Archived: Chasewood Care Limited

Chasewood Care Ltd 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. The care home is registered to accommodate 107 older people in six units across two floors of one building. The care home provides the service for older people, who may live with dementia. Fifty seven people lived at the home at the time of our inspection visit.

We previously found the provider was in breach of the Regulations in safe and well-led and rated the service requires improvement overall. We asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions of safe and well-led, to at least good. The provider sent us their action plan in February 2018 and we looked at their action plan as part of this inspection. We found the provider had not taken the actions they said they would take to improve the service, in line with their action plan. The provider had not made the improvements in the quality of the service required to meet the Regulations and continued to be in breach of the same Regulations and in breach of other Regulations and of the conditions of their registration.

The provider had not sent us the copies of their audit reports by the 28 of each month, as required by the additional condition of registration we imposed in December 2016.

There was not a registered manager in post. The previous registered manager had retired from the service in December 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. The manager had worked at the service since June 2017. They had not registered with us. There had not been a registered manager in post for fifteen months.

We found systematic and widespread failings in the oversight, monitoring and management of the service, which meant people did not always receive safe care. There was not an effective system to identify and manage risks to people’s safety in how the premises were used. The provider’s fire risk assessment had not been reviewed since January 2017 and contained out of date information. There were no signs or reference points to support an evacuation in an emergency or to enable people, staff or visitors to find their way around the building. There was not enough mobility equipment to ensure people were supported safely when they needed support.

The system and process of assessing individual risks to people’s health and safety, through personalised care planning, was not effective. People’s care plans did not give staff the guidance they needed to support people safely and minimise their personal risks. People’s care plans were not updated accurately when their needs and abilities changed, which put them at risk of poor care that did not meet their needs.

Improvements were required in the management and administration of medicines to ensure people received their medicines when they needed them and in accordance with their prescriptions.

The oversight, monitoring and auditing of the service failed to identifying risks, trends or patterns that would have enabled to them make changes to minimise the risks of a re-occurrence and make improvements to the quality of service. The provider had not ensured that all allegations of abuse were referred to the local safeguarding authority and had failed to notify us when they did make such referrals. The provider had not always notified us when a person died and had failed to notify us of other important events at the service. Failures to notify us of serious injuries and safeguarding incidents, had prevented us from monitoring the service effectively.

Records related to people’s care, support and treatment were incomplete or not up to date. There was not an effective or auditable system of sharing important information about people’s needs, any incidents they were involved in or any changes to their abilities. Care plans contained insufficient detail about people’s personal histories and interests to support staff to deliver person centred care.

The provider did not operate an effective complaints handling system that would have enabled them to identify trends or areas of risk that they could have addressed to improve people’s experience of the service.

People felt staff had the skills and experience to care for and support them, but staff did not always receive the training they needed to support people effectively. Some staff did not recognise that the way they supported a person who presented behaviour that challenged was uncaring and could amount to a deprivation of the person’s liberty. Staff had variable understanding of the meaning of dignity, respect and promoting independence. People had limited opportunities to engage in meaningful activities that they enjoyed.

People were not consistently offered a choice of meals and the provider had not ensured there were sufficient supplies to provide the meals according to their planned menus. The provider had failed to ensure that people were enabled to find their way around independently, due to a lack of directional signs or points of reference along the corridors.

The provider, manager and staff did not work together to improve the quality of the service. People’s or relatives’ views of the service not sought, heard or responded to. Staff experienced a lack of communication, inconsistent direction and guidance and were not supported to be instrumental in making the required improvements. The provider had not met with the staff to hear their concerns or suggestions for improving the service.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures. This is the second time the service has been in special measures since November 2015. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

The care home provides accommodation and personal care for up to 107 older people, some of whom live with dementia. at the home at the time of our inspection visit. At the time of our inspection, one unit was out of use, awaiting refurbishment. Fifty-one people lived in five units on two floors.

The previous registered manager had retired from the service in December 2016. The current manager had worked at the service since June 2017. They had not yet registered with us, but they had applied to be the 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.

At the last comprehensive inspection in December 2016, we judged that improvements were required in delivering a safe, effective, responsive and well-led service. At our focused inspection in August 2017, when we looked only at the KLOE of well-led, we found some improvements had been made, but some further improvements needed to be made in the governance of the service.

At this inspection we found the required improvements had not all been made since August 2017. Some of the improvements we had identified as required at our previous inspections in 2015 and December 2016, were ongoing. At this inspection, we found the required improvements had still not been completed in managing and mitigating risks to people’s safety and wellbeing or in the leadership and management of the service. The service continues to be rated requires improvement in safe, effective and well-led and has been re-rated from good to requires improvement in caring. We will re-inspect the service within 12 months, to check whether all the required improvements have been made.

The provider’s quality assurance system was not sufficiently robust to identify and mitigate risks related to the premises. The provider took action to mitigate some obvious risks identified during our inspection, but their premises risk assessment had not been robust enough to identify them prior to our inspection visit.

Risks to people’s safety and wellbeing had not all been identified and were not minimised in their paper care plans. The provider’s plan to implement electronic care plans was still in progress and people’s paper care plans had not been updated when people’s needs changed.

The provider had not made all the improvements they said they would make since our previous inspection. Improvements were required in the provider’s understanding of the legal responsibilities of being a registered person and in preparing and supporting their manager to become a registered person.

The provider had not maintained effective oversight of staff’s practice to ensure they understood how to manage risks to people’s health and wellbeing. Staff did not consistently use the equipment described in people’s care plans to ensure they were supported safely. Staff did not demonstrate they understood their responsibilities to provide safe care in relation to good infection prevention and control practice.

People were offered a choice of meals that supported them to maintain a balanced diet that met their preferences. However, improvements were required in staff’s practice and record keeping, to ensure risks to people’s mealtime experience and dietary intake were minimised.

Staff were trained in the fundamental standards of care and in subjects that were appropriate to people’s needs and people were supported to obtain advice from healthcare professionals when their health needs changed.

The manager understood their responsibility to apply for the authority to restrict people’s liberty in their best interests. Staff demonstrated they understood the principles of the Mental Capacity Act 2005, by supporting people to make day-to-day decisions about their care and support.

People told us they felt well cared for because staff were kind to them. However, Staff did not always consider the wellbeing of those people with complex needs who could not express themselves verbally. There was not enough information in people’s care plans for staff to understand their histories and interests to enable staff to provide person centred care that focused on them as individuals.

People were supported to maintain their cultural and religious traditions and were able to engage in activities around the home and local community. People told us they had no complaints about the service. Complaints and concerns were responded to and resolved promptly while maintaining effective relationships between the complainant and the provider.

The provider and manager planned to continue to improve and develop the service. A newly implemented system for medicines management and administration gave assurance that medicines were managed and administered safely. The planned service developments included bringing the local community into the home, networking opportunities and working in partnership with other health and social care agencies.

There were breaches of the Regulations. The provider had not ensured that the premises used by the service were safe to use for their intended purpose and were used in a safe way. The provider had not adequately assessed and minimised risks to service users’ health and safety and had not done all that was reasonably practicable to mitigate any such risks. The provider’s systems for governance and quality assurance were not sufficiently robust to ensure risks to the quality of the service were identified and mitigated.

You can see what action we told the provider to take at the back of the full version of the report.

One local commissioning authority had told us they had stopped making admissions to the home in March 2017, because of their concerns about the management of the home. We found the provider and manager were making improvements to the premises and management to improve the possibility of renegotiating with that local authority and with other commissioners of care.

When we inspected the home in December 2016 we rated the service as requires improvement overall and requires improvement in safe, effective, responsive and in well-led. We planned to re-inspect the service within 12 months of that inspection to see if the required improvements had been made.

The provider had notified us when the registered manager had left the service, but had not notified us of how the service was being managed in the absence of a registered manager. We had received information from various individuals and external agencies about who was responsible for day-to-day management of the service.

We decided we should check how the service was being managed and whether the required improvements had been made in well-led. For that reason we have only looked at the well-led key question and this report only covers our findings in relation to the management of the service. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chasewood Care Limited on our website at www.cqc.org.uk.

At this inspection we found some improvements had been made, but we need to be confident that the improvements in management and leadership are sustained before we can change the rating. The rating will remain at requires improvement until the next comprehensive inspection when we will review of all the key questions.

The service is required to have 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 and associated Regulations about how the service is run.

At our previous inspection the registered manager had told us they would stop working as the manager in December 2016, but would continue to support the provider to manage the business for three months. At this inspection, the provider showed us written confirmation from the registered manager that they had ceased working for the provider completely on 31 March 2017 and wished to be deregistered with CQC. This meant there had not been an active registered manager for more than six months. The quality of leadership and guidance for staff had been inconsistent since our previous inspection.

Since March 2017, the provider had appointed several different individuals and agencies, with a view to appointing a permanent manager. The person they had appointed in June 2017 had just been confirmed as a permanent member of staff. They told us they planned to apply to be the registered manager straight away.

The provider explained they had delayed notifying us because it had taken longer than anticipated to recruit the right person. They had delegated the responsibility to notify us of any changes to several unregistered people and agencies they had trialled in the management role.

The provider confirmed they now understood that some responsibilities could not be delegated to non-registered persons. They said they would be responsible for keeping us informed by use of statutory notifications in future, in accordance with their legal obligations.

We found significant improvements had been made to the leadership and management of the service under the new manager, who was also a qualified nurse. They had brought experience and skills to their role and implemented best practice improvements.

With the manager’s support and guidance as a qualified professional, the provider had changed the use of some rooms and had begun a large scale refurbishment of the home. They had recruited additional staff, made changes to staff’s working practices and invested in new equipment.

The improvements had a direct and beneficial impact on how people were cared for and supported. Staff had confidence in the manager’s experience and leadership because they could already see improvements in people’s well-being. Staff recognised that people’s appetites had improved, because they were more active and were more interested in their surroundings and in socialising with others.

Staff had all had an opportunity to speak with the manager and had been encouraged to develop skills and experience, to equip them to take a lead role in subjects that interested them. Staff had been supported with safer medicines administration by changes in how medicines were supplied, relevant training and by safer working practices.

Staff were looking forward to changing from paper based recording to electronic recording, because it would save time and information would be more readily available, which will enable safer and more effective care and support.

The manager had maintained the regular monthly quality assurance checks and improved the way information was analysed, which enabled them to take action to improve the quality of the service.

The service provides accommodation and personal care for up to 107 older people who may live with dementia. Forty-nine people were living at the home in 6 units on the day of our inspection.

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. The registered manager told us they planned to retire in December 2016. The provider had already appointed a new manager in the expectation they would register with CQC at the end of their probationary period. We have referred to the new manager as the ‘service delivery manager’ throughout this report.

At our previous inspection in April 2016, we found breaches of the regulations related to managing risks to people’s safe care and treatment and the governance of the home. We gave the home an overall rating of requires improvement. We added a condition to the provider’s registration, to ensure they regularly monitored the quality of the service and shared the results of their quality monitoring audits with us every month.

This was because the provider had not taken sufficient improvements since our prior inspection in November 2015, when we had rated the service as inadequate overall and had served a warning notice to the provider and the registered manager. The service was placed in 'Special Measures’ in November 2015, and continued to be in ‘special measures’ in April 2016, because the requirements of the warning notices served on the provider and registered manager had not been met. There were ongoing breaches in the regulations.

At this inspection, we found sufficient improvements had been made to meet the regulations, and to take the service out of 'special measures’. However, further improvements were needed and the provider, registered manager and service delivery manager told us about their ongoing plans to improve.

Since our previous inspection, the provider had recruited a new manager, which meant there was more management time available to deliver a quality service. The registered manager continued to provide business support and had oversight of the service and the new manager was responsible for the quality of delivery of the service.

The provider’s plans to improve how the service was managed included maintaining a separation of responsibilities between business support and service delivery, to ensure there will be sufficient management time make further improvements.

The provider had ensured people were supported by a consistent group of staff. No-one else had moved into the home since February 2016, so staff had had time to get to know everyone well.

Improvements had been made in managing and administering people’s medicines and the protocols in place ensured people received ‘when required’ medicines appropriately and consistently. Regular checks were made of staff’s competency to administer medicines and to ensure they were stored safely, in line with professional guidance.

The premises were regularly checked to ensure risks to people’s safety were minimised through safe infection control practice and monitoring the condition of the building, the furniture and equipment. The provider had agreed contracts with external professional services to service and maintain essential supplies and equipment.

People were safe from the risks of harm, because staff understood their responsibilities to protect people from harm and were encouraged and supported to raise concerns under the provider’s safeguarding and whistleblowing policies.

People were supported by staff who understood the risks to their individual health and wellbeing and knew how to minimise the risks. The new manager had already identified that improvements were required in recording staff’s knowledge about how best to support people, to ensure their knowledge was available to be shared with new and relief staff.

Accidents, incidents and falls were investigated and actions taken to minimise the risks of a re-occurrence for the individual, but improvements were required in the overall analysis of accidents and incidents to identify any service wide contributory factors.

People’s needs were met effectively because staff had the necessary skills and experience and received appropriate training and support. Staff understood people’s needs and abilities because they worked with experienced staff until they knew people well. Staff had recently been encouraged to reflect on their practice and to consider how to develop their skills and knowledge, to improve people’s experience of care. The service delivery manager planned to ensure new staff worked towards obtaining the Care Certificate, once they had taken over the full responsibilities of a registered manager.

The registered manager understood their responsibility to comply with the requirements of the Deprivation of Liberty Safeguards (DoLS). They had applied to the Supervisory Body for the authority to restrict people’s rights, choices or liberty in their best interests. Staff understood and acted within the principles of the Act to support people to make their own decisions.

Improvements were required in supporting people to maintain a balanced diet that was suitable for their individual dietary needs and met their preferences. Staff did not all demonstrate an awareness of, or work to, the provider’s policy of ensuring people were offered a choice of meals and second helpings. Staff did not appear to have sufficient time to ensure people were supported and encouraged to eat a wide variety of foods, when they wanted them. People at risk of poor nutrition or hydration were supported by healthcare professionals, and staff followed their advice. However, improvements were needed in analysing the food monitoring records that staff kept, to identify any actions that could be taken to support people to maintain a healthy weight and appetite.

People were cared for by kind and thoughtful staff who knew their individual preferences for care and their likes and dislikes. People were able to choose how they spent their day and were supported to socialise or spend time alone, according to their preferences. People enjoyed spending time with staff who took an interest in them as individuals.

Care was planned to meet people’s individual needs and abilities and care plans were regularly reviewed and updated when people’s needs changed. The new manager had already identified that care plan reviews needed to include staff’s up-to-date knowledge about how people responded to their support.

Staff were guided and supported in their practice by a management team that they liked and respected. Staff spoke enthusiastically about the improvements already made in the quality of the service. Staff were looking forward to being informed and involved in implementing further improvements because they shared the same values and vision for the service. Staff recognised that people who lived at the home would benefit from all staff being listened to and feeling valued, because they recognised the importance of creating a happy atmosphere at the home.

Chasewood Lodge Residential Home provides accommodation, personal care and support for up to 107 older people living with advanced dementia and physical frailty due to older age. At the time of the inspection 67 people lived at the home. The home has two floors; with four care units on each floor. The ground floor units are Blue-Bell, Fern Way, Poppy and Leaf Lane. The second floor units are Copperfield, Tulip, Holly Rise and Forget-me-not. Those people living on Leaf Lane had physical frailty due to older age as well as dementia.

The home is required to have 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 and associated Regulations about how the service is run. At the time of this inspection the home had a registered manager; who had been in post since 1997.

At our previous inspection in November 2015, we found four breaches in the legal requirements and regulations associated with the Health and Social Care Act 2008. Breaches were found in the management of medicines, the safe care and treatment of people and people’s consent to care and treatment. A breach in the good governance of the home resulted in enforcement action being taken and we served a warning notice on the provider and the registered manager. The home was placed in ‘Special Measures.’ The special measures framework is designed to ensure a timely and coordinated response where we judge the standard of care to be inadequate. Services in special measures are inspected again within six months.

At this inspection we looked to see if the provider and registered manager had responded to make the required improvements in the standard of care to meet the regulations. Whilst we found some areas of improvement had been made, we found no improvement to the management oversight to check that duties delegated to junior staff members had been carried out effectively, that we identified in November 2015. This meant that the requirements of the warning notices served on the provider and registered manager following our November 2015 inspection had not been fully complied with.

Risks around people’s care were not managed consistently. Staff did not always have the skills, knowledge or training they needed to manage risks to people. People had their prescribed medicines available to them and improvement had been made in the safe storage and administration of medicines. However, further improvement was required in the safe management of people’s ‘when required’ (PRN) medicines. Staff were not given adequate guidance on when to give PRN medicine and were not trained to administer one person’s PRN medicine. Since the last inspection, staff had completed fire safety and fire aid training to deal with emergency situations that might arise, such as a person choking or in the event of a suspected fire.

Improvements had been made in gaining people’s consent and staff worked within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. Further training was planned for staff to give them a greater level of awareness about the act. Improvement had been made to people’s Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records and to inform staff which people had a DNACPR in place.

People said they enjoyed their food and we saw nutritious meals were available. Staff supported most people with their food and drink as required. Whilst people were referred to healthcare professionals when needed, improvement was needed in the communication of important ant information from staff about people to healthcare professionals.

Most staff showed a caring approach toward people they supported. However, we saw examples of when this could be improved to ensure people’s dignity was respected.

People’s care records were not person centred and staff had a limited knowledge about people so that their personal and individual needs were not always met. Some improvement had been made to offer social activities and further improvement was planned for with the recruitment of an activities staff member.

Systems to assess the quality of the service provided were not effective. We found there was no improvement to the management oversight to check delegated duties had been carried out effectively.

At the last comprehensive inspection in November 2015, this provider was placed into special measures by CQC. This inspection found on-going breaches of the Health and Social care Act 2008 (Regulated Activities) Regulations 2014 and not enough improvement to take the provider out of special measures.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

You can see what action we told the provider to take at the back of the full version of the report.

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

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

Is the service safe?

We looked at the management of medicines. We were satisfied medicines were administered safely.

We looked at equipment , furnishings and fittings. We saw the majority of the furnishings were in good order. We saw some of the equipment used to support people in moving was not of a required standard for safety.

The provider and staff understood their responsibilities regarding Deprivation of Liberty Safeguards (DoLS). There were people living at Chasewood who were under deprivation of liberty safeguards. We asked the provider to follow up on issues relating to people's best interests under the Mental Capacity Act 2005.

Is the service effective?

People had an individual care plan which set out their care needs. These provided staff with the information they needed to support people with their care. Assessments included people's needs for equipment, skin integrity and specialist dietary requirements. We saw some inconsistencies and insufficient information in some care records which could impact on the care provided.

We saw people's nutritional and hydration requirements were met by the service. We saw the service catered for the needs of the different cultures and ethnicities of people living in the home.

Is the service caring?

People were supported by staff who were kind, caring and patient. When staff were undertaking care tasks or talking with people, they treated people with dignity and respect.

Typical comments from people living at Chasewood included:

'Everybody is very kind.'

'I've been here quite a while, I like it here, I haven't any reason to complain.'

"I'm friends with all of them (staff), they're lovely."

Is the service responsive?

People had access to a range of health care professionals. During our inspection we observed health care workers had visited the home. We were informed the GP made weekly visits to the service.

Is the service well-led?

We noted the service had not been sending statutory notifications to the CQC since September 2013. This meant we had not been able to monitor any incidents or events which had happened in the home since August 2013.

We saw audits had been undertaken regularly but they were not robust. The information gathered had not been assessed appropriately to ensure people using the service would benefit from them.

We saw the manager was effective in dealing with safeguarding issues which had arisen in the service.

Most of the people who lived at the home were not able to tell us how they were cared because of their complex needs. In the five care plans we looked at, we saw that people's needs and abilities had been assessed before they moved into the home. We saw that the manager had identified risks to people's health and well-being and their preferences. The detailed instructions for staff meant that care and support were person centred.

Care staff we spoke with understood their responsibilities to keep people safe from the risk of abuse. Care staff were confident that the manager would respond appropriately to any concerns they raised.

Care staff told us that they felt well supported in their role. Care staff had regular training and one-to-one meetings with senior staff. Care staff told us they discussed their practice and personal development.

The manager's quality assurance system included observing staff in practice and giving them feedback. The manager responded appropriately to complaints and concerns. The manager took appropriate action to resolve issues and minimise the risk of re-occurrence.

We asked relatives about the care provided to their family and they each told us that the care delivered to people was good. They told us, 'The staff make me very welcome and look after my relative well.'

Most of the people who lived at Chasewood Lodge had high support needs and were not able to talk to us about their experience of care. When we asked them if they were comfortable however, they smiled and nodded.

Staff we spoke with understood the needs of the people using the service. We observed the care delivered to people and saw this was respectful and maintained people's dignity. There were sufficient staff on duty to meet people's needs whilst we were at Chasewood Lodge.

There were procedures for preventing the spread of infection in the care home and staff understood what these were.

We found that the provider investigated any complaints made to them about the care delivery. People who lived at Chasewood Lodge told us they had no concerns about the care provided for them.

Records we looked at were generally well maintained and provided necessary information about people's care needs although we found some gaps in information on care records.