Archived: Rosemount Care Home

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions is the service safe. We found progress had been made and the provider was now meeting the regulations. In particular, medicines were administered safely and there was a structured approach to quality assurance to check on the effectiveness of medicines management.

Rosemount Care Home 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. Rosemount Care Home accommodates up to 60 people. At the time of our inspection there were 53 people living at the home, some of whom were living with dementia.

The home had a registered manager. 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, relatives and staff told us the registered manager was supportive and approachable.

People and relatives had positive feedback about the care provided at the home. They told us the care people received was good and staff were kind and considerate. We observed there were positive interactions between people and staff.

People, relatives and staff told us the home was safe.

There were sufficient staff on duty to meet people’s needs. People told us staff responded as quickly as they could to their requests for assistance. We noted staff were visible around the home and available to support people when needed.

Staff had a good understanding of safeguarding procedures and the provider’s whistle blowing policy. They knew how to raise concerns and told us they would not hesitate to do so if they were concerned about people’s safety.

The provider followed the agreed local safeguarding procedures when dealing with safeguarding concerns. Previous concerns had been fully investigated involving advocates when needed.

There were effective recruitment processes to help ensure new staff were recruited safely.

Health and safety checks were completed and risks were assessed to help maintain a safe environment. Personalised evacuation plans were written to help ensure people received the support they needed in an emergency.

Management supported staff well and staff received the training they needed. Records confirmed training, supervisions and appraisals were up to date.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff supported people to meet their nutritional and healthcare needs. We saw people received support with eating and drinking in line with their needs. Care records showed people had input from a range of health care professionals.

People’s care plans were accurate and contained personalised information which reflected their particular circumstances.

Previous complaints had been fully investigated and resolved in line with the provider’s complaint procedure.

There were opportunities for people, relatives and staff to provide feedback about the home. This included regular meetings and using the electronic system to provide on-going feedback at any time.

At the time of our inspection there was a registered manager in post, who had been in post since September 2016 and registered with the Commission to manage the carrying on of the regulated activities since October 2016. 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.

Our first comprehensive inspection of this service took place in May 2015 where we identified the provider was in breach of multiple regulations of the Health and Social Care Act 2008. The provider achieved compliance with legal requirements following subsequent inspections in December 2015 and April 2016, as they had taken steps to make the necessary improvements.

This inspection took place on the 15, 19 and 20 December 2016 and was unannounced. The inspection team consisted of one inspector. It was carried out in line with re-inspecting timeframes based on the rating allotted to the service following our last inspection.

At this inspection we found improvements to the service overall had been made and there was a positive feeling amongst people, relatives and staff about the home and service delivered. However, we found some shortfalls did exist.

People were complimentary about the service and told us they felt safe living at the home. Their relatives told us they had not seen anything of concern about how people were treated when they visited the service. People were supported appropriately with their mobility and staff adopted safe practices when assisting them. However, we found shortfalls with the management of medicines that put people's health and wellbeing at risk. Stocks of medicines were not well managed and several people did not have their prescribed medicines available to them. Recording around the administration of medicines was also not robust.

Risks that people were exposed to in their daily lives because of their physical and mental health conditions had been assessed and measures were in place to minimise people's exposure to risk. Environmental risks had been appropriately assessed and these were regularly reviewed. Checks on equipment and the premises were carried out regularly. Accidents and incidents were recorded and monitored for any emerging patterns and trends so that preventative measures could be put in place where needed. Emergency planning had also been considered and guidance was in place for staff to follow about how to support people in the event of, for example, a fire or flood.

Safeguarding policies and procedures were in place and records showed that historic safeguarding matters had been referred to the local authority safeguarding teams in line with protocols. Staff were aware of their own personal responsibility to report matters of a safeguarding nature in order to protect vulnerable people from harm or abuse.

Recruitment procedures were robust and staffing levels at the time of our inspection were appropriate to meet people's needs. Staff had been trained in key areas relevant to their roles and also in specific areas related to the needs of the people that they supported. Staff supervisions, appraisals and competency assessments were carried out regularly to ensure that staff remained competent in their roles and that they were fully supported to deliver good standards of care.

Staff and people enjoyed good relationships. People and their relatives reflected that staff were kind and patient in their approach. People's needs were met and they were supported to access routine medical healthcare services to promote their health and wellbeing. Where necessary referrals to specialists such as speech and language therapists had been arranged. When people were ill external healthcare support was obtained promptly.

CQC monitors the application of the Mental Capacity Act (2005) and deprivation of liberty safeguards. The Mental Capacity Act (MCA) was appropriately applied and applications to deprive people of their liberty lawfully had been made to prevent them from coming to any harm where they lacked capacity. The service understood their legal responsibility under this act; they assessed people’s capacity when their care commenced and on an on-going basis when necessary. Decisions that needed to be made in people’s best interests had been undertaken and records about such decision making were maintained. We observed people were asked for their consent during the course of care being delivered.

People were supported to eat and drink in sufficient amounts to remain healthy. There were monitoring tools in place which ensured that where there were changes in people's health and wellbeing this was identified and actions were taken to prevent any deterioration in people's conditions. For example, food and fluid charts and positional change charts were used where people were at risk of malnutrition and pressure damage. However, we found that some of these records were not fully and appropriately maintained.

People told us they felt fully involved in the service and they were kept informed by the manager through meetings and general feedback. Staff promoted people's independence, privacy and dignity and they demonstrated respect towards people at all times. Care was person-centred and care records were individualised containing a range of information about each person's needs and preferences. The provider supported social inclusion through providing a range of activities for people to enjoy. People were afforded the right to make their own choices in their daily lives and staff facilitated these choices wherever possible.

Complaints were recorded and well managed and feedback was sought from people, relatives, staff and external healthcare professionals on a regular basis so that improvements in the service could be made.

People, their relatives and staff gave positive feedback about the registered manager and deputy manager who were relatively new to the service, whom they said had instigated positive change. The provider had a range of quality assurance systems and processes in place but these were not always followed effectively by staff and there was insufficient management oversight to ensure that they were. As a result, the shortfalls we identified in medicines and records at this inspection were not identified and brought to the registered manager's attention.

We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely Regulation 12, entitled Safe care and treatment and Regulation 17, entitled Good governance. You can see the action we have asked the provider to take at the back of the full version of this report.

This report only covers our findings in relation to these regulations and the domain areas in which they are reported. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Rosemount Care Home’ on our website at www.cqc.org.uk’

Rosemount Care Home is registered to provide accommodation for up to 60 people. At the time of our inspection there were 45 people using the service, some of whom were living with dementia.

At the time of our inspection there was no registered manager in place at the home. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. A manager was overseeing the running of the home and had been in post for approximately four weeks. She had previously been the registered manager of one of the provider’s other homes. She stated that she was in the process of starting a formal application to register with the CQC. We have written to the provider to remind them that a registered manager is required as part of their registration requirements.

People told us that staff were still busy, but that they did not have to wait long for care or support. Staff were more visible around the home and available to check on the safety of people throughout the day. Call bells did not ring for long periods and call bell records did not show significant time elapsing before bells were answered. Additional nursing staff had been recruited and there was reduced use of agency nursing staff. Sufficient care staff were rostered to work, although short term sickness remained an issue. Action was being taken to further address sickness and support staff.

Records had improved. Documents related to the Mental Capacity Act and best interests decision making had been reviewed and updated. Records related to the application of topical medicines were up to date. Daily record completion had improved and showed only minor gaps or omissions.

This meant the provider had met the requirements of the warning notices issued. We have not changed the ratings we gave in these domains following our comprehensive inspection in April/May 2015, as we wish to be assured that the changes instigated to date will be sustained in the long term.

' 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 '

Is the service caring?

We saw people's needs were assessed and care was planned in line with their assessed needs. We found specific care plans were in place in relation to areas such as mobility, nutrition and skin integrity and monthly reviews had been undertaken.

People we spoke with told us that they were happy with the care they received. People's comments included, 'I think everything is alright. I have been here quite a while now and wouldn't stay if it wasn't'; 'It couldn't be better'; 'I'm quite happy here. The staff are good. I am well looked after.'

Is the service responsive?

We spent time observing care at the home and how staff responded to people's needs. We saw that staff responded in an appropriate and timely fashion. Staff were supportive, considerate and sympathetic to people's individual needs. We saw that call buzzers were responded to within an appropriate timescale. Additional advice from other professionals was sought to ensure appropriate care was provided.

One person told us, 'It couldn't be better. The staff are nice and pleasant. If I press the buzzer they come in a reasonable time.' One staff member told us, 'They are all individuals and they all need individual help.'

Is the service safe?

People were protected against the risks associated with the use and management of medicines. They received their medicines at the times they needed them and in a safe way. Medicines were stored and administered safely and medicine administration records were held securely.

Is the service effective?

We observed that staff supported people, where they were unable to eat or drink for themselves. We saw that this support was provided on a one to one basis and that staff engaged with people during the meal time; asking them if they wanted more food, a drink or generally conversing with them.

We saw there was a record of what people had eaten or drunk and a note made of their weight. Where there were concerns that perhaps weight was being lost, then action or advice was taken.

Is the service well led?

In this report the name of a registered manager appears who was not in post at the time of the inspection. Their name appears because they were still the registered manager on our register at the time of the inspection.

The acting manager showed us that a range of checks and audits were now in place to ensure that care was effectively delivered. We saw that care plans and medicines had been audited and changes made where necessary.

There had been one staff meeting and a "residents'/ relatives'" meeting. We saw that suggestions from the meeting had been taken forward and a radio provided for people to listen to.

The acting manager had in place a process to ensure that all staff working at the home had regular supervision sessions and annual appraisals.

' 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 '

Is the service caring?

We saw people's needs were assessed and care was planned in line with their assessed needs. We found specific care plans were in place in relation to areas such as personal hygiene, mobility, skin integrity and nutrition and monthly reviews had been undertaken.

We observed the majority of staff to be caring and compassionate in their dealings with people who used the service and were able to describe the type and frequency of care that people received. One staff member told us, ' I'm not a rocket scientist, but if I can make someone's life better; put moisturiser on their legs, do their hair, put batteries in their hearing aid and make them smile, then I feel I have made a difference.'

People who used the service told us, "I get everything I need. Overall, I feel I have been very fortunate.' Other people we spoke with said," I think the care workers are very good. I've never had a problem' and 'I am happy here. The staff are OK.' Relatives we spoke with told us, 'The staff are very good; mum wouldn't be here if they weren't' and 'I am happy with the care; there is not a lot that you can complain about.'

Is the service responsive?

We looked at seven care records for people who used the service. Whilst the files indicated that care plans had been reviewed at monthly intervals we found the quality of some reviews were limited. We found that the same or similar phrases had been repeated consecutively. For example, in one care plan we saw multiple entries which stated, 'Stoma remains in situ' with no further information to indicate that the person's care had been effectively reviewed.

We spent time observing staff delivering care and supporting people. We noted call buzzers rang for long periods of time. We spent time monitoring the call buzzer system and found that, whilst there were times when a number of call buzzers rang at once, there were also times when single call buzzers rang, often for a period of five minutes. We witnessed one member of staff who entered a room and silenced a person's buzzer but then left without assisting the person. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

People we spoke with told us that a range of activities took place. One person told us, 'There are activities, yes. A newsletter comes out each month. There is baking and quizzes.' Another person told us, 'There are activities, yes, but there could be more. It is very difficult to get out.' We spoke with the activities co-ordinator for the home. She was enthusiastic and eager to try and develop a range of events for people at the home. She also told us that she tried to provide individual time for people who had particular issues and spoke in detail about how she had encouraged one person to become more socialised.

Is the service safe?

We noted a number of people were prescribed 'as required' medicines. We found that for 13 people, of the 20 records we examined, there were no specific care plans in relation to these medicines. We also found there were gaps in recording people's pulses before they were given the medicine Digoxin, for their heart. We saw that front sheets used to ensure people's identity could be checked were missing and the temperature of fridges used to store some medicine were not within safe prescribed limits. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

We examined the files of five members of staff. We found that appropriate recruitment processes had been followed. We saw evidence of an application form, notes from a formal interview process, confirmation on checks on people's identity and two references, one of which was from the person's most recent employer. There was confirmation that people had been checked by the Disclosure and Barring service (DBS), to ensure that they were fit and appropriate to work with people in a caring capacity.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst the manager told us that no applications have needed to be submitted, people's care plans reflected that these issues had been considered and indicated that appropriate actions or best interest meetings would be held if the need arose. Nursing staff within the home had received training on DoLS and the Mental Capacity Act 2005.

Is the service effective?

We saw that people had access to outside professionals and that there were regular reviews of people's care carried out by opticians and dentists. We saw evidence that where there were concerns about people's health then advice was sought from general practitioners, district nurses or other health care professionals. One relative told us, 'One time they got straight on to the doctor and got some cream for her skin. They don't delay in getting things done.'

We spent time observing meal times within the home and looking at how people were supported. We noted the lunchtime meal provided for people requiring a soft diet consisted of mashed potato covered with pureed chicken fricassee. The cook confirmed with us that no fresh vegetables were provided with the meal provided for people requiring soft diets. We also noted that these meals had been placed in the hot food trolley without any covering. This meant that the food had become dry and crusted through exposure to the heat. We also witnessed one care worker supporting two people with their meals at the same time. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service well led?

The manager told us, and records confirmed that he carried out a range of audits such as checks on equipment, the quality of meals and the general environment of the home. He told us that the regional manager undertook checks on the home and these included checking that care records were up to date and complete, cleanliness, staff training and medication records.

We saw that complaints and safeguarding incidents were investigated and, where necessary, action taken to change or improve care delivery.

The manager told us that there had been no recent residents' or relatives' meetings. He told us he had an open door policy and that he had undertaken a number of manager's surgeries, advertising his availability to discuss issues at certain times each month. We saw notes from these surgeries, but noted the last one occurred in September 2013.

Staff told us that they had some supervision sessions but that they did not occur very often. Staff also told us that yearly appraisals were not always undertaken. We spoke to the manager about staff supervision and appraisals. He told us he was aware of the situation. He said, 'I'm behind with supervision, I do know that.' There was no formal plan available to indicate how the manager would be addressing this position. We did not consider that the manager had an effective overview of the situation and when appraisals and supervisions would be completed.

People and staff told us that consent was gained before care was delivered and we found that the provider acted in accordance with people's wishes.

We found people's needs were assessed and care and treatment was planned and delivered in line with their individual care plans. We observed that relationships between staff and people appeared to be good and people looked clean and well cared for.

There were enough qualified, skilled and experienced staff to meet people's needs. One person said, "I can't complain, the staff are always there to help when I need them."

The provider had effective systems to regularly assess and monitor the quality of service that people received.

During our inspection we looked at the care records for five people. We found care records contained accurate and appropriate information and could be accessed in a timely manner.

Many people were unable to tell us their experiences owing to the nature of their illness and some others were asleep during our visit. We spoke with three people who lived in the home. They told us they had no complaints regarding their care as the staff were very attentive. They said the home was clean, comfortable and their bedrooms were always clean and tidy. Comments included, "It's a very good home, I like it here" and "My bedroom is kept spotless, the staff work very hard."

The domestic staff on duty at weekends had been increased from one to two staff. This meant there were enough domestic staff on duty to ensure the home was kept clean and tidy at all times.

We looked around the communal areas in the home and three bedrooms. These were clean and free from preventable malodours.

We looked at the records for five people who lived in the home and found these were up to date and provided staff with up to date information about how individual needs should be met. This meant that people were protected from unsafe and inappropriate care.

Relationships between staff and people were clearly good. People told us staff treated them with respect and helped them to remain as independent as possible.

People we spoke with were positive about the care and support they received. Comments included, 'The care is good; staff look after me properly' and 'It's got everything I need.' Relatives told us, 'The care is smashing, first class' and 'It's a care home with a capital C.'

We found there were infection control systems in place and, in most cases, we found these were adhered to.

We found there were suitable numbers of skilled, qualified and experienced care staff on duty but there were not always sufficient domestic staff.

People and relatives told us they felt comfortable approaching the staff, or the manager, if they wanted to discuss any concerns and we found there were systems in place to assess and monitor the quality of the service.