Hart Care Residential Home

Hart Care is a residential care home providing the regulated activity of personal and nursing care to up to a maximum of 54 people. The service provides support to older people. At the time of our inspection there were 30 people using the service.

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

Since our last inspection, the provider had taken action to ensure the service was now well led. A new management team was in place who had the skills, knowledge and experience to perform their roles and improve the quality of care provided. The quality of the service people received was monitored and audited to help ensure it was consistently good.

Improvements had been made in how the service managed people’s medicines. People’s medicines were now administered safely and as prescribed for them. Staff received medicines training and had their competencies checked to ensure safe practice. Medicine audits and checks were in place to identify and issues or concerns. However, we made a recommendation in relation to ensuring best practice is followed in relation to medicines given through a patch on people's skin.

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; the policies and systems in the service supported this practice. However, we made a recommendation with regards to records relating to mental capacity assessments and best interests’ decisions.

Risks to people were regularly assessed with measures in place to mitigate them. However, we made a recommendation about updating care plans and risk assessments to ensure they reflect actions taken to manage risk.

People told us they were happy living at the service, they felt safe, and staff treated them with respect and kindness. Staff understood the importance of safeguarding people wherever possible from poor care and harm. When staff had any concerns about people, they knew where to escalate and report these concerns.

Staffing levels were sufficient to meet people's needs and staff were recruited safely.

Staff were being supported to complete a new mandatory training programme and refresher courses, to ensure they had the skills required to complete their roles. The induction training was also being improved and aligned to the Care Certificate.

The provider had infection control procedures in place to protect people and prevent the spread of infection. Staff accessed personal protective equipment (PPE) and acted in accordance with government guidance.

Staff told us they felt supported by the managers and provider and morale within the staff team had improved.

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

Rating at last inspection

The last rating for this service was requires improvement (published 20 August 2021)

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective and well-led which contain those requirements.

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.

Follow up

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

We last inspected the service on 19, 25 August and 1 September 2020, the service was rated as Inadequate because we found the provider to be in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took enforcement action to impose conditions on the providers registration to help ensure people were no longer exposed to risk of harm. we asked the provider to complete monthly action plans to show what they would do and by when, to improve.

Following the last inspection the provider had taken the decision not to provide any nursing care to people while improvements were being made. People who had been receiving nursing care had been supported the provider and the local authority to move to an alternative placement.

During this inspection we found improvements had been made towards meeting the requirements to ensure people received safe care. However, these improvements still need to be further developed and embedded across the service to ensure the quality of care continues to be consistent and safe.

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

Medicines management had improved since our last inspection. Medicines were stored safely, and staff had regular training to ensure they continued to have the skills and competencies to administer medicines safely. However, further improvements were still needed to ensure people received all medicines in the way they needed. Records showed that people received their regularly prescribed medicines safely. However, there were some concerns over the administration of medicines prescribed to be given ‘when required’ (PRN) There was not always person-centred guidance around how and when these medicines should be given.

Systems to assess and monitor the quality of the service had been developed and improved. However, these still needed to be embedded across the service and had not in all cases identified some of the gaps found at this inspection, particularly in relation to medicines.

Risks to people’s health and well-being were being assessed, mitigated and managed.

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.

Based on our review of the key questions Safe and Well-led the service was able to demonstrate how they were meeting some the underpinning principles of Right support, right care, right culture.

People with a learning disability who were new to the service were being supported to settle into their new home. The provider had liaised with the specialist learning disability team to help ensure people’s needs were understood and appropriately met and staff had undertaken some initial training to help ensure they had the skills needed to support people. Some aspects of care planning and delivery of care, such as medicines was not person centred and had not fully taken into account people’s choices, and best practice guidance.

The provider had appointed a new management team providing more stable, consistent leadership and support. The management team had shown commitment to driving continue improvement to develop the service and to provide people with safe care.

People, their relatives and staff told us the managers were open, supportive and displayed good management skills. One person said, “The manager is approachable. He’s sorted out any little problems I have had, the place has improved since he arrived”. Relative comments included; “The manager and deputy are brilliant”, “The manager is approachable and effective, and I can’t speak highly enough of him”,

People told us they felt safe living at the service. Since the last inspection the management team had developed robust safeguarding policies and procedures and staff had undertaken updated training to recognise and respond to abuse or poor practice.

There had been improvement with the providers processes to record, analyse and report accidents and incidents. We saw where action had been taken to safeguard people and mitigate future risks.

Improvements had been made in the way risks relating to people’s health and well-being were assessed and managed. However, care planning information still needed to be improved for people with long-term health conditions, such as Diabetes to ensure staff had the information required to understand and manage risks associated with these health needs.

Staffing levels and the organisation of staff had improved, and systems were in place to keep staffing arrangements under regular review. Staff felt supported and undertook regular training relevant to their role.

The home was clean and tidy on the day of the inspection and the provider had appropriate systems in place to prevent the risk of infection.

We have made a recommendation about medicines management and care planning specifically relating to people with a learning disability and/or autism, and care planning of long- term health conditions such as Diabetes.

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 Inadequate (published 02.10.2020) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made

This service has been in Special Measures since 01.10.2020. 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

We carried out an unannounced focussed inspection of this service on 19 August, 25 August and 1 September 2020 due to concerns that had been raised. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve, safe care and treatment, safeguarding people from the risk of abuse, staffing, good governance and staffing.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 assurances that the service can respond to COVID-19 and other outbreaks effectively.

The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hart Care Residential and Nursing Home on our website at www.cqc.org.uk.

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

Systems and processes to monitor the safety and quality of the service were not effective.

Risks in relation to people’s health and care needs, such as skin breakdown, catheter care and diet were not always identified, assessed or understood by staff delivering care. Where guidance was in place for staff to monitor and reduce risks these were not always being followed consistently. People’s monitoring charts were not being completed consistently, such as charts monitoring food and fluid intake and re-positioning to prevent skin breakdown.

Care plans did not contain sufficient information about people’s specific needs to ensure staff knew how to deliver appropriate care. Where information was recorded this was not always accurate, up to date and did not provide evidence of staff interactions.

Medicines were not managed safely, and we were not assured people received their medicines as needed and as prescribed. When mistakes were made in relation to medicines these were not always escalated appropriately, and action was not always taken to ensure mistakes did not happen again.

People were not safeguarded from the risk of abuse. Staff did not always recognise potential safeguarding concerns and when concerns were reported these were not always appropriately escalated and actioned to ensure people were safe. The provider had not learned from previous safeguarding concerns, which had meant people continued to be at risk of poor practice and potential abuse occurring again.

Accidents and incidents were not appropriately managed and there was no effective system in place to learn from accidents and prevent re-occurrence.

Staff were not always sufficiently trained to provide safe and effective care. The service had a training plan for staff, however training was not in all cases up to date and did not address gaps in staff skills and knowledge that had been identified.

Staffing levels and the organisation of staff were not sufficient to meet people’s need and to keep them safe. Staff told us they did not always have time or there were insufficient numbers of staff to meet people’s needs and complete daily tasks.

People were not protected by infection control practices in the home. Staff had not undertaken sufficient training and did not have the information they needed to ensure people were fully protected from the risks of infection.

Quality checking processes and audits were either not completed or were ineffective across all areas of care. This meant people were at risk of receiving poor care because the risks to their safety and wellbeing were not mitigated or managed effectively to protect them from harm.

On the second day of the inspection we escalated the most serious concerns found to the local authority and requested assurances from the provider that they would take immediate action to ensure people were safe. The provider responded promptly and since the inspection has worked with the local authority and other agencies to ensure people became safe and have their needs met. The provider has recruited a consultancy company to assist them with these improvements.

On the second day of the inspection we were informed by the provider that the registered manager was no longer working in the service. Since the inspection an interim manager has been appointed to assist with the running of the service.

We have made a recommendation in relation to recruitment records.

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

Rating at last inspection The last rating for this service was Good (Published 16.01.2019)

Why we inspected

We received concerns in relation to people’s nursing needs, the management of medicines and the escalation and management of incidents. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

The overall rating for the service has changed from Good to Inadequate. This is based on the findings at this inspection.

Enforcement

We have identified breaches in relation to the management of risks, safeguarding, medicines management, staffing and the governance of the service at this inspection.

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 discharge our regulatory enforcement functions required to keep people safe as and to hold providers to account where it is necessary for us to do so.

For 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

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 of 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.

Hart Care Nursing and Residential home is registered to provide nursing and personal care for up to 54 people. Most people using the service have multiple health care needs. There were 40 people living at the home on the first day of our inspection; 20 people had nursing care needs supported by the registered nurses at Hart Care Nursing Home and 20 had their nursing needs met by the local community nurses. Two people were staying at the service for a period of respite (planned or emergency temporary care provided to people who require short term support). There were four further admissions by the second day of our inspection.

Hart Care Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection. The home is a large detached home set within Dartmoor National Park located outside the large village of Yelverton on the south-western edge of Dartmoor. People have access to a well-maintained garden.

At our last inspection we rated the service Good. At this inspection we found the service remained Good overall. There was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Why the service is rated Good.

Since the last inspection in July 2016 the provider had appointed a new registered manager at the service. They registered with the Care Quality Commission (CQC) in July 2017. The registered manager had worked with the local authority quality assurance team (QAIT). They had put in place processes and developed a service improvement plan (SIP) which set out the actions required, by whom and the time scales. The registered manager and staff had prioritised the actions in the SIP and had made great progress working through these. This was an evolving effective tool which the registered manager regularly reviewed and added further actions to, when identified.

The service was well led by the registered manager. The culture was open and promoted person centred values. People, relatives and staff views were sought and taken into account in how the service was run. There were effective systems in place to monitor the quality of care provided. The registered manager made continuous changes and improvements in response to their findings.

People remained safe at the service. People said they felt safe and cared for in the home. People were protected because staff knew how to recognise signs of potential abuse and how to report suspected abuse. People’s care needs were assessed before admission to the home and these were reviewed on a regular basis. Risk assessments were undertaken for all people to ensure their individual health needs were identified and met.

There were sufficient and suitable staff to keep people safe and meet their needs. Thorough recruitment checks were carried out. New staff received an induction that gave them the skills and confidence to carry out their role and responsibilities effectively. The registered manager was working with staff to ensure they had completed all the provider’s mandatory training and update training.

People had a varied and nutritious diet. There was a designated activity staff member to support people to engage in activities they were interested in, on an individual and group basis.

People knew how to make a complaint if necessary. They said if they had a concern or complaint they would feel happy to raise it with the management team.

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 were supported to lead a healthy lifestyle and have access to healthcare services. Staff recognised any deterioration in people's health, sought professional advice appropriately and followed it. People received their medicines on time and in a safe way.

Further information is in the detailed findings below.

Hart Care Nursing and Residential home is registered to provide nursing and personal care for up to 54 people. Most people using the service have multiple health care needs. There were 43 people living at the home on the first day of our inspection; 26 people had nursing care needs.

At the last inspection on February 2015, four breaches of regulation were found. These were because:

• People who use services were not protected against the risks associated with unsafe recruitment processes.

• People who use services were not protected against the risks associated with a poorly managed complaints system.

• People who use services were not protected against the risks associated with a poor quality assurance system.

• People who use services were not protected against the risks associated with poor supervision and appraisal systems.

The provider wrote to us with an action plan to say what they would do to meet the breaches of regulation by July 2015. At this inspection, we found they had followed their action plan and met the legal requirements.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had resigned their position as registered manager at the home. They had applied to CQC to remove their registration. They continued to work at the home as a registered nurse for two days a week. The provider was actively recruiting a new registered manager at the time of our visit. In order to ensure the safe running of the service they had employed an acting manager for two days a week, supported by a deputy manager to keep people safe. The provider also visited the home on alternate weeks to monitor the service and support the staff.

There were adequate staffing levels to meet people’s needs. Improvements had been made to the scheduling of staff on duty. People felt there were adequate staff levels but said sometimes staff response times to bells was slow. The acting manager was taking action to monitor the response times to people’s call bells.

People were supported by staff who had the required recruitment checks in place. Staff received an induction and were knowledgeable about the signs of abuse and how to report concerns. Staff had received training and had developed skills and knowledge to meet people’s needs. Staff relationships with people were caring and supportive. They delivered care that was kind and compassionate.

Measures to manage risk were as least restrictive as possible to protect people’s freedom. Medicines were safely managed and procedures were in place to ensure people received their medicines as prescribed. The acting manager was taking action to address any concerns highlighted.

Care plans were personalised and recognised people’s health, social and psychological needs. People’s views and suggestions were taken into account to improve the service. Health and social care professionals were regularly involved in people’s care to ensure they received the care and treatment which was right for them.

Staff demonstrated an understanding of their responsibilities in relation to the Mental Capacity Act (MCA) 2005. Where people lacked capacity, mental capacity assessments had been completed and best interest decisions made in line with the MCA. Improvements were being made to the provider’s computer system to ensure staff were aware of people’s legal positions and best interest decisions were recorded.

People were supported to eat and drink enough and maintain a balanced diet. People were positive about the food at the service.

The provider had a range of quality monitoring systems in place which were used to continually review and improve the service. The acting manager had identified gaps in some of the systems and had put in place an action plan. Where there were concerns or complaints, these were investigated by the provider and action taken. In addition, the premises and equipment were managed to keep people safe.

Is the service safe?

Is the service caring?

Is the service effective?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

There were 40 people living at Hart Care Nursing and Residential Home when we visited. The summary is based on conversations with 10 people using the service, nine staff supporting them, four people's families, two health care professionals, the deputy manager, observation and records. The registered provider also sent us information which we requested.

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 they had confidence in the staff supporting them, one person saying, 'I feel safe. They do take care'. We saw excellent examples of people being treated with respect and dignity but also an example where they were not.

Equipment was well maintained and serviced regularly therefore not putting people at unnecessary risk. The management of medicines ensured people received their medicines when they were due and medicine management was audited and any concerns in the arrangements had been followed up robustly.

Systems were in place to make sure that staff learned from events such as complaints. However, the monitoring of some aspects of the service, such as accidents and incidents, maintaining policies and procedure and reviewing the fire risk assessment had lapsed. This increased the potential for risks to people.

The home was acting appropriately in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards and had taken advice where they thought an application needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This means that people will be safeguarded as required.

The home was without a registered manager. The staffing arrangements were not set by a person able to take people's care needs into account when making decisions about the numbers, qualifications, skills and experience required. An appropriately qualified person would ensure that people's needs were always met. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to having a registered manager and ensuring the staffing arrangements safeguard the health, safety and welfare of people using the service.

Is the service caring?

Generally people were supported by kind and caring staff and there were comments about staff member's friendliness. We saw examples of good engagement and humour. However, people also told us they could feel rushed by staff.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes following consultation with them. We saw one staff spend considerable time talking through the menu with a person who had specific food likes and dislikes.

Is the service effective?

The service was effective because people's health and care needs were understood and met. Their health and care needs were assessed with them, and they were involved in writing their plans of care.

Specialist mobility and equipment needs had been identified in care plans where required and provided. Medicines were managed so that people's health was promoted in line with their wishes.

Health care professionals said they had confidence in the service, one adding that senior staff had a 'good grasp of issues' and were proactive in ensuring people's health needs were met.

Is the service responsive?

People were very clear that the deputy manager and provider were available and they had confidence that issues would be dealt with. The home managed complaints and took action where this was required. People's opinion had recently been surveyed although the results not collated. However, we saw that some issues raised had already been discussed in staff meetings, such as laundry, to try and address concerns.

The home responded appropriately and in a timely manner to changes in people's health care needs.

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service did not have an effective quality assurance system but was taking steps to correct this. However, some of the timescales which had been set had not been met so further work was needed.

People using the service and staff at the home felt the home was well led, as expressed through their confidence in the deputy manager and provider.

We did an unannounced visit to the home. We spoke to 11 people who used the service, one person's family, four staff, the acting manager and the provider.

People were receiving the care that they needed. Their comments included "They are very good"; "Staff are very good"; "The standard of care is pretty good" and "I think it is alright." People looked comfortable and, with the exception of staining following people's lunch, the standard of personal care appeared to be satisfactory. Staff explained how they ensured that people's needs were met, including regular visits to the most frail to change their position or offer them a drink. They said "We never miss those visits." We saw that people had drinks and a call bell within their reach. We saw staff assisting some people with their lunch time meal. This showed that people's needs were understood and being met.

Call bells rang throughout our visit and the provider showed how the response times could be checked. The majority of people felt that staff responded quickly enough when they needed assistance; there were some negative comments.

Staff felt that the majority of the time there were enough staff. They said that the acting manager and provider always tried to meet staffing shortfalls, using agency staff if necessary.

People we met told us, "It's very, very nice here" and "The staff are all wonderful, they all interact so well together and they have a lot of patience." We met many people and everyone felt well cared for. One person told us, "...there are enough staff, you don't have to wait long when you ring your call bell." Another person told us, "I have been in some horrible ones but this is clean and friendly and it's nice to see the garden, it's good here." We were told, "The new Matron is ever so nice."

We found that the staff knew people well and were able to meet their varied needs because they were skilled and experienced. People told us their choices were respected and they felt treated like individuals.

The environment at the home was clean and people told us it felt, "Homely." We saw people enjoying the two lounges, conservatory and gardens. People told us they liked being able to, "..choose to do their own thing."

There was a complaints policy and process in place. People at the home and staff all felt confident to raise any issues they may have and felt these would be managed appropriately.