Edward House

Edward House is a residential care home based in Burgess Hill, West Sussex. It provided personal care to 12 older people at the time of the inspection. Some of whom were living with dementia and other health conditions which included diabetes. The home is registered to support up to 22 people. The home accommodated people over two floors. People had individual rooms and had access to communal bathrooms, lounges and a dining room.

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

Oversight of risks, although improved, required further embedding in practice to ensure all risks, for all people, were minimised. This related to the oversight of people’s fluid intake, infection, prevention and control practices of senior staff and the accuracy of records to document staff’s actions and provide assurances of the care people had received.

The leadership and management of the home had significantly improved. The registered manager had improved oversight of people’s care and the running of the home. Actions were taken in a timely manner when there were issues or concerns. There was increased emphasis on improving the culture to improve people’s experiences and care. People, relatives and staff were involved in on-going discussions and were complimentary about the changes made. They told us the atmosphere was happier, and more pleasant. The registered manager welcomed feedback and used this to drive improvements within the home and to people’s care. Staff worked alongside external healthcare professionals to ensure people received appropriate and coordinated care.

People’s care and the management of risks associated to it, had improved since the last inspection. People and relatives told us people felt safe and there were enough staff to meet their needs, and our observations confirmed this. People were supported by suitably qualified staff and received safe and appropriate support which included access to their prescribed medicines. Incidents and accidents were analysed and lessons learned to inform changes in people’s care. When there were concerns about people’s well-being, the registered manager had liaised with the local authority for them to consider as part of their safeguarding duties.

People’s care was person-centred and tailored to their needs and preferences. Staff were provided with improved information about what was important to the person and what they enjoyed doing. Changes had been made to the environment and they spent time in the garden enjoying the outside space. Events had been organised to increase people’s social experiences such as barbecues and themed events. People received care that met their interests and preferences and told us they were happy living at the home.

Rating at last inspection and update

The last overall rating for the home was requires improvement (Supplementary report published 29 May 2020). The home was rated as Inadequate in the key question of Well Led and has been in Special Measures since 28 June 2019. During this inspection the registered manager demonstrated that improvements have been made. The home is no longer rated as Inadequate in any of the key questions. Therefore, the home is no longer in Special Measures.

Why we inspected

We carried out an announced focused inspection on 22 July 2020. We contacted staff and relatives on 20, 21 and 22 July 2020 and undertook a site visit to the home on 22 July 2020. We gave the registered manager and provider notice of the inspection to enable CQC and the registered manager to consider any infection prevention and control protocols due to the COVID-19 pandemic. We also established if people had COVID-19 or associated symptoms.

The provider completed an action plan after the last inspection to show what they would do and by when to improve in relation to the breaches of Regulations 9 (Person-centred care) and 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we checked they had followed their action plan. We also checked they had met the Warning Notice we previously served in relation to Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and they were now meeting legal requirements. This report only covers our findings in relation to the key questions of Safe, Responsive and Well-led.

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 remained Requires Improvement. This is based on the findings at this inspection.

In June 2019, the previous registered manager notified us of an unexpected death of a person who had fallen and sustained a head injury. This incident is subject to a potential criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

Enforcement

We have identified a breach in relation to safe care and treatment at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow-up

We will continue to monitor the intelligence we receive about the home until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

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

Some improvements had been made since the last inspection, including staff understanding and practice in supporting people to move around safely. However, there remained continued concerns about safety at the home. Risks to people were not always monitored and managed so that people were supported to stay safe and lessons were not always learned when things went wrong. Staff had not all been assessed as competent to administer people’s medicine and some people were not receiving their medicine as prescribed. Infection control procedures were not always followed to keep people safe from risks of infection.

Risks associated with nutrition and hydration were not always monitored and managed effectively and some people received food that was not appropriate for their needs.

Inconsistent information in records meant that staff did not always have the information they needed to provide effective care. Accurate records were not maintained to support monitoring of risks and this meant that the provider could not be assured that people were always receiving safe care that was appropriate for their needs. A new electronic records system had not yet become embedded in practice. There was a continued lack of oversight and governance because some management systems remained ineffective in identifying shortfalls in practice.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. However, one person had conditions attached to a DoLS authorisation that were not consistently met.

Care was not always provided in a way that was responsive to people’s needs. People were not supported to follow their interests or to engage in meaningful occupation. Some people told us they were bored and did not have enough to do. Some social activities were offered but these were not personalised to people’s interests and people were not consistently supported with activities that were meaningful to them.

Staff were not aware of the Accessible Information Standard (AIS) and people were not always provided with information is a way that was responsive to their needs. Staff practice did not always support people’s privacy and respect their dignity.

Staff demonstrated an understanding of safeguarding and there were enough staff to care for people safely. Recruitment systems ensured staff were suitable to work with people. Staff supported people to access health and social care services. Assessments were holistic and people were supported to plan for care and the end of their life.

People were supported by staff who knew them well. People said staff were kind and caring. One person said, “There are some good ones here.” People knew how to raise complaints and felt their concerns would be addressed.

Improvements in the management of the home were evident but were not yet embedded and sustained. Not all previous breaches had been addressed. Staff described improved leadership and were clear about their roles and responsibilities. Staff said they felt well supported and engaged with developments at the home. One staff member said, “Things are improving, the home is going in the right direction now.”

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 Inadequate (published 10 September 2019). We found continued breaches of regulation. We imposed a condition requiring the provider to send us information on a monthly basis, to show how they were monitoring the quality and safety of the service and making improvements. This condition was implemented just before this inspection. At this inspection the provider had made some improvements and the service is now rated as requires improvement.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

Enforcement

We have identified breaches in relation to managing risks to people, managing medicines, providing personalised care and the management and oversight of the service at this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. The overall rating for this service is ‘Requires improvement’. However, the service will remain 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.

Edward House is a residential care home providing personal care to 17 people aged 65 and over at the time of the inspection. The service can support up to 22 people. The care home accommodates people in one adapted building.

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

Risks to people were not always managed to keep people safe. We observed that staff were not always using appropriate techniques when supporting people to move. Risk assessments were not completed for people’s individual needs such as dementia or Parkinson’s Disease. This meant that staff did not always have the information they needed to support people safely, in the way they preferred.

Systems for ordering and administering medicines were not robust and records were not consistently maintained. Guidance for staff about when some medicines should be administered was not clear.

Staff reported incidents and accidents and kept records detailing what had happened. Reviews of practice following incidents were not completed consistently. This meant that safety concerns were not always effectively managed and opportunities for learning were missed.

Staff understood their responsibilities for safeguarding people and knew how to report concerns. People told us they felt safe at the home, one person said, “I want to be here, it is safe.” A relative told us they felt confident that their family member was looked after well and was safe at the home. There were enough staff employed to keep people safe.

There were significant shortfalls in the way the service was led. Governance systems were not effective in identifying issues relating to staff competency and the administration of medicines identified at this inspection. There had been a failure to make improvements following the last inspection, when breaches of regulation were identified. Changes had not been made and sustained. There were persistent breaches in areas of medicine management, risk assessment and governance.

Although staff and people spoke well of the registered manager the culture at the home was not always open and positive. Some staff had not been consistently supported.

Systems for monitoring quality at the service were not robust and this meant that there was a failure to learn from mistakes and to make improvements. Audits that the registered manager had relied upon were not always accurate and this meant that some shortfalls were not known by the registered manager or the provider and had therefore not been addressed.

The registered manager had failed to identify negative experiences for people and the impact on their dignity, through poor deployment of staff, lack of competency in manual movement and shortfalls in identifying call bell failures.

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

Rating at last inspection and update: The last rating for this service was requires improvement (published 13 December 2018). The provider completed an action plan after the last inspection to show what they would do, and by when, to improve. At this inspection the provider had met the breach of regulation 13, however, not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

We received concerns in relation to the management of medicines, staffing and people’s care needs. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well Led only.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Requires Improvement to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe and Well-Led sections of this 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 Edward House on our website at www.cqc.org.uk.

Enforcement

We have identified continued breaches in relation to the management of risks and administration of medicines and the management and governance of the service at this inspection. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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 rating, 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.

Edward House is situated in Burgess Hill in West Sussex and is one of a group of homes owned by the provider, Nicholas James Care Homes Limited. Edward House is registered to accommodate 22 people. At the time of the inspection there were 19 people accommodated in one adapted building, over two floors. Each person had their own room and access to communal bathrooms. The home provided accommodation for older people and those living with dementia.

The home had a registered manager. A registered manager is a ‘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 home is run. The management team consisted of the registered manager, a deputy manager and senior care assistants. An area manager also regularly visited and supported the management team.

At the previous inspection on 11 April 2016, an area identified as needing to improve was people’s access to stimulation and interaction, to occupy their time. At this inspection, it was evident that improvements had been made. An activities coordinator had been recruited and people were provided with activities that they found engaging and enjoyable. People had also enjoyed visits outside of the home. One person told us, “They are very good to me. I went to a World War Two local airfield where they have a museum with pictures of the aircraft that flew from there. I enjoyed that”.

Although improvements had been made since the previous inspection on 11 April 2016, at this inspection we identified concerns about the care people received. Medicines were not always administered or managed safely. One person who had a specific healthcare condition, did not always receive their medicines in a timely or person-centred way. Appropriate checks to ensure people received the correct medicines were not always made. One person, who was living with dementia, accessed the community independently. The registered manager had not identified, or taken appropriate action, to mitigate potential risks that might occur. Another person, sometimes displayed behaviours that challenged others. Staff told us that these occurrences were becoming more frequent. An incident had occurred where another person, as well as a member of staff, had been struck by the person. The registered manager had not considered this in accordance with the provider’s safeguarding procedures and had not raised the incident with the local authority, so that this could be considered under safeguarding guidance. The failure to identify and mitigate risks, to ensure people were receiving safe care and treatment, was an area of concern.

There was a lack of oversight of staff’s practice and of the systems and processes that were in place to ensure people received good care. Audits conducted by the registered manager as well as the provider, had failed to identify shortfalls that were found at the inspection in relation to medicines management, a potential safeguarding concern, staff competence in relation to dispensing and administering medicines and a lack of understanding about the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Neither had they identified that there were insufficient assessments and guidance provided to staff in relation to people’s specific healthcare needs. That reviews had sometimes failed to identify any changes in people’s needs or support requirements. That staff had failed to accurately document decisions that related to people’s care. Care was not always person-centred and people's expressed wishes, about the gender of their care giver, was not always respected. The lack of oversight to assess, monitor and improve the quality and safety of the services that people experienced was an area of concern.

People were not always supported to have maximum choice and control of their lives. Staff did not always support them in the least restrictive way possible. The policies and systems in the home did not always support this practice. This was identified as needing to improve.

People were complimentary about the food and drink. They told us they had choice and staff respected their right to change their mind. One person told us, “If you don’t like anything they will make you an omelette, a jacket potato or a sandwich”. However, people did not always have access to a dignified or sociable experience.

There were appropriate recruitment procedures. People were cared for by sufficient numbers of staff to meet their needs. One person told us, “I think they have enough staff to keep us safe because if there are any problems they stay on to help out. You cannot fault them”.

People were protected from infection and staff demonstrated correct techniques to ensure that cross-contamination was minimised.

People were supported to access healthcare facilities to maintain their health. They told us that they were supported to access GPs as well as external healthcare professionals.

People were happy living at the home. They told us that staff were kind, caring and compassionate.

People were involved in their care and able to contribute to discussions. People were supported to plan for their end of life care.

People were aware of how to raise concerns and complaints. Residents’ and relatives’ meetings, as well as surveys, enabled people to voice their opinions and make suggestions about the way the home was run.

People had space to be with others or to spend time on their own. People were complimentary about the environment and told us that it was ‘homely’ and met their needs.

People and staff were complimentary about the management of the home. People told us that they could approach the management if they had queries about their care.

This is the first time that the home has been rated as requires improvement. We found three breaches 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.

Edward House provides accommodation for twenty-two older people, some of whom are living with dementia, who may need support with their personal care needs. On the day of our inspection there were eighteen people living in the home. The home is a large detached property situated in Burgess Hill, it has a communal lounge and dining room and a garden.

The service had a registered 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.

There was a lack of stimulation for people. Observations of an activity in the afternoon showed people enjoyed taking part in the activity and this provided a sense of fun and enjoyment. However this was the only activity or stimulation provided throughout the day and people spent most of their day sitting in their chairs with little to do. People and relatives both felt that the activities provided needed to improve. One person was overheard saying “I am sitting around all day and doing nothing.” A relative told us “There could be more things to do I think, but I understand an activity co-ordinator starts next week so that should be good.” This is an area of practice in need of improvement.

There were sufficient numbers of staff to ensure people’s needs were met and their safety maintained. Staff had received induction training and had access to ongoing training to ensure their knowledge was current and that they had the relevant skills to meet people’s needs. People were safeguarded from harm. Staff had received training in safeguarding adults at risk, they were aware of the policies and procedures in place in relation to safeguarding and knew how to raise concerns. People felt safe, one person told us “I don’t think about it really so it must be safe.”

Risk assessments had been undertaken and were regularly reviewed. They considered people’s physical and mental health needs as well as hazards in the environment and provided guidance to staff in relation to the type of support people needed and the amount of staff required. People were encouraged and enabled to take positive risks. People’s independence was not restricted through risk assessments, instead risks were assessed and managed to enable people to be independent. Observations of people assessed as being at risk of falls showed them to be independently walking around the home. Staff were aware of the importance of keeping people safe whilst not restricting their freedom. One member of staff told us “Keeping the residents safe is a priority but not to the exclusion of everything else”. There were low incidences of accidents and incidents, those that had occurred had been recorded and were used to inform practice.

People received their medicines on time and told us that if they were unwell and needed medicines that staff provided these. People were asked for their consent before being offered medicines and were supported appropriately, being offered a drink to take their medicine safely and comfortably. Medicines were administered by trained staff and there were safe systems in place for the storage, administration and disposal of medicines.

People were asked for their consent before being supported with anything. For people who lacked capacity, mental capacity assessments had been undertaken to ensure best interest decisions were made on their behalf. People who were deprived of their liberty had appropriate applications made to the local authority to ensure that they were not being treated unlawfully.

People had access to relevant external health professionals to maintain good health. Records confirmed that external health professionals had been consulted to ensure that people were being provided with safe and effective care. People’s clinical needs were assessed and met and they received good health care from external professionals to maintain their health and well-being.

People were involved in their care and decisions that related to this. People were asked their preferences when they first moved into the home. Regular reviews ensured that staff were meeting people’s current needs. Relatives confirmed that they were involved in their loved ones care and felt welcomed when they visited the home and knew who to go to if they had any concerns. There were various processes that people and their relatives could use to make their comments and concerns known.

People were treated with dignity, their rights and choices respected. Observations showed people being treated in a respectful and kind manner. People’s privacy was maintained. When staff offered assistance to people they did this in a discreet and sensitive way. People confirmed that they were treated with dignity and their privacy maintained.

There was a homely, friendly and relaxed atmosphere within the home. People were complementary about the leadership and management and observations confirmed that the aims of the provider were embedded in staff’s practice. Quality assurance processes were carried out to ensure that the quality of care provided, as well as the environment itself, was meeting the needs of people.

The other people living at the home had complex needs and were not able to tell us about their experiences. Hence we used a number of different methods to understand their experiences of the service. We spoke with five relatives, a health care professional, the deputy manager and four members of staff. The relatives told us that they were satisfied with the level of care their relative received. They told us that they were involved in the planning of their care. They were kept informed about any changes in the care provided to their relatives. Staff told us that they understood the needs of the people living at the home and that they were able to support them. We looked at the care records of people and found that they contained the relevant information about the individual. We found that pre assessment had been carried out prior to admission. The care plans were reviewed on a regular basis and any changes in care needs were properly recorded.

We saw staff treating people with respect and helped them to be in control wherever possible. The relatives told us that they knew how to raise issues with the management. They were confident that management would listen to their concern and that it would be addressed appropriately.

The provider told us people views were taken into account in the way in which they were cared for. A relative told us they were kept abreast and they were consulted when changes were made to their care their relative received.

We found people were pre assessed prior to coming to the home to live. Care and treatment was delivered and planned in relation to people's care plan.

Staff told us they were supported and received appropriate training to deliver care to meet people's needs. We found staff were supervised and appraised.

We found that feedback from people, their representatives and other health professionals was used to assess and monitor the quality of the service delivered and to make changes.