The inspection took place on 27 and 28 October 2015 and was unannounced.
Tiled House provides accommodation and nursing care for up to 29 older people, most of whom are living with dementia. The home is in the village of Shawford, near Winchester. People have access to gardens.
Tiled House has 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.
Recruitment practices were not safe. Before a member of staff was recruited, relevant checks such as identity checks, obtaining appropriate references and Disclosure and Barring Service (DBS) were completed, however the provider did not obtain a full employment history for all staff recruited. There was a risk that staff may be unsuitable for the role.
Some improvements were required to medicines management to ensure staff were able to identify when people might require pain relief. Medicines were administered in a caring and professional manner. The provider used protocols for people who required pain relief such as paracetamol. These gave clear guidelines to staff about when and how often this type of medicine should be given for individual people. However, pain assessments were not in use in the home. We have made a recommendation in relation to pain assessment.
Protocols were not in place for medicines, other than pain relief, which needed to be administered ‘as required,’ describing to staff how and when the medicine needed to be administered. Therefore there was a risk that these medicines may not be administered appropriately due to a lack of clear guidelines.
Communal areas of the home were clean and smelled fresh, however we found four bedrooms which contained a strong malodour. This stemmed from the mattresses on people’s beds which were stained. The mattresses identified were all replaced before the end of the inspection. We have made a recommendation in relation to infection control.
Staff had completed safeguarding training and were able to explain to us how they protected people from abuse. The safeguarding policy was available for staff to review and staff knew where it was kept and where to find relevant telephone numbers for reporting any concerns people had experienced abuse.
A range of tools were being used to assess and review people’s risk of poor nutrition or skin damage. There were specific risk assessments for each person in relation to falls, nutrition, moving and handling and mental health and cognition. Support plans were written for people in relation to each identified risk.
There were enough staff on duty to meet people’s needs. Staffing levels were calculated by the provider which took into account the number of people using the service and their dependency level. This was reviewed and updated regularly and the registered manager told us she was able to increase or decrease staffing levels over and above the calculated level, if this was necessary. From observation, we saw there were enough staff to meet people’s needs and staff took their time assisting people without rushing them. They also used the time supporting people to socially interact with them rather than just ‘completing a task.’
The high use of agency staff in the home was mitigated by actions taken by the registered manager to ensure agency staff had the right skills, experience and qualifications to meet people’s needs. Actions included training agency staff and using regular agency staff.
Staff had received appropriate training to meet people’s needs. Records showed that staff had received training in key areas such as infection control, first aid, moving and handling, food hygiene and health and safety. Clinical training was provided for trained nurses. Recently nurses had completed training in wound care, mouth care, diabetes and venepuncture (the process of obtaining intravenous access to people’s veins in order to take samples of people’s blood for analysis).
Staff had a regular supervision meeting with the registered manager and an annual appraisal. Areas for improvement were discussed during staff appraisals. All staff told us they respected the registered manager and felt supported in their role. Staff were knowledgeable about people’s needs and how to support them. Staff said they knew about people’s needs from handovers, care plans, risk assessments, people themselves and their families.
We saw that care was delivered in line with people’s wishes. People chose where they wanted to sit to eat their lunch. We saw that staff were very patient with people while they took time to decide and then supported them to sit in the place of their choice.
- We checked whether the provider was acting in accordance with the requirements of the Mental Capacity Act 2005 (MCA). The MCA is a law that protects and supports people who do not have the ability to make decisions for themselves. We found that staff had received training and were able to describe some of the key principles. Mental capacity assessments had been undertaken which were decision specific.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. We found that the registered manager understood when an application should be made and was aware of a Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty. Relevant applications had been submitted and staff were aware of which people were subject to a DoLS.
People were supported to have sufficient to eat and drink and maintain a balanced diet. Drinks were readily available throughout the day and staff encouraged people to drink. Fruit squash and water was available all day and we saw staff regularly pouring drinks for people. No one was without a drink within easy reach at any time. A tea trolley came round during the morning serving tea, coffee, biscuits and yogurts. We saw staff encouraging people to eat and drink.
The meals offered were home cooked, freshly prepared and nicely presented. There was a choice of two main courses and a vegetarian choice. There were also a hot pudding with an alternative of fruit. People were encouraged to have second helpings.
Staff were aware of any special diets or people’s dietary preferences. The chef showed us a list of people’s special diets which was kept in the kitchen. She said she was aware of people’s likes and dislikes. Care plans included risks assessments in relation to each person’s risk of choking or malnutrition and there were plans in place to address any identified risks. Staff explained that they ensured people received sufficent to eat and drink by encouraging fluids and checking monitoring charts.
People were supported to maintain good health through access to ongoing health support. A GP visited every Tuesday but also came on other days if people were ill. Records of GP visits were recorded within people’s care plans ensuring that all staff were aware of the advice given by the GP.
We observed staff interacting with people in a kind and compassionate manner. They responded promptly to people who were requesting assistance and they did so in a patient and attentive way. We also noted a considerable amount of warm and friendly exchanges between staff and people which were, when people were able, reciprocated in the same manner. Staff were cheerful and the atmosphere in the home was relaxed. People seemed calm and contented.
Staff spoke with people while they were providing care and support in ways that were respectful. We observed that people were addressed with their chosen names. Staff ensured people’s privacy was protected by ensuring all aspects of personal care were provided in their own rooms
People’s care plans included a ‘This is me’ record which gave a brief life history. It included what name people liked to be known as, the places they had lived, their school, job, hobbies and interests. This enabled staff to really get to know people and understand what was important to them. People were involved in decisions about their care and were offered choices in all aspects of their daily life.
Most people required a high level of support to meet their care needs. Staff and the registered manager told us they encouraged independence whenever this was possible.
People’s care plans included the range of all expected risk assessments and care plans. For example in relation to skin care, mobility, communication and medication. These were evaluated regularly and showed they had all been reviewed recently. The provider had well organised records and the guidance provided for staff in order that they met people’s needs was detailed and comprehensive. The records were written well and provided step by step information for staff to enable them to provide appropriate care that met people’s needs.
The registered manager told us they were recruiting for an activities co-ordinator, as there was no-one in post at the moment. However, all the staff were aware of the importance of stimulus and mental exercise for people. Staff involved people in playing games of with soft balls, and a game of rope-quoits. Some people had jigsaws; some were reading newspapers or magazines. Most people were wide awake and involved with whatever was happening.
People, staff and relatives were aware of how to complain or raise a concern but most people said they had not had need to do so. All said they would approach the registered manager, who they felt would listen and respond appropriately.
The registered manager was required, by the provider, to work two day shifts providing nursing care. This meant she was only available in a management role for three days a week. Without support from a deputy or an administrator, this was insufficient and meant the service breached regulations which may not have happened had the registered manager been able to carry out her management role on a full time basis. The registered manager told us she worked extremely long hours in an attempt to fulfil her clinical duties as well as her registered manager role but was unable to carry out all the tasks she would like.
There was a positive and open culture within the home. All staff were highly complimentary about the registered manager. She was extremely well respected as a leader. Staff said they were actively encouraged through meetings and appraisal to give feedback about the service.
The home had a registered manager in post who was aware of her responsibilities both regulatory and to the home. Relevant notifications had been submitted to the Care Quality Commission (CQC). There was high visibility of the registered manager ‘on the floor’ and positive interaction between the registered manager, people and staff.
Policies and management arrangements meant there was a clear management structure within the home.
The quality of the service was closely monitored through a series of audits including care plan, catering, medication and night time audits. Quality assurance audits were carried out by the provider. As a result action plans had been drawn up and all actions completed.
During our inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we asked the provider to take at the back of the full version of the report.