The Close

The Close is a residential care home which was providing accommodation and personal care to 25 people at the time of the inspection. The service can support up to 30 people. The service accommodates people in an adapted period building, with some accommodation being in a newer wing on the ground floor. There are communal spaces and secure gardens for people to enjoy.

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

One risk relating to broken electronic keypads on external doors and doors to stairways, had not been fully assessed and robustly reduced. Information about this risk had not been effectively communicated to all staff. This placed people at potential risk of harm in the event of a fire.

Other risks were assessed, and clear actions were in place to reduce them. Medicines were well managed. Staff had a good understanding of safeguarding procedures and knew how to report abuse should they suspect it. There were enough staff to meet people’s needs. Four staff were working without the required vaccinations for COVID-19. The provider had shared this information with the Care Quality Commission prior to our inspection and had a plan in place to address this. Staff were safely recruited, well trained and received a good induction.

Oversight of the service was mostly very good. There were effective audits in place to monitor quality and safety. The provider acknowledged that they should have had better communication with staff to share information about the broken keypads. They have since put new communication systems in place.

This service was placed in Special Measures in 2017 and has, over time, been working hard to bring about the required improvements. We noted significant improvements. However, we identified a continued breach of regulation 12 (safe care and treatment) relating to fire safety. We also identified a breach of Regulation 12(3), but the Government has announced its intention to change the legal requirement for vaccination in care homes.

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 requires improvement (published 4 September 2019.)

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 the provider remained in breach of regulation 12 (safe care and treatment) but had made improvements and was no longer in breach of regulation 17 (good governance). An additional breach of regulation 12 (3) has been identified following this inspection.

This service has been in Special Measures since 11 October 2017. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

The inspection was prompted in part by information received from the provider which stated that staff were continuing to work despite being unvaccinated for COVID-19 infection. A decision was made for us to inspect and examine any risks this may pose.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

We inspected and found there was a concern with an aspect of fire safety so we widened the scope of the inspection to become a focused inspection which included the key questions of Safe and Well-Led.

We have found evidence that the provider needed to make improvements relating to fire safety. They immediately put plans in place to reduce the risks we identified relating to fire safety and ensure future risks were reduced. The provider had already taken action to reduce risks posed by unvaccinated staff. Please see the safe section of this full report. You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We have identified a breach in relation to fire safety and failure to meet COVID-19 vaccination requirements at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

People’s experience of using this service:

We found some improvements since the last inspection including a comprehensive set of quality monitoring for the risks associated with the environment. On the additional day of the inspection work had begun to address issues with the environment. However, the management and oversight of the works needed further attention.

Risks to individuals had been better managed and people were safer. However, records to evidence this were not routinely up to date. We also found where risks had been identified records to monitor appropriate action had been taken to reduce risks were not always in place.

The home was generally clean and tidy and communal areas and people’s bedrooms were routinely cleaned and monitored. However, procedures and systems were not in place to safely control risks of infection and prevention of cross contamination.

People were not supported to have maximum choice and control of their lives and assessments did not always support them in the least restrictive way possible; the policies and systems in the service did not support this practice.

The provider had begun to develop and embed a system of quality assurance and governance. However, there were still some aspects of service provision which required closer monitoring and when concerns and issues were noted action was required in a timelier way to address concerns.

Some aspects of the buildings safety had been addressed including replacing systems to control the temperature of the hot water. However, this was not monitored to ensure its ongoing effectiveness. Most action had been taken to address areas of concern in relation to fire safety and evacuation if required.

Medicines were managed safely and people told us they received their medicines on time.

Staff were suitably trained and felt supported by the deputy manager who was acting into the manager role. Staff told us they worked together as a team and we saw new staff were safely recruited.

People in the home told us staff looked after them well and they felt involved in how they were supported.

The chef was knowledgeable about people’s dietary needs and people told us they enjoyed the food. Options were available to those who wanted them. We also saw when people required additional support in this area appropriate referrals were made

External professionals told us the home worked well with them, following advice and ensuring any additional support required was implemented.

Rating at last inspection: At our last inspection published in October 2018 we found the provider required improvement over all the rating of requires improvement overall remains.

Why we inspected: When we completed our previous inspection on 15 May 2018, the service continued in special measures from the inspection before. In line with our methodology we completed this comprehensive inspection to ensure improvements had been made. Reports sent to the Care Quality Commission following the previous inspection were used to form part of the plan.

Enforcement: we have had ongoing concerns since 2016 and added a condition to the provider’s registration in 2017. We have identified continued breaches in relation to Safe care and treatment, the environment and governance procedures at this inspection. We have also identified a new breach in relation to consent and the implementation of the Mental Capacity Act.

Follow up: The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any Key Question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

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

The last inspection to this service was on 9 August 2017. The service was rated as inadequate overall with an inadequate rating in safe, responsive and well led and requires improvement in effective and caring, the other two domains we inspect against. There were nine breaches of regulation including person centred care, dignity and respect, need for consent, premises and equipment, fit and proper persons employed, staffing, good governance, safe care and treatment and for not displaying their inspection report. We placed a positive condition on the providers registration requiring them to send us information monthly to demonstrate how they were assessing and managing risk.

We inspected the service again on 15 May 2018 in line with our methodology to check progress made at the service. We met initially with the acting manager and later the provider and found on balance they had worked hard to improve the service and had met most of our previous concerns but still found a lack of clear leadership and oversight.

The Close 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 service was spacious with both ground floor and first floor accommodation and generous outside space.

The Close Residential Home provides personal care for up to 30 people over 65 years of age, including people living with dementia. There were 27 people using the service at the time of the inspection.

There was a registered manager for the service. They were not present during the inspection and were on extended leave. 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, (HSCA) and associated Regulations about how the service is run.

In summary, we found during our inspection on 15 May 2018 that things had started to improve and some of the previous breaches had been met. However we identified two repeated breaches for: safe care and treatment and good governance. The service was not yet good enough and there was a lack of oversight of risk. The quality assurance systems deployed by the provider had not identified some of the concerns we identified as part of this and previous inspections. The service was in breach of the conditions of their registration and there was no effective leadership. We have rated well led as inadequate and therefore the service will remain in special measures.

Risk assessments had been completed but not always updated or revisited with the person to ensure that they had capacity to make decisions and understand the risks they were taking.

Audits helped ensure people had their medicines as intended and any mistakes could be identified quickly and rectified. However the audits had not identified that the medicines room exceeded the recommended temperatures for a period of ten days which could lessen the effect of the medicine.

The provider had been working through their action plan, and had updated most records within the service, although some care plans still required updating. They had improved the overall experience for people using the service. They adequately supported their staff who felt well supported and felt things had changed for the better. People benefitted from consistent support from staff that were familiar with their needs.

We found there were enough staff for people’s assessed needs and the service employed staff locally rather than relying on agency staff. The service had adequate processes in place to help ensure they recruited the right staff. Staff were adequately supported and trained to help ensure they were competent in their role.

We found staff were responsive and caring to people and the atmosphere was relaxed. Activities were provided but these were limited and required further development to take into account the needs and interests of people using the service.

The service demonstrated good engagement with other health care professionals and staff did notice changes to people’s health or change in risk such as increased falls. They had equipment in place to support people’s health care conditions and these were maintained.

The service provided appropriate end of life care.

People were supported to eat and drink sufficiently. Weight loss was identified and staff took appropriate action, which was effective.

Care records had improved and were mostly comprehensive but some of the language was generic and did not give clear detail. Care plans were kept under review and showed how people liked to be supported and what they could do for themselves.

The service was hygienic and did not have any odours but we did identify a few areas of concern, which should be addressed by the service. The environment was spacious and comfortable but needed refurbishment in some areas particularly carpets which were threadbare.

We saw people were comfortable and engaged for most of the day. Staff were attentive and people were encouraged to stay mobile and active.

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.

A registered manager was 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.

At our last inspection of the home in September 2016, we found three breaches of regulations. These were in respect of risks to people’s safety not having always been assessed or managed well and consent not being obtained from people in line with relevant legislation. Also the provider did not have robust and effective systems in place to monitor and drive improvement within the home. Following that inspection we rated the home overall as Requires Improvement.

At this inspection we found that the required improvements had not been made. The provider continued to be in breach of these three regulations. These were in respect of Regulations 11, 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found six new breaches in respect of Regulation 9, 10, 15, 18, 19 and 20A. We have now rated the home overall as Inadequate.

You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Risks to people’s safety had not always been assessed or managed well. This included risks to individuals and risks from unsafe premises. Due to our high level of concern in relation to gas and fire safety, we reported these to the Norfolk Fire and Rescue Service and the Local Authority Health and Safety teams respectfully. They took action against the provider regarding shortfalls in these areas.

There were not always enough staff to keep people safe or to meet their individual needs and preferences. Although some people were engaged in various activities for part of the day, at other times the staff did not have time to provide people with adequate stimulation to enhance their wellbeing.

Checks to ensure that staff were of good character before they started working in the home had not all been completed as is required by law. People did not always receive their medicines when they needed them.

Staff had received training in a number of different subjects but some demonstrated they were not competent to provide people with effective care. Consent had not always been obtained from people in line with the relevant legislation and less restrictive measures not always considered before restraining people.

People did not always have choice or control over their care. Some areas of the home were not freely accessible to people including their rooms or the secure outside garden space. People were not always given a choice of what they could eat or drink.

People received support with their healthcare needs and some staff were kind and caring. However, this was variable in practice with some people’s dignity and privacy being compromised by practices used within the home. Some of these were task-based and institutional in nature.

The leadership within the home was poor. Effective communication was not always in place in respect of people’s needs and practices that were taking place in the home.

The provider had failed to ensure that the governance systems they had in place were effective at assessing and monitoring the quality of care people received. They had also failed to identify issues that placed people at risk of avoidable harm. This was in part due to the fact that both the provider and registered manager lacked knowledge in relation to regulation and risk assessment.

The staff were happy working in the home. They felt supported and that they worked well as a team.

The overall rating for this service is 'Inadequate' and the service is therefore in '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. 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.

This unannounced inspection took place on 1 September 2016. There were 26 people receiving care at that time.

The service had a registered manager in place. 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.

Systems were not always followed to ensure people’s safety was effectively managed. Staff were aware of the actions to take to report their concerns. However, a matter had not been reported to the local authority as required by local protocols.

There were sufficient staff to ensure people’s needs were met safely, but staff were very busy and did not always have time to engage with people. Staff were only employed after satisfactory pre-employment checks had been obtained.

People were supported to manage their prescribed medicines. People’s health and nutritional needs were met.

People received care from staff who were trained and well supported. Staff treated people with dignity and respect and in a caring manner.

Where people did not have the mental capacity to make decisions, processes had not have been followed to protect people from unlawful restriction and unlawful decision making. People were involved in every day decisions about their care. There were examples of where people were encouraged to be as independent as possible. However, this was not always the case.

People’s care records did not always provide staff with sufficient guidance to ensure consistent care to each person. However, staff were aware of people’s needs.

There were organised events for people to take part in. However, there were limited opportunities for people to develop hobbies and interests or take part in activities of daily living.

Records were not always stored securely.

The service did not have an effective quality assurance system. Concerns identified in this inspection had not been previously identified, compromising the quality and safety of the service.

People and their relatives had opportunities to comment on the service provided and people’s comments were listened to and acted on. People had access to information on how to make a complaint and were confident their concerns would be acted on. The registered manager provided strong leadership for staff who felt well supported.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

We looked at three out of 28 people's care records and saw that associated risks were identified such as personal care, diet and eating, mobility and skin integrity, and these were monitored and reviewed on a monthly basis.

We spoke with five people who used the service about the choice of menu and the availability of drinks. They all told us that either the chef or cook would come round every morning to discuss what was on the menu. One person told us, 'We definitely get enough to eat and drink; I always have a jug of water on my table in my room as well'.

There were enough qualified, skilled and experienced staff to meet people's needs. People we spoke with all told us that the staff were, 'Lovely'.

During our inspection of 24 October 2012 we observed a person living at The Close being moved in a wheelchair without the use of foot plates. At the time of our observations we spoke with a healthcare professional who was at the home to assess people's needs in relation to wheelchairs. They told us that moving a person in a wheelchair without using foot plates placed them at risk of injury.

We also observed people sitting in the dining area of the home who's welfare was not checked by staff members for periods of up to 45 minutes.

On 1 November 2012 the provider sent us an action plan telling us that staff have been made aware of the potential risks of moving people in wheelchairs without the use of footplates and that it would not happen again. Measures have also been put in place to ensure people's welfare is checked on a regular basis.

People we spoke with during our inspection told us they liked living at The Close Residential Home. One person who we spoke with told us, "I am being looked after very well. I have lovely chats with my carer and she listens to what I have to say". Another person we spoke with told us, "The staff here always speak to us very nicely, they really do care".

Care and treatment was planned in a way to provide support to people, but during our inspection we observed that care was not always delivered in a way that ensured people's safety and welfare.

We saw that staff members were trained to dispense people's medicines safely and appropriately. We also saw that medicines were stored securely, and that regular audits were undertaken to ensure people's safety.

Staff members underwent appropriate checks prior to starting work at The Close, so that people were supported by suitably qualified and experienced staff.

There were systems in place to regularly check and monitor the services provided to people at the home.