Orangery Care Home

The care home accommodates up to 60 people in a three storey building, providing care on four designated units for people who require nursing and/ or dementia care. Communal areas were located on the ground floor, and the service was situated around an enclosed courtyard area and secure garden. At the time of the inspection there were 52 people living there.

The service had a registered manager. A registered manager is a person who has registered with the 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 Act 2008 and associated Regulations about how the service is run.

People had been safeguarded from the risk of abuse; staff understood both their role and duty to protect people and had access to relevant guidance. A range of risks to people had been assessed and care plans were in place to manage them. The required utility and equipment safety checks had been completed to ensure their safe use. People were safe as they were cared for by sufficient numbers of staff whose suitability for their role had been assessed. Processes were in place to ensure people received only the medicines they required, from trained staff. The service was clean and staff had undergone relevant training to enable them to understand how to protect people from the risk of infection. Processes were in place to ensure learning took place following incidents and improvements had been made to people’s care to reduce the risk of repetition.

People’s needs had been assessed prior to them being offered a service. The provision of people’s care reflected good practice guidance. Staff had received a suitable induction to their role, on-going training and supervision.

People’s nutritional and fluid intake needs had been identified and met. Processes were in place to ensure staff worked both across the organisation and with external professionals to ensure people’s health and social care needs were met. People were supported to access a range of healthcare professionals.

The service was in the process of being refurnished to ensure it met people’s needs. The garden was attractive, secure and accessible for people.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People told us they liked the staff, whom they felt had promoted both their independence and their privacy and dignity, visitors were welcomed. Staff treated people kindly and ensured they were comfortable. Overall people were asked for their views about their care and offered choices about their care. The registered manager had taken action to ensure all staff consistently promoted the choices available to people at lunch.

Staff understood people’s needs and work was underway to ensure written care plans were fully centred on the individual. Staff had undertaken training in meeting the needs of those living with dementia, although some staff were more confident than others in their interactions with people. People’s needs for social and spiritual stimulation had been met. People’s complaints had been listened to, responded to and used to improve the service. People had been well supported at the end of their lives.

People were cared for within a positive culture where staff felt valued. Staff felt improvements had taken place to the quality of people’s care under the leadership of the registered manager. There was a clear management structure and oversight and support provided both from the provider and regional manager. The registered manager was visible and accessible to people within the service. Processes were in place such as audits, trackers, surveys and meetings to monitor the quality of the service and to drive improvements for people. Staff worked in partnership with other agencies.

The service 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. The registered manager was unavailable during the inspection. The inspection was facilitated by the deputy manager with the assistance of the clinical lead and the provider.

At our last inspection of this service on 01 and 02 February 2016 we found two breaches of legal requirements in relation to safe care and treatment and requirements relating to workers. The provider sent us an action plan dated 04 October 2016 informing us the required actions had been completed. At this inspection we found the two breaches of legal requirements had been met.

Body slings are used in conjunction with hoists to support a person while they are being lifted and transferred. The provider was not following good practice guidance in relation to the requirement to provide individual body slings for people in order to minimise the potential risk of cross-contamination from the sharing of these slings. The risk assessments and processes they had in place were not equivalent to or better than the recognised guidance. The provider took action following the inspection and bought slings for people. Time is required to embed the new practice of using individual slings for people’s safety within the staff culture.

Processes were in place to safeguard people from the risk of abuse. Staff had undergone relevant training and understood their role and responsibility to safeguard people from abuse. People and their relatives told us they felt that risks to people were managed safely. Risks to people associated with the delivery of their care had been identified and addressed for their safety.

People and their relatives provided mixed feedback regarding the adequacy of staffing levels. Observations and records demonstrated that overall there were sufficient staff deployed to meet people’s needs safely. There was no use of agency staff; therefore people benefited from continuity in the staff providing their care.

People told us they received their prescribed medicines at the correct time. Nurses administered people’s medicines safely, having undergone training and medicine competency assessments. People did not have ‘PRN’ protocols; these are used for the administration of medicines that are to be given ‘as required’. We brought this to the attention of the deputy manager, who took immediate action to address this for people ensuring the required protocols were put in place. It will take further time to ensure this is embedded in staff’s practice.

The majority of people told us they felt staff had the right skills and training to meet their care needs. Staff received an induction and relevant training to ensure they could care for people effectively. Nurses were supported to maintain their professional registration.

Staff spoken with were able to demonstrate their understanding of the Mental Capacity Act (MCA) 2005 and its application in their daily work with people. Staff had identified through the use of MCA assessments who was being restricted of their liberty and therefore required an application under the Deprivation of Liberty Safeguards (DoLS).

People generally gave positive feedback about the quality of the meals provided. Risks to people associated with eating and drinking were assessed and managed effectively. People were offered a sufficient amount and variety of food and drink to meet their needs.

People told us they had been supported by staff to ensure their health care needs were met, which records confirmed.

People experienced caring relationships with the staff who looked after them. Most people spoken with reported they felt involved by staff in decisions about their care. People’s records documented the areas of their life within which they could exercise choices and their communication needs. Staff were heard to consult people about decisions about their daily care.

The majority of people and their relatives spoken with told us that people’s privacy and dignity was upheld in the provision of their care. Staff were observed to knock before they entered people’s bedrooms and all care was provided in private.

People’s care needs were assessed prior to them being accommodated to ensure the service was suitable for them. Records showed formal reviews of people’s care also took place with them and their relatives. Staff were responsive to people’s individual care needs. Most people and their relatives spoken to felt people’s needs for social stimulation had been met.

Records demonstrated people’s complaints had been listened to and either responded to or were in the process of being investigated. Processes were in place to seek people’s feedback and the comments received were acted upon to improve the service for people.

Processes were in place to promote communication between people, their relatives and staff. However, people provided mixed feedback regarding how open they experienced the service to be.

People and their relatives provided mixed feedback about the management of the service, whilst staff provided positive feedback about the new registered manager.

Staff received guidance about the provider’s expectations for people’s care. There were sufficient managers in post and processes to monitor staff practices. Not all staff consistently acted in the manner the provider expected them to and the processes in place to ensure they did so were not always effective. We found aspects of care where staff had received guidance to ensure people’s safety, which some staff had failed to follow consistently.

The registered manager had recently introduced a range of trackers to monitor people’s health and to identify what actions were being taken. Although the registered manager had introduced a comprehensive range of audits, further time was required for them to all become effective at identifying all issues in relation to people’s care and embedded over time. The audit process had not identified or addressed the issues we identified at the inspection.

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.

Recruitment processes did not always evidence that people had been protected from the risks of unsuitable staff. Some checks, such as identity and criminal record checks, had been completed satisfactorily. However, the provider had not ensured that investigation into and explanation of gaps in applicants’ employment history had always been recorded. Evidence of suitable conduct in previous relevant employment positions had not always been requested.

Environmental risks had not always been addressed, because there was no robust programme in place to maintain regular checks on, for example, water temperatures, smoke alarms or sensor mats. There was a risk that people may be at risk of harm due to unidentified faulty equipment.

Specific risks affecting people’s health and welfare, such as the risk of falling, were managed safely. Staff were aware of those at risk, and took actions as required to promote their safety.

People’s medicines were stored, administered and disposed of safely. An audit in January 2016 had identified some issues, for example with recording administered medicines. Actions were implemented to promote safe medicines administration.

There were sufficient staff deployed to meet people’s identified needs. Rosters and shifts were planned to ensure additional staff were available at times of high demand, for example to administer medicines or support people to rise in the morning.

People were safeguarded from the risk of abuse, because staff understood how to identify and report concerns. The registered manager notified and appropriately managed concerns to ensure people were protected from harm.

The staff training programme had been re-scheduled from 1 January 2016 to ensure all staff were supported to develop and retain the skills required to meet people’s needs effectively. Formal and informal meetings and competency assessment ensured staff demonstrated the required skills to meet people’s needs.

Staff understood and implemented the principles of the Mental Capacity Act 2005. They listened to and respected people’s wishes. Nurses knew when it was appropriate to assess people’s mental capacity to ensure they could make an informed decision about their care. A best interest decision was made for people by those appropriate to do so when they lacked the mental capacity to make the decision for themselves. People’s liberty was only restricted when it was lawful to do so, to protect them from harm. Records demonstrated that lawful process was followed in these cases.

People’s dietary needs and preferences were known and met effectively. People were supported to maintain sufficient nutritional intake. Nurses liaised with health professionals to ensure people’s health needs were reviewed, and care provision effectively supported their identified needs.

People and their relatives described staff as caring and attentive to their needs. We observed caring interactions, where staff promptly responded to indicators of people’s discomfort.

People’s views and comments were listened to, and relatives were asked for information to inform people’s care. People were encouraged to help with daily tasks if they wished, such as gardening and helping in the kitchen.

People’s dignity was promoted, and their privacy respected, as staff took appropriate actions to ensure people were treated in a dignified and respectful manner.

People’s care needs and wishes were documented and reviewed regularly to ensure changes were identified and addressed. Staff were attentive to changes in people’s wellbeing or health. They took appropriate measures to support people’s recovery or provide respectful and kindly end of life care.

Activities were arranged daily. A volunteer visited people who remained in their rooms, to ensure they did not feel socially isolated. Complaints had been addressed appropriately. People and their relatives were confident that concerns they raised would be considered and responded to.

The provider’s values of welcome into the home and provision of care that promoted people’s wishes and independence were demonstrated in the care people experienced. The registered manager and deputy manager were respected by people, relatives and staff. They provided leadership that listened to and acted on the views of others.

Audits were used to identify issues and review the effectiveness of measures put in place to drive improvements to the quality of care people experienced.

We found two breaches 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.

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found:

Is the service safe?

The service was safe. People who use the service told us they felt safe. Staff had received safeguarding training and knew how to recognise and deal with cases of suspected and actual abuse.

People's care plans included full needs and risk assessments to ensure they were protected from receiving inappropriate care.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. During our visit we noted that the provider had awareness of DoLS. We were shown copies of four requests for deprivation of liberty authorisations, and noted that these had all been properly completed.

Is the service effective?

The service was effective. People told us they felt appropriately cared for and that they thought staff were properly trained and competent to carry out their duties. Each person had a fully completed and up to date care plan which was tailored to their specific needs.

Staff told us they always asked people's permission before offering them any kind of care or treatment. There were processes in place to ensure that decisions could be made in a person's best interest if they lacked the capacity to make decisions for themselves.

People's views were taken into account, for example through the use of regular satisfaction surveys, and staff also had the opportunity to give their feedback.

There were sufficient numbers of staff to provide an appropriate level of care to people. Care staff had either completed, or were in the process of completing, appropriate qualifications in health and social care.

Is the service caring?

The service was caring. People we spoke with were positive about the service they received. One of the people who uses the service said 'I like being here'. They said they liked playing dominos, music and dancing. They said they thought all the staff were very friendly. Another person told us that 'the food is smashing and the staff are good'.

Care staff had a good awareness of people's needs. They were able to consistently monitor people's health and wellbeing and where necessary make amendments to a person's care plan.

Is the service responsive?

The service was responsive. There were sufficient staff numbers to ensure that staff were able to attend to people's needs in a timely manner, and to engage with people in a sensitive and empathic way.

Care plans were regularly updated to reflect changes in people's needs.

Is the service well led?

We found that the service was well led. The service had a registered manager. The provider regularly talked with all staff to seek their views, and to share any issues with them that might affect the service.

There were systems in place to monitor and assess the quality of the service on a regular basis, for example, a service user satisfaction survey was completed annually. The provider had systems in place such as audits to monitor and evaluate the quality of the service on a continuous basis.

We spent time at the home observing care and found that generally people had positive experiences. People were seen to smile and respond to staff when spoken with.

The provider was transparent in the information they provided about fees, contracts and terms and conditions. People knew how much they were required to pay for the service. One relative spoken with said " Oh yes we are kept well informed about the changes in fees."

The provider worked in co-operation with others to ensure peoples' need were met and people were protected from the risks of abuse.

The management of medicines was robust and protected people from harm. There were enough qualified, skilled and experienced staff to meet people's needs. Relatives told us staffing levels were good. One relative said "One relative said 'I visit my mum almost every day and at different times of the day, I would say there are always enough staff.

People were supported in promoting their independence and their privacy and dignity was promoted and respected. One person said "Staff always talk to me before doing anything with me".

People were provided with a choice of suitable and nutritious food and drink. We spoke with two relatives about the food at the home. They told us their relatives enjoyed the food. One of them said "The food always looks appetising and there is lots of it".

Staff at the home did not respond appropriately to a potential safeguarding issue. We found staffing levels during the lunchtime period were inadequate and people's needs were not being fully met.