Salt Hill Care Centre

Salt Hill Care Centre can accommodate up to 53 people (including couples) and provides nursing care, personal care and respite care to older and younger adults living with dementia, physical disabilities, learning disabilities and mental health support. At the time of our visit there were 29 people using the service.

People’s experience of using this service and what we found

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

Right Support:

There was not a high incidence of falls in the service. However, risk assessment processes required further improvement.to protect people from avoidable harm.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The provider did not always seek or consider partnership working with all specialist health and social care professionals and external agencies. Further work was needed to provide effective care and support to autistic people, people with learning difficulties, people living with dementia and people who were semi-independent.

People and relatives said their family members were safe from abuse and protected from the risk of infection. Staff records confirmed they had received training and they were appropriately inducted and supervised. There were enough staff deployed to provide care and support to people. People’s nutrition and hydration needs were met.

Right Care:

The provider did not always refer to nationally recognised guidance when developing care plans for autistic people, people with a learning disability, people living with dementia and people who were semi-independent.

The provider did not work in line with the Accessible Information Standard, to meet the communication needs of autistic people and, people with a learning disability and people whose first language was not English.

People and relatives described staff as caring, compassionate, thoughtful, and patient.

Care plans were now more person-centred as they provided detailed information about people’s life stories and preferences for care. Improvements were made to make it a dementia friendly environment.

Right Culture:

Further improvements were required in relation to the provider’s quality assurance systems, around the auditing of administration of medicines, care planning, assessing and managing risks, communication, and obtaining people’s consent.

The provider did not always operate effective systems and processes to make sure they assessed and monitored the service against all regulations.

The provider had introduced new quality assurance systems but it was too early for us to determine how effective they were. The management team were working hard to develop a positive and improvement driven culture.

Rating at last inspection and update

The last rating for this service was inadequate (published 11 October 2022) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. This service has been in Special Measures since 10 October 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

The inspection was prompted in part due to concerns received by local authorities about ineffective management and to follow up concerns found at our last inspection of the service. A decision was made for us to inspect and examine those risks.

We found no evidence people were at risk of harm from these concerns. However, we found further improvements were needed in relation to management of medicines, assessing and managing risks, effective care planning, meeting people’s communication needs, need for consent and good governance.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified breaches in relation to person-centred care, need for consent, safe care and treatment, and good governance.

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

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Salt Hill Care Centre can accommodate up to 53 people (including couples) and provides nursing care, personal care and respite care to older and younger adults living with dementia, physical disabilities, learning disabilities and mental health support. At the time of our visit there were 51 people using the service.

People's experience of using this service and what we found

People and relatives said they were safe from abuse. Comments included, If she (family member) felt unsafe, she would speak to us or the (registered) manager” and “If I felt (family member) was unsafe I’d talk to the senior staff.”

We found people were at risk of potential or actual abuse because appropriate action was not always taken when people sustained unexplained bruises. We have made a recommendation about this.

There were insufficient staff inappropriately deployed to support people who were assessed as highly dependent on staff to provide care and support to them. We have made a recommendation about this.

Medicine practices were not always safe as the service failed to follow its medicines policy and procedures. People, staff, and visitors were at risk of infection because the service did not do all that was possible to prevent it.

People received care and support that was not always, caring, person-centred and dignified. People received care and support from staff who were not always suitably qualified, skilled, and competent to meet their needs. People were not always supported to live healthier lives. This was because the service did not always work effectively with other healthcare services to meet their needs. People did not always receive nutritional snacks. We have made a recommendation about this.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; The registered manager did not work in accordance with the Mental Capacity Act 2005 and its Codes of Practice.

The design, decoration and adaptation of the building was not suitable for some people who lived there.

People received care and support from a service that did not always promote an open and empowering environment for people living with a learning disability, people living with dementia or people living in the service who were semi-dependent.

Quality assurance systems did not enable the provider to identify where quality and safety was being compromised and, learn when things went wrong. We have made a recommendation about the duty of candour. There was no scrutiny at board level therefore, the provider failed to monitor progress against plans to improve the quality and safety of the service. Records relating to care and the management of the service, were not fit for purpose.

The service was not able to demonstrate how they were meeting the underpinning principles of Right support, right care, right culture. This was because care and support did not always reflect current evidence-based guidance, standards, and best practice to meet the needs of people with a learning disability.

Right support: The service did not consider dementia as part of the care planning process other than to record it as a medical condition. This meant people did not get the individualised care and support needed.

Right care: People did not always receive person-centred care and support as staff were not always trained and competent to deliver care appropriately. Social activities were limited to the building and staff designated to provide entertainment did not have access to specialist training and appropriate resources. Care records were generic, illegible and did not consistently provide staff with enough information to know who and what were important to people.

Right culture: The culture of the service was not always inclusive, open, and empowering for people living a with a learning disability, autism, dementia, and complex health needs. This was because staff were not appropriately enrolled to role specific training to help enable them to work effectively. Quality assurance systems did not help the service to use lessons learned to improve quality and care for people using the service.

Rating at last inspection

The last rating for this service was good (published 23 August 2018).

Why we inspected

The inspection was prompted in part due to concerns raised by a local authority and concerns received relating to another of the provider’s services. A decision was made for us to inspect and examine if there were similar risks at this service. So we widened the scope of the inspection to become a focused inspection which included the key questions of safe, effective and well-led. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

After our inspection the registered manager sent supporting evidence to show risks to people from faulty wheelchairs were now mitigated.

You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively. This included checking the provider was meeting COVID-19 vaccination requirements.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well- led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Windsor Care Centre on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

We will continue to monitor the service and will take further action if needed.

You can see what action we have asked the provider to take at the end of this full report.

We have identified breaches in relation to quality assurance; risk management; building and premises, consent, effective and person-centred care planning; management of medicine; infection control and staff training.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service.

This will usually lead to cancellation of their registration or to varying the conditions the registration

.

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.

Salt Hill Care Centre can accommodate up to 53 people (including couples) and provides nursing care, personal care and respite care to older and younger adults living with dementia, physical disabilities, learning disabilities and mental disorders. At the time of our visit there were 49 people using the service.

The provider is required to have a registered manager as part of their conditions of registration. 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. At the time of our inspection, there was a registered manager in post.

When we completed our previous inspection on 4 and 5 May 2017, we found concerns relating to end of life care. At the time this area was included under the key question of ‘Caring’. We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework this area is included under the key question of ‘Responsive’. Therefore, for this inspection, we have inspected this key question and also the previous key question of ‘Caring’ to make sure all areas are inspected to validate the ratings.

At our previous inspection, the provider was rated ‘Requires improvement’ in all key questions of ‘Safe’, ‘Effective’, ‘Caring’, ‘Responsive’ and ‘Well-led’. We found a number of breaches in the Health and Social Care Act 2008 (Regulations) 2014. We asked the provider to send us an action plan to show what improvements would be made, by 23 July 2017. The provider submitted the action plan by the specified date.

We found the service had made the required improvements and are now rated 'Good' in all key questions.

People and relatives gave positive comments about the caring nature of staff. Comments included, “(Staff) very friendly, tolerant, forgiving and always around to help”, “They (staff) are always quite cheerful.”

People told us staff made sure those close to them felt like they mattered. Staff had a good understanding of people’s care and support needs. Staff ensured people’s privacy and dignity was respected and they were supported to be independent. Information about people was kept secure.

People said they felt safe from abuse. Comments included, “I feel quite safe” and “It’s as safe as houses. I would speak to (name of staff) if I felt unsafe.”

People were protected from harassment, discrimination and breaches of dignity and respect. Staff were aware of their responsibilities to safeguard people from abuse. Safe recruitment practices were in place and there were sufficient staff to care for people. Risks to people’s safety were assessed and medicines were administered safely.

People were cared for by staff who were appropriately inducted and trained. People’s nutritional needs were met. They were supported to live healthier lives and had access to healthcare services.

We have made a recommendation in relation to the provision of snacks. This was because people and relatives told us there was not a wide variety of snacks on offer. This was confirmed by our observations.

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 showed the service acted in accordance with the Mental Capacity Act (2005).

End of life wishes and preferences were captured with people and their relative’s involvement. The service was responsive to peoples’ care needs and social well-being. All complaints received were responded to in line with the service’s complaints policy and procedure. Reviews of care were not carried out consistently and documented.

We have made a recommendation in relation to reviews of care.

People, relatives and staff were positive about the service and how it was managed. There were effective quality assurance systems in place to monitor and assess the quality of the service delivered. The service sought feedback from people and their relatives' however, they acknowledged further work was still required in this area.

The most recent comprehensive inspection of the service was on 4 and 5 February 2016. The inspection resulted in an overall rating of ‘good’, with a ‘requires improvement’ in the key question is the service well-led. We found a breach in Regulation 18 CQC (Registration) Regulations 2009 (Notification of other incidents). A requirement notice was issued and we requested an action plan to be submitted by the provider on 13 April 2016. The provider failed to submit an action plan by the required date.

People and their relatives said the service was safe. Comments from people included, “Oh yes, quite safe” and “Yes, I’m safe here.” This was supported by relatives whose comments included, “Yes, she’s (family member) safe and well looked after, I can guarantee that she’ll be safe here.”

We found various work practices that placed people at risk of receiving unsafe care. This ranged from staff not having relevant training; people’s dependency levels not being regularly assessed to ensure appropriate staffing levels are in place; unsafe handling and administration of medicines to concerns about health and safety of the premises.

People and their relatives gave mixed feedback concerning how skilled and competent staff were. Comments included, “Seem alright. My laundry gets done; I just leave it on the bed” and “No. There needs to be more staff and better trained staff. I see them go to a resident in a chair and pull her up by her hands. I know they should put their arms under her arm and lift her.”

We found staff did not receive appropriate induction and training. The service did not always act in accordance with the Mental Capacity Act 2005. This legislation was put in place to protect people who are not able to make specific decisions. The service ensured people had access to a range of health care professionals to in order to maintain good health.

People felt the service was caring. Comments included, “The caring could not be better, the girls do their utmost to look after them all. They always offer me something to eat or drink, they’re very hospitable. I can come any time and I can make a cup of tea” and “They (Staff) look after her (family member) really well, her hair is always brushed, she never smells, she gets showered.”

We observed some good care practices. For instance staff were cheerful; attentive and encouraged people to eat. However, on other occasions we observed care was impersonal. We found people’s choices about end of life care was not reviewed regularly or discussed with appropriate others, to determine whether changes were needed.

Pre-admission assessments undertaken to establish peoples’ care needs were not designed to capture all the relevant information. We have recommended the service consider relevant nationally recognised evidenced –based guidance on the completion of assessments. People did not always receive care that was responsive to their specific needs. This was evident when reviewing the care of people who were diabetic; at risk of developing pressure ulcers and who were socially active.

People and their relatives gave a mixed response in regards how complaints were handled. Comments included, “I don’t have anything to complain about. It’s okay here”, and “There’s a resident who swears a lot, using really unpleasant words and I didn’t want my wife exposed to it. I told the (Registered) manager but he didn’t do anything about it so I said not to bring my wife into the lounge anymore. I don’t see why any of us should have to put up with it. I would prefer for her to come to the lounge and her daughter would too. I sent the (Registered) manager an email about it but he never responded to it. Why should we suffer?” We looked at how the service responded to complaints.

Relatives gave mixed views about the leadership of the service. We addressed how complaints about the registered manager are handled with a director. We found complaints were not always responded to appropriately.

Quality assurance systems did not operate effectively to ensure the welfare and safety of people who used the service. Information requested by the Care Quality Commission (CQC) was not submitted by the required deadline. Staff spoke positively about the support they received from the registered manager however; we found unsatisfactory management support placed people’s welfare and safety at risk. Records relating to care and the management of the service were not fit for purpose and the service failed to seek the views of people. People and their relatives were not given the opportunity to provide feedback about the service delivered.

We found a number of breaches of regulation Health and Social Care Act 2008 (Regulations) 2014. You can see what action we told the provider to take at the back of the full version of this report.

The most recent comprehensive inspection of the service was on 1 May 2014 The service was meeting the requirements of the regulations at that time.

People and their relatives were happy with the quality of the care provided and felt staff were friendly, kind and took good care of them. We observed people were looked after in a caring environment and saw staff were attentive to people’s needs, being gentle and compassionate when people became distressed.

People’s safety was maintained and protected. Staff were knowledgeable about how to keep people safe and had undertaken the relevant training. Risks assessments were put in place and risk management plans clearly recorded what actions must be taken by staff to reduce those risks. A review of medicines records showed medicines were administered in line with the service’s medicines policy. The service carried out safe recruitment practices which ensured people were cared for by staff that were of good character. We observed there was sufficient staff to provide care and support to people; this was supported by our review of staff rosters.

People and their relatives felt staff were efficient at their jobs and were adequately skilled to provide care, treatment and support. Staff were appropriately inducted, trained, supervised and appraised. They spoke positively about management ensuring they acquired the relevant skills to carry out their job roles.

Where people lacked the mental capacity to give consent the service ensured it acted in line with the Mental Capacity Act (2005). Staff demonstrated a good understanding of the act and knew the correct procedures to follow to ensure people who lacked capacity were still involved in the decision making process. During our visit we observed the service complied with the Deprivation of Liberty Safeguards (DoLS) by ensuring they applied for authorisation from the supervisory body before placing any restrictions on people who lived in the home.

People were effectively supported at meal times. They spoke positively about the meal choices available and expressed satisfaction with the food on offer. Where people were at risk of malnutrition appropriate professional assistance was sought. The service promoted the health and wellbeing of people by ensuring they had access to health professional. For instance regular GP visits. A health professional gave positive feedback about the clinical knowledge of a staff member and care that was given to people.

People felt the care delivered was specific to their individual needs. Staff demonstrated a good understanding of not only people’s care needs but what they liked and disliked. Care records evidenced what was important to people. People social needs were met. We observed an activity taking place during our visit and saw good interaction by staff and people were actively engaged. Relatives thought the service responded promptly to their requests. People and their relatives knew how to raise concerns and the complaints log evidenced all complaints received were responded to appropriately.

People, their relatives and staff felt the service was well managed. This was because management was effective, supportive and visible in the service. The provider sought feedback from staff, people who received care and their relatives. This covered all aspects of service delivery.

We found robust quality assurance systems in place to improve the quality and safety of people who used the service. The service ensured the quality systems in place were reviewed for their effectiveness.

We found a breach of regulation 18 of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People who used the service were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the DoLS. The deputy manager informed us they had requested six standard DoLS applications from the local authority for individuals they anticipated they may have to use restraint for in event they wanted to leave the home. This demonstrated people were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under the DoLS.

We saw completed induction programme schedules undertaken by the staff members and completed interview questionnaires which confirmed their fitness to do the job. Training records reviewed indicated what courses the staff members had undertaken, also what relevant qualifications they had achieved in order for them to be able to perform their duties. For example, safeguarding adults, mental capacity act 2005 (MCA) and DoLS, basic fire safety, moving and handling, infection control, first aid and emergency treatment. This demonstrated people could be confident they would be safe and their health and welfare would be met by staff members who were appropriately qualified and physically and mentally able to do the job.

Is the service effective?

We spoke with two people who told us how staff obtained consent from them when providing care. One person commented, 'Staff always asks for my permission.' This was supported by the staff we spoke with. One staff told us; 'In many cases, I obtain consent verbally.' Another staff member said, 'I would ask them and get their preference of what they want and explain what needs to be done.' We reviewed their training records and saw they had undertaken relevant training. This meant before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

We looked at the home's Selection and Recruitment of Staff Policy dated September 2010. This documents detailed how the home would ensure vacant positions were filled by the most suitably and qualified and experienced applicant by the effective selection, screening and recruitment processes. The policy stated that subsequent job offers would depend on satisfactory clearance. For example, a minimum of two references, one of whom must be the applicant's current or most recent employer; a check on any apparent gaps in employment history; verification of personal identity and check on the validity of professional, educational qualifications. This demonstrated the service had effective recruitment and selection procedures in place to ensure the health.

Is it caring?

People told us the staff members who supported them knew them well. One person said, 'They (staff) know what I like to eat and make sure I get it. They speak to me in a respectful way and listen to what I have to say.' We spoke to three staff members who confidently explained the care needs of the people they supported. One staff member when referring to a person they supported told us, 'X is not fully mobile and requires assistance with eating and drinking, they can become physically aggressive. It is important that staff explain what they would be doing before providing care to them." We reviewed the care plan of the person and saw it supported what the staff member had told us. This meant people could be confident that staff members knew the care needs of the people they supported.

Is it responsive?

We looked at the relative communication records. This noted discussions staff had with the individual's family members and what action had been taken to address their changing behaviour. We saw the family members expressed gratitude with the care that had been provided and agreed with the home that more help would need to be sought from the person's social worker and GP. This meant care plans was regularly reviewed and changed to meet the changing needs of people who used the service.

There was evidence that learning from incidents / investigations took place and appropriate changes were implemented. For example, the deputy manager told us. 'We had a resident who was always falling. We noticed this occurred at night time so management decided that an alarm mat which would alert staff members every time the person got out of their bed. This enabled staff to assist them and we found falls had stopped.' This helped to ensure the likelihood of further accidental injury was reduced.

Is it well-led?

People who used the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. We reviewed the residents' survey dated December 2013 and saw that the majority of the forms were completed by people's relatives who responded positively on all the questions asked. For example, relative rated the quality of care received, how they were involved in the running of the home and the choice of meal as excellent. On one of the questionnaires a relative commented, 'X has been at Salt Hill Care Centre for a year now and seems very happy and settled. The staff team are friendly and are always happy to answer any questions we may have.' One person we spoke with told us, 'There are no improvements necessary.' We saw comments boxes was situated on all floors in the home. This showed the service regularly sought the views of people and those who acted on their behalf.

We asked for and received a summary of complaints people had made and the provider's response. The complaints log recorded dates complaints were received, what they concerned and what actions were taken. This showed people's complaints were fully investigated and resolved, where possible, to their satisfaction.

People said they were offered a choice of food and drinks. We found people were provided with choices of food and drink that took into account their individual preferences and needs, including their cultural and religious requirements.

There were mixed responses to whether people thought there were enough staff to provide care to them. One visitor we spoke with told us: 'I feel there is always enough staff.' Another person said: 'No, definitely not! Half the ones I had when I came here have gone.' We found there were enough qualified, skilled and experienced staff to meet people's needs.

People told us staff looked after them well. One person said: 'They really look after me.' We found all staff received a comprehensive induction that took account of recognised standards within the sector and was relevant to their workplace and their role.

We saw surveys asked people various questions about aspects of care received. We found the service sought feedback from people who use the service or others acting on their behalf.

We found the provider had reported all incidents that affected the health and safety and welfare of people who used the service to the Care Quality Commission.