Archived: Dorcas House

People’s experience of using this service:

Since the last inspection in September 2019, improvements had not been made to address the areas we had identified as requiring action, and this inspection found further risks to people’s safety were now present.

There was a continued failure to ensure all peoples risks were identified and managed well and this meant people were not safe and were at risk of avoidable harm. People’s care plans lacked detail on their risks and the de-escalation techniques to be used when one person was distressed. Further guidance was also required on people’s individual risks, including what the risk meant for the person concerned and information, so staff knew how and when to contact professional bodies for advice and guidance.

Staffing rotas show that the registered manager works seven days per week every week and the provider works six nights per week every week. This is not good practice and the provider confirmed there was no contingency plan was in place to ensure continuity of care to support people in the case of emergencies or annual leave.

Overall people were supported to receive their medicines as required however, improvement was required in the reviewing of PRN ‘as required’ medication. The general day to day practice supported infection control, but improvement was required to ensure all equipment is maintained cleanly to promote good infection control.

The provider’s inadequate procedures and processes meant they had failed to ensure that people consented to their care. The Mental Capacity Act (MCA) includes how people are given choices about their care and how they want it delivered. Care records for one person showed they were not allowed out when it was dark, with no record of why this restriction was in place. The provider also had a generic smoking risk assessment and a generic wheelchair risk assessment for all people living at the home, that did not take account of people’s individual capacity, individual risks or consent. The registered manager had a limited understanding of the principles of the MCA and would benefit from additional training.

Staff said training was appropriate to them in their role in supporting people’s daily care. At the last inspection (September 2019) the provider told us training was up-to-date with the exception of two staff which was being addressed. At this inspection we found the training had still not been completed for one member of staff.

Staff liaised with other health care professionals to meet people’s health needs and support their wellbeing. However, at the time of the inspection there was no process in place to record future medical appointments.

Required environmental improvements to the design and decoration of the home to support people’s individual needs had not been completed therefore risks to people’s safety remained.

People gave positive feedback about the choice of food provided. However, we saw one person at risk of choking was not supported with the correct diet to keep them safe. This meant the person was at immediate and ongoing risk of harm to their health, safety and wellbeing.

There was limited opportunity for some people to enjoy activities to avoid social isolation. There was no evidence that activities had developed with people’s past interests and hobbies in mind. People we spoke with told us they were bored because there was a lack of activities.

The service has been rated as requires improvement in the key question ‘well led’ since February 2017 (and inadequate from November 2018). This inspection found the required improvements had not been made and further areas requiring improvement were identified.

The processes in place to monitor, audit and assess the quality of the service being delivered were not effective. The provider had a long history of not being able to improve the quality of the service provided to people or meet legal requirements. Provider audits not been effective in effecting sustained improvement and had not identified some the concerns we raised at this inspection.

At the last inspection (September 2019) we reported, “The provider was unable to demonstrate the systems they had in place to enable them keep themselves up to date with good practice or legal requirements.” At this inspection we found neither the registered manager or the provider had received any further training or taken any action to keep themselves up to date with good practice or legal requirements.

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 (published November 2019) and there were multiple breaches of regulation. Following the inspection, the condition on the provider registration requiring a monthly update remained in place.

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Enforcement

Since the inspection in November 2017 there has been a condition placed on the providers registration. These conditions instructed the provider to send us regular updates on checks that had been carried out at the service to ensure the quality and safety of the service. The provider has submitted updates as per the conditions in place, however the quality of the submissions is not robust, and this has been discussed and shared with the provider.

This inspection found the provider remains in breach of regulation 12 safe care and treatment, this meant we found a failure to ensure all peoples risks were identified and managed well. We also found a breach of regulation 11, consent because people had not consented to some aspects of their care and regulation 9, person centred care. There was also a continued breach of regulation 17, this means insufficient action had been taken to make or sustain improvements in the service provided.

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

Follow up:

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.

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.

People’s experience of using this service:

Since the last inspection in November 2018 we found limited improvements had been made to address the areas we had identified as requiring action, and further improvement was still required.

There was a failure to ensure all peoples risks were identified and managed well. People’s risks were known to staff however, care plans lacked detail on the de-escalation techniques to be used when one person was distressed. Further guidance was also required on people’s individual risks, including what the risk meant for the person concerned and information, so staff knew how and when to contact professional bodies for advice and guidance.

Staff knew people well and were able to demonstrate they knew people’s risks when providing care on a daily basis.

The registered provider had failed to take action to safeguard people from the risk of abuse. Two incidents had not been identified as safeguarding concerns by the management team so that the appropriate actions to alert the Local Authority and CQC had not been made. Both incidents were reported to the Local Authority by the inspector following the inspection.

People were supported to receive their medicines as required and general day to day practice supported infection control, but improvement could be made to ensure all equipment is maintained cleanly to promote good infection control.

Staff had an understanding of the importance of gaining consent from people before providing support. However, the Mental Capacity Act (MCA) includes how people are given choices about their care and how they want it delivered. Improvements are required as some people told us they felt they were not always involved in making decisions about how their care was delivered. The registered manager had a limited understanding of the principles of the MCA and would benefit from additional training. Deprivation of Liberty (DoLS) records need to improve to ensure expiry dates are monitored and new applications are made in a timely way, so people are deprived of their liberty in a lawful way.

Staff said training was appropriate to them in their role in supporting people’s daily care, however we saw that further training was required to support people’s individual care needs. For example, challenging behaviour training.

Staff liaised with other health care professionals to meet people’s health needs and support their wellbeing.

The design and decoration of the home did not support people’s individual needs and improvements were required for example, work in making the garden a useable space for people to enjoy.

People gave mixed feedback about the choice of food provided. We saw people were offered regular drinks throughout the day to support their wellbeing.

There was limited opportunity for some people to enjoy activities which would avoid their social isolation. Many of the activities planned were games and activities with staff within the home. People we spoke to told us they did not always enjoy the activities and sometimes chose not to join in.

The service has been rated as requires improvement in the key question ‘well led’ since February 2017 (and Inadequate from November 2018). Whilst this inspection found some improvements had been made, the provider audits had not been fully effective in effecting sustained improvement and had not identified some the concerns we raised at this inspection. The processes in place to monitor, audit and assess the quality of the service being delivered were not always effective.

No links to the immediate and local community had been developed or maintained and this was an area that needed improvement

Staff felt supported and communication within the staff team was good.

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 (published 08 August 2018) and 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/ sustained, and the provider was still in breach of regulations.

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Enforcement

At our inspection in November 2017 we found the home had not meet regulations around the governance systems and we placed conditions on the providers registration. These conditions instructed the provider to send us regular updates on checks that had been carried out at the service to ensure the quality and safety of the service. The provider has submitted updates as per the conditions in place, however the quality of the submissions is not robust, and this has been discussed and shared with the provider.

This inspection found that whilst some limited improvements had been made the provider remains in breach of regulation 12 safe care and treatment, this meant we found a failure to ensure all peoples risks were identified and managed well. We also found a breach of regulation 19, because the provider failed to have effective recruitment and selection procedures ensuring a record of checks made. The provider remains in breach of regulation17, good governance. This means insufficient action had been taken to make or sustain improvements in the service provided. The condition will remain on the providers registration.

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.

The service has been in breach of regulations relating to the governance of the service since February 2017. We have carried out two subsequent inspections since this time and at out last inspection in November 2017 we found the home had continued to not meet regulations around the governance systems in place and we placed conditions on the providers registration. These conditions instructed the provider to send us regular updates on checks that had been carried out at the service to ensure the quality and safety of the service. The provider has submitted these updates as per the conditions in place. This inspection was carried out to check that improvements to meet legal requirements planned by the provider after our inspection in November 2017 had been made. We found that whilst improvements had been made to the governance systems they had not been sufficient or sustained and the breach of regulation continued to not be met. The conditions will remain on the providers registration.

We found notifications had not been submitted as required to the Commission on three separate occasions. This is a breach of Regulation 18 Notification of other incidents. You can see what action we told the provider to take at the back of the full report.

The home has a registered manager who was present throughout the inspection. 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.

The risks associated with peoples’ care had not always been identified or well managed. Where incidents had occurred, there were no robust systems in place to analyse the cause or put steps in place to reduce the chance of reoccurrence. The risks around managing peoples’ diabetes had not been managed well and we saw people had been provided with foods that were not in line with a diabetic diet. We found the provider had breached the regulations in relation to safe care and treatment. You can see what action we told the provider to take at the back of the full version of the report.

People received their medicines safely although we found improvements were needed in the identification of medicines. Staff understood safeguarding procedures and action to take should they have concerns.

People had their privacy respected although we found some practice where supporting people in a dignified manner could be improved.

People were supported by staff who had the skills and knowledge to meet their needs. Staff training had been provided around people’s individual needs. However, we found the support people living with mental health conditions received needed improving. People had their healthcare needs met and were assisted to have foods and drinks they enjoyed.

People’s care had been reviewed to ensure it continued to meet their needs, although these reviews did not involve the person themselves.

Not all people had been involved in activities of interest to them.

Staff felt supported in their roles and felt able to provide feedback to the registered manager should they have any.

At the last unannounced comprehensive inspection in February 2017, we judged that improvements were required in delivering a safe, effective, caring, responsive and well-led service. During this inspection we found the provider continued to be in breach of the regulation related to governance. We carried out an unannounced focused inspection of this service on 18 July 2017, when we looked only at the key question of Well-led. During this inspection we found the provider continued to be in breach of the regulation related to governance. This was because the registered provider had failed to establish and operate effective systems to ensure compliance with the regulations, or to monitor the quality and safety of the service. After our inspection in July 2017 we served a Warning Notice to the registered provider which required them to be compliant with this regulation by 13 October 2017. A Warning Notice is one of our enforcement powers.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key question ‘is the service well-led’ to at least good.

We undertook an unannounced focused inspection of Dorcas House on 30 November 2017. This inspection was done to check that improvements to meet legal requirements planned by the provider after our inspection in July 2017 had been made. The team inspected the service against one of the five questions we ask about services: is the service well led. This was because the service was not meeting legal requirements. This report only covers our findings in relation to this focussed inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dorcas House on our website at www.cqc.org.uk.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

At this inspection we found the required improvements had not all been made since July 2017. Some of the improvements we had identified as required at our previous comprehensive inspection in February 2017 were on-going. We found partial improvements had been made to meet the Warning Notice of Regulation 17. Further improvements were needed and we are considering what further action to take. The service continues to be rated as 'requires improvement', because, although some action had been taken, other actions had been planned, but not yet fully implemented.

There was a registered manager in post who was present throughout the inspection. 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 and their relatives were satisfied with the service they received however we found that the service was not consistently well led. The systems in place to assure the safety, quality and consistency of the service were not consistently effective. Checks and audits had not been effective at identifying matters that needed to improve. Despite this being brought to the attention of the registered manager at our last inspection; they had not taken timely or sufficient action to improve this aspect of the service.

You can see what action we told the provider to take at the back of the full version of the report.

After our comprehensive inspection in February 2017, the registered provider submitted an action plan detailing how they would improve to ensure they met the needs of the people they were supporting and the legal requirements.

We carried out this unannounced focussed inspection on 18 July 2017 to see if the registered provider had followed their plan and to determine if they were now meeting legal requirements. This report only covers our findings in relation to this focussed inspection which looked at whether the service was ‘well-led’. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Dorcas House on our website at www.cqc.org.uk.

Dorcas House is registered to provide personal care and accommodation for up to eleven people who live with dementia, mental health related conditions or physical disabilities. At the time of our inspection nine people were living at the home.

We undertook this announced focused inspection on 18 July 2017 to check that the provider had followed their own plans to meet the breach of regulation and legal requirements. Although the registered provider had addressed some of the concerns that we had identified at our last inspection, we found that there continued to be no effective quality assurance processes in place and this inspection identified a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to good governance. We are considering what further action to take.

There was a registered manager in post who was present throughout the inspection. 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.

We found that whilst there were some systems in place to monitor and improve the quality and safety of the service provided, these were not always effective and did not identify if the service was consistently compliant with the regulations. The processes that had been introduced had failed to identify concerns raised at our inspection in February 2017. Records were not always robust to ensure the effective running of the home. Staff felt supported by the registered manager.

We identified that there was a continued breach 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 this report.

The registered manager was present during our inspection. 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 felt safe living at the home. Staff knew what action to take in the event of a fire; however the fire risk assessment was not current. Staff knew how to report any concerns so that people were kept safe from abuse. Risk associated with people’s health conditions had been assessed. People and their relatives told us there were sufficient numbers of staff to meet their individual needs. The management of medicines was not always safe and did not always follow good practice guidelines. We recommend that the service consider current guidance and take advice on safe storage of medication and take action to update their practice accordingly.

People were supported by staff who had been provided with most of the key training they needed to safely meet people’s needs. Not all the staff who we spoke with were confident about how to comply with the principles of the Mental Capacity Act. People had a choice of nutritious meals and drinks but the dining experience needed improvement. People told us that they had regular access to a range of health care professionals which included general practitioners, diabetic nurses, dentists, options and chiropodists.

The majority of people we spoke with told us they were happy at the home and were happy with the care provided. Generally people made decisions about their daily lives. People’s privacy and dignity had not always been protected.

People’s preferences and choices about their care and support needs were sought and were known. However, people and their relatives told us they had not consistently contributed to the routine review process. Some people told us some activities of particular interest to

them were provided for them to participate in. However the activities offered on occasions were not engaging enough for all people in the home. People knew how to make complaints and the registered provider had arrangements in place so that people were listened to.

We found that whilst there were some systems in place to monitor and improve the quality and safety of the service provided, these were not always effective and did not identify if the service was consistently compliant with the regulations and failed to identify concerns raised in our inspection. People and their relatives considered the home to be well-led and the registered manager was consistently described as kind, supportive and approachable.

You can see what action we told the provider to take at the back of the full version of this report.

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 safe?

We found that care was provided in an environment that was safe, accessible, clean and adequately maintained. People were safe and their health and welfare needs were being met because there were sufficient numbers of staff on duty who had appropriate skills and experience.

We spoke to several people who lived at the home and asked them if they felt Dorcas House was a safe place to live. People told us they felt safe. Comments included, 'I feel safe here' and 'I'm okay thanks, they look after me alright.' We found that the home's safeguarding procedures were robust and staff understood their role in safeguarding the people they supported. We checked staff training records and saw that staff had received recent training in safeguarding vulnerable adults. The staff and manager had a good understanding of whistle blowing policy.

Secure systems were in place to manage people's money and valuables. We found that people's money and valuables were stored securely and appropriate records were maintained to monitor income and expenditure.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have been made under this legislation for any person living at Dorcas House, we found that the provider understood their responsibilities in relation to the law.

We checked people's care plans and found most of them to be detailed, relevant and up to date. However, some records which related to people's health and mobility were sometimes inconsistent and inadequately recorded. This meant that some people were at risk of receiving inadequate or inappropriate care. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to these shortfalls.

Is the service effective?

People told us that they were happy with the care that had been delivered and the care staff who supported them. We found that most of the care staff had worked at Dorcas House for many years and knew the people who lived there very well. Care staff told us that they were well trained, competent and able to safely meet the needs of the people who used the service.

We found that care staff had regular meetings with the manager of the home and had the opportunity to discuss their training and development needs, welfare and any concerns they might have about the people they were caring for.

We checked people's care records. We found no evidence to show that people had given their consent to the care and support they received. For those who did not have the capacity to make informed decisions about their safety and welfare, there was no evidence to show that the provider had involved (or had tried to involve) next of kin, medical or social care professionals or an advocate (independent specialist who can act and advise in a person's best interests) to assess people's capacity to act and make decisions about their care and support.

We concluded that the in the absence of appropriate records regarding consent there was no formal record to show that the provider has always acted in accordance with people's views. This could impact on people's choice about how their care was given. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to these concerns.

Is the service caring?

People were supported by kind and attentive staff. It was apparent to us during our observations that care staff were attentive, polite and sought consent before providing care and support. We saw that care staff were patient with the people they were supporting and treated them with respect and dignity. People commented 'The staff are very good, very kind to me.'

During our inspection, we spoke to a medical professional who regularly visited the care home. He was complimentary about the standards of care being delivered and the competence of staff delivering care and support. He told us that the manager and staff at the home were caring and people seemed to be well cared for.

Is the service responsive?

We found that people's complaints were not always fully investigated or resolved effectively. During our inspection, we ascertained that a number of complaints had been made by a resident at the care home. These matters had been recorded but not in the appropriate complaints book. Examination of those complaint records revealed that although they had been dealt with, they had not been investigated or progressed in accordance with the home's policy.

Records revealed that meetings were held between staff and people using the service to discuss ongoing concerns and improvements at the home. However, we noted that there were no systems in place to obtain confidential feedback from people living at the home, their relatives or any visiting professionals about the service being provided. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to these concerns.

Is the service well-led?

A check of care records showed that the provider did not have an effective system to regularly assess and monitor the quality of service that people received.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to quality assurance and the improvements they will make.

People were very complimentary about care staff and the standards of care being provided. Comments included, 'I like the staff, they are nice' and 'Yes I like it here, the food is good.'

We examined care plans and found that people's needs were properly assessed and that care and support was planned and delivered in line with their individual care plans. We found that people who used the service had given their consent and were consulted about the care and support they received.

People's privacy, dignity and independence were respected and their views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

We found that care staff were suitably trained, supervised and supported to deliver care safely and to an appropriate standard.

We found the home to be clean, homely and comfortable. People were complimentary about the care staff. Comments included, 'It's good here, I like the food and the staff' and 'They are pretty good to me.'

From our observations it was apparent that care staff were attentive, polite and sought consent before providing care and support and that people were treated with respect.

During our inspection we found that one person's care plan had insufficient detail about their needs and risk assessments had not been undertaken. There were few activities or outings provided for people to enjoy. We concluded that overall care and support was not delivered in a way that ensured people's safety and welfare.

Care staff did not have regular supervision or appraisal meetings with their manager and they were not always properly supported to provide appropriate levels of care to people who used the service. We also found that some members of care staff were in need of refresher training.

We saw that people were protected against the risks associated with medicines and the provider had an effective system to regularly assess and monitor the quality of service that people received.

We found the home to be clean, homely and comfortable. People were complimentary about the care staff. Comments included, 'I like it here, the staff are good to me' and 'The care staff are great.'

From our observations it was apparent that care staff were attentive, polite and sought consent before providing care and support.

Records showed that two people had recently fallen and sustained injuries. Examination of their care plans revealed that there had not been any investigation into the circumstances of these incidents to try and prevent further occurrences. We checked other care records and could not find any documentation which indicated people's likes and dislikes and their preferences towards food and bathing. We could not find any documentation showing when and how often people were receiving personal care.

The findings of our inspection identified that overall care and support was not delivered in a way that ensured people's safety and welfare. We found that people who use services were not always involved in making decisions about their care and support. Comments included, "It would be nice to go out more often."

The provider did not have an effective system to regularly assess and monitor the quality of service that people received.