La Fontana

La Fontana is a nursing home providing personal and nursing care to people aged 65 and over. At the time of the inspection there were 68 people using the service. It accommodates people in three separate units, each of which has separate adapted facilities. Each unit specialises in providing care to people living with dementia.

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

Risks relating to infection prevention and control (IPC), including in relation to the COVID-19 pandemic, were assessed and managed. Staff followed recommended IPC practices and safe visiting was supported. Daily cleaning of the home was being improved and the importance of wearing facemasks at all times emphasised to staff.

People's medicines were generally well managed and administered safely. Minor improvement was needed in the management of topical creams to ensure people had them applied as prescribed. Staff needed to ensure there was always prompt action when changes were needed in medicine administration.

People said they felt well cared for, listened to and were happy living at La Fontana. People told us they felt safe. Systems, processes and practices safeguarded people from abuse. Staff knew how to identify and report safeguarding concerns.

Risks to people were assessed and reduced as much as possible. Risk assessments for people who expressed feelings or an emotional reaction were being improved. Equipment was safe for people and staff to use.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests.

Staff were recruited in a safe way. People said there were enough staff to support them.

Staff told us morale, teamwork, training and communication were good. Staff culture was positive and proactive. We observed many positive, kind and caring staff interactions with people.

There were thorough reviews of all accidents, incidents and near misses. Actions were taken to prevent reoccurrence to ensure people were safe.

The current management team (supported by the provider’s quality and compliance manager and operations manager) had clearly worked hard to manage the home well since the last manager had left. There were effective systems in place to monitor and review the quality of the service and to make sure improvements were carried out.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 28 April 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for La Fontana on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

La Fontana is a purpose-built care home providing personal and nursing care up to 76 older people aged 65 and over. At the time of the inspection 39 people were receiving care. One person returned to their home during the inspection. People could spend time in their bedrooms or the communal spaces available to them. There were three wings split up into two sections each.

This inspection was carried out to follow up on the infection control risks identified at the December 2020 inspection triggered by a significant COVID-19 outbreak at the home.

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

Improvements were found at this inspection and the home was no longer in breach of the regulations in relation to infection control. Since the last inspection all staff had received training and supervisions. We spoke with five members of care and support staff who all agreed that improvements had been made since the last inspection. Comments included, “There were some areas we needed to improve on - and we have improved in those areas…we are more conscious now and very careful”, “practice has tighten up here, more clear guidance, what to do and when, we now have a PPE area just for PPE - it is safe”, “Staff are now more aware, washing hands, sanitising, more vigilant, keeping their distance”, “I have no concerns and feeling safe here at work…everybody has tried so hard”

People were smiling and engaging with staff in the communal areas of the home. The home was calm. People appeared comfortable in the presence of staff wearing personal protective equipment (PPE). Staff supported people in a kind and caring way throughout the inspection and were always wearing adequate PPE for the interactions they had.

Staff were allocated to specific units to minimise the risks of cross infection. All areas of the home had separate entrances and exits so no staff needed to walk through other units. One area of the home was set up to isolate people who were positive with COVID-19. This had a separate staff team who understood best practice to reduce the risks of infections spreading.

Staff had a clear understanding of their role to keep people safe. They had easy access to PPE such as gloves, masks, aprons and visors from stations carefully located around the home. Staff knew how to use PPE and we observed best practice being followed. Staff informed us they were comfortable to challenge each other if they observed poor use of PPE. One staff said, “There were some areas we needed to improve on, and we have improved in those areas…we are more conscious now and very careful.”

The management was now ensuring current infection prevention and control guidance and best practice was followed throughout the home. Competency checks were regularly completed with staff to ensure practices continued to remain in line with training and guidance. Audits of infection control were regularly occurring at the home to identify shortfalls which were then rectified. The provider informed us that learning from this home was rolled out to their other services.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 28 April 2020). The ratings have not changed because the last two inspections have been targeted. This means we have not looked at enough areas to re-rate the service.

Why we inspected

We undertook this targeted inspection to check whether the urgent enforcement of adding conditions to the provider’s registration on infection and prevention control had been met and driven improvements. The overall rating for the service has not changed following this targeted inspection and remains requires improvement. We will support the removal of the conditions to the provider’s registration because enough improvements were found.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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 coronavirus and other infection outbreaks effectively.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

La Fontana is a ‘care’ home that provides personal and nursing care to people aged 65 and over. La Fontana provides long term and respite accommodation for up to 76 older people with personal care and nursing care needs. La Fontana accommodates people across three separate units, each of which has separated adapted facilities. Each unit specialises in providing care to people living with dementia. At the time of the inspection 46 people lived at the home with nursing, mental health needs and some were living with dementia.

We undertook this targeted inspection to follow up on specific concerns which we had received about a significant outbreak of COVID-19 at the service. A decision was made for us to inspect and examine those risks.

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

People were not always protected from the risk of acquiring infections as staff were not always following government guidance relating to Personal Protective Equipment (PPE). Staff were observed not following good hand hygiene or social distancing practice when moving from unit to unit.

Staff were not following government guidelines regarding close contact with people. Staff were observed going into people’s bedrooms without following the appropriate PPE guidance.

Staff were not following relevant guidance regarding the use of PPE and maintaining social distancing from each other which increased the risk of cross infection.

Staff had received training in infection control, however the training had not been embedded into practice. On the day of the inspection staff were observed wearing the PPE outside the building when taking their breaks. They did not change their masks when re-entering the units.

The PPE supply was not stored in an area that was easily accessible for staff when supporting people who had tested positive with COVID-19. Following our inspection, the provider took immediate action to ensure there were sufficient donning and doffing stations in all units so staff could safely put on and remove PPE.

Staff were not following the provider’s policy with regard to safe social distancing. For example, on the day of the inspection staff took their breaks together. They were not physically distancing from each other inside and outside the building. Following the inspection, the provider made arrangements for staff to maintain safe social distance whilst taking breaks and ensured good practice was monitored. Following the inspection, the provider arranged for additional training for all staff.

The registered manager had compiled a risk assessment and action plan in relation to the COVID-19 pandemic. The COVID-19 action plan had not identified the need for increased cleaning and the cleaning of other frequently touched areas around the home such as door handles.

At our inspection the registered manager demonstrated a lack of awareness in most aspects of safe infection control processes. Following our inspection, the registered manager worked closely with the local authority to update their policies in regards infection control. Improvements were noted by the infection control visit carried out by the Clinical Commissioning Group on 14 December 2020.

We found the following examples of good practice.

Staff reported people were in good spirits despite the current restrictions of being cared for in their rooms. Where some people were unable to stay in their rooms the communal areas were available. Activity co-ordinators visited people regularly to support them with one to one activities. People were supported to keep in touch with loved ones via telephone, mobile phone and via the internet.

Staff and people were regularly tested in line with the government’s current testing programme.

The size of the home and variety of spaces meant there were light and airy, well ventilated spaces and large gardens, which supported social distancing.

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 took urgent action and imposed conditions to the providers registration. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so. We will continue to monitor the service.

We have identified a breach in relation to Regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Why we inspected

CQC have introduced targeted inspections to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question. This inspection has not been rated.

We have found evidence that the provider needed to make improvements. Please see the Safe section of this report. We have signposted the provider to resources to develop their approach.

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 requested 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.

Further information is in the detailed findings below .

Please see the safe section of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for La Fontana on our website at www.cqc.org.uk.

La Fontana is a nursing home that was providing personal and nursing care to people

aged 65 and over. At the time of the inspection there were 57 people living there.

La Fontana accommodates people across three separate units, each of which has separated adapted facilities. Each unit specialises in providing care to people living with dementia.

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

Improvements had been made in regards the assessment of risk. However, they needed further development to ensure they were more focused on outcomes for people. Measures were being taken in regards national concerns in regards infection. Hand gel and information was available to visitors to the service on the appropriate protection, for example washing hands.

Improvements in systems and processes had been made to protect people from potential abuse and avoidable harm. Staff had received additional training in supporting people who may pose a risk to each other. Incidents of people hurting themselves and each other had reduced. Care plans contained control measures for staff to follow to keep people safe and staff had received additional training in regards behaviours and understanding dementia.

People received more personalised care responsive to their individual needs and choices. There was a focus on treating people as individuals. People had developed relationships with staff, and feedback from people and relatives was overall very positive. Staff had got to know people and their relatives really well, their likes, dislikes, about their family and what was important to them.

There were enough staff to meet people's needs, although there were some vacancies with ongoing efforts being made to recruit staff. Staff understood their responsibility to report incidents. Reporting and recording of accidents and incidents had improved.

Improvements had been made to minimise restrictions on people’s freedom and people were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

Staff had received more training. This additional training had ensured people benefited from a staff team who were competent, motivated and happy in their work. Staff had been trained in the safe administration of medicines and were assessed as competent before supporting people with their medicines. People told us they received their medicines safely.

People's concerns and complaints were listened and responded to. People and relatives said if they were unhappy about anything, they could tell nurses or senior staff, who addressed their concerns.

Improvements had been made in making sure people’s care records reflected their care and health needs. Staff had undertaken further training on the electronic care record system. People’s care records were audited regularly, with ongoing improvements being made.

The provider monitored reports to identify trends, make changes and improvements to prevent recurrence. For example, accidents and incidents. Staff understood their responsibility to report incidents. Reporting and recording of accidents and incidents had improved.

Whilst it was evident the service had made improvements since our last inspection, there were still areas that needed to be improved. These included the oversight of risk, such as safe swallow and falls.

Quality monitoring systems and processes had improved.. Where audits or practice observations identified areas for improvement these were followed up. People, relatives and staff all reported improvements in the quality of care. All said the decision to allocate staff to work in specific units had meant, staff had got to know people and their visitors better, which had improved the quality of care.

The last rating for this service was requires improvement (published 2 November 2019) and there were multiple breaches of regulation. We imposed conditions on the provider's registration. These required the provider to carry out specified audits and report on the outcomes of these audits to CQC each month. At this inspection we found improvements had been made and the provider was no longer in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for La Fontana on our website at www.cqc.org.uk.

La Fontana was a residential care home that was providing personal and nursing care to people aged 65 and over. At the time of the inspection there were 65 people living there.

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

People lived in a home where quality audits were carried out but were not always effective in ensuring improvements were made. Shortfalls identified at this inspection had not been identified and addressed by the provider’s own quality assurance systems.

Systems and processes in place to protect people from the risk of abuse were not fully effective. Staff knowledge and responses to the needs of those living with dementia needed further developing. People had behaviour care plans in place, however the records in the care plans were not up to date. There were not individualised interventions or strategies to help alleviate people's anxiety or behaviours that challenged.

Accidents and incidents were reviewed to help identify themes and trends. Audits had not identified under recording of these incidents and it was not clear if all unexplained injuries were recorded, investigated and reported.

Improvements were required into the induction to new staff at the service. There were a number of staff who did not know people well. Some staff and relatives raised concerns in regard to staff being employed who had limited understanding of the English language. Although there were sufficient staff on duty there was a high use of agency staff in the home, including agency nurses. We found the agency staff had not always had their identity and skills checked before they started work at the service.

A recommendation made at our last inspection in regards medicine management had mostly been met. There have been improvements to the way people’s medicines were managed since our previous inspection. However, some further improvements were needed to the way information was recorded about people’s medicines, further improvements were needed for medicines prescribed to be given ‘when required’.

Systems were in place to ensure people were protected from the risk of the spread of infection. The service was able to demonstrate when infections had occurred. Current and national guidance was followed.

A recommendation made at our last inspection in relation to the service revisiting guidance

relating to the Mental Capacity Act 2005 in relation to supporting people to make decisions, had not been met. Where people lacked capacity to make decisions or give consent, staff did not always act in accordance with the Mental Capacity Act (MCA). Mental capacity assessments and best interest decisions had not been fully completed in line with the principles of the MCA. DoLS applications were out of date.

There was a risk people may not be protected from harm because staff lacked the specialist knowledge and skills to care for people living with advanced dementia and complex needs. Although some new staff praised their induction others told us they felt they needed more guidance.

People had their nutritional needs assessed. Pictorial menus were observed on tables. People told us they enjoyed the food at La Fontana. Throughout the inspection staff were observed offering people regular drinks and snacks in a caring way.

People lived in a comfortable home which was well-maintained and regular checks were carried out to promote people’s safety. People had bedrooms where they could spend time in private or with visitors. There were ample communal spaces and garden areas for people to use.

Throughout the inspection we observed kind and respectful interactions between staff and people using the service. People told us staff were kind and respected their privacy and dignity. Visitors said they always felt welcomed at the home and staff kept them informed about the care of their loved ones.

Each person who lived at the home had a care plan, but these lacked details and were not person centred. Daily records were called ‘wellbeing checks. They did not give a true reflection of what the persons needs were. The provider had a new on-line care system in place and told us the care plans were a ‘work in progress.’

The provider had a complaints procedure and people and their relatives told us they were aware of the process to make a compliant. However, there were shortfalls in the recording of complaints.

There were shortfalls in the oversight of the service. Although there had been improvements in notifying CQC of incidents and safeguarding alerts. The provider quality assurance systems did not identify and rectify previously identified breaches of regulation, ensure the quality of service provision and mitigate the risks to people.

Rating at last inspection: The last rating for this service was requires improvement (published 15 February 2019). Following this inspection, we imposed conditions on the provider's registration. These required the provider to carry out specified audits and report on the outcomes of these audits to CQC each month. At this inspection there had not been enough improvement made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about the safe welfare of people using the service. A decision was made for us to inspect and examine the risks.

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

Following the inspection, we have been informed that all staff have undergone training on ‘Behaviours that Challenges’.

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

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for La Fontana on our website at www.cqc.org.uk.

Enforcement

We identified eight breaches of regulations in relation to person centred care, consent, safe care and treatment, safeguarding, good governance, fit and proper persons employed, staffing, receiving and acting on complaints. Please see the action we have told the provider to take at the end of this report.

Following the inspection, the Care Quality Commission (CQC) took enforcement action by varying conditions already imposed on the providers registration. This required the provider to provide CQC with a monthly report outlining actions and progress towards making the required improvements.

Follow up

We met with the provider on 03 December 2019 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.

La Fontana 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.

La Fontana provides accommodation for up to 76 older people who need nursing and personal care. At the time of the inspection there were 69 people living at the home. The majority of people were living with a dementia and many had complex nursing or other support needs.

The service had 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.

Although people who were able to, told us they felt safe living in the home, the systems in place to protect people from harm needed to be improved. There were frequent incidents involving people becoming anxious and physically challenging to other people. These incidents were not always being reviewed to identify factors that could prevent further incidents from occurring. Care plans and risk assessment were not always updated following incidents.

Risks to people were not always being identified and management plans put in place to mitigate risks. Staff told us at times they were using unplanned restraint for one person during personal care. Staff had not received all of the training required to ensure they felt confident to manage incidents.

Some improvements were required to the processes in place where people lacked the capacity to make decisions for themselves.

People’s care plans were of mixed quality, were not consistently person centred and some contained contradictory information. Some of the plans lacked specific details of people’s communication needs, and preferences for how they wanted to be supported.

The provider had not notified the Care Quality Commission and the local authority of safeguarding incidents in line with their legal responsibility. The governance systems had not been fully effective in improving the quality and maintaining the safety of people. A new governance system had been introduced and had not been fully embedded to demonstrate its effectiveness.

Staff knew how to recognise and report abuse and felt confident concerns would be acted upon. Staff told us they felt supported in their roles.

Medicines were stored and administered safely. Some improvements were required to the recording of external creams, ‘when required’ medicines, and the competency checks of nursing staff.

We received some mixed feedback from people and relatives regarding the staffing levels in the home, there were enough staff available to meet people’s needs. The provider had procedures in place to ensure that suitable staff were recruited.

There were systems in place to protect people from the risk of infection. There were a range of checks in place to ensure the environment and equipment in the home was safe.

The provider had met their responsibilities with regard to the Deprivation of Liberty Safeguards (DoLS). DoLS is a framework to approve the deprivation of liberty for a person when they lack the mental capacity to consent to treatment or care and need protecting from harm.

People’s nutritional needs were assessed and their weights were monitored where required. Our observation of the mealtime experience was mixed. People commented positively about the food, although some said it was repetitive. The registered manager had plans in place to review and update the menu.

People were supported to access a range of healthcare professionals. The home maintained links with the local community.

People and their relatives spoke positively about the staff supporting them. Staff described how they supported people in a way that promoted their privacy and dignity. Staff spoke positively about the people they supported.

There were a range of activities on offer for people to take part in. Records demonstrated some people’s social needs were not consistently met. People, their relatives and staff had the opportunity to provide feedback on the service.

Relatives, staff and health professionals commented positively about the management of the service.

We have made two recommendations to the service. One in relation to the service revisiting guidance relating to the Mental Capacity Act 2005 in relation to supporting people to make decisions. The second recommendation identifies that improvements are made to aspects of medicines management, including the recording of external preparations, ‘when required’ medicines, and the competency checks of nursing staff.

We found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of Regulation 18 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 the report.

At the last inspection on 16 and 22 July 2015 we found there were breaches of legal requirements. We asked the provider to take action to make improvements to: People’s food choices and the support they received at meal times; the accuracy and completeness of care records; the effectiveness of their quality monitoring system; and the deployment of sufficient numbers of suitably qualified staff. We received a provider action plan stating the relevant legal requirements would be met by 28 February 2016. At this inspection we followed this up and found the actions had been completed, although some further improvement was needed to ensure people’s care records were consistently up to date. We have also made a recommendation about best practice in relation to dementia care.

People’s mealtime experiences had improved greatly and there were more regular staff employed to meet people’s nursing and personal care needs. Management was more visible around the home and the registered nurses were far more active and effective in providing support and leadership to the care staff.

La Fontana provides accommodation for up to 76 older people who need nursing and personal care. At the time of the inspection there were 74 people living at the home. The majority of people were living with a dementia and many had complex nursing or other support needs.

The service had 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.

The registered manager told us the service philosophy was to provide a high standard of care, meet people’s needs and provide a safe environment. People and their relatives told us the service was responsive to their needs and the registered manager was open, accessible and approachable.

We observed staff supported people in a caring and considerate way and they had a good understanding of each person’s needs and preferences. A person who lived in the home said “The staff are nice and caring and on the whole they are patient and respectful”. A relative said “The best thing about this place is the care and attention they [staff] give to the residents. I would recommend this home; it's just like a big family”.

People told us they felt safe and secure. A person who lived in the home said “There are always staff around and they are there within minutes if anything happens”. A relative told us they felt well informed about changes in their relative’s needs and felt their relative was being cared for safely.

There were always three qualified nurses on each day shift to ensure people’s clinical care needs were met. The service also worked in close partnership with other local health and social care professionals to meet people’s health and wellbeing needs.

People received their medicines safely from registered nurses and people were protected from the risk of infection. The home’s environment was spacious, clean and bright throughout with lots of natural light.

The home had good facilities for people living with a dementia, including secure spacious gardens, a reminiscence room with traditional shop displays and its own animal farm. People, relatives and other members of the local community were invited to various events at the home, including: open days, Alzheimer’s days, fetes and other celebrations. This encouraged social interaction with the community and helped to raise awareness of dementia care.

People's care needs and risks were assessed and care was delivered to meet their needs. One person said, 'I'm very well looked after. I really do thank my daughter for getting me here.'

People were protected from harm as there were appropriate safeguarding procedures.

Staff were supported by the provider through appropriate training and the home had suitable systems to monitor the quality of service provided.

Medicines were managed safely. One person told us, 'My medication comes on time usually.'

There were sufficient numbers of staff to meet people's needs. One person told us, 'There are enough staff. I don't use the call bell often but when I do they come quickly.'

People's care records were accurate and contained relevant information.