Archived: Manton House

People’s experience of using this service: Since the last inspection the previous manager had left and there was a new registered manager in post. They have worked at the service previously as a deputy manager so were familiar with the service. They had started to make some improvements in the short time they have been the registered manager. At the last inspection we rated the service requires improvement in responsive and well led. During our most recent inspection despite improvements noted we found further improvements were required in each key question.

¿The service required financial investment to ensure in remained in a good state of repair and décor and was suitable for the needs of people using the service. There was no clear refurbishment plan and the environment had not been sufficiently updated since our last inspection.

¿Hazards identified on the first day of inspection had not been identified by the provider which increased the risks to people using the service.

¿We were encouraged by the immediate actions taken by the registered manager on our feedback and their willingness and genuine efforts to improve the service. They however need to reach a point where they are able to identify their own priorities and there needs to be clearer provider oversight and robust quality assurance processes.

¿Individual risks were identified and appropriate actions taken but risk assessments and care plans were not always updated in a timely way and information was not easily accessible to all staff. Staff were confident they could recognise abuse and knew what actions to take to promote people’s safety

¿Staffing levels were appropriate to meet people’s needs and there was an assessment tool in place to determine the number of staffing hours necessary according to people’s needs. The tool

was not very explicit and did not take account of the environment.

¿Staff recruitment processes were adequate and helped ensure only suitable staff were employed.

¿Staff audited medicines to help ensure people had their medicines in stock and administered when needed. We have made a recommendation about medicine audits to help ensure all areas of medicine management are identified as part of the audit.

¿People were supported to eat and drink enough for their needs but staff practices did not demonstrate a sufficiently individualised approach to meeting people’s dietary needs. We have made a recommendation about this.

¿The environment was not sufficiently personalised. However, the registered manager took some immediate actions to rectify this.

¿Staff knew people well but without consistent leadership the staff team had delivered the service as they thought best. This led to inconsistencies in how people were supported. Staff were kind but some had outdated practices.

¿Staff training was mostly up to date and there were plans to update it.

¿Most people were settled at the service and staff responded to people in a timely way. Some people were regularly engaged and staff took their time when delivering personal care and support. People were supported to stay active but this was an area for development as activities were limited in scope and not suitable for everyone. Community engagement was improving. We have made a recommendation about activities.

¿Care plans described people’s needs but care staff did not access care plans regularly or contribute in reviewing them. We have made recommendations about care planning and recording of people’s care needs.

¿Staff consulted with people about their care needs but capacity to make decisions had not always been clearly established.

Rating at last inspection: The rating at the last inspection on 26 September 2017 was requires improvement in responsive and well led with no breaches to the Health and Social Care Act Regulations.

Why we inspected: Previously we had rated this service as requires improvement and therefore have been back to ensure it had improved to good. We had received an action plan telling us what the service managers would do to improve provision and we checked this action had been taken.

Follow up: We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve the rating of the service to at least Good. We will require them to provide an action plan detailing how this will be achieved. We will revisit the service in the future to check if improvements have been made.

Manton House provides care for up to 22 people, some of whom were living with dementia. There were 10 people living in the home on the day of our inspection. The building offered accommodation over two floors. On the ground floor there was a communal lounge, reminiscence room and separate dining room where people could socialise and eat their meals if they wished.

Following our last inspection, the manager at that time decided not to register with the Commission. The provider appointed another manager in July 2017. The appointed manager registered with the Care Quality Commission in September 2017. The previous manager continues to be registered for another location for the same provider and offers support to the newly registered manager of Manton House. 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 of the Health and Social Care Act 2008 and associated regulations.

At the last inspection on 22 February and 01 March 2017 the service was rated ‘Inadequate.’ The report was’ published in May 2017. At that inspection we identified seven regulatory breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Six of these regulatory breaches were in relation to a lack of person centred care for people. People's privacy was not maintained at all times and there was poor monitoring of the service. The principles of the Mental Capacity Act were not being followed as assessments on capacity to make decisions were not completed in all cases where required. Care and treatment was not always provided in a safe way. Risks to people's safety who were living in the service had not always been assessed. Where they had been, actions had not always been taken to mitigate these risks. Not all areas of the premises had been adequately assessed to ensure the environment was safe for people to use. Some people's medicines had not been well managed. The nutritional and hydration needs were not being met for all people living in the service to sustain good health. Suitably qualified, competent, skilled and experienced staff had not always been deployed in the home. Staff had not always received appropriate training, supervision or support to carry out their role. We took enforcement action to protect people by imposing a condition on the providers registration. We told the provider they could not admit any new people to the home from 12 May 2017 without the prior written agreement of the Care Quality Commission. This included people seeking respite care.

At the last inspection the provider was also in regulatory breach of the Health and Social Care Act 2008 (Regulated Activities) 2014 due to not having systems in place to assess monitor and improve the quality and safety of the service provided. They had failed to assess, monitor and mitigate risks relating to the health, safety and welfare of people living in the service. An accurate and complete contemporaneous record in response of each person living in the service was not in place. We took enforcement action in the form of a warning notice regarding this failure to meet standards. This required the provider to take immediate action in relation to assessing the risks to the health and safety of people and the effective governance of the service.

Following the inspection the provider sent us an action plan detailing how the identified breaches would be addressed. This inspection was to check improvements had been made and to review the ratings. We found the provider and registered manager had taken sufficient action to address previous concerns and comply with required standards. As a result, the provider has complied with the Warning Notice and condition imposed.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Since our last inspection, the service had experienced a period of considerable change. It was evident that the new registered manager had effected improvements to the leadership of the service. Although significant improvements had been made to address previous shortfalls raised in our last visit, Manton House is on an improvement journey and these improvements were yet to be embedded and sustained.

At the last inspection we found there was insufficient activity provision and people's preferences were not sought. At this inspection we could see there were improvements, however activities and peoples preferences were not wholly implemented. This is an area requiring improvement.

At this inspection we found systems for monitoring quality and auditing the service had significantly improved and were being used to continually develop the service. However, the frequency of auditing peoples care plans meant the registered manager could not be assured people reliably received all of the care they needed. This is an area requiring improvement.

Staff were trained in adult safeguarding procedures and knew what to do if they considered people were at risk of harm or if they needed to report any suspected abuse. People who were able to said they felt safe at the home.

People’s care records showed risks to their safety were assessed and the action needed to mitigate those risks. These assessments and care plans were reviewed and updated at regular intervals to ensure people's changing needs were met. Accidents and incidents were accurately recorded and were assessed to identify patterns and trends. Records were detailed and referred to actions taken following accidents and incidents.

There were sufficient staff in place to meet people's needs. The registered manager used a dependency tool to assess staffing levels and to ensure they were based on people's needs, were up to date and reviewed monthly. Staff recruitment procedures ensured only those staff suitable to work in a care setting were employed.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely.

Staff received an induction into the service and senior staff checked competencies in a range of areas. Staff had received a range of training and many had achieved or were working towards a National Vocational Qualification (NVQ) or more recently Health and Social Care Diplomas (HSCD). Staff received formal supervision and annual appraisals from their manager.

People were supported by staff who understood and effectively applied the principles of the Mental Capacity Act, 2005 and the Deprivation of Liberty Safeguards. Staff confidently applied the MCA to make sure that people were involved in decisions about their care so that their human and legal rights were protected. People were supported to have maximum choice and control of their lives and staff assisted them in the least restrictive way possible.

People had sufficient to eat and drink and were supported by staff to maintain a healthy diet. Observations of meal times showed this to be a positive experience, with people being supported to eat a meal of their choice and where they chose to eat it. Staff engaged in conversation with people and encouraged them throughout the meal, noting who liked to sit with whom. Nutritional assessments were in place and special dietary needs were catered for.

People's health care needs were assessed monitored and recorded. Referrals for assessment and treatment were made when needed and people received regular health checks.

Caring relationships had been built between people and staff. Staff working in the home were predominantly caring and compassionate. Staff knew the needs and preferences of the people they cared for and people were given reassurance and encouragement when they needed it. Where people needed support in order to make their own day to day decisions this was provided by staff. Where people had short term memory loss staff were patient in repeating choices each time and explaining what was going on and listening to people's stories. People's rights to privacy, dignity and independence were taken into account by staff in the way they cared for them.

People looked comfortable and happy moving around the home, some people stopping for rests or a nap, other people enjoyed having a late breakfast, doing a crossword or reading the newspaper. Staff were always visible to interact or sit with people. Each person's needs were assessed and this included obtaining a background history of people. Care plans and assessments were comprehensive and showed how people's needs were to be met and how staff should support people. Care was individualised to reflect people's preferences.

The home had been decorated and arranged in a way that supported people living with dementia. The service was brightly decorated and stimulating for the people living there. The communal areas of the service were clean and well-furnished with a homely feel. People's rooms were individualised, with personal items such as ornaments, photos and furniture. The outside area was accessible with paths and benches.

Complaints were listened to and managed in line with the provider's policy. Relatives told us that they felt welcomed at the service and people and relatives said that they would be confident to make a complaint or raise any concerns if they needed to.

People and their relatives were involved in developing the service through meet

Manton House provides accommodation and personal care for a maximum of 22 older people, some of whom may be living with dementia. At the time of our inspection there were 15 people living in the home.

This inspection took place on 22 February and 1 March 2017 and was unannounced on both days.

Due to a number of concerns raised about the home we brought forward the scheduled inspection so we could check that people were receiving safe care. At this inspection, we found people's safety was being compromised in a number of areas.

Although some risks to people had been assessed and documented, these assessments were not always adhered to by staff in order to deliver safe care. People's care plans and other associated records did not have the necessary information to reflect people’s care needs. Although all people had a care plan in place, plans were very brief and lacked detail.

People's medicines were not managed or stored safely. Some people living at the home did not receive their medicines how the prescriber intended.

Recruitment processes were not always adhered to. Appropriate risk assessments were not carried out where there may have been concerns about a person’s suitability for the job role.

Not all staff had received the level of training required to meet the current needs of people who used the service. This meant some people may be at risk of not receiving appropriate care and support. Staff were not supported through regular supervision. Although the registered provider and manager were aware of this, a plan to address this had not been put in place.

The principles of the Mental Capacity Act (MCA) 2005 were not fully understood by all staff and the correct process for making best interest decisions had not been followed in all cases.

There were 16 CCTV monitoring cameras covering the internal communal areas of the service, including corridors, the dining room, kitchen and lounge areas. There were no assessments to show that people who lacked capacity had been considered when installing the CCTV.

People’s care records did not always reflect their current needs and care was not always delivered in line with people's assessed needs. Some people had specialist diet requirements, records of support provided however records did not always show that this care had been delivered.

Improvements were needed with regard to the provision of meaningful activities for people to take part in. There were few stimulating activities for people on offer. The environment was not dementia friendly and did not reflect current good practice guidance.

Our inspection identified serious concerns regarding the management and leadership of the service and the quality of their care delivery. People were being put at risk of physical harm and there was insufficient governance to monitor the care being delivered. There had been a lack of effective leadership and management at the service which had led to a significant deterioration in the quality of the service.

We found the home was in breach of seven regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

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.”

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.”

Manton House is registered to provide accommodation and personal care to a maximum of 22 people. People living at the home are older people, some of whom live with dementia. There were sixteen people living in the home when we inspected.

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.

Staff understood how to protect people from harm and from the risk of abuse. They understood their responsibilities in keeping people safe. Risks to people’s safety had been assessed and actions taken to reduce these risks.

Recruitment processes were in place to ensure that staff employed in the service were suitable for the role. People received their medicines when they needed them and the staff had received enough training to enable them to provide people with effective care. Staff were confident in reporting incidents and accidents and appropriate action was taken when one occurred.

Staff did not always ask people for their consent and people were not always assumed to have capacity to make choices. Staff at times respected people’s rights where they were not able to consent to their own treatment. The home was inconsistent in its’ compliance with the requirements of the Mental Capacity Act 2005 (MCA).

People were supported to access healthcare professionals when needed and in a timely manner, with prompt action taken in response to changes to a person's health needs. People received enough to eat and drink to meet their needs, however they were not empowered to make choices of food prior to eating.

Staff had good knowledge about the people they cared for and understood how to meet their needs individually. People received most care according to their preferences and people and relatives were consulted about their care when coming into the home.

Some activities were carried out in line with people's preferences, however there was not enough stimulation and a variety of planned activities.

Although staff were caring towards people, practices did not always respect people’s privacy when entering their rooms and their dignity at mealtimes. We have made a recommendation about seeking more current guidance in respect of dementia care. Staff were kind and compassionate. They consistently demonstrated humour and warmth during their interactions with people. Feedback from people and their relatives about the care they received was complimentary..

Staff were well motivated. There was good teamwork within the service and staff felt supported in their roles.

Feedback was not actively sought from people using the service and their relatives so any action could be taken to improve. There were some systems in place to assess and monitor the quality of the care provided, however feedback was not always acted upon.

Staff rotas showed there were enough staff members for the home and this number met the provider's staffing assessment tool. People using the service said there were enough staff available to meet their needs.

Systems were in place to regularly check and monitor the way the service was run.

People received the care and support they required to improve their health and well-being. However, care was not always adequately planned and records were not written in enough detail to provide clear guidance to staff members.

People were provided with meals and alternatives were available. Staff members assisted them appropriately with eating and drinking. One person told us that their meal was, 'Delicious'.

Medicines administration records were kept and people received their medicines in a safe way. People told us they always received their medicines when they were due.

The service had a policy and procedure to guide people in how to make a complaint although information about taking complaints further was not accurate. People told us they would be able to make a complaint.

Staffing information showed that there were enough staff available to meet people's needs. However, this was because the manager was also acting as one of the care staff team and only spent one day a week working in the manager's role.

There were systems in place to monitor the way the service was run, although these had not identified that care records were not always updated properly. Records of some audits that had been completed had not been kept.