Limetree House Upper Poppleton

Limetree House Upper Poppleton provides accommodation and support with personal care for up to 26 older people, some of whom may be living with dementia. At the time of this inspection there were 22 people using the service. Accommodation was in one building over two floors which were accessed by stairs and a lift.

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

People told us they felt safe and supported by the staff who worked in the home. However, systems for oversight and checks of environmental related risk management had not highlighted shortfalls identified over the course of the inspection.

Work was required to ensure good infection control practice was effectively implemented. We have made a recommendation about this.

Work was required to improve the recording and auditing of some medicines. We have made a recommendation about this.

Where incidents and accidents had happened lessons had been learnt and action to reduce future risk had been taken.

Staff were recruited safely, and staffing levels were enough to meet people's individual needs.

Staff were supported by the management team and worked closely with healthcare professionals to meet people's needs.

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

Rating at last inspection

The last rating for this service was good (published 2 April 2020).

Why we inspected

We initially carried out an announced Infection Prevention and Control (IPC) outbreak inspection; this was to follow up on IPC arrangements. We inspected and found there were concerns with infection prevention and control, and window safety so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led only.

We looked at IPC 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 coronavirus and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Limetree House Upper Poppleton on our website at www.cqc.org.uk.

Recommendations

We have made recommendations about infection prevention and control, medicines practice and governance systems.

Follow up

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

Limetree House Upper Poppleton is a care home providing personal care for up to 26 older people. At the time of our inspection 22 people lived at the service.

People’s experience of using this service

We received positive views from relatives and healthcare professionals about the support provided to people. Care and support was tailored to each person's needs and preferences. People and their relatives were fully involved in developing and updating their planned care.

People were supported with activities and interests to suit them and to aid their independence. Staff knew people’s likes, dislikes and personalities well.

Staff demonstrated effective skills in communication. Recruitment checks were in place to ensure staff were suitable to work at the service. Staff had received training and support to enable them to carry out their role. People, relatives and professionals felt staff were skilled to meet people’s needs.

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. People received their medicines on time and their health was well managed. Staff had positive links with healthcare professionals, which promoted people’s wellbeing.

The registered manager was approachable. All feedback was used to make continuous improvements to the service. The provider had systems in place to safeguard people from abuse and staff knew how to minimise risks.

The property was undergoing planned refurbishment. This left some areas which did not meet best practice for infection control. The registered manager assured us action would be taken to improve these areas until the refurbishment was completed.

For more details, please see the full report which is on the Care Quality Commission’s (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (report published 4 September 2017).

Why we inspected

This was a planned inspection based on the previous rating.

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.

Limetree House is a residential care home. It provides personal care and accommodation for up to 26 older people and is owned and managed by Roseville Care Homes Limited. The home is a large detached property set in private gardens in the village of Upper Poppleton on the outskirts of York. There is some parking on the site, and on the road nearby. At the time of our inspection there were 20 people living at the home and receiving a service.

At the time of the inspection the home had a manager who was registered with the care Quality Commission (CQC). 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 registered manager is referred to as the 'manager' throughout this report.

People told us they felt safe living at the home with the care workers who supported them. Care workers had received training in safeguarding adults from abuse and harm. Systems and processes were in place to ensure any concerns were reviewed and escalated for further investigation. Actions were implemented to mitigate re-occurrence and to help keep people safe from avoidable harm and abuse.

The provider had completed risks assessments in relation to the environment at the home and in relation to the needs of people who lived there. Care and support was provided based on the assessed risks which meant people could live their lives safely without undue restrictions.

Safe systems were in place to manage people's medicines. Care workers were trained in medicine administration and their competency was checked. Audits had been introduced for the management and administration of medicines to ensure people received their medicines in line with their prescription.

The manager reviewed people’s needs to ensure there were enough care workers to meet people's individual needs.

People received support from care workers who respected people’s dignity and privacy and promoted their independence. Care workers followed people’s wishes and preferences.

Care plans were reviewed monthly and information was centred on the person and written from the person’s perspective. People had been involved in their care planning and reviews.

People were free to live normal lives and where they required assistance, this was provided. Arrangements were in place for people to maintain links with the local community, friends and family.

The manager and care workers had an understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). People were assumed to have capacity and where people’s capacity to make decisions had come into question, the provider had submitted applications to the local authority.

The provider supported care workers with training and a programme of regular supervision had been implemented to ensure they had the up to date skills and knowledge to carry out their role.

People had access to other healthcare facilities and support that helped them to maintain a healthy lifestyle.

Residents meetings were held where people could discuss and contribute to the running of their home and provide feedback on the service they received.

The provider had systems and processes in place to receive and manage any complaints, incidents or accidents. Evaluations of this information included any actions implemented as a result.

The provider completed a range of quality assurance checks around the home. These checks helped to maintain and improve standards of service.

Everybody spoke positively about the way the service was managed. Care workers understood their levels of responsibility and knew when to escalate concerns. The manager had a clear understanding of their role and responsibilities and requirements in regards to their registration with the Care Quality Commission (CQC).

We inspected this service on 31 May and 2 June 2016. This inspection was unannounced. At the time of our inspection, there were 25 people using this service.

The service was last inspected in June 2014 at which time it was compliant with all the regulations we assessed.

The registered provider is required to have a registered manager in post as a condition of registration. On the day of the inspection, there was a manager in post and they were in the process of applying to become the home’s registered manager, however, the home had been without a registered manager since January 2016. A registered manager is a person who has registered with the 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.

During our inspection, we found that appropriate checks had not been completed to ensure the gas system and passenger lift were safely maintained.

This was a breach of Regulation 15 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We identified issues with the storage and recording of medicines administered to people who used the service.

This was a breach of Regulation 12 (2) (g) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

You can see what action we have taken in response to these breaches of regulation at the back of the full version of this report.

We found that people’s needs were assessed, risks identified and risk assessments put in place to keep people safe. We found that staff understood their role and responsibilities with regards to safeguarding vulnerable adults from harm.

The registered provider ensured appropriate checks were completed so that only people considered suitable to work with vulnerable adults had been employed. We found that sufficient numbers of staff were employed to meet people’s needs.

Staff were described as knowledgeable, skilled and experienced. Training was provided and in the process of being updated. A new system of supervisions had been introduced and work was on-going to ensure all staff received regular supervision.

People who used the service were supported to make decisions in line with relevant legislation and guidance.

We received positive feedback about the food available at Limetree House and found that effective care and support was provided to ensure people ate and drank enough.

People who used the service were supported to access healthcare services where necessary.

We made a recommendation about the registered provider developing a more dementia friendly environment.

Staff were kind, caring and attentive to people’s needs. People were supported to make decisions and their privacy and dignity were respected by staff.

People’s needs were assessed and person-centred care plans developed.

Positive progress had been made to support people to engage in activities. However, our observations and feedback from people who used the service showed us this work was on-going. We have made a recommendation about continuing to develop the support provided for people to engage in meaningful activities in the body of our report.

People told us they felt able to raise issues and concerns and we saw that a system was in place to listen, learn and respond to people’s experiences of using the service.

We received consistently positive feedback about the new manager and observed that positive changes and improvements had been made under their leadership. However, further progress was needed to embed new systems and processes, to update training and supervisions, and to increase the monitoring of medication management within the home.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People felt safe because their rights and dignity were respected and they were included in decisions taken about their care.

People were safe because the service had an effective system to manage accident and incidents and learn from them, so they were less likely to happen again.

People received their medicines as prescribed and in a safe way. People were supported to manage their own medicines if they wanted this task and the service had systems in place to ensure people’s medication did not run out.

The provider carried out routine checks on the environment and ensured checks on equipment and essential services like gas and electricity were properly and regularly maintained.

Is the service effective?

The service provided individualised care that was based on people’s assessed needs. People were able to contribute to the way their care was delivered.

People were supported to maintain good health as their health and well-being was regularly monitored and healthcare support was promptly sought, when necessary.

People’s needs, wishes and choices were discussed with them and respected. People’s independence was promoted and respected.

Is the service caring?

People told us the staff were kind and friendly. Staff knew the people they were caring for and also knew about their preferences and choices. This helped to ensure people received the care they wanted and needed. One person told us “The house is comfortable. All the staff help us when we need help.”

People were consulted about their care and support. The staff understood the need to respect people’s privacy and dignity, when providing that care.

Is the service responsive?

There were arrangements in place to speak with people about what was important to them. This included consulting about how the service was being run, as well as discussing their individual care needs and choices.

People were supported to make decisions about their care and treatment. However, a greater understanding of the impact of a person’s mental capacity on their abilities to make those decisions would enable staff to better ensure people’s human rights were always being met.

People knew to speak out if they were unhappy about any aspect of their care and the service ensured that complaints and concerns were properly looked into. People we spoke with knew who was in charge at Limetree House, so knew who to go to, should they have a concern.

Is the service well-led?

The service had arrangements in place to ensure people’s views were taken into account when decisions were made about how the service was operating.

The managers learned from accidents and other incident in the home. They put systems in place to minimise the risk of the same incident happening again. When they found issues the managers put action plans in place and checked that those actions had been carried out.

The staff were aware of their roles and responsibilities. They met with managers so they could have a say in what was working well and what areas needed to improve.

One inspector visited the service, but we had made arrangements to speak by telephone with a pharmacist inspector, should we need further advice about the way people's medicines were being managed.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

Is the service safe?

At this visit we looked only at the way medicines were being managed. We found medicines were safely stored in people’s rooms, to protect the health and wellbeing of other people living there. We spoke with two people about the way their medicines were managed. They told us they did not run out of medicines and the staff checked with them regularly to make sure they were not running out. One person told us they were asked to take their medication whilst the care worker was present, rather than leaving the medication with them for them to take later.

The service had systems in place to ensure the medication trolley was not left open and unsupervised, to prevent unauthorised people having access to medications.

The provider had introduced a series of regular checks so as to be satisfied people were getting their medication as it was prescribed to them. This helped to promote people’s health and wellbeing.

Is the service effective?

N/A

Is the service caring?

N/A

Is the service responsive?

N/A

Is the service well led?

N/A

A pharmacist inspector re-visited Limetree House to check that improvements had been made, and to check that people were now receiving medicines safely, and at the times they needed them.

People told us that medication systems had improved since our last visit in November 2013. One said “Staff check I’m managing (my medication) alright. They don’t just leave it with me now.” We asked another person if they had noticed any difference in the way medicines were managed. They responded “Absolutely. Yes.”

We noted improvements in most areas of medication management, however further improvements were still required in order for the service to demonstrate that people were properly protected from the risks associated with unsafe medication practices. Medication records needed to be accurate, detailed and kept under review and robust arrangements were needed to ensure people did not run out of their prescribed medication.

We spoke with three people who lived at Limetree House and with one visitor. Two of the four people told us they thought the home was cleaner than it had been in the past. One said “The new cleaner is good.” A second person said “The cleaner keeps my room clean. I’m very satisfied with the cleaning.”

We found the service overall was much cleaner though further improvements would improve the experience of people living there and better help to minimise the risk of a spread of infection.

People told us they received their medicines when they needed them. One said “They bring me my medicines. I take them while they (the staff) watch me.” We noted though that one person had been left with a tablet in a pot and did not know what it was for, or whether they should take it.

Medication systems at Limetree House were still not good enough. People were not always receiving their medication safely and appropriately, which meant the provider was not doing all it could to protect people’s health and well-being.

People told us they were included in decisions about their care and their views and opinions were listened to and respected.

People told us they received good care from kind and helpful staff and visiting healthcare professionals held the same overall view.

The service was dirty and needing a deep clean. There were not good systems in place to minimise the prevention and spread of infection.

The service did not manage medicines in a robust way in order to ensure people received their medicines safely and at the times they need them.

There were enough staff to meet people’s needs, though on some occasions they seemed to lack direction and leadership.

The quality of the service provision was not being kept under review, which means the service was not regularly assessing and managing the risks to the safety and well-being of the people who live, work and visit there.

People’s records did not provide accurate and up-to-date information about their care needs. Other records required for the effective running of the service were poorly maintained.

However we saw a few people who looked less well cared for and we noted that those people had said they wanted to look after their own care. The service could consider how they were supporting those people to care for themselves, whilst ensuring their well-being, health and independence was maintained.

We saw there were now better systems in place to ensure prescribed medicines were available when people needed them. There was also clearer guidance for staff to follow to ensure prescribed creams were applied to the right part of the body. Good medication processes help to promote people’s health and well-being.

We noted the service had improved the quality of the care records. These were now a more accurate record of the care people needed. This helped to ensure people receive the care and support they want and need. The quality of these records needed to be sustained and built on, so that all people’s individual preferences, needs and choices were looked into and recorded.

People we spoke with said that staff routinely checked with them before providing any care and support. This showed staff were respecting their rights. We found complaints were managed in a satisfactory way, with people telling us they were confident that any concerns raised would be looked into properly.

We found overall that recruitment processes at the service were robust and appropriate checks were completed before staff were deployed. This helped to ensure only suitably vetted people worked there.

Whilst people looked, and told us they were well cared for we found some aspects of care planning needed improving. Identified risk of harm to people was not always acted upon and care records were not always updated as people’s needs changed so they weren't an accurate record of people's care needs.

We also found some failures in the way medicines were managed. We saw that in the previous month some prescribed medicines for two people had run out. This meant their care and wellbeing had not been protected.