Larkswood

Larkswood is a residential care home providing accommodation and personal care to up to 18 people. The service provides support to people with a range of care needs such as frailty of old age and dementia. At the time of our inspection there were 15 people using the service.

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

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, the provider had taken steps to enhance people's safety by placing sensor mats next to people's beds at night-time, without seeking their permission. The provider assured us that the relevant permission would be sought after the inspection.

Staff were not wearing masks in line with government guidance at the time of the inspection.

Some statutory notifications that the manager or provider was required to send to CQC in line with regulatory requirements had not been submitted.

Staffing levels were sufficient to meet people’s needs. One person said, “I always think they could do with a couple more staff if we are all ringing our bells and they are running around, but I only have to wait 5 minutes. If staff have time they will sit and chat”. People received their prescribed medicines as required. People’s risks had been identified and assessed as needed.

People’s views about the home were gathered through residents’ meetings; the management team knew everyone well. One person said, “The food is nice here. We’re spoilt with tea and biscuits, tea and cake, you won’t go hungry here. I know who the owner is and the managers. They can’t do enough for you really”. A range of audits had been implemented to monitor and measure the service overall and were used to drive improvements.

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 good (report published 29 August 2019).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Larkswood on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Larkswood is a residential care home providing personal care for up to 18 older people, some of whom were living with dementia. At the time of the inspection, there were 14 people using the service. People living at Larkswood had conditions associated with older age, with the majority of people living an active independent lifestyle. Larkswood accommodates people in one adapted building.

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

The last manager had left the service in July 2019. Since the service registered in January 2011, there has been a continual change of management. Comments from staff, people and their relatives indicated that the management changes have led to a feeling of unsettlement and worry.

Despite this, feedback and our observations confirmed the management changes had not impacted staff morale or delivery of meeting and caring for peoples assessed needs. Many staff had worked at the service for a long time. Staff told us they felt they were overall well supported by the deputy manager, provider and worked together effectively as a team.

Due to the lack of consistent management, records of how staff were being supported and how complaints were being recorded required improvement.

Between the deputy manager and provider, they had made significant improvements to governance and oversight arrangements, implementation of systems and processes to safely assess and manage risks to people, including with their medicines. Under their leadership, there had been a renovation of people's care records and supporting documentation. The improvements made, needed more time to be sustained, maintained and fully embedded into the culture of the service.

People received care and support that was safe. One person said, “I am safe here and staff are kind to me.” One relative explained this was their first experience of residential care and said, “I feel Mum is safe because she is not at such a risk of falling and help is always at hand.”

People were supported by staff who received training and were able to identify and respond appropriately to abuse. There were sufficient staff to meet people's needs. The provider used a dependency tool to determine staffing levels. Information was reviewed following falls or changes in a person's health condition.

Training and observation of staff practice ensured staff were competent in their roles. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People enjoyed a healthy balanced and nutritious diet based on their preferences and health needs. One person said, “Food is very nice, all very good.” Another person said, “The cook is wonderful, and we have such a good choice.”

People received care from staff who were kind and caring. One relative said, “Staff seem very kind and look after people well.” A visitor said, “This is a very friendly, family home.” People told us staff always respected their privacy and dignity. Staff supported people to be fully involved in their care planning and reviews.

People and relatives told us the service was well-organised and commented on the pleasant working atmosphere amongst staff. The provider and deputy manager provided a visible presence.

Staff felt well supported in their roles. One staff member said, “It’s really very good, we chat and can have a joke, everyone is happy, I am happy. [Provider] is very supportive.” A system of audits monitored and measured aspects of the service and were used to drive improvement. The manager worked proactively with the NHS and Social Services to proactively meet peoples care needs.

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

Rating at last inspection and update:

The last rating for this service was requires improvement (published 28 August 2018) and there were four breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected:

This was a planned inspection based on the previous rating.

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 Larkswood 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.

Larkswood is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Larkswood is registered to provide personal care for up to 18 older people. At the time of the inspection there were 17 people living at the service.

The service had 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.

We last inspected the service in December 2016. At that inspection, we asked the provider to take action to make improvements as we found systems to assess, monitor and improve the quality and safety of the service were ineffective. We also identified the adaption and design of the home did not always consider the needs of people living with dementia and there was a lack of personalised activities. These areas of practice required improvement. At this inspection we checked to see if the provider had taken actions to address these issues.

Quality assurance and information governance systems were in place, however these remained in need of improvement. The service had not been able to consistently identify or act on quality and safety issues. There was no on-going development plan in place to help ensure the service could continuously learn and improve the quality of care it was delivering.

The provider had made changes to the home environment to consider the needs of people with dementia. This helped people with dementia to be at ease in the service and remain as independent as possible. There was now a range of personalised activities that people had helped choose on offer every day.

Medicines were not always being managed safely. Recording and guidance for administering medicines and ordering, storing and disposal of medicines were areas of practice that all required improvement to ensure people were not being placed at risk of avoidable harm.

The registered manager had not always complied with their obligations to submit relevant statutory notifications or display the service’s Care Quality Commission (CQC) performance assessment rating.

There was a ‘Consent to Care and Treatment Policy’ in place. Staff received MCA training and could explain the consent and decision making requirements of this legislation. Staff had a good awareness of people’s capacity and gave us examples of how they put this into practice when supporting various people.

However, formal assessments of people’s mental capacity to be able to make decisions about different activities had not always been carried out. It was not always documented that people, or a relevant person acting in their best interests, had been involved and consented to their care. This requires improvement to help make sure people have the right support to make their own decisions.

An assessment of people’s physical, psychological and social needs was carried out with the person and other relevant people before they started using the service. People’s differences were respected during the assessment process and there was no discrimination relating to their support needs or decisions. The assessment process required improvement to make sure there was enough detail about the support they needed, why this was and what their preferred support outcomes were.

People had been involved in planning their care and had the opportunity to regularly review this. Staff talked to people, relatives and other staff to be able to know about them and how they liked to be supported. Care plans required more detail about people’s likes and dislikes, backgrounds and personal history to help staff know to meet people’s needs in a personalised way.

Everyone we spoke with said they felt safe. People had risk assessments in place and were supported to identify and manage any potential hazards to their well-being. There were systems and processes to keep people safe from abuse. Staff received safeguarding training and knew how to recognise and report any signs of abuse, including discriminatory abuse, to help stop or prevent this.

The service had enough staff working during each day and night to meet people’s needs. There was a call bell system in operation that people could use at any time to alert staff they required support. People said staff answered calls promptly. There were safe recruitment practices. The service was clean and free from odours. Staff received infection control and food hygiene training and followed best practice guidance in these areas.

Deprivation of Liberty Safeguards (DoLS) had been applied for people that required them using the correct processes. Conditions on authorisations to deprive a person of their liberty were being met appropriately.

Staff had regular training, updates and supervisions and had the right skills, knowledge and experience to deliver effective support to people. People received timely support with their medical and health care needs. The service also shared information and worked with other agencies to support people with on-going health needs. People had enough to eat and drink and had support with any nutritional or complex food and drink needs.

People told us that staff were caring. One person said, “They are always kind and helpful”. Another person said, “The staff are very nice and I get on well with all of them”. Staff said they thought being caring was one of their main responsibilities. One staff said, “Our main priority is caring. You have to be very kind and take people’s feelings into consideration”.

People were involved in making decisions about their care and encouraged to be as independent as possible. Staff listened to people and communicated with them in ways they understood.The service took steps to remove barriers to understanding for people with protected characteristics under the Equality Act 2010. People’s privacy and dignity was respected. People’s confidentiality was kept and information about them was managed in line with the principles of the Data Protection Act.

People had support to develop and carry on with their established social interactions and relationships to avoid becoming isolated. There was a complaints policy in place and people told us they felt confident if they complained they would be listened to and staff would help them resolve their problem.

People had sensitive and empathetic support with planning, managing and making decisions about their end of life care, including their religious or spiritual wishes. Staff worked with relevant health and social care services to ensure people had as comfortable and dignified a death as possible.

People spoke highly of the manager and said they thought the atmosphere and culture of the service was good. Staff told us the registered manager was good at communicating with them and they felt they could speak with them openly. One staff said, “The manager is always free to talk to if anything is wrong”. Staff well-being and equality, diversity and human rights (EDHR) were respected. However, the service required improvement to introduce formal policies to uphold staff

EDHR rights in the workplace.

There was a clear set of values that staff were expected to put into practice when supporting people. Supervisions, appraisals and disciplinary processes were used as ways to support staff to understand how to do this in a constructive manner. People and staff were involved in developing the service. The service also shared information and worked in partnership with the local authority and health and social care professionals to help gain input and advice about how improve people’s care.

Full information about the Care Quality Commission’s regulatory response to more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Larkswood is a residential care home which is registered to provide accommodation for up to 18 people who require support with personal care. People had a mixture of needs some people were living with dementia and some people had mental health needs. At the time of our visit there were 16 older people living at the home and two people receiving short term care.

Larkswood is situated in Worthing in close proximity to shops and the seafront. The atmosphere was friendly and warm. Bedrooms are spread out over two floors, serviced with a lift with one bedroom on a mezzanine level. Bedrooms were personalised with people’s own belongings including personal photographs. Eleven bedrooms had en-suite facilities including toilets and the remaining rooms had sinks. Communal areas included a spacious lounge area and a dining room which both provided access to the garden and patio area.

The home had a registered manager who had been in post since December 2014. 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.

The home was previously inspected on 19 September 2014 and then again on 3 and 4 September 2015 and we identified different breaches of Regulations during both inspections. In September 2015 we found improvements had been made and action taken by the provider to address the concerns from our inspection in September 2014. However, we identified new breaches of the Regulations in relation to managing medicines, assessing people’s capacity to consent to care and treatment and assessing risks to people surrounding their nutritional needs. Recommendations were also made in relation to improving how risks were assessed on behalf of people, staff training, adaption and decoration of the home, caring approaches used, personalised activities and quality assurance systems. We found at this inspection the provider had taken action to address the breaches and concerns identified however, this was not always consistent and further development was required. As such, the service remained 'Required Improvement' overall.

The previous inspection noted significant gaps in people’s medication administration records. This was in breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this inspection we found actions had been taken and there were no significant gaps in people’s MARs. At this inspection we found improvements had been made and this regulation was now met.

At the last inspection we found the service was not working in accordance with the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). Appropriate capacity assessments were not carried out when people could not consent to their care and treatment. This was in breach of Regulation 11Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider completed an action plan of how this was to be addressed. At this inspection we found improvements had been made and this regulation was now met.

At the previous inspection we found when people were at risk of malnutrition there were gaps in people’s daily food records which meant staff could not ensure that people’s needs were being met in this area. This was in breach of Regulation 14 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found improvements and actions had been taken by the provider to ensure daily records were completed on behalf of people who had been assessed with this need therefore this regulation was now met.

The previous inspection recommended the provider sought guidance regarding effective quality assurance systems as we identified areas which had been overlooked. At this inspection we noted the provider had implemented systems and improvements had been made. However, shortfalls remained with this system as it had not highlighted all the areas we had identified at this inspection. This was influenced by a lack understanding of current legislative guidance on how providers meet the Regulations.

People were offered choices regarding food and drink and offered snacks throughout our inspection. However, on the first day of our inspection, we observed the lunchtime experience was lacking in atmosphere and interaction with staff. The provider took immediate action and this had improved by day two of our inspection.

Our last inspection identified the adaption and design of the home did not always consider the needs of people living with dementia. This is an area which still required improvement. At this inspection we found there was a lack of visual information and helpful signage to support all people.

Concerns were highlighted during our last inspection associated with a lack personalised activities. Whilst the registered manager had taken action and improved activities offered to people there were further improvements to be made to ensure the practice was consistent daily.

The home was mostly clean and tidy however we identified an odour caused by urinary incontinence in the entrance to one of the bedrooms which the provider had identified as an area for improvement and had plans to address this.

The last inspection identified a concern with regard to a lack of staff training in subjects such as dementia. We found at this inspection improvements had been made and all staff had completed the necessary training to enable them to fulfil their role and responsibilities. Staff were provided with supervision, appraisal and staff meeting opportunities.

People said they felt safe at the home and there were sufficient staff to meet their needs. Staff were trained in adult safeguarding procedures and knew what to do if they considered people were at risk from harm.

We received mixed responses at the previous inspection from people regarding whether staff used a caring approach. At this inspection we observed and people told us, they had developed meaningful and trusting relationships with people. Staff used a caring approach, knew people well and people’s privacy and dignity was respected. Staff demonstrated concern for people's well- being and supported them when they were in discomfort or distress.

People had access to health care professionals when needed. People received personalised care and felt consulted about the support they received. People were able to spend their time as they wished, relatives and friends visited daily. Care plans reflected detailed information relevant to each individual and guidance for staff on how to meet people’s needs. People and their relatives spoke positively about the activities they were offered.

Staff enjoyed working at the home and found the registered manager and deputy manager approachable. People, relatives and a clinical psychologist described the management team as supportive, flexible and caring. The culture of the home was open and people and their relatives knew who to contact if they needed to raise a concern and complaint.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

What people told us and what we found

We considered all the evidence we had gathered under the outcomes we inspected. We spoke with eight people using the service and two relatives and a visiting social worker. We also spoke with the acting manager and four care staff. We also looked at care plans and other documentation within the home. We used the information to answer the five questions we always ask.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

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

Is the service safe?

The service is not as safe as it could be.

At the time of our visit there were 14 people who lived at the home. We spoke with eight people. They raised no concerns about their safety with us during our visit and said if they had concerns they would discuss them with the acting manager.

Each person's care file included risk assessments which covered areas of potential harm. When people were identified as being at risk, their plans showed the actions required to manage these risks, however they were not regularly reviewed.

Safeguarding procedures were in place to protect people from the risk of abuse. We found staff understood their roles and responsibilities about safeguarding the people they supported.

We found evidence that people were not always protected from the risks of unsafe or inappropriate care and treatment as the care provider did not maintain accurate and relevant records. We have asked the provider to tell us how they intend to ensure they comply with their legal obligations concerning planning and delivering safe care.

Systems were in place to ensure medication was administered safely and according to people's needs. There were procedures in place to manage and mitigate foreseeable emergencies. These included procedures in relation to flooding, fire and evacuation and the loss of power.

Is the service effective?

The service is not as effective as it could be.

People were being cared for by staff with the appropriate skills. Staff we spoke with were able to tell us about the individual needs of people who lived at the home.

There was not always evidence that people's social and emotional needs had been met. There was no forum in place to enable people to be involved in decisions about their care and support needs. People we spoke with felt they were cared for by a consistent team of staff who were caring and skilled.

Is the service caring?

The service is not as caring as it could be.

The people we spoke with told us they were happy with the care and support provided. We saw staff had meaningful conversations with people as they moved through the home. We noticed that staff were attentive to people's needs and fostered a friendly atmosphere in the home. We spoke to people who used the service. One person said 'The staff are lovely, they have a tough job but they do it well'. Another person said 'In the circumstances they do well as it can get very busy'

Staff said they were aware of people's preferences, interests, aspirations and diverse needs, but felt they needed more time to meet those needs.

Is the service responsive?

The service is not as responsive as it could be.

People's needs had been assessed before they moved into the home. The home's policy stated that care plans were reviewed monthly but we saw no evidence that they had been updated to reflect people's current needs. We also found the home's acting manager was not able to produce all of the records requested during the inspection.

There were no activities organised in the home in which people could participate in order to help meet their social and emotional needs. The staff we spoke with told us that they needed more time to arrange these.

The service does not have a formal complaints policy. Although the service had not received any written complaints, the provider took account of verbal concerns to improve the service

We saw that staff were responsive to individual's needs. People had the food they wanted and their personal care was attended to promptly. However we found that care plans did not always contain information about the needs of the person concerned. Some people also told us that their social and recreational needs were not being met. One person said 'I am a bit bored to be honest.' Another person said' There's not much to do and it's nice to get out'

Is the service well-led?

The service is not as well led as it could be.

We found the provider did not have systems in place to continually monitor and identify shortfalls in the service and any non-compliance with the essential standards of quality and safety. We have asked the provider to tell us how they will make improvements to ensure they meet their legal obligations concerning this.

All of the people we spoke with who used the service and the staff spoke positively about the acting manager at the service. The staff told us that they felt well supported and that the manager was approachable. They told us that they felt confident to raise any issues or concerns with the manager and that they always felt 'listened to'.

The acting manager said the home was developing processes to collect people's views about the care and support they received and also a system to help ensure staff learnt from incidents and accidents.

We found that assessments of care were inadequate. We also found records about staff training, supervision, deployment and personal development records were not available for inspection.

People told us that they were very happy in the home and told us staff were kind. One person told us 'Care is very good.' People told us they had a choice in how they spent their days.

People told us that staff understood their needs and provided appropriate care and support. We were told that staff responded quickly and dealt with any issues when people asked for assistance. One person told us 'If I want anything staff will get it for me.' Another person told us that staff are 'Very responsive, they act quickly.'

We found that people were protected from the risk of abuse and that staff understood about safeguarding vulnerable adults. One person said 'I feel absolutely safe here.'

We found that the two areas identified as non-compliant in the previous inspection in November 2012 had been attended to. For example we found that annual training courses had now been planned and a new quality monitoring processes had been introduced.

You can see our judgements on the front page of this report.

People told us they were very happy in the home and everyone remarked on the kindness of the staff. One person told us "I can't think of anything that could make it any better." Another person said "This is a wonderful place to live, it's just like home, the staff are so kind."

People told us that staff understood their needs and provided appropriate care and support. We were told that staff were responsive when people asked for assistance and quickly dealt with any issues. One person told us "I only have to mention something and it's done."

However we found that over the past two months, documentation had fallen short of the home's own standards. For example the monthly reviews of the care plans and ongoing quality monitoring had not taken place. The manager acknowledged this and told us that plans were in place to rectify the lapse.

The provider was not able to evidence that during 2012 staff had undertaken their annual update of mandatory training.