Redmount Residential Care Home

Redmount Residential Care Home (referred to as Redmount in this report) is a residential care home providing personal care to up to 36 older people. At the time of our inspection there were 18 people using the service.

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

People were happy living at the service and spoke positively about staff and the care they received.

Since our last inspection, improvements had been made to the culture of the service and quality-of-care people received. The provider's quality assurance processes and management oversight had improved and was driving improvements across the service.

Risks to people's health and safety were effectively managed, including fire safety, infection prevention and control and risks associated with the environment.

Risk assessments were carried out to identify any potential risks to people and measures put in place to mitigate these.

There had been improvements to the way people’s medicines were managed since our previous inspection. People now received their medicines in a safe way, as prescribed for them.

People benefitted from an improved mealtime experience and were supported to eat in line with their needs and preferences. People's weights were monitored, and action was taken where there were concerns.

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 now supported this practice.

People received person centred care and care plans provided staff with enough information to be able to care for people safely and in the way that they wanted to be cared for.

People told us they were safe at Redmount. Staff understood their responsibilities in safeguarding people from abuse and knew how to report any concerns they had.

Systems were in place to ensure there were enough staff to meet people's needs and staff were recruited safely.

People were supported by staff who were competent and had received appropriate induction, training and support. Staff spoke positively about the leadership and management of the service.

Staff worked closely with healthcare professionals and sought their advice, guidance and support on how to meet people's needs.

People were supported to maintain relationships and take part in activities they enjoyed.

People's views were sought and used to drive improvement within the home. The provider had systems in place to ensure any concerns were dealt with appropriately.

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 10 June 2022) and there were breaches of regulation. 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 undertook this inspection to follow up on action we told the provider to take at the last inspection and to confirm they now met legal requirements.

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 COVID-19 and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Redmount Residential Care Home is a residential care home providing personal care for up to 36 people aged 65 and over. At the time of the inspection there were 21 people living at the service.

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

The provider had failed to have sufficient oversight of the service to ensure people received safe and consistently well-managed care and support. This impacted on the quality of the health, safety and care provided to people. Concerns identified at the previous inspections had not been fully addressed. Repeated concerns had been noted at this inspection.

People were placed at risk of unsafe care as their care needs and associated risks had not been routinely assessed, updated and monitored. Recognised risk assessment tools and monitoring records in place were not always accurately completed.

People at risk of losing weight were not always managed safely. Systems in place to monitor people’s weight had failed to ensure timely or appropriate action was taken when people had lost weight.

People who were at risk of skin damage did not always receive effective pressure area care. Repositioning schedules were not in place for people who needed support to move in bed and records did not demonstrate that people had their prescribed creams applied to protect their skin.

There were poor infection prevention and control measures in place at Redmount Residential Care Home. Staff did not always use PPE effectively and safely and in accordance with current government guidelines.

People were not always protected from risks associated with their environment. The services fire risk assessment identified several actions which needed to be completed were outstanding from the previous fire risk assessment dated September 2020.

Medicines were not always managed safely. People did not get always get their medicines as prescribed for them or when they needed them which put their health at increased risk.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Staffing was not always planned or deployed in a way that met people's specific health care needs. People who required support and assistance were being left for long periods of time as staff were busy in other parts of the service. We have made a recommendation about this.

A lack of direction and leadership provided to staff resulted in areas where the culture of the service needed to be improved. Although we observed many positive interactions between people and staff during the inspection, the language some staff used when talking with people, was disrespectful and did not promote their dignity.

Although people told us that they enjoyed the food provided at the home, we observed people did not receive a person-centred dining experience. Records did not accurately record what people had eaten or drank and they were not always given what they had originally been offered or requested eat.

People were supported by staff who had received training to help ensure they could meet people's needs safely and effectively. However, staff induction specific to the service, had not been fully completed. We made a recommendation about this.

People felt safe and received care from staff who had been appropriately recruited and trained to recognise signs of abuse or risk and understood what to do and who to contact if they suspected people were at risk.

Feedback from relatives was mainly positive and they felt staff were kind and caring and doing their very best for people living at the service.

Accidents and incidents were recorded and reviewed by the manager and provider to identify any learning which may help to prevent a reoccurrence.

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 (29 July 2021). 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 the provider remained in breach of regulations.

The service remains rated requires improvement. This is the third consecutive inspection where the service has been rated requires improvement.

Why we inspected

The inspection was prompted in part due to concerns received about medicines management, manual handling, staffing and poor-quality care. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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 COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this report.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk management, person centred care, dignity and privacy, choice and consent, and good governance at this inspection.

We also made two recommendations in relation to staffing arrangements and the deployment of staff and ensuring that all staff working at the service have completed an induction.

Please see the action we have told the provider to take at the end of this report.

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Redmount Residential Care Home is a residential care home providing personal care to people aged 65. The service accommodated up to 36 people in one adapted building, with a two passenger lifts to access the rooms on the first, second, third and lower ground floors. At the time of the inspection there were 30 people living at the service.

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

People who were able to share their views with us were happy living at Redmount and were extremely positive about the staff that supported them.

The service was not operating in accordance with the regulations and best practice guidance. This meant people were at risk of not receiving the care and support, that promoted their wellbeing and protected them from harm.

Effective systems were not always in place to assess and manage risk to people's safety.

People's monitoring charts were not being completed consistently in relation to skin care and nutrition and hydration. Risks to people's health and welfare had not always been assessed and detailed guidance was not always available for staff to refer to.

People were not always protected from the risk and spread of infection. We were not assured that staff were using personal protective equipment (PPE) in accordance with the government guidance and the service did not always follow its own procedures when permitting visitors to enter the building. This was addressed immediately with all staff undergoing supervision on infection prevention and control topics and the management team conducting daily spot checks on PPE compliance.

Not all aspects of medicines management were carried out safely and people did not always receive their medicines as prescribed.

People were not always being supported by enough staff or staff effectively deployed to ensure people’s needs were met. People told us, and we observed, people often had to wait for staff to meet their needs. We made a recommendation about this.

Quality assurance and governance arrangements in place to monitor and improve the service were not always robust or effective in identifying shortfalls we found during the inspection. Following the inspection, the provider shared with us their action plan for addressing the concerns found during the inspection and took immediate action.

People were protected from the risk of abuse. Staff were trained in recognising signs of abuse and people spoke positively of the atmosphere in the home and found staff kind and caring.

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.

Record showed staff received training, supervision and appraisals. People were supported to access healthcare services they needed.

The management and staff team had worked in partnership with other healthcare professionals.

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 1 April 2019). There were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made and the provider was still in breach of regulations in relation to safe care and treatment, infection prevention and control and governance.

The last rating for this service was requires improvement (published 1 April 2019). The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

The inspection was prompted in part due to concerns received about skin care, people's needs not being met, staff culture and record keeping. A decision was made for us to undertake a focused inspection to review the key questions safe, effective and well led to examine those risks.

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 COVID-19 and other infection outbreaks effectively.

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.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full 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 Redmount Residential Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

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.

Redmount Residential Care Home is a ‘care home’ without nursing, operated by Your Health Limited. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

People living at Redmount Residential Care Home were older people, many living with long term health conditions or dementia. The service accommodated up to 36 people in one adapted building, with a two passenger lifts to access the rooms on the first, second and lower ground floors. At the time of the inspection there were 23 people living at the service.

At the time of the inspection the service was in a whole service safeguarding process. This meant the local authority safeguarding team were monitoring and working with the service to ensure people were protected from abuse and their rights safeguarded.

The service 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. People told us they liked the registered manager and were sorry she was leaving.

At the last inspection of the service on 19 and 26 May 2016 the service was rated as ‘good’ in all areas. On this inspection we identified concerns and four breaches of legislation and have rated the service as requires improvement as a result.

People could not be confident of experiencing consistently safe of high quality care because systems to assess, monitor and mitigate risks and provide high quality care were not operating effectively. We found concerns that had previously been identified by the service’s own internal auditing systems or through the provision of support from the Quality improvement team from the local authority but had not yet been resolved. Although actions had been taken in many cases we found learning had not been sufficient to avoid repetition of the concerns. This meant some systems were not being operated in line with good practice. People’s records, including those for the administration of medicines were not always accurate, up to date or completed in line with good practice.

People were not always receiving support to mitigate risks from their health and care needs. Risks from people’s care had not always been fully assessed and mitigated. Records relating to people’s dietary intake when they were at risk from poor nutrition were not completed in enough detail. Other records in relation to the management of risks to skin damage were not clear, or backed up with important information needed to make a judgement on how to reduce risks.

People told us they were not always supported by sufficient staff to meet their needs, although they spoke positively about the staff caring for them. Staff were recruited safely with a robust system in place to ensure they were suitable to be working with people. We have made a recommendation about re-assessing staffing levels.

People did not always benefit from an environment adapted to meet their needs, particularly in relation to people living with memory impairment. Redmount is a large adapted building set over four floors. People’s rooms were mainly en-suite which afforded people additional privacy, but we saw little adaptation or signage to help people understand their environment or orientate themselves when they had some memory loss. We have made a recommendation about the adaption of the environment to meet the needs of people living with memory impairment.

People were not always supported well because staff training was not always being put into practice and supervision did not always identify when poor practice had been carried out. We saw instances of where people were not being supported in line with training staff had received, including being transferred poorly in a wheelchair and staff not always using infection control equipment correctly. We have made a recommendation about staff supervision and support.

Some staff training was behind schedule, including for areas such as fire safety training, although we could see training had been booked.

People’s rights were not always being protected because there was not always a clear understanding of the Mental Capacity Act 2005 (MCA) in practice. We have made a recommendation about this. While we saw examples of people being offered choices in their day to day lives and being asked if they consented to their care, the records of decisions made on people’s behalf when they lacked capacity did not cover all areas needed to meet the requirements of the MCA.

People were supported by staff who understood about how to protect them from abuse, and what to do if abuse was identified. People told us they felt safe at the service, and most told us they had good relationships with the people caring for them. We saw people being supported to celebrate special occasions and engage in good humoured interactions with staff throughout the inspection. People could expect to have their privacy and confidentiality protected.

People all had a plan of their care, but this was not always personalised, accurate or drawn up and reviewed with the person concerned or their supporters where relevant. We found some care plans did not provide sufficient detail on how people’s needs were to be met. Staff told us they had little time to read people’s full care plans, and did not have input into how they were written. Arrangements were made for positive end of life care when appropriate.

People benefitted from food choices that met their needs and preferences. People told us they enjoyed the food and had choices open to them. In particular, one person who was vegetarian told us they received a good variety and choice of meals.

Staff knew people well, and we saw evidence of compassionate, caring and supportive relationships in place. However, we also saw evidence this was not always the case. For example, one person had a poorly implemented and understood care regime, which had caused them distress and staff frustration. The service respected people’s diversity, and told us they would not discriminate against people because of protected characteristics under the Equality Act, such as age, religion, gender or ethnicity.

People benefitted from a programme of activities they told us they found engaging and enjoyable. We saw activities being carried out that engaged people and supported them to celebrate special events. People had opportunities to have a say about the way the service was run, although systems for doing so were not always operating well. Systems were in place for the management of complaints. Visitors could visit the service at any time, and told us they were made welcome.

We found four breaches of regulation on this inspection and you can see what action we have asked the provider to take at the end of this report. We also identified a number of good practice recommendations.

This inspection took place on the 19 and 26 May 2016, and was unannounced. The inspection team consisted of two adult social care inspectors. The service was previously inspected on the 29 May and 3 June 2015, when we found improvements had been made, but further improvements were still needed in relation to medicine administration and some areas of record keeping. Following that inspection the provider sent us an action plan telling us how they were going to meet this regulation. At this inspection in May 2016, we found that improvements had been made.

The home 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.

People said they felt safe and well cared for at Redmount their comments included “I do feel safe” “the staff are very kind and would do anything for you” “they call the doctor right away” I’m very happy here”. Relatives told us the staff were brilliant, people are safe and well looked after. One relative said “I wouldn’t change a thing I’m perfectly happy with the care of [person name].

One health care professional said the staff were very caring and compassionate and people were safe and well looked after. We saw people were happy to be in the company of staff and were relaxed when staff were present.

People told us they were happy living at the home, staff treated them with respect and maintained their dignity. Throughout our inspection, there was a relaxed and friendly atmosphere within the home. Staff spoke affectionately about people with kindness and compassion. People and relatives told us they were involved in identifying their needs and developing the care provided. People's care plans were informative, detailed and designed to help ensure people received personalised care. Staff knew how each person liked to be addressed and consistently used people’s preferred names when speaking with them.

People who used the service told us they knew how and were able to raise concerns and there were systems to help ensure people were protected from all forms of abuse. Staff had received training in safeguarding vulnerable adults and whistleblowing. Staff demonstrated a good understanding of how to keep people safe and how and whom they would report concerns to.

People told us there were sufficient staff on duty to meet their needs one person said there was always someone around and they have time to “sit and talk”. The registered manager used a dependency assessment tool to review staffing levels which was based on people’s changing needs and adjusted the rota accordingly.

People were encouraged to take an active part in the running of the home. We saw that two people had recently been appointed to the home’s interview panel of future employees. Recruitment procedures were robust and records demonstrated the registered manager had carried out checks to help ensure that staff employed were suitable to work with vulnerable people.

People received their prescribed medicines on time, in a safe way, and given the time and encouragement to take their medicines at their pace. There was a safe system in place to monitor the receipt and stock of medicines held by the home. Medicines were disposed of safely when they were no longer required. We saw from records, changes of directions had been appropriately documented and double signed on MARs and recorded in people’s care plans. Staff had received training in the safe administration of medicines.

Risks to people’s health and safety had been assessed and regularly reviewed. Each person had detailed risk assessments, which covered a range of issues in relation to people’s needs. Accidents and incidents were recorded and reviewed by the registered manager who collated the information to look for any trends that might indicate a change in people's needs, reviewed staff practice and updated people's risk assessments and care plans accordingly.

People told us the staff knew them well and they were happy with the care and support they received. People said staff responded quickly to their needs and sought help and advice from health care professionals when needed. We saw the home engaged proactively with health and social care agencies and acted on their recommendations and guidance to improve people’s wellbeing and people had access to a range of health care services.

People told us staff received lots of training; one person said “they have it every week”. People were supported by staff who were knowledgeable about each person’s individual care needs and provided care and support in line with people’s wishes. New staff undertook a detailed induction programme which followed the Skills for Care framework, including the Care Certificate. This is an identified set of standards that care workers use in their daily work to enable them to provide compassionate, safe and high quality care and support. Individual training records showed staff received regular training, support and supervision. The home had appointed Dignity and End of Life Champions and several staff including the registered manager had become Dementia Friends which is an initiative run by the Alzheimer’s society.

Staff demonstrated a clear understanding of the principles of the mental capacity Act 2005 (MCA) in their practice. People told us they were involved in all aspects of their care and support. We saw staff sought people’s consent throughout our inspection and made every effort to help people make choices and decisions.

People told us they enjoyed the meals provided by the home. Their comments included, “the food is gorgeous,” “I enjoy the food here,” and “there’s always plenty of choice.” People were freely able to help themselves to snacks and drinks when they wanted, and we saw people who were not able, being offered snacks and drinks throughout the day.

People and staff told us that the home was well managed. The management and staff structure provided clear lines of accountability and responsibility. Staff knew who they needed to go to if they required help or support. There were good systems in place for staff to communicate any changes in people’s health or care needs through handover meetings. Regular staff and head of department meetings enabled staff to discuss ideas about improving the service.

People who used the service told us they were encouraged to share their views and were able to speak to the manager when they needed to. Resident’s meeting were held regularly and we saw people were able to discuss all aspects of the home and the care provided, where people had raised concerns or suggested new approaches these had been adopted.

The registered manager carried monthly audits to review health and safety practices such as fire safety, equipment checks, medicine audits and analysis of accidents and incidents.

Records were stored securely, well organised, clear, and up to date.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five 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?

This is a summary of what we found:

Is the service caring?

People we spoke with who lived at the home told us that staff were caring and looked after them well. A relative told us 'if I had had any concerns I would have moved (my relative). But the care here is really wonderful, its very clean and there is no smell.' A person who lived at the home told us 'I couldn't ask for better. They really are excellent.'

We saw staff laughing and joking with people who lived at the home, but still remaining respectful and courteous. We watched a member of staff help a person walking down a corridor. We saw that they were patient and supportive and encouraged the person who was finding the walking difficult. We saw another member of staff supporting a person to eat. We saw the staff member engaged their attention and touched their hand each time to see if they were ready for more food. We saw the person ate well as a result.

We saw one person at the home had been identified as having mental health issues and that they presented behaviours that challenged staff. We spoke with a member of staff and asked them how they supported this person. They told us they could remember the person from before their mental health deteriorated and they spoke about them with compassion and a caring attitude. They told us that they would try to support the person but if they were resisting care or distressed they would make them comfortable and leave them, returning later to try again.

This demonstrated to us that the staff were patient and caring towards the people who lived at the home.

Is the service responsive?

We identified instances where the home had been able to respond to people's deteriorating health quickly. One person told us 'I felt I had a chest infection in the morning, I saw the doctor at lunchtime and had the antibiotics by tea time. You can't get better than that.'

However we also identified concerns that changes in people's care needs had not always been responded to appropriately or in a timely way. As an example we found that some referrals to other agencies such as the dietician had not been actioned despite being identified as being needed. This left people at risk of not having their healthcare needs addressed in a timely way.

We found the home's management were responsive to concerns from outside agencies or relatives. We saw a meeting had been held with relatives to share what actions the home's management was taking to ensure people's care and welfare needs were being addressed. One relative told us 'The care here is excellent ' second to none. I was worried as a lot of staff had left. But we have had a meeting and they have reassured me about what they are doing.'

Is the service safe?

We identified concerns over the ways in which records and care plans were maintained. Many were incomplete or inconsistent about people's care needs. At times when the home was heavily reliant on agency staff, the lack of cohesive and accurate care plans or management systems put people at risk of unsafe or inadequate care.

We identified concerns over the systems for obtaining consent to care or recording of best interest decisions where people lacked capacity to consent.

We found there were enough staff on duty to meet people's needs. Although there was a high use of agency staff the home manager had taken steps to reduce the risks associated with this.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. On this inspection we did not identify anyone who was deprived of their liberty, but the home's management agreed to review people to ensure their rights were respected.

Is the service effective?

People told us their needs were met. However we identified issues of concern with regard to the updating of assessments of people's needs.

We found that specialist referrals for example to district nurses or dieticians had not always been made in a timely way and actions taken were not always recorded. This could lead to unsafe care or needs not being followed up appropriately.

We found that records were poorly organised. This meant that some information could not be located in an emergency.

Is the service well led?

On 25 February 2014 we served a fixed penalty notice on Your Health Limited for failing to have a Registered Manager in place at Redmount Nursing Home. A fine of '4000 was paid. On this inspection the home had a manager in post. However they had not made a successful application to the Care Quality Commission for registration as the manager. Therefore the home still did not have a Registered Manager in post.

We saw that the new manager was trying to push forward developments at the home with a limited permanent staff team and having to work as a Registered Nurse on shifts due to the staffing issues at the home. Support was being provided by the organisation's head office throughout the week and new staff were being recruited to replace the dependency on agency staff.

We found that some of the management systems were ineffective or poorly understood, records were out of date and policies and procedures needed reviewing to ensure they were current and accurate.

We found action was being taken by the organisation to address the concerns.

People had clear assessments of their needs and plans and strategies were in place to meet them. People's care plans had been reviewed regularly.

We saw that care workers interacted with people in a relaxed and respectful manner. People had access to age appropriate social activities.

During our visit we saw that people were offered choices throughout the day which supported their independence and provided a meaningful quality of life.

Care workers were skilled and experienced. Since our last inspection we were told by the nurse manager that they (the manager) had overall responsibility for staff supervision and that some staff supervisions had been delegated to another registered nurse. We saw records that showed only four care workers out of 18 had received any supervision or appraisal. Registered nurses had not received any clinical supervision for the past two years.

Systems were not in place to support the ongoing development of the quality of services provided and to support the manager and staff.