Archived: Smallcombe House

This inspection was prompted by information of an incident of alleged serious abuse involving a person using the service. This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident.

Smallcombe House 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.

Smallcombe House accommodates up to 32 people across three floors, one of which contains the foyer, communal lounge, dining room and offices. At the time of our visit there were 24 people living at the service.

There was 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.

People told us they generally felt safe at the service. Their feedback was mixed, with both positive and negative responses to our enquiries about their experiences of care.

We found the service to be inadequate in safe, effective, caring, responsive and well-led. At our inspection in March 2018 the service was Requires Improvement in all five domains with one breach of regulations regarding the quality of record-keeping. The provider had sent CQC an action plan, but we found that none of the actions had been completed and the service had deteriorated. At this inspection we found the provider was in breach of an additional nine regulations.

People did not receive a caring service. We found institutional practices delivered by poorly trained and insufficient staff. During the first two days of our inspection we observed only one out of three care staff engaged with people in a warm and friendly manner.

The service was not clean, there was a strong unpleasant odour in the communal lounge and in some people’s bedrooms. Furniture in the lounge was worn and dirty with visible stains. Equipment used to support people had not been cleaned. We found toiletries left in bathrooms alongside prescribed creams for people which constituted a risk of cross infection. Communal toilets on the ground floor were not cleaned frequently enough. This lack of cleanliness did not support people’s dignity. We raised this at our inspection on 23 July 2018, however action was not taken until after our second visit on 30 July 2018. We again visited on 07 August 2018 and found that the odour, whilst not being completely absent, had reduced and all furniture in the lounge had been steam cleaned. The service was generally cleaner overall, however we identified two people’s rooms which needed further cleaning.

People were supported to sit in the lounge during the day, however we observed little interaction or stimulation for people. The majority of people appeared asleep or withdrawn. We observed, on the first two days of our inspection, that some staff communicated with people in a brusque and task focussed manner. On the third day we observed some staff were communicating appropriately and engaging with people.

There were not enough competent staff at the service to support people safely. The service used high numbers of agency staff. Agency staff received minimal information about people and were given a list of tasks to carry out. There was no information provided about people’s preferences. The provider had sent an action plan to CQC on 06 August 2018 which stated this information had been updated. When we inspected on 07 August, we found this information had not been fully updated.

People’s care records were not up to date and daily records were disorganised, making it difficult to understand people’s current needs. Accidents and incidents were not recorded clearly and were not followed up according to the provider’s policies on reporting incidents and safeguarding.

The management of the service was ineffective. Since the inspection in March 2018 the quality of the service had deteriorated significantly. Systems in place to monitor the quality and effectiveness of the service had not been used effectively. None of the shortfalls found in the inspection of March 2018 had been addressed. We found further shortfalls on 23 July 2018 and fed these back. No action was taken. We again inspected on 30 July 2018 and following this requested an immediate action plan from the provider. We carried out a further follow up visit to check on the safety of the service on 07 August 2018.

We found ten breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. Full information about CQC's regulatory response to any concerns found during inspections is added to

reports after any representations and appeals have been concluded.

These breaches were followed up as part of our inspection. You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for Smallcombe House, on our website at www.cqc.org.uk. The service was rated requires improvement.

Smallcombe House is a ‘care home’. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Smallcombe House at this time provides care and support to 32 older people, some whom are living with dementia. At the time of our inspection there were 26 people living at the service.

The service is over three floors, with people’s rooms on the lower two floors. Communal dining and lounge areas are located on the entrance floor.

A registered manager was in post at the time 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 home is run.

At this inspection we found there were still shortfalls around accurate and consistent record keeping, medicines and effective systems to monitor and review the quality of the service. The service has been rated as requires improvement for a third consecutive time. The Care Quality Commission will be monitoring improvements within the service.

Staffing was kept at the level deemed safe by the provider. However, feedback we received from people was that staff were often busy and did not always respond promptly. Body maps had identified bruising or skin tears to people. However, systems were not in place to effectively take any action that may be required.

People’s dignity was not always upheld. Communication styles were not always altered to take account of people’s different support needs. Care records were inconsistently completed and lacked detail in some areas of people’s care. There was no activity coordinator in post and people said they lacked stimulation.

Assessments and checks were completed of the environment and fire procedures. The service was compliant with the Deprivation of Liberty Safeguards. Staff were supported through induction, supervision and training. Meetings were held with people and staff so people could raise suggestions and be involved.

People were encouraged and supported to remain independent. Visitors were welcomed at the service. People spoke positively about the registered manager and their relationships with staff. Staff felt valued and supported. Communication systems were in place to inform staff of changes to peoples care.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We made one recommendation in regards to supporting people with their nutritional needs. You can see what action we told the provider to take at the back of this report.

Smallcombe House provides accommodation and personal care for up to 32 older people. At the time of our inspection there were 26 people living at the home.

A registered manager was in post at the time 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 home is run.

The home was not always safe as medicines were not always given as prescribed and records relating to people’s medicines were not always accurate. Accident and incidents were reported but did not show clear actions taken to prevent future occurrences. Risk assessments were in place and had guidance in place for staff on how to support people in a way that minimised risks.

Staffing levels were safe. Staff were supported through an induction process and regular supervision. Staff had regular training although we found there was no training for staff in the Mental Capacity Act 2005, the Deprivation of Liberty Safeguards (DoLS) or diabetes.

The home was not always effective as people’s healthcare needs were not always met. People were at risk of not receiving appropriate care in relation to their nutrition and hydration needs.

The registered manager was aware of their responsibilities in regards to (DoLS). DoLS is a framework to assess if the deprivation of liberty for a person when they lack the capacity to consent to care or treatment or need protecting from harm is required. The registered manager kept clear records of the steps taken in the DoLS process. Staff were not always knowledgeable in how the Mental Capacity Act 2005 and DoLS was relevant to their role.

The home was caring and responsive. People and relatives told us that staff were kind and caring. We observed positive interactions and relationships between staff and people living at the home. Staff knew people well and their personal preferences. Care records were person centred and gave details of how people wished for their care to be delivered.

The home was not always well-led. Notifications had not always been sent to the Commission, which is a legal requirement. Audits were in place to assess and monitor the quality of care. However, these were not always effective in identifying areas that required improvement or instigating the necessary changes. People and staff could contribute their feedback and ideas through meetings and surveys.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition, a breach of the Care Quality Commission (Registration) Regulations 2009 was also identified. You can see what action we told the provider to take at the back of this report.

At the previous inspection, we asked the provider to take action relating to infection control and hygiene. The provider sent us an action plan following the inspection. This outlined how they would address the issues and when they would achieve compliance. At this inspection we found they remained non-compliant.

We considered our inspection findings to answer questions we always ask;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. If you would like to see the evidence supporting our summary please read the full report.

Is the service caring?

People we spoke with reported on how caring the staff were. One person told us staff were 'so good to me' and another, the 'girls are brilliant, every one of them.' A person told us 'I wouldn't want to be anywhere else,' and another 'I can't find any fault at all' about the care provided.

We observed a frail-looking person walking in a corridor. A member of staff very politely reminded the person they needed their frame to walk safely. They promptly went and brought the person's their frame. We observed a lunchtime meal. Staff supported people in a caring way, taking time to listen to their individual requests and comments. A religious service took place during our inspection. The person who led the service made sure people who wished to be involved were supported and able to participate as they wished.

Is the service responsive?

The provider sent out questionnaires regularly to receive people's view on services provided. Results were collated and if themes were identified, an action plan developed to ensure issues were addressed.

A person told us 'Oh yes I choose what I do.' A different person told us they could get up and go to bed when they wanted. A person reported they chose not to go to the communal rooms. They said 'I like to keep nice and quiet.' They said they were pleased staff respected this. We saw two people were still eating breakfast at 10:00am. One of the people told us this was because they chose to do this.

People told us staff came quickly when they needed them. One person reported if they used their bell 'they come straight away.' We met with a person who told us they were feeling ill. When we reported this to a member of staff, they attended the person promptly.

We saw a typed note in the care office which listed the names of eight people and stated they needed to be got up by the night staff. Two senior care workers and the manager assured us the list related to people who were known to prefer to get up early. The wording on the list did not support this position. We have asked the provider to review the use of such lists when responding to people's care needs.

Is the service safe?

Staff told us if they found a person who was unwell or who had fallen, other staff attended to support them promptly when they rang the bell. The provider had a system to analyse accidents, to identify trends and reduce risk to people.

Staff told us they were trained in relevant areas to meet people's needs. One member of staff told us 'there's loads of training here,' and another 'a lot of time is put into training.' The staff we spoke with confirmed they had been trained on infection control.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. No applications had been submitted from this home. Relevant staff we spoke with were aware of appropriate actions to follow in relation to these safeguards.

We saw a lack of systems to ensure cleanliness in a wide range of equipment and facilities across the home. This included commode inserts, contaminated laundry, wheeled equipment and raised toilet seats. When we spoke with staff, they all reported on different ways for the cleaning and decontamination of such items. There was no procedure to direct staff on the areas we identified during the inspection. The provider therefore did not have effective systems to reduce risks of cross infection.

We have warned the provider they must take action to meet the requirements of the law to ensure there are suitable arrangements in relation to cleanliness and infection control.

Is the service effective?

The service provided care to people, including people who were living with dementia. Staff told us they had been trained in dementia.

People were assessed for risk such as risk of falls and pressure ulcer risk. The provider had not ensured all people who had pressure ulcer risk, including tissue damage, had a care plan in place. Where a care plan was in place it did not always reflect interventions reported on by staff. One of the people had a movement position record. It was not consistently completed in a regular way.

The provider was not consistently ensuring all people had relevant assessments in place. This included a person who had a swallowing difficulty. Relevant records and care plans were not always drawn up. A person who had a urinary catheter did not have a care plan or other records to show their catheter bag was changed in accordance with manufacturers' instructions. Where a person's needs were changing, care plans were not always updated. This included a person whose dementia needs were changing. When we talked with staff, their responses showed a lack of consistency in approach in meeting the care needs of people living in the home.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the care and welfare of people.

Is the service well led?

The home had a registered manager who had been in post for several years. They were supported by a deputy. The home was visited regularly by a manager from the provider, who completed a report on their visit.

The provider had a range of audit systems, however these did not include all relevant areas. For example they did not have an audit system in relation to informal matters brought up by people. This meant they could not audit such issues to identify trends in matters which concerned people.

The home used a dependency tool in relation to staffing levels. Information from staff indicated the tool did not always identify relevant matters relating to people who were living with dementia. There was also no formal system for staff to notify the provider where they had concerns about occasions when there were insufficient staffing levels. The provider therefore could not monitor and assess if their staffing levels were always sufficient and suitable for the people cared for in the home.

The provider had not identified other relevant matters in relation to the home. This included ensuring underclothing was not used communally, people's personal items were identified and returned to them and items were stored of in a safe way and disposed of when relevant.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing and monitoring the quality of service provision.

We spoke with people and staff and observed how people were respected and involved in Smallcombe House. One person we spoke with told us 'staff are very respectful when helping me with my personal care.' We observed staff knocked on doors and asked permission before entering rooms and spoke kindly and appropriately with people. The home employed a full time chaplain and was in the process of employing a full time activities coordinator.

People told us they felt safe with carers and their needs were met in the way they preferred. One person told us 'staff come when I press my buzzer and are all nice. I don't wish to be anywhere else but here.' Staff told us they spent a lot of time talking with people and their families and by doing this got to know individual likes, dislikes and preferences. We observed people had risk assessments and management plans in order to meet their health and welfare needs.

Staff demonstrated a good understanding of infection control risks. The kitchen and laundry areas were clean and tidy and systems were in place to minimise infection risks to people. We observed cleanliness in people's bedrooms and some communal areas had not been well maintained. For example we saw debris and stains on floors and light pulls. The provider did not have appropriate systems in place to assess, detect and control the spread of infections in all areas of the home.

All the staff we spoke with said senior staff and the manager were approachable and would listen to any concerns. Staff told us they had received regular supervision which they found helpful to their roles. Staff said there were opportunities to obtain further qualifications relevant to their roles. This included National Vocational Qualifications (NVQ).

The provider had systems in place to assess and monitor the quality of the home. We saw minutes of separate care staff and managers' meetings. Staff told us they understood the importance of making comments on behalf of people who lived in the house. We saw minutes of general house meetings involved people, relatives and staff. The manager told us these forums gave people, relatives and staff additional opportunities to express their views and experiences. We saw records which showed health and safety was discussed with all staff. This meant systems were in place to manage risks to people's safety and welfare.

We saw that people experienced safe and effective care based on detailed care plans and risk assessments that identified and met individual needs.

People using the service were protected from abuse as they were supported by a staff team who had appropriate knowledge and training in safeguarding adults. People told us that if they had concerns they would report them to the manager or senior person on duty.

In order to protect people using the service we saw that the organisation carried out rigorous staff recruitment process and staff received training suitable to their role. We also saw that people were safe and their health and welfare needs were met by sufficient numbers of appropriate staff.

The provider had effective systems in place to monitor and assess the quality of service.