Archived: Pat Shaw House

Updated 31 October 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on the 23, 24 and 30 August 2017 and the first day of the inspection was unannounced. We arrived at 5:30am on the first day of the inspection due to anonymous concerns that we had received. We told the registered manager that we would be coming back over the next few days.

The inspection team consisted of one inspector and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of service. The expert by experience had experience in the care and support of older people in residential, nursing and dementia care services.

Before the inspection we reviewed the information the Care Quality Commission (CQC) held about the service. This included statutory notifications of significant incidents reported to the CQC and the report for the last inspection that took place on 28 and 29 April, and 4 May 2016, which showed the service was rated as ‘Requires Improvement’. We contacted the local authority safeguarding adults team and looked at the local authority’s recent monitoring report and used this information to support our planning of the inspection.

During the inspection we spoke with 13 people using the service, four relatives and 18 staff members. This included the registered manager, the director of resident services, three team leaders, six care workers, five care assistants, an administrator and a chef. We also spoke with three health and social care professionals who were visiting the service at the time of the inspection. We looked at 11 people’s care plans, five staff recruitment files, staff training records, staff supervision records and audits and records related to the management of the service.

Some people living at the service were not fully able to tell us their views and experiences so we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We carried out these observations during different parts of the day.

Following the inspection we spoke with two health and social care professionals who had worked with people using the service for their views.

Updated 31 October 2017

The inspection took place on the 23, 24 and 30 August 2017 and the first day of the inspection was unannounced. We told the registered manager that we would be coming back over the next few days. At our previous inspection on 28 and 29 April, and 4 May 2016 we found the provider was in breach of two regulations relating to good governance and notifiable incidents and was rated ‘Requires Improvement’. At this inspection we found that they were now meeting their legal requirements, however there were some inconsistencies in the records we reviewed.

Pat Shaw House is a care home without nursing which provides accommodation for up to 38 people across three floors. At the time of our inspection 36 people were living in the home, with 11 on a respite basis which could lead to a permanent placement. People who develop nursing needs have them met by the local community nursing teams. The service does not admit people who are living with dementia but it continues to care for them if they develop the condition once they have moved in.

There was a manager in post at the time of our inspection who had recently completed their registered manager interview process. They were registered shortly after the inspection was completed. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At the time of the inspection the service was in a period of transition. A new registered manager was in post who was trying to create a settled environment. People who used the service and their relatives spoke positively about them, and staff felt confident that the appointment could bring a level of stability to the service.

Risk assessments were in place to identify and manage areas of risk to people, which had improved since the last inspection. However, information was not consistent throughout people’s care records as some assessments had not been updated. Some records to document the care of people had not been fully completed.

The management of people’s medicines were not always in line with legislation and best practice as people’s medicines, including topical creams were not always recorded accurately. Medicines were administered and recorded by staff who had received medicines training, with training being refreshed if errors were made. The registered manager was in the process of reviewing their medicines policy.

The provider had reduced the number of agency staff since the last inspection and was still in the process of recruiting to permanent positions. Despite mixed comments from people and staff about staffing levels, the registered manager was aware when extra staff were required and saw they had requested this to help meet people’s needs.

People who used the service and their relatives told us they felt safe using the service and all staff had a good understanding of how to protect people from abuse. Staff were confident that any concerns would be investigated and dealt with.

The provider took appropriate steps to ensure robust staff recruitment procedures were followed.

Staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff were aware of the importance of asking people for consent and the need to have best interests meetings in relation to decisions where people did not have the capacity to consent to their care. The provider was aware when people had restrictions placed upon them and notified the local authority responsible for assessment and DoLS authorisations.

There was an induction and training programme in place to support staff in meeting people’s needs effectively. New staff shadowed more experienced staff and had their competency assessed before working independently.

We saw that more regular supervisions were now being carried out since the registered manager had started and staff spoke positively about the benefits of them.

Staff told us they contacted other health and social care professionals, such as the GP, occupational therapists and speech and language therapists, if they had any concerns about people’s health. We saw monthly meetings were held to discuss concerns about people’s health and well-being.

People and their relatives told us that staff were kind and caring and knew how to support them. Staff understood the importance of respecting people’s privacy and treating people with dignity and respect.

Care records had been improved since the previous inspection as they had been audited and were more organised. They included person centred information however there were inconsistencies in the files we reviewed as some people’s monthly care plan evaluations had not been regularly updated.

The provider supported people to take part in a range of events held throughout the year. However, people commented that day to day activities were not always available and we observed minimal engagement throughout the inspection.

People and their relatives knew how to make a complaint and were able to share their views and opinions about the service they received. Regular residents meetings had started to take place.

We could see that there had been an improved approach to quality assurance since the registered manager had started and audits were in place to monitor the quality of the service, but were not always consistent to monitor the care provided to people. A number of audits to improve the service were in the process of being implemented at the time of the inspection.

The registered manager was aware of their responsibilities in relation to their registration requirements and notifiable incidents, and learning had taken place since the previous inspection.

We made two recommendations in relation to the management of people’s medicines and day to day activities.