Archived: Rowan Tree Lodge

Rowan Tree Lodge is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

At the time of the inspection nine people were living at Rowan Tree Lodge. The care home is a large detached house converted into a nursing and care home for 16 older people.

At the time of the inspection there was a new manager in post, but they had not yet registered with CQC. We returned to Rowan Tree Lodge for a second day of inspection to meet the new manager who had started their role in August 2018.

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 carried out an unannounced comprehensive inspection of this service on 24 April 2018. Breaches of legal requirements were found regarding the governance of the service. This was because people's care plans lacked guidance around care and support. Governance arrangements were not always robust to ensure a safe, well managed service.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report covers our findings in relation to those requirements and additional concerns we found at this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Rowan Tree Lodge on our website at www.cqc.org.uk.

At this inspection we still found issues with the governance of Rowan Tree Lodge, which meant the service remained in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In addition, we found breaches of Regulation 12, regarding the safe care and treatment of people who lived at the home.

You can read what actions we told the provider to take at the end of this report.

Whilst we found that some improvements had been made to the safety of the service and to how it was led, we have not revised the rating for the service. We will check this during our next planned comprehensive inspection.

At this inspection we found that information in people’s care plans was still not always consistent. Record keeping processes had not always ensured that information was up to date and reliable for staff. Staff had not always taken timely action in line with care plans.

We found that although the service had addressed some cleanliness issues, we had concerns about other aspects of the service’s safety. This included the day-to-day management of fire risk and water hygiene.

We found that checks and monitoring processes did not always ensure robustly the safe care and treatment of people who lived at the home. This included checks to protect people from pressure sores.

The area manager had looked to improve protocols for people’s ‘as required’ medicines. They made further significant improvements between the two days of our visit. The area manager was also liaising with GPs to get clearer directions for people’s prescribed creams. The service managed other medicines safely.

There were enough staff to meet people’s needs. People who lived at the home, relatives and staff confirmed this. The area manager had carried out checks to recruit new staff, although some references needed clarification.

Staff were aware of their responsibilities to safeguard people from abuse and avoidable harm. Staff had confidence that managers would deal with any concerns.

People who lived at the home told us care staff were wonderful. However, we also found that the service needed to improve on how they listened to people’s needs and wishes.

Staff were knowledgeable about people’s needs, but some aspects of person-centred care needed to improve. The service was developing their activity offer.

We observed staff engaging with people and heard good examples of how the responsiveness of care to individual’s needs had made a big difference.

The area manager had developed their own and the service’s audit checks. These needed further improvement, as they had not picked up on significant issues we found.

The staff, manager and area manager at the service were warm and welcoming. They were helpful, engaging and acted on any concerns we had. The area manager worked hard between the two days of our visit to make further improvements.

As the manager was new, not everyone knew who they were. However, the manager and area manager held regular meetings with relatives to keep them up to date with changes. We heard positive feedback about the new manager.

There were regular team meetings and staff we spoke with felt well supported.

There had been no notifications to CQC since we last inspected the service, the area manager confirmed to us no notifiable events had occurred. The service had displayed ratings from our last inspection as required.

The inspection took place on 24 April 2018 and was unannounced. The last inspection of the service was 19 & 20 April 2017 and the rating for the service following this inspection was Good.

Rowan Tree Lodge is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At the time of the inspection 10 people were living at Rowan Tree Lodge. The care home is a large detached house converted into a nursing and care home for 16 older people.

At the time of the inspection there was no registered manager in post. The current manager who was present for the inspection had resigned and was due to leave this month. Following the inspection the provider informed us a new manager had been appointed and was due to start their employment at the service in May 2018. 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.’

During this inspection we found the provider was in breach of one regulation of the Health and Social Care Act (Regulated Activities) Regulations 2014. The breach related to a lack of governance arrangements to asses and monitor standards in the care home. We also raised concerns around a number of records as they were inconsistent. For example, people had a plan of care however we found they lacked information. This meant there was a risk staff did not have the guidance needed to support people safely and in accordance with their individual needs.

We also found some further progress was needed with regard to medicine practices to support the safe management of ‘as required medicines’, the application of creams and for people who wished to look after and administer their own medicines. We have made a recommendation regarding this matter.

We walked around the home and observed that three fire safety doors were not closing securely on their rebates; this included the fire door in the lounge. These doors were fixed during the inspection by the maintenance person to promote fire safety. Other areas of the home and equipment were safely maintained. Environmental risks were recorded and required actions taken to ensure safety of the premises.

Overall, we found the home to be clean though we were concerned regarding the cleanliness of the laundry room. This was brought to the area manager’s attention to action. People told us the home was kept clean.

Sufficient numbers of suitably skilled experienced and trained staff were employed to provide care for people in accordance with their individual needs. During the inspection the area manager increased the provision of domestic hours to support more robust cleaning of the laundry room.

Staff had a good understanding of people's individual care needs and sought advice from external professionals to promote people’s health and wellbeing. People spoke positively regarding the care and support they received from the staff.

Our observations showed good interaction by the staff with people they supported. Staff were attentive, kind and respectful in their approach. People and relatives told us the staff respected their rights and wishes regarding day-to-day activities.

Risks to people’s safety and wellbeing were recorded to enable staff to support people safely whilst promoting their independence. Accidents and incidents were recorded and an analysis undertaken to look for trends or patterns to minimise the risk of re-occurrence.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person's mental capacity was made.

Staff understood the concept of safeguarding and knew how to report any concerns. Records evidenced safeguarding referrals to the local authority had been made appropriately.

People were offered a good choice of meals which took into account people’s dietary needs and requirements. People told us they enjoyed the meals.

There was an informal programme of staff led social activities. The area manager appreciated this needed to be improved to provide more choice and stimulation.

The service had a complaints’ policy and procedure. Complaints received had been logged and responded to appropriately. People and relatives told us they felt able to raise any issue with the staff.

People living in the home, relatives and staff were positive about the management and leadership of the service.

There were systems in place to consult with people who used the service, to assess and monitor the quality of their experiences.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory notifications. The ratings from the previous inspection were on display in accordance with requirements.

You can see what action we took at the back of this report.

This was an unannounced inspection which took place on 19 & 20 April 2017. The home re-opened in January 2017 following a long period of closure for refurbishment and general maintenance.

The service was last inspected in August 2015 and at that time we found breach of Regulation 9 HSCA (RA) Regulations 2014 with respect to people not having an effective plan of care to meet their needs; risks to people’s health and safety were not always recorded to help form the plan of care.

This inspection was a comprehensive inspection, during which we reviewed the previous breach. We found improvements had been made and the breach was met.

There was 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.

There was a calm, ’homely’ and relaxed atmosphere in the home. We observed staff providing care and support; this was carried out in a caring, kind, respectful and unhurried manner. Staff were on hand to help people when they needed it.

Arrangements were in place for monitoring the standard of the environment and equipment to ensure it was safe. This included health and safety checks and service contracts.

Risks to the people living at the home were appropriately assessed and recorded in care records.

People had a plan of care which set out their health and social care needs. We saw people and relatives were involved with the plan of care and care reviews. People were supported to maintain their health and well-being by accessing a range of external health professionals.

People we spoke with and their relatives told they had confidence in the staff’s ability to care for them.

Staff received training and support and had a good understanding of their roles within the service and what was expected of them.

Staff were recruited safely subject to the completion of appropriate checks to ensure they could work with vulnerable people. We saw the required checks had been made.

We found there were sufficient staff on duty to meet people’s care needs. We saw care and support given when this was needed and requested.

Medicines were administered safely to people and the registered manager completed medicine audits to ensure the safe management of medicines.

The staff we spoke with described how they would recognise abuse and the action they would take to report any actual or potential harm. Training records confirmed staff had undertaken safeguarding training.

Staff sought consent from people before providing support. When people were unable to consent, the principles of the Mental Capacity Act 2005 were followed in that an assessment of the person’s mental capacity was made.

When necessary, referrals had been made to support people on a Deprivation of Liberty (DoLS) authorisation. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests. The applications were being monitored by the registered manager of the home.

We saw people’s dietary needs were managed with reference to individual preferences and choice. Lunch was a relaxed occasion and people said they liked the meals served.

Social activities were organised in the home though the registered manager appreciated these need to be developed further.

We saw a complaints procedure was in place and people, including relatives, we spoke with, were aware of how they could complain.

The registered manager was able to evidence a range of quality assurance processes and systems to monitor standards within the home and to drive forward improvements. This included a number of audits (checks) for various aspects of the service.

Staff and people said the home was well managed and the registered manager approachable and supportive.

The registered manager had a good understanding of their role and responsibilities in relation to what was expected from them as a registered manager with us, the Care Quality Commission, (CQC).

The registered manager had notified us, the CQC, of any notifiable incidents in the home in accordance with regulations.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People told us they felt safe and well cared for.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents and complaints and concerns. This reduced the risks to people and helped the service to continually improve.

The manager showed an understanding of the Mental Capacity Act 2005 which is the legislative framework for the decision making process regarding people who may lack mental capacity. The manager was able to talk about a recent review of care which included a decision being taken in a person's best interest regarding resuscitation in case of an emergency. The assessment and decision included relative and medical input and this was documented. The home was therefore able to show they had acted appropriately in ensuring the person's rights were maintained and that an appropriate assessment had taken place.

Is the service effective?

People's health and care needs were assessed with appropriate referrals being made to external professionals who could assess and support the care of people in the home. Care needs had been identified in care plans and these had been reviewed. We looked at the care of two people in depth and the care plans reflected their current needs.

Visitors confirmed that they were able to see people at any time as visiting times were flexible. They said that staff kept them informed and they were therefore always up to date with any changes to people's care.

Is the service caring?

People were supported by kind and attentive staff. We saw that nursing staff and care workers showed patience and gave encouragement when supporting people. People commented, 'The care is excellent. I'm very settled here.' Other comments made were: 'The staff are very kind, they treat us like family', 'The staff have organised my visit to the hospital and somebody will be going with me. They are really helpful', 'Staff are fantastic. They are very good and are really caring.' A relative we spoke with was very impressed with the care. They said they felt involved in the care and staff were quick to respond to any changing care needs their relative might experience.

People using the service and/or their relatives completed a satisfaction survey. Where shortfalls or concerns were raised these could be addressed.

People's preferences and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

We saw that people were supported to complete a range of daily activities. People were supported as their care needs changed. This was particularly evident with changing medical and nursing care needs.

Following our last inspection in February 2014 we had made a requirement to improve the way quality and safety was monitored in the home. The service had responded by sending an action plan. We found that most of this had been achieved and things had improved.

During the inspection we discussed how some of the audit processes could be further improved. The manager sent us a plan of action following the inspection which showed the new management team in the home were responsive to feedback and discussion from regulatory bodies.

Is the service well-led?

The service had a quality assurance system. The new manager was continuing to develop this. Records seen by us showed that key areas were monitored satisfactorily. As a result the quality of the service could improve.

Staff told us that, despite management changes, they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and felt things were well monitored by the manager. This helped to ensure that people received a good quality service at all times.

The home has been without a Registered Manager for some time. We [the Care Quality Commission] are taking separate action with the provider to address this breach of the conditions of registration. The new manager of the home told us she was in the process of applying for registration to the Care Quality Commission to become registered at Rowan Tree Lodge.

We found care records were up to date and set out methodically. Details of daily care observations were recorded and added to people's care records, giving information required to provide the care people needed.

We found that essential works required by other regulators had been completed. Staff commented how much easier it was to complete their duties now this work was done, for example, in the kitchen area.

We found where records were being kept, these were of a good standard. Some areas of record keeping in relation to safety checks required more work, but this was being dealt with by the new manager.

We found the systems in place to continually monitor the quality of the service remained poor. Mechanisms were in place to bring areas that required improvement to the attention of the provider, but these were not applied consistently. Also, the provider did not always respond to the information supplied by staff, on areas of the service that needed attention, for example, maintenance of premises.

We found there was improvement in some areas. We found that staff considered people's opinions in the way their care was delivered. Family members were kept up to date on any changes to their relatives care.

We noted that some of the work to the premises, required by the Fire Authority, had been completed but as further works were still required, the Fire Authority had given a final extension of time for these to be completed.

We noted that people's care plan's contained instructions on areas of care, but these were sometimes not followed. As an example, staff had identified where people were at risk of chest infections, but had not liaised with other clinicians to deliver care to address this. We noted that staff tended to sit in another room, away from people who lived at the home. This meant that people who required it, needed to call out for help.

We found that some staff records were not available for inspection and that in some instances the appropriate checks had not been carried out before people were allowed to work at the home. The home has continued to operate without a Registered Manager and nurses in charge of the home had expressed that they did not feel supported by the provider when trying to make the required improvements.

We found feedback was mixed; one person told us they were happy at the home, that the staff were "Helpful and occasionally will help me walk round the house." This person told us the food was good and that they had managed to put on weight. Two people who lived at the home told us how willing the care staff were to help. One person told us "The carers are friendly and look after us."

One relative expressed concern about the care provided. They explained "I am concerned by the lack of direction of management. Good caring staff are considering leaving." They gave examples of poor care experienced by their family member and were concerned at the lack of understanding of some staff, of the importance of managing their family member's condition closely.

Following our last inspection of February 2013 the provider was asked to make improvements in all areas we inspected. The provider submitted an action plan detailing how improvements would be made and when they would reach the standards required. When we checked on required improvements, we found some progress had been made but that further work was needed to reach and maintain the standards of care required.

We were shown copies of menus, which covered a four week period. The menus showed a variety of foods, including plenty of fresh fruit and vegetables. We asked people if they enjoyed the food they were given, if there was enough variety, and if portions were sufficient. All people we spoke with said they enjoyed the food and were happy with the variation in their meals.

We asked a relative of someone living at the home, how they found the care, and how their family member had settled in. They told us "The care is good. My mother is doing well here. She didn't cope when living at home on her own."

When we were shown around the home, we found that although some redecoration work had taken place, there were still many areas that needed further attention. When we observed care being given to people at the home, we noted that staff were respectful and warm towards people. However, most of the interaction between staff and people living at the home, was task orientated.