Bluebell House

Bluebell House is a residential care home that provides personal care and support to 24 people aged 65 and over at the time of the inspection. Lounge and dining areas are available on two floors and bedrooms on three floors. These can be accessed by a passenger lift. Most people living at Bluebell house are living with dementia and/or conditions associated with frailty and old age.

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

People said they were comfortable and being well cared for. One person said, “It’s not been fun with lockdown but the staff have been great and we are certainly well cared for.”

At the last inspection we found medicines were not always managed safely. We issued a requirement in relation to this as people were at risk. We asked for and received an action plan which showed what the provider was doing and had implemented to ensure this requirement was met. At this inspection we found medicines management had improved since our previous inspection. People received their medicines safely and in the way prescribed for them.

At the last inspection we found risks to hot water outlets had not been risk assessed. We were made aware following the inspection that thermostatic valves had been fitted to all hot water outlets. At this inspection we saw these measures were being monitored monthly to ensure the valves were working and where temperature changes noted the valves were adjusted to keep people safe from the risk of scalds from hot water.

At the last inspection we found the provider quality assurance processes were not robust as they had failed to identify the risk areas we had highlighted during the comprehensive inspection. At this inspection we found regular and robust audits were being completed to keep people safe. These were being monitored by the providers quality assurance manager and by visits from the directors. During the pandemic some of this had been completed remotely, but in more recent month’s visits to the home for quality monitoring had been resumed.

Most staff said there were always sufficient staff on duty for the number and needs of people they cared for. Two staff felt they would benefit from additional staff during the afternoons, but said people’s needs were being met. One staff member said they sometimes struggled to keep people entertained throughout the day. They said they were aware the service had recently employed an activities person to work at the home and believed this would benefit people.

Since the last inspection there had been several safeguarding alerts raised. One was raised by the registered manager and was handled well to keep people safe. Two others had been raised by other agencies and were reviewed with the local authorities safeguarding team. We discussed these with the registered manager and provider who were looking at lessons learnt and sharing with their other services where practice could be improved.

Recruitment processes ensured people were protected as only staff who had been assessed and checked as being suitable to work with people who may be vulnerable, were employed.

Infection control and measures to keep people safe from risk of the spread of Covid were reviewed during this inspection. Training and the right personal protective equipment (PPE) were in place. Measures for visitors to the service were in place. This included ensuring temperature checks were completed. Visitors were also asked to sign a health declaration and wear PPE.

We made one recommendation in respect of ensuring staff were using surgical masks correctly at all times.

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 (Report published 1 May 2019)

We identified a breach of regulation 12 in regard to safe medicine practices. 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We had also received several individual pieces of information of concern about people’s healthcare needs not being met in a timely way and the attitude of the registered manager in one incident.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

We found no evidence during this inspection that people were at risk of harm from these concerns. The provider completed a full investigation into each of the concerns and have shared any lessons learnt. Please see the safe and well led sections of this report.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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 coronavirus and other infection outbreaks effectively.

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

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.

People’s experience of using this service:

People said they felt safe and well cared for by a staff team who understood their needs. Staff said they had sufficient training and support to do their job effectively. They knew people’s needs, wishes and what was important to them.

Most but not all risks had been assessed and plans in place to mitigate identified risks. Risks to some hot water outlets had not been fully risk assessed, although the provider was addressing this by installing mixer valves which would prevent hot water reaching a temperature which was a risk of scalding.

Care and support were well planned and there were enough staff to meet people’s assessed needs. People were treated with kindness and respect.

People benefitted from the food and fluid being carefully monitored and by being offered a variety of meals, snacks and drinks throughout the day.

People’s medicines were not always managed safely.

There were a range of activities which people enjoyed. This included regular visits from local school children, which people really enjoyed and looked forward to.

People were supported in the least restrictive way possible; the policies, systems and culture in the service supported this practice.

People said they were listened to and could make their concerns known, but these were not always recorded.

Rating at last inspection:

At the last inspection the service was rated as Requires Improvement (The last report was published January 2018). At this inspection the overall rating remained as Requires Improvement. This was the third time the service has been rated as requires improvement.

Why we inspected:

This was a planned inspection to look at improvements the service had made following the previous rating. At this inspection we found improvements had been made in the areas we identified previously. Care plans were now more detailed and contained more individualised content. There were more meaningful activities and people appeared engaged and well cared for. However, we found other areas which required improvement. Medicine management was not robust and placed people at risk. Following our initial feedback, the manager completed an audit of all medicine records and stock and had made some changes to systems. They had also addressed this with senior care staff. Hot water temperatures on some sinks were in excess of what is considered safe for vulnerable people. This had not been risk assessed. The service was in the process of fitting regulator valves to prevent water being too hot and therefore reduce the risk of possible scalding. However, at the time of the inspection, this risk remained.

Enforcement: Action we told the provider to take. We have made one requirement notice in relation to regulation 12- safe care and treatment. You can see this in full at the end of the report.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned based on the rating. If we receive any concerns, we may bring our inspection forward.

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

At this inspection, we found there had been some improvements in relation to planned activities for people, but this was not consistent. We found people were still spending large parts of the first day without any engagement. In relation to regulation 17 we found little had improved and this continued to be a breach. This was because audits and systems for checking the quality of care and support delivered had not identified the number of issues we found, such as care plans not updated or missing important details and records of medicine storage showing medicines were being kept in temperatures above the recommended temperature.

Prior to completing this inspection we received some information of concern from the local safeguarding team who had collated a number of safeguarding alerts and concerns. These centred on healthcare professionals raising concerns about the service not requesting emergency medical assistance in a timely way and poor communication. There was also an alert raised by a relative about lack of stimulation for people.

Donnington House is registered to provide personal and nursing care for up to 36 people. They provide care and support for frail older people and those people living with dementia, but do not provide nursing care. On the day of the inspection there were 18 people living at the home, including one person who was having a short break there.

There was a registered manager who has been in post for a number of years. They are also the registered manager for the providers other home situated next door. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

People were at risk of receiving inconsistent or inappropriate care. This was because not everyone had a care plan covering all aspects of their needs. This meant staff did not always have a guide about how best to plan and deliver people’s care and support. For example in working with people living with dementia and associated agitation. Care plans were not person centred and did not always reflect people’s needs, preferences, interests, hobbies or past lives. This meant staff would have limited knowledge about people and events that were important to them, and would limit what staff could talk to people about.

Healthcare needs were not always being well planned for. Care plans lacked detail about how staff should respond to someone with epilepsy for example. One person’s plan had not been updated in respect of their wound care and pressure sore, which had in fact healed but their plan did not reflect this.

One of the medicine trolleys was situated in a space which was too warm to be able to ensure that effectiveness of medicines would not be compromised. Despite the service regularly monitoring, the temperatures in the trolley being above the recommended temperature no action had been taken. We had identified a similar issue in the inspection completed in June 2016. Once we fed this back, the trolley was moved to a cooler area downstairs, next to another medicines trolley. However this also had high temperature reading in the warmer months.

Risks of scalds from hot water outlets had not been checked, to ensure hot water temperatures were maintained with recommended safe limits.

People, relatives and staff felt their views were not always listened to but did feel the registered manager was approachable. People could make their concerns and complaints known but this was not always fully documented to show how they had been resolved.

The registered manager had not kept CQC informed of all notifiable incidents.

People received their medicines safely and on time.

Staff had good training and support to help them to do their job safely and effectively.

Staff understood how to keep people protected and who to report any concerns to. Recruitment practice was robust and ensured only staff who were fit to work with vulnerable people were employed.

People’s rights were protected because the service understood and applied the Mental Capacity Act 2005. They assessed people’s capacity to make decisions. Where people lacked capacity, Applications to Deprivation of Liberty Safeguarding teams had been made. Where restrictions such as bed rails and pressure mats were being used to keep people safe, best interest decisions were recorded.

People, relatives and staff felt their views were not always listened to but did feel the registered manager was approachable. People could make their concerns and complaints known but this was not always fully documented to show how they had been resolved.

We found four breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, responsive and well-led to at least good. During this inspection we found improvements had been made to the detail of care plans which enabled staff to provide more personalised and consistent care. We found health conditions and people’s preferred routines and likes and dislikes had been more clearly recorded. Risks were being clearly monitored and risk assessments detailed what staff should do to mitigate any risks identified. A new activities person had been employed who was providing a programme of activities throughout the week both in groups and to individuals, depending on their wishes and interests. We checked the accident and incident reports and found they linked to whether a notification had been sent to CQC. There were no gaps in reporting.

Where we had previously identified gaps in the quality assurance and audits to ensure people were kept safe, these had been rectified. Hot water was being regularly monitored to ensure it was not a risk of scalding people. The medicines storage areas were being more closely monitored to ensure the temperature did not rise above the recommended level. The provider had installed a cooling unit to the medicines storage room which helped to keep the temperature at a consistent level. The audits were being overseen by the manager and provider, who had increased their visits to the service.

No risks, concerns or significant improvement were identified in the remaining Key Question through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Donnington House 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. Donnington House is registered to provide personal and nursing care for up to 36 people. They provide care and support for frail older people and those people living with dementia, but do not provide nursing care. On the day of the inspection there were 18 people living at the home.

Since the last inspection the registered manager has resigned. The provider’s compliance manager was providing management cover over four days per week, whilst they are recruiting a new 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.

Just prior to Christmas we received some information of concern about staffing levels and we asked the provider to send us some information. They staffing levels had fallen below their preferred levels but this was due to staff sickness which they were unable to cover at short notice. People were kept safe because staff worked extra hours to ensure people’s needs were being met.

People were kept safe because staff understood about how to report abuse and recruitment practices were robust. Staff received training and support to help them do their job effectively. Medicines were being safely managed and people’s healthcare was being closely monitored.

Staff were caring, kind and attentive towards people. Staff worked in the least restrictive way to enable people to have choice in their everyday lives. People were offered a good range of meals, snacks and drinks throughout the day.

We could not improve the rating for responsive from Requires improvement because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

When we last inspected this service in May 2015 it was rated overall requires improvement. We issued a requirement notice cause we found there were not sufficient staff available at key times to meet people’s needs. We also highlighted that their mental capacity assessments were not decision specific. Care plans did not show how people were involved in the development and review of their plans. Following the inspection, the registered manager sent us an action plan to show how she would address the requirement relating to staffing.

At this inspection we saw there had been a small increase and changes in rota patterns to ensure there were sufficient staff available at lunch times. They had also purchased a hot trolley to ensure food would be kept warm if people needed to wait for assistance with eating their meal. Improvements had also been made in respect of ensuring mental capacity assessments were decision specific. Where possible they had made sure people or their relaitves had signed to show they were involved in the review of their care plan.

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 2014 and associated Regulations about how the service is run.

The Care Quality Commission (CQC) is required to monitor the operation of the Mental Capacity Act (2005) (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. DoLS are put in place to protect people where they do not have capacity to make decisions and where it is considered necessary to restrict their freedom in some way, usually to protect themselves or others. At the time of the inspection, applications had been had been made to the local authority in relation to people who lived at the service. The registered manager told us these were waiting to be approved. We saw that where mental capacity assessments had been completed, these were now more decision specific.

Recruitment processes showed only staff were employed who were suitable to work with vulnerable people. Staff understood how to keep people safe following risk assessments, using the right equipment and reporting any concerns.

People’s medicines were being well managed, which included written guidance to tell staff when they should consider an as needed medicine (PRN) for people who lacked capacity. The room medicines were stored in was too hot to ensure medicines were fully effective. Following our feedback the medicines were moved to a cooler room.

Staff received training in all aspects of health and safety as well as understanding the needs of older people and dementia. Staff had support and supervision to help them understand their role and do their job effectively. Staff said they felt valued and listened to.

People said they felt safe and well cared for. Staff knew people’s needs and preferences. One person said ‘‘Staff have been very kind to me. They are lovely.’’ Another reported, ‘‘I can’t fault the staff who work here, all very good.’’ One relative said they were always made welcome and that they believed staff were kind to their relative. They said ‘‘I do believe (name of relative) does get good care. The staff are always caring when I visit.’’

Staff knew how to protect people from potential risk of harm and who they should report any concerns to. They also understood how to ensure people’s human rights were being considered and how to work in a way which respected people’s diversity.

Care and support was being well planned for people’s health and personal care needs. Risks were identified and actions put in place to minimise these. Daily records showed people’s personal, health and emotional needs were monitored. However we found care plans did not contain detail about people’s social histories or their personal preferences. Staff could describe individual’s needs and wishes, but they were not always documented as part of the plan. People confirmed they were able to see their GP when needed and relatives confirmed they were kept informed of any change in the needs of their relative.

Audits were used to review the quality of care and support being provided, although these had not picked up on some care plans lacking detail about people’s social histories.

We found two breaches of Regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The action we have asked the provider to take can be found at the back of this report

Before people living in the home received any care or treatment they were asked for their consent and staff acted in accordance with their wishes. Throughout our visit we saw staff involving people in their care.

We saw people's privacy and dignity being respected at all times. We saw and heard staff speak to people living in the home in a way that demonstrated a good understanding by staff of people's choices and preferences. When asked, one person living in the home confirmed that the staff 'always asks me if I am ready to get up and if I want a cup of tea'.

Staff we spoke with were clear about the actions they would take should they have any concerns about people's welfare.

We looked at care records for four people living in Donnington House. We spoke with staff about the care given, looked at records relating to them, met with them and observed staff working with them.

We saw that people's care records described their needs and how those needs were met. We saw that people's mental capacity was assessed to determine whether they were able to make particular decisions about their lives.

During our visit to the home we saw sufficient staff on duty to meet the needs of people living in the home. We spoke with most of the staff working during our visit. Many of the staff had worked at the home for a number of years with one saying "we are like a family here".

As part of the quality monitoring system people who lived in the home and their relatives were sent surveys to complete. These surveys asked their views of the home. Improvements were made in the home following the results received.

Many people at the home lived with dementia. People who were able to tell us their experiences, and two people's families, spoke highly of the service. Comments included, "The staff are brilliant. You can't fault them" ; "(The manager) would deal with any problem" and "Xxx is lovely. She seems to be very patient with people". We observed care workers providing sensitive and respectful care to people who were confused and anxious.

Two health care professionals said they had no concerns and people's health was promoted. They said that the standards of personal care people received ensured their hygiene and dignity. However, one person's nails had not been kept at a safe length, which had caused a minor injury.

Comments about the food provided were varied and included, "Cannot be faulted" and "Passable". We found that people received adequate amounts of food and liquids, that there was a varied diet provided for them and dietary needs were monitored.

People said that the manager would deal with any concerns. However, there was almost no understanding amongst staff of the safeguards which should protect people who lack the mental abilities to make decisions about their welfare and staff lacked knowledge of local arrangements to protect people from abuse. This meant that people might not be protected or their rights upheld.

People's health care needs were met and there were some activities available for people. A district nurse said she had confidence in the home's management. The need for adequate food and fluids was recognised and dietary health was monitored to ensure people's welfare was promoted.

People told us that they felt safe at the home and we saw that there was strong leadership and arrangements in place to safeguard people from abuse. This included staff training but this did not extend to non care workers and so this may increase risk.

Medicines were properly handled at the home because they were securely stored and administered. Records were clear and orderly although not fully complete.

The home environment was safe and where the local authority food safety inspection visit had identified some concerns they were quickly dealt with.

Staff were properly trained, supervised and supported in their role. One person told us, "Staff are fairly consistent and exceedingly good".