used the service told us 'The food is good and there is a choice'.

A family member told us "I am very happy - I have felt that they have been really accommodating and always go the extra mile. The place is very clean and I think that it is generally well maintained - I haven't had any concerns".

Thank you cards that we viewed were positive and complimentary about the service and staff. A selection of cards from people using the service said "it is a place where residents are treated with genuine warmth, dignity and respect and we could not have chosen a finer caring environment" and "I spent four weeks and I enjoyed every minute. I was completely relaxed and slept so well - keep up the good work".

People chose how to occupy themselves in the service. We observed that people were spending time in the communal areas talking to staff and family members. During our inspection we observed people spending time in their bedrooms reading, listening to music and completing activities.

Care plans that we looked at were inconsistent and there was not any evidence of regular reviews of assessments and planning to support the delivery of care to meet individual needs. Six monthly reviews had not been completed since October 2012.

People we spoke with told us that staff treated them respectfully and supported them to do things for themselves. They confirmed that their care and welfare needs were being met and that they were consulted about the support they received. All made positive comments about the service. One person said 'I didn't want to come into a care home, but I feel this is the best choice I could have made'. Another person said 'When I came here I didn't want to do anything' and then told us how staff had encouraged them to become more mobile, so that now they were much more active. Another person's relative told us how the person had regained weight as a result of the care they had received.

People told us they felt safe in the home and that staff treated them well. They were confident that staff had the appropriate knowledge and skills to meet their needs and made positive comments about the staff team. For example, one person said the staff 'Really are good, very agreeable, they will listen'. Another person said the staff were 'Very good indeed'. Others described the staff as 'Kind and caring'. People told us that the management listened to what they said and took action when necessary.