This inspection took place over four days: 23/05/14, 02/06/14, 03/06/14 and 04/04/14. Two of the visits took place during the evening. It was performed by two inspectors. They were supported on 03/05/14 by a third inspector. During the inspection, we spoke with all of the 20 people living in the home and observed care for people in the sitting rooms and dining room. We met with four people's relatives. We spoke with 14 members of staff. We also inspected the facilities in the home, and looked at records.At the previous inspection, we had warned the provider they needed to take action to become complaint with the law by 30/05/14, across a range of areas. These related to ensuring people were provided with appropriate care to ensure their welfare, to ensure there were sufficient staff on duty with the appropriate skills to meet people's needs. Additionally we warned the provider they needed to appropriately assess and monitor the quality of service offered to people and ensure accurate records were maintained. We additionally asked the provider to take action to appropriately safeguard people from abuse and that staff were supported in their roles by training and supervision. The provider sent us an action plan in which they confirmed they would take action and would be compliant by 30/05/14. At this inspection we found the provider had not taken appropriate action to become compliant with the law. We additionally found they had become non-complaint with the law in relation to two other areas.
We considered our inspection findings to answer questions we always ask;
Is the service caring?
Is the service responsive?
Is the service safe?
Is the service effective?
Is the service well led?
Below is a summary of what we found. If you would like to see the evidence supporting our summary please read the full report.
Is the service caring?
Relatives reported staff cared about the people living in the home and knew their needs. One relative described the 'compassion and the care and the thoughtfulness shown' by staff. We observed staff supporting people a kindly, friendly way at times. We saw a registered nurse taking time to support a person who was confused and distressed.
We also saw staff were variable in their responses to people. For example we saw a member of staff take cups away from two people with no interaction to find out if they had finished or would like anything more to drink. We observed a person who stood up and tried to leave a sitting room. The member of staff in the area asked the person to sit down again, as they might be unsafe. This member of staff did not ask the person if they wanted anything. All, apart from one of the care workers, supported people who needed help to eat by standing up above them. This made the meal a functional occasion and did not support the person in social engagement.
We are going to take action to ensure the provider meets the requirements of the law in relation to ensuring people's dignity, privacy and independence are respected.
Is the service responsive?
We saw the home manager had sent out questionnaires to people about service provision. A person's relative had raised an issue. This had not been responded to by the home.
The provider had taken some action to ensure staff had been trained to meet the general needs of people, including moving and handling and first aid. They had not ensured staff were trained in conditions which may be associated with older age, including prevention of pressure ulceration and stroke care. Two people had sustained pressure ulceration while in the home. Staff told us although training had been provided in dementia care, the training did not relate to the complex needs of the people cared for in the home. We saw staff did not consistently respond to people who were living with dementia in an effective way, in accordance with national guidelines.
We are going to take action to ensure the provider meets the requirements of the law in relation to ensuring staff are appropriately supported in their roles to deliver care and treatment to people in a safe way and to an appropriate standard.
Is the service safe?
We found people were not safe as the home was not following guidelines on infection control and hygiene. This involved not following precautions for the prevention of spread of infection, including in the management of laundry. We also observed a wide range of areas which were not clean, such as dirty commodes and stained arm rests to chairs in lounge areas.
CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. No applications had been submitted from this home. Information from some staff indicated they may not be following these guidelines when delivering care to certain people. Alerts had not been made to the local authority on all relevant occasions to ensure people were protected from risk of abuse.
We found the provider had not taken action to ensure there were sufficient numbers of staff on duty to meet the high dependency needs of people. The home also did not have sufficient registered nurses in post who had the skills or experience to meet the needs of people with complex dementia needs.
We are going to take action to ensure the provider meets the requirements of the law in relation safeguarding people from abuse, ensuring effective standards for hygiene and prevention of spread of infection and ensuring there are sufficient numbers of suitably qualified staff on duty.
Is the service effective?
Relatives said they felt the service was effective in meeting people's needs. One relative told us their relative had 'improved enormously since they've been here.'
The home specialised in caring for people who were living with dementia who had nursing needs. We found people's dementia care plans were not clear and did not include all relevant information relating to each person. When we spoke with staff they gave us information about management of these people's behaviour which differed from care plans.
The home were not following guidelines on prevention of pressure ulceration. One of the people we met with had sustained pressure ulceration in the home. They did not have a care plan about how this was to be managed. The person was not always having their position changed on a regular basis to reduce their risk.
Two of the people we met with had specific advice from external healthcare professionals about their care and treatment in their records. This advice was not reflected in these people's care plans. Staff we spoke with reported they did not know about this advice. We did not observe the advice was being followed in practice when people's care was being provided.
We are going to take action to ensure the provider meets the requirements of the law in relation to meeting people's care and welfare needs.
Is the service well led?
The Old Parsonage did not have a registered manager in post. A person was appointed into this role but they left their employment before 02/06/14.
The provider performed monthly visits to the home and made a report. These visits had not identified the home's continued non-compliance with the law or other areas which needed action. The audits had also not identified staff were not completing records contemporaneously, that some records were incomplete and others were not in place.
We are going to take action to ensure the provider meets the requirements of the law in relation to ensuring they have effective systems for assessing and monitoring the quality of service provision and maintenance of accurate and appropriate records.