Archived: The Croft

At the last inspection in March 2017 we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.The breaches were:-

Regulation 9 Person-centred care

Regulation 11 Need for consent

Regulation 12 Safe care and treatment

Regulation 13 Safeguarding service users from abuse and improper treatment

Regulation 14 Meeting nutritional and hydration needs

Regulation 17 Good governance

Regulation 18 Staffing

Following our last inspection we asked the provider to take action to make improvements. During this inspection we found improvements had been made and there were no continued or new breaches of regulations.

There was not 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 provider had secured the services of a manager consultant with a background in mental health. Arrangements were in place to appoint a new manager and candidates were due to be interviewed on 28 September 2017.

People had care plan documents which were accurate, up to date and regularly reviewed. We found these described people’s individual needs and provided staff with a profile of people’s mental health needs. Where risks to individual people had been identified we found staff had been given guidance and advice on how to mitigate these risks.

Staff had been trained in safeguarding vulnerable adults. They told us they felt able to speak to the manager if they had any concerns

There were enough staff on duty. A new board on the wall told people who used the service who were their staff member for the day.

Staff provided appropriate support to people with dignity and respect. We found changes had been made in the service which promoted people’s independence.

Pre-employment checks were carried out on staff to ensure they were of suitable character and had the necessary skills to care for vulnerable people. Staff completed an induction when they first started work which supported them to get to know the home and people who used the service. Staff received regular supervision, appraisals and training. Staff had recently registered to undertake training in mental health.

The provider had used the knowledge and skills of a manager from another service to implement a programme of checks which ensured people were protected from living in an unsafe environment. These included, for example, fire safety and water temperature checks.

Accidents and incidents were recorded by staff. These were monitored by managers to ensure the right actions had been taken and prevent the same type of accident happening again.

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.

Some people in the service were provided with additional staff hours to support them to carry out activities of their choice. Staff had begun to engage with people about the type of activities they would like to see provided.

Staff had completed food and fluid charts to monitor the food and fluid intake of people were at a nutritional risk. People made positive comments about the meals and we found people had a menu choice. Alternatives were available if people preferred other options.

We saw discussions had taken place with mental health professionals. The staff had made referrals to other health care professionals when they assessed people required addition support. We saw referrals had been made to dieticians, the speech and language therapy team (SALT), GP’s, community nurses and community psychiatric services. Systems and processes were in place to monitor and improve the quality of the service. We saw the senior management team had visited the service and carried out audits of the home which resulted in actions being required to improve the service.

A recent survey had been put in place and some survey returns were still expected by staff. The responses received at the point of our inspection were largely positive.

Since our last inspection there had been no complaints made about the service. We saw people had been given information on how to make a complaint. People told us they felt able to make a complaint to staff should the need arise.

People’s medicines were administered by staff who had been trained to carry out these tasks. Staff were required to undertake training before being assessed as competent to give people their medicines. We found people’s medicines were stored securely and regular audits were in place to ensure medicine counts were correct.

Since our last inspection improvements had been made to both the internal and external property. Following our last inspection a fire officer had visited the premises and recommended improvements to fire doors. We found these improvements had been carried out.

At our last inspection of The Croft in December 2016 we reported that the provider was in breach of the following regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014:-

Regulation 9 Person Centred Care

Regulation 12 Safe care and treatment

Regulation 14 Nutrition and Hydration.

Regulation 15 Premises

Regulation 17 Good governance

Regulation 18 Staffing

The overall rating for this service was 'Inadequate' and the service was placed in 'special measures'. This is where services are kept under review by CQC and if immediate action has not been taken to propose to cancel the provider's registration of the service, the location 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.

Following the last inspection the provider sent us an action plan. At this inspection we found there were some improvements. However, we also found there were further regulatory breaches.

The registered manager was not present in the service during the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found there were discrepancies between the number of some of the medicines in the home and the records. We could not be reassured people had received their medicines in the way in which they were prescribed.

The service failed to identify and record risks people posed to themselves and others, as well as have in place actions and guidance to support staff on how to reduce these risks. This meant people who used the service continued to be at risk.

People had in place Personal Emergency Evacuation Plans (PEEPs), these plans were available to emergency services to assist them evacuate people from the building. Following concerns we found during the inspection we asked the local fire safety officer to visit the home. They made recommendations to the staff on how to improve fire safety on the premises.

We looked at staff records and found prospective staff had completed application forms and undergone Disclosure and Barring Service checks. However, we found references had not been obtained for two staff before they had started to work in the service. This meant recruitment checks were incomplete and staff were working in the service without thorough checks on their background in place.

As a result of the home requiring refurbishment, there were shortfalls in cleanliness.

Staff had failed to support people who had lost weight. One person had a low body mass index (BMI) which placed them at increased risk of cardiac arrest. Staff took action when we raised the issues.

We found staff were keen to learn about their role and people’s conditions. We found staff had not received sufficient support, training and guidance to enable them to care for the people who lived at The Croft. We found records which were incorrect and other issues within records which staff were unable to explain.

We saw the service did not comply with the requirements of the Mental Capacity Act 2005. Staff did not understand when to use mental capacity assessments and undertake best interests’ decisions. This meant people who used the service were making choices when their mental capacity was impaired and no checks were in place to ensure they understood the consequences of their decisions. As a result people were at risk of inappropriate care.

We saw food was freshly prepared for people who were given a choice of menu. Kitchen staff were aware of people’s dietary requirements and demonstrated to us how they were able to meet the needs of people who required specific diets.

Staff were caring and well-meaning towards people, however, we found whilst staff told us they enjoyed their work, their lack of understanding of people’s needs undermined their caring role.

We looked at people’s independence and found some people were able to go out and about and travel independently as they wished. We found people had varying degrees of independence and recommended people’s plans were reviewed to promote their independence.

We found assessment information had been gathered by staff into care plans, however, we found staff did not understand some of the information and the implications for people’s care needs. Staff had not given due weight to changes in people’s presentation and they had not sought appropriate help and support for people. We saw that partnership working between the service and other professionals was compromised as the service did not have in place accurate records which would adequately support any need for further investigation.

The audits carried out in the home failed to address the deficits we found during our inspection.

During our inspection we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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. This service remains in special measures due to an overall rating of inadequate at this inspection. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. If the service demonstrates improvements when we next 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.

Following this visit we wrote to the provider to outline our serious concerns about the operation of the service and they supplied an action plan detailing how they intended to rectify the issues. We also met with members of the provider’s senior management team at their request, to discuss their intended actions in order to ensure a robust plan was in place, to drive improvements.

At the last inspection on 4 August 2014 we rated the service as “Good” and the service met the regulatory requirements.

The home had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff interacted with people in a friendly manner.

We checked to see if people were given their medicines in a safe manner and found there were no gaps in the Medicine Administration Records (MAR). However we found medicine profiles of people giving information on their allergies and photographs were missing. This put people at risk of being given the wrong medicines.

Risk assessments had been carried out in relation to the building, although not all staff had signed these. We found risk assessments for people’s mental and physical health to be missing from their records. This meant staff did not always have the guidance in place to help them mitigate the risks to people using the service.

Staff recorded incidents in the home; we found the registered manager reviewed the incidents before compiling their monthly report. We found the incidents had not been reviewed in sufficient detail to ensure people in the home were kept safe. CQC requires registered services as a part of their registration to notify the commission when there are incidents of a safeguarding nature or the police are called out to a home. We found not all of the notifications had been made.

We found areas of the home to be unclean and the decoration was in a poor state of repair. The local Infection Control team had visited the home in October and December. They had highlighted the lack of cleanliness in October and found there was no change in December. The registered manager had put together an improvement plan to redecorate the home but was unsure of the budget available to them at the time of our inspection to carry out the plan.

The registered provider carried out appropriate pre-employment checks to ensure staff were safe to work with vulnerable people.

Staff were not supported to carry out their role through regular supervision and appraisal. We found staff were caring for people without having had training to meet people’s needs. For example we found not all staff had received training in mental health. No staff members had received training in meeting the needs of people with learning disabilities or diabetes.

We found the needs of people with specific dietary needs had not been addressed in the service. This meant people were put at risk of receiving inappropriate foods.

Staff supported people to attend medical appointments. We found one person who had lost weight and wanted to see their GP about feeling unwell. The person was not supported to convey their possible symptoms to their GP. We also found a staff member had told a clinician a person was improving following an incident when the police were involved. The staff member did not record if they had discussed with the clinician the person’s behaviour. The clinician made a decision based on inaccurate information. This meant the people were put at risk of clear communication between the service and its partners.

People had additional one to one staff hours allocated to them and we found they chose how to spend this time. Some people chose to go out with staff support. We also observed staff engaging people in board games.

We found the service made applications to deprive people of their liberty as guided by the Deprivation of Liberty Safeguards. We found in one person’s care plan the home was required to keep all doors locked to keep the person safe. During our inspection we found the front door to the home open.

Assessments were carried out with people prior to their admission to the home. We found the assessments did not always include people’s mental health needs and their current presentation.

We found people with specific needs did not always have care plans in place to ensure staff were given guidance on how to care for people. In their on line brochure we learned the service used the Recovery Star model. The Recovery Star is a recognised model which uses ten life domains to optimise individual recovery and gain the information to create recovery-focused care plan. Although staff had carried out the first stage of the model they had failed to develop the model into people’s plans to promote their recovery.

Quality audits carried out in the home by the registered manager and the regional manager failed to discover and address the deficits we found in the service.

The local police had worked with the service to reduce the number of call outs to the home. We found the work of the staff team in considering if the police were necessary had reduced the number of times police were involved in the service.

During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Details of any enforcement action taken by CQC will be detailed once appeals and representation processes have been completed.

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

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

Is the service safe?

People told us that they felt their rights and dignity were respected.

Systems were in place to make sure that managers and staff learn from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduces the risks to people and helps the service to continually improve.

Staff knew about risk management plans and showed us examples where they had followed them. People were not put at unnecessary risk but also had access to choice and remained in control of decisions about their care and lives.

The registered manager sets the staff rotas, they take people's care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helps to ensure that people's needs are always met.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary needs had been identified where required. People said that their care plans were up to date and reflected their current needs.

One person had an full time outreach support worker and told us that the service had helped them to find them. Other people we spoke with were also supported by an outreach worker's.

Is the service caring?

We spoke with ten people being supported by the service. We asked them for their opinions about the staff that supported them. Feedback from people was positive, for example; 'the staff are great', 'they do what I ask them, sometimes I help to write my care plan', 'I feel I can talk to staff about anything."

When speaking with staff it was clear that they genuinely cared for the people they supported.

People using the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were taken on board and dealt with.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People knew how to make a complaint if they were unhappy. One person said that they had made a complaint and were satisfied with the outcome.

The service worked well with other agencies and services to make sure people received care in a coherent way.

Is the service well-led?

The service has a quality assurance system, and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the service and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

The relationships between staff and the people who they supported were good and personal support was provided in a way that promoted and protected their privacy and dignity. This was confirmed when we spoke with six people who used the service.

Suitable arrangements were in place for handling complaints and for protecting people from abuse.

There was a competent staff team who had the training, skills and experience to meet the specific conditions of the people who they supported.

During this inspection we found the provider had made significant improvements to ensure people received effective personalised care, treatment and support.

The arrangements for supporting people to make decisions about their daily lives and preferences were recorded in their care plans. Each person was supported to take appropriate risks to promote as much independence as possible.

We saw relationships between staff and the people who they supported were good. Personal support was provided in a way that promoted and protected their privacy and dignity. This was confirmed when we spoke with two people who used the service.

People told us they had a monthly meeting with their key worker. They said they were always consulted and were always asked about what was important to them. One person told us 'They take notice of me and what I want and we always agree on the best way forward.

We saw care plans were not sufficiently detailed to show how staff should help people to meet their needs. This meant staff did not always have the information they needed to support each person and keep them safe.

The arrangements for supporting people to make decisions about their daily lives and preferences were recorded in their care plans. Each person was supported to take appropriate risks to promote as much independence as possible. However we saw some people's risk assessments had not been agreed and signed.

The relationships between staff and the people who lived at the home were good and personal support was provided in a way that promoted and protected their privacy and dignity.

The meals provided by the home were satisfactory and gave people a varied, nutritious diet.

Suitable arrangements were in place for handling complaints and for protecting people from abuse. People told us they could share any worries with the staff and felt their views were listened to.

There was a stable and competent staff team who had the training, skills and experience to understand the specific conditions of the people who lived there.