We carried out a review of the data available to us about Phoenix Park Care Village on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Phoenix Park Care Village, you can give feedback on this service.
Hilltop predominately provides care for older people. Some people have nursing, dementia, mental health or challenging behaviour needs. The ground floor accommodates a mixture of people some with nursing needs. The first floor accommodates people who all have nursing needs. There were 59 people living in the Hilltop unit at the time of our visit.
Overfields predominately provides care for younger adults who have complex care needs relating to their mental health. There were 34 people living on this unit at the time of our visit.
Fairways is a 35 bedded unit. Mainly for men with mental health needs and challenging behaviour needs. This unit opened on 17 July 2018. There were 13 people living on this unit. Altogether there were 106 people living at the service at the time of the inspection.
Phoenix Park Care Village is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.
At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and 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.
There were two registered managers’ in post due to the size of the service. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Minor issues were found on the first day of the inspection. These were regarding medicines ‘as required' protocols that required reviewing or implementing for eight people and there were minor issues with unsecured gloves and cleaning fluid found in two areas. These issues were corrected immediately by the management team. Staff were provided with supervision and further training during the inspection to make sure these minor issues would not re-occur. We found no further concerns in these areas over the next two days of the inspection.
People were protected from harm and abuse. Staff knew how to recognise and report potential issues. Safeguarding issues were reported and acted upon. Incidents and accidents were monitored and investigated. Risks to people’s wellbeing were assessed, monitored and addressed to maintain people’s health and safety. Staff were aware of how to support people if they displayed challenging behaviour.
There were enough skilled and experienced staff to meet people's needs. Staff undertook training in a variety of subjects had supervision and an annual appraisal to maintain and develop their skills.
People had maximum choice and control over their lives. Staff supported people in the least restrictive way. Policies supported this practice. People were involved in making decisions about their care and support.
People’s dietary needs were assessed and monitored to ensure their dietary needs were met.
Staff provided people with caring, kind and compassionate care and support. Staff provided appropriate reassurance and support if people became anxious, upset or displayed challenging behaviour. People’s privacy and dignity was protected. Information was provided to people in a format that met their needs, in line with the Accessible Information Standards.
An assessment of people’s needs took place. People were not accepted to live at the service if their needs could not be met. People’s needs were reassessed as their needs changed. Staff understood people’s preferences for their care and support. Complaints were investigated and this information was used to improve the service. End of life care was provided for people.
The management team were open and transparent and operated an ‘open door’ policy. Quality assurance checks and audits were undertaken to monitor the quality of service provided. The provider asked for feedback from people living at the service, their relatives, staff and visiting health care professionals. Feedback received was acted upon to maintain or improve the service. The provider continued to look at how the service could be improved. There was now a clinical nurse lead working at the service to further develop the care and support provided to people. Confidential information was held securely.
Further information is in the detailed findings below.
The service is comprised of two units known as Hilltop and Overfields. Hilltop offers 77 single, en-suite rooms for older people some of whom may be living with dementia, complex health conditions requiring nursing care and behaviours that may challenge the service and others. Overfields provides 34 single en-suite rooms for younger adults with complex needs and mental health conditions. The service offers a number of communal lounges, conservatories, kitchens, a mixture of dining and bistro areas, games rooms, a hairdressing and beauty salon, secure gardens and outdoor seating areas.
At the time of this comprehensive inspection, there were two registered managers in post. The registered provider had made one registered manager responsible for Hilltop and the other responsible for Overfields. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We carried out this unannounced comprehensive inspection of the service on 16 and 19 December 2016 to check that the registered provider was now meeting legal requirements and had achieved compliance with the regulations following breaches identified at the inspections on 17, 25 & 28 September 2015, 27 & 28 January and 12 February 2016 and 1, 2 and 8 September 2016.
At the aforementioned inspections the registered provider was non-compliant with regulations 9, 12, 17 and 18 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. This meant the registered provider was not meeting the requirements of regulations pertaining to providing person centred care, providing safe care and treatment, utilising effective systems to monitor and improve the quality of service provision and ensuring staff had the skills, abilities and experience to meet people's needs.
During this inspection we saw improvements had been made throughout the service and appropriate action had been taken to ensure compliance with the regulations.
People who used the service received person centred care. Care plans contained accurate descriptions of the current care needs and detailed guidance to enable staff to deliver care and support in line with their preferences.
People received safe care and treatment in a clean and hygienic environment. Staff wore personal protective equipment when required and worked in line with best practice guidance to ensure appropriate standards of infection prevention and control were adhered to. The environment was clean and free from unpleasant odours.
The registered provider’s governance systems had been reviewed and developed to ensure their effectiveness. Quality assurance tools such as audits, checks, questionnaires and observations were undertaken to highlight shortfalls in care and support and to drive the continual improvement of the service.
Staff had completed relevant training to equip them with the skills and abilities to deliver care safely and effectively in a number of subjects including safeguarding of vulnerable adults, The Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards, fire awareness, first aid, dignity in care, dementia and mental health awareness.
People who used the service were protected from abuse and avoidable harm. Staff were aware of their responsibilities to report signs of potential abuse and poor care. Known risks were identified and mitigated. Plans were in place to deal with foreseeable emergencies. Staff were recruited following appropriate checks and any gaps in their work history were explored. People’s medicines were stored, ordered and administered safely by staff who had completed relevant training.
Staff received effective levels of support, guidance and mentorship. Consent was gained before care and treatment was delivered. The principles of The Mental Capacity Act 2005 were followed and relevant legislation such as the Deprivation of Liberty Safeguards was adhered to. This helped to ensure people received the support they required in the least restrictive way. People ate a healthy and balanced diet of their choosing. When concerns with people’s nutritional intake were highlighted, relevant professionals were contacted for their advice and guidance. People received care and treatment from a range of healthcare professionals as required.
People who used the service were supported by caring staff who knew their needs and understood their preferences. People were encouraged to make decisions in their daily lives and to maintain their independence. Staff upheld people’s dignity and treated them with respect.
Pre-admission assessments were completed before people were offered a place within the service. Reviews of people’s care took place periodically and when their needs changed. Care plans were updated to reflect this. People, or their appointed representative, were involved in the initial and on-going planning of their care. The registered provider had a complaints policy in place which was displayed within the service. When complaints were received they were investigated and responded to in line with the registered provider’s policy.
Staff told us that the management team were approachable and a visible presence within the service. The registered provider utilised effective systems to drive improvement and ensure the service worked in line with best practice guidance. Staff efforts were recognised and celebrated internally. The CQC were notified of specific events that occurred within the service as required.
The service is separated into two units, Hilltop and Overfields. Hilltop offers 77 single, en-suite rooms for older people some of whom may be living with dementia, complex health conditions requiring nursing care and behaviours that may challenge the service and others. Overfields provides 34 single en-suite rooms for younger adults with complex needs and mental health conditions. The service offers a number of communal lounges, conservatories, kitchens, a mixture of dining and bistro areas, games rooms, hairdressing and beauty salon, landscaped gardens and outdoor seating areas.
At the time of this comprehensive inspection, there was no registered manager in post. Two managers who worked at the service had applied to become registered and completed their ‘fit persons’ interview with a Care Quality Commission (CQC) registration inspector but the application process was still in progress. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
We carried out this unannounced comprehensive inspection of the service on 1, 2 and 8 September 2016 to check that the registered provider was now meeting legal requirements and had achieved compliance with the regulations identified in breach at the comprehensive inspection on 17, 25 & 28 September 2015 and the focused inspection on 27 & 28 January and 12 February 2016.
At the comprehensive inspection of the service on 17, 25 & 28 September 2015, we found the registered provider was non-compliant with regulations 9, 10, 11, 12, 13, 17 and 18 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. This meant the registered provider was not meeting the requirements of regulations pertaining to providing person centred care, treating people with dignity and respect, obtaining appropriate consent and following the principles of the Mental Capacity Act 2005, providing safe care and treatment, safeguarding people from abuse and improper treatment, utilising effective systems to monitor and improve the quality of service provision and ensuring staff had the skills, abilities and support to meet people's needs.
At the focused inspection on 27 & 28 January and 12 February 2016 we found the registered provider had failed to take appropriate action to achieve compliance with any of the regulations identified during the previous inspection in September 2015. We also found evidence that the registered provider was in breach of regulation 19. This meant the registered provider was not meeting the requirements of regulations pertaining to employing fit and proper persons.
After the focused inspection on 27 & 28 January and 12 February 2016 the registered provider contracted the support of a management company to help them make the required improvements and ensure they achieved compliance with the regulations.
At the previous inspections of the service, we found that people did not always receive person-centred care. During this comprehensive inspection we found that some people’s care plans were up to date, reflected their current care and support needs and provided appropriate guidance to enable staff to support people effectively. However, some care plans contained contradictory information, did not reflect people's current care and support needs or contain adequate guidance to ensure they were supported consistently and in line with their preferences.
We also found that there was more than one format or style of care plan in use at the service, which meant staff may have found it difficult to find information in a timely way. A regional director informed us that an internal action plan had been created and that the service would have all care plans up to date using the chosen format and style by 15 October 2016. This was an on-going breach of regulation 9.
At the previous inspections of the service, we found that people were not always treated with dignity and respect. During this comprehensive inspection we observed numerous positive interactions between people who used the service and staff. Staff spoke to people clearly and at a suitable pace as well as giving people time to respond before supporting them with the choices they made. People were supported to take part in activities as a group and individually.
At the previous inspections of the service, we found that consent was not always gained before care and treatment was provided and the principles of the Mental Capacity Act 2005 (MCA) were not followed when people lacked the capacity to make informed decisions themselves. During this comprehensive inspection we found that the registered provider had made satisfactory improvements in this area, meetings were held to ensure decisions made on people’s behalf were made in the person’s best interests and in line with their known wishes. Throughout the inspection we heard staff gaining people’s consent before care and treatment was provided.
At the previous inspections of the service, we found that people did not always receive safe care and treatment. During this comprehensive inspection we found medicines were managed safely; PRN [as required] medicine protocols were clear and provided relevant information to enable staff to understand when and why they should be administered. However, some infection prevention and control practices increased the risk of healthcare related infections spreading throughout the service and effective monitoring of people’s needs did not always take. Risks were not always appropriately mitigated and some care plans did not contain appropriate guidance to enable staff to manage people's behaviours that challenged the service and others. This was an on-going breach of regulation 12.
At the previous inspections of the service, we found that restraint and physical interventions were used in a dis-proportionate way and we saw least restrictive practice was not always followed. Effective action was not taken to analyse the number of incidents that occurred and subsequently learning was not achieved and appropriate action was not taken to prevent their re-occurrence. During this comprehensive inspection we reviewed the number of incidents that occurred and saw a significant reduction since our last inspection. Records showed staff had been trained to carry out physical interventions safely.
At the previous inspections of the service, we found that the registered provider had failed to operate good governance systems in the service. During this comprehensive inspection we found a time specific action plan had been created with the management company employed by the registered provider and weekly meetings occurred, which were attended by the registered provider’s nominated individual, regional and quality directors as well as a representative from the management company. Completed actions were signed off after their completion. However, two significant areas were still outstanding, the completion of appropriate and accurate care plans for each person who used the service and staff training, mentoring and support. We found that the reviewing of care plans failed to highlight errors and inconsistencies, auditing failed to ensure infection prevention and control working practices were effective and risks were managed appropriately. This was an on-going breach of regulation 17.
At the previous inspections of the service, we found that people were not always supported by adequate numbers of suitably trained and experienced staff. During this comprehensive inspection we found staff were not trained in line with the registered provider’s policies and had not received effective and consistent supervision and appraisal. This was an on-going breach of regulation 18.
At the last inspection, we found that recruitment practices were not established and operated effectively. During this comprehensive inspection we saw evidence to confirm, before prospective staff were offered a role in the service appropriate checks were undertaken. The staff files we saw showed staff had been recruited safely and any gaps in their employment history had been explored.
People who used the service were encouraged to take part in activities of their choosing and staff encouraged people to make choices in their lives and maintain their independence.
People were provided with a wholesome and nutritious diet. We saw that a minimum of two choices were offered for each meal and fresh fruit and snacks were available for people throughout the day. When concerns with people’s nutritional intake were highlighted, action was taken including gaining the advice and support from community dieticians and the Speech and Language Therapy team.
People’s private and confidential information was stored and handled appropriately.
The registered provider had a complaints policy in place and information regarding how to raise concerns was displayed within the service. We saw evidence to confirm when complaints were received they were investigated and responded to in line with the registered provider’s policy. Learning from complaints was used to drive improvement across the service when possible.
When accidents, incidents and other notifiable events occurred with the service, the CQC and local authority teams were informed without delay.
Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.
The service is separated into two units Hilltop and Overfields. Hilltop offers 77 single ensuite rooms for older people some of whom may be living with dementia, complex medical conditions and behaviours that may challenge the service and others. Overfields provides 34 single ensuite rooms for younger adults with complex needs and mental health conditions. At the time of our inspection there were 12 vacancies within the service. The service offers a number of communal lounges, conservatory, kitchens, a mixture of dining and bistro areas, games rooms, hairdressing and beauty salon, landscaped gardens and outdoor seating areas.
At the commencement of our inspection there was a registered manager in post. 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. By the third day of our inspection the registered provider had decided it would be prudent to move the registered manager to run another registered service.
We carried out an unannounced comprehensive inspection of this service on 17, 25 & 28 September 2015. During the inspection we found the registered provider was in breach of Regulations 9, 10, 11, 12, 13, 17 and 18 of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. This meant that the registered provider was not meeting the regulations relating to providing person centred care, treating people with dignity and respect, obtaining appropriate consent and following the principles of the Mental Capacity Act 2005, providing safe care and treatment, safeguarding people from abuse and improper treatment, utilising effective systems to monitor and improve the quality of service provision and ensuring staff had the skills, abilities and support to meet people’s needs.
The registered provider gave us their assurance that further admissions to the service would not take place until we were satisfied appropriate arrangements were in place to ensure people’s health, safety and welfare was protected and the registered provider had achieved compliance with all of the relevant regulations.
We undertook this focused inspection on 27 & 28 January and 12 February 2016 to check whether the registered provider was now meeting legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Phoenix Park Care Village on our website at www.cqc.org.uk.
This inspection was completed because the registered provider’s nominated individual told us, ‘all of our internal governance measures have evidenced a positive service to the clients, and we are confident that a return inspection will show significant improvement to the ratings previously offered’ and ‘I am confident that the service being offered is both safe and effective, and is able to evidence a sustained level of good practice and outcomes for clients’. The nominated individual suggested a phased lift to the voluntary suspension of new admissions so we inspected to ascertain whether compliance had been achieved.
At our comprehensive inspection of the service in September 2015 we found that people did not always receive person-centred care. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 9. People’s care plans were not appropriate, did not reflect people’s current level of need and assessments of people’s need were not completed when their needs changed or when they were discharged from hospital.
At our comprehensive inspection of the service in September 2015 we found that people were not always treated with dignity and respect. This was a breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 10. Staff did not always treat people dignity and respect and inappropriate language was used in people’s care plans.
At our comprehensive inspection of the service in September 2015 we found that the service had failed to ensure consent had been gained from people or through a best interest forum before care, treatment and support was provided. This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 11. Consent was not always gained before care and treatment was provided and the principles of the Mental Capacity Act 2005 (MCA) were not followed when people lacked the capacity to make informed decisions themselves.
We also found that the requirements around ensuring the appropriate legal framework was in place when someone was deprived of their liberty was not in place. The registered provider had failed to take sufficient action to meet the requirements of regulation 13 (5) of the Health and Social Care Act 2008, (Regulated Activities) regulations.
At our comprehensive inspection of the service in September 2015 we found that people did not always receive safe care and treatment. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 12. People did not receive their medicines as prescribed, instructions to staff regarding when medicines to reduce people’s anxieties should be used were inadequate and contained no insight into people’s behaviours. Care plans did not contain appropriate guidance to enable staff to manage people’s behaviours that challenged the service and others. Infection control practices did not reflect current guidance and staff’s actions increased the chance of spreading infections throughout the service.
At our comprehensive inspection of the service in September 2015 we found people were not protected from abuse or avoidable harm. This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 13. Restraint and physical interventions were used in a dis-proportionate way in response to the risk of harm posed to people who used the service.
At our comprehensive inspection of the service in September 2015 we found that the registered provider had failed to operate good governance systems in the service. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 17. Quality assurance systems failed to highlight shortfalls in relation to substandard infection control practices, failures to implement professional advice and guidance, ineffective and inaccurate care plans and the lack of concordance with the MCA.
At our comprehensive inspection of the service in September 2015 we found that people were not always supported by adequate numbers of suitably trained and experienced staff. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. During this focused inspection we found that the registered provider had failed to make satisfactory improvements in relation to the requirements of Regulation 18. When staff were recruited appropriate checks and monitoring did not always take place and some staff we spoke with raised concerns over staffing levels.
During this focused inspection we found that the registered provider was in breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, fit and proper persons employed. Recruitment practices were not established and operated effectively. You can see what action we told the registered providers to take at the back of the full version of the report.
Phoenix Park Care Village is a purpose build home situated on the outskirts of Scunthorpe. It is registered to provide accommodation for people who require nursing or personal care for a maximum of 111 people.
The service is separated into two units Hilltop and Overfields. Hilltop offers 77 single en-suite rooms for older people some of whom may be living with dementia, complex medical conditions and behaviours that may challenge the service and others. Overfields provides 34 single en-suite rooms for younger adults with complex needs, disabilities and mental health conditions. At the time of our inspection there were 109 people living at the service. The service offers a number of communal lounges, conservatory, kitchens, a mixture of dining and bistro areas, games rooms, hairdressing and beauty salon, landscaped gardens and outdoor seating areas.
The inspection took place over three days on 17, 25 and 28 September 2015. This was an unannounced inspection which meant that staff and the registered provider did not know that we would be visiting. At the last inspection in June 2014 we found the registered provider was compliant with all the standards we assessed.
The service had a registered manager in post. 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.
We brought the inspection forward due to the number of incident notifications we had received from the service. We also had a number of concerns raised by relatives of people living at the service, which included concerns regarding the cleaning standards and poor standards of care. A local Member of Parliament [MP] and two of their constituents had also raised concerns about the care practices taking place at the service. There was also one on-going investigation into allegations of abuse which relates to an ex-employee at the service. This continues to be investigated by Humberside police.
We found the information submitted to the CQC and local safeguarding teams was not always accurate and lacked the detail needed to understand fully what the concern had been. Therefore, we found it difficult to determine if further investigations were required; if the concerns should be escalated to other agencies or if the registered provider had taken the appropriate steps to mitigate any risks. Other agencies also reported to us that they had experienced difficulties accessing information from the registered manager when requested. Although staff told us they felt well supported we found that the governance systems in place at the service were not as effective as they could have been and we struggled to obtain information from the registered manager during our inspection.
We found that a number of people regularly displayed behaviours which challenged the service and others, which had led to physical interventions such as hand holds being used by staff. We found not all staff involved in these types of incidents had received appropriate physical intervention training.
For those who had received physical intervention training we found this was not accredited as recommended by the department of health and it did not assist staff to safely support someone using physical interventions; record what actions staff needed to take; the holds to be used for each person; or inform them that they needed to maintain very detailed information about how they had dealt with incidents.
We saw safety gates were widely used throughout the service. Staff explained that these were in place to prevent some people with behaviours that challenged accessing the individual bedrooms of people who lived in the home. We requested evidence to ensure this risk had been assessed, but the registered manager could not produce any risk assessment documentation to support these actions. We found no evidence to show that staff had taken any action to determine if alternative, less restrictive methods had been explored.
We found the home admitted people with a wide range of complex needs and conditions; many of which were related to a mental disorder. However, staff had not received training in supporting people with specialist conditions such as mental health disorders and Asperger. We also found that there were 58 people who had been assessed as requiring nursing care at the location. Of the qualified nurses employed at the service only one was a registered mental health nurse and none of the nurses were based in the Overfields unit. Thus we found that there was an over-reliance on care staff to provide the care and that these staff had not received the training needed to deliver these expectations.
Safe staff recruitment processes were not always followed. We saw one person had been employed even though they had received a serious warning from the police authorities on their Disclosure and barring service [DBS] check and one of the references stated they would not employ this person. We found that the registered provider had not completed a risk assessment for this person around the disclosure and had not taken any additional steps to ensure the person was fit to work at the home and with vulnerable people.
The Mental Capacity Act [MCA] 2005 was not fully understood by all staff members and there was also a limited understanding of the MCA Deprivation of Liberty Safeguards [DoLS] and what restriction, if any could be implemented within practice. We saw that 11 safety gates were being widely used throughout the Hilltop unit but we did not see MCA documentation to evidence this as in the best interests of people and the least restrictive option that could be identified.
People who used the service and their relatives told us there was a good range of food available which looked well-presented and appetising. We saw positive interactions between some people and staff and people told us the staff were caring. However, we also saw there was a lack of meaningful activities taking place in the Hilltop unit and many people appeared to be sleeping for most parts of the day. A number of people were supported by staff on a one to one basis but we saw very little communication and interactions between those people and staff members in these situations on the Hilltop unit.
People’s dignity was not always respected on the Hilltop unit. We saw people being left in positions which compromised their dignity. Effective and safe standards of hygiene had not been maintained in all areas of the service.
The storage and administration of medicines were safe and well managed along with thorough maintenance checks that ensured equipment was safe and fit for purpose.
We found multiple breaches of the Health and Social Care Act 2008 [Regulated Activities] Regulations 2014. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. We are considering our enforcement actions in relation to the regulatory breaches identified. We will report further when any enforcement action is concluded. You can see what action we told the registered providers to take at the back of the full version of the report.
Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, and the staff supporting them and from looking at records.
If you want to see the evidence supporting our summary please read the full report.
Is the service safe?
The service is safe. People felt safe because their rights and dignity were respected by the staff. People told us they felt safe.
Members of staff understood the safeguarding systems in place and it was clear that learning took place following any incidents or accidents.
Members of staff understood the home's policy on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
The home had robust risk management processes in place and staff supported people to take positive risks to promote their independence.
Recruitment processes were safe and thorough. People were supported by staff that had been checked with the Disclosure and Barring Service and whose references had been checked before they started work.
The home had a robust training policy which required its staff to achieve nationally recognised qualifications in care. This ensured people were protected from unsafe practices.
Is the service effective?
The service is effective. People were able to express their views about their health. People were involved in the assessment of their needs and care plans reflected their choices and preferences. Staff supported people to be as independent as possible.
People and their relatives were involved in discussions about their care plans. People were effectively assessed to identify the risks associated with nutrition and hydration. People's identified needs were monitored regularly and effectively.
Is the service caring?
The service is caring. We saw people were cared for by staff who showed patience and encouragement. People commented, 'I don't think there are any improvements they could make; I do feel safe here' and 'I have no problems or concerns.' A relative said, 'My mum does get good care' and 'Staff are very friendly; it's really lovely care.'
Staff knew the people they cared for and understood their preferences and personal histories.
Policies and procedures were in place to ensure staff understood how to respect people's privacy and dignity.
People and their relatives were encouraged to make their views known about their care and treatment and these views were respected.
The home had involved appropriate professionals in the planning and delivery of care.
Is the service responsive?
The service is responsive. Members of staff actively listened and acted on people's views and decisions. People were given the information at the time they needed it.
People's capacity to make their own decisions was considered under the Mental Capacity Act 2005.
Concerns and complaints were encouraged. People were made aware of how to complain.
Is the service well led?
The service is well led. There were effective systems in place to continually review safeguarding concerns, accidents and incidents.
The registered manager had robust systems in place to monitor and assess the quality of the service provided to people. Where gaps or shortcomings had been identified the registered manager took swift action to address the issues.
Members of staff were clear about their roles and responsibilities. Staff were motivated, well trained, supported, and open. They acted in caring way. The registered manager understood their responsibilities and was supported by head office management to deliver what was required.
We found people who used the service understood the care and treatment choices available to them. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan. We also found care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People told us they were well cared for.
We found people were supported to be able to eat and drink sufficient amounts to meet their needs. People who used the service were generally satisfied with the meals and drinks provided.
People told us they were happy living at the home and confirmed they felt safe. They told us the home was kept clean and tidy. We found there were effective systems in place to reduce the risk and spread of infection.
We found there was enough equipment to promote the independence and comfort of people who use the service. We also found that there were sufficient staff employed to meet people's needs.
Although the majority of people were unable to communicate with us due to their complex physical or mental health needs we spoke with nine people who used the service and observed practice to gain information about peoples experiences of the service provided.
We found people were supported to be able to eat and drink sufficient amounts to meet their needs and that they were provided with a choice of suitable and nutritious food and drink. People who used the service told us that they enjoyed the meals provided. Comments included "The food is very good" and "The food is fantastic." People told us they had a choice at meal times and one person said "We have different choices every day, we don't have the same thing twice in a week." We observed staff were patient and supportive when assisting people with their meals.
We found that one to one support was well managed and that there was sufficient staff to support people.
We found that there were good standards of cleanliness and that this had continued to improve since our last inspection. People who used the service told us that they were satisfied with the cleanliness of the home and told us their room was cleaned every day. Comments included "The home is kept marvellous" and "The home is kept clean and tidy."
We found that that the environment was clean and tidy and systems were in place to ensure that this could be maintained. We found significant improvement to the standards of cleanliness in Overfields dining and kitchen areas and in food hygiene practice. People we spoke with told us that their rooms were cleaned on a daily basis and one person commented 'I can have my room and bed cleaned more than once a day, I just need to ask and staff will do it."
People told us they were satisfied with the cleanliness of the home. One person told us 'They come in everyday to clean my room.'
People told us they liked the staff and their needs were met. Comments included 'The staff are very good' and 'There is always someone around.'
difficulty expressing their opinions about the service and whether their care needs were
met. However we spoke to a number of people who told us they were well looked after and happy living in the home. Comments included 'I am well looked after.'
People using the service confirmed that they liked the food provided. One person confirmed they had had their dinner and when asked if they had enjoyed it answered 'Yes.'
We spoke with a relative who visited the home daily. They stated staff attended frequently to their relative. They told us carers are lovely and they communicate any changes relating to their relatives health and wellbeing. They told us they were 'Very satisfied with the care.'
Comments included "It is fantastic, I was able to bring in my own things, I couldn't have picked better", "They let me lead my life", "I don't like mixing with the others so I stay in my room, the staff brought me a bird table to watch outside my window and the manager gave me some interesting proposals for getting out more", "I can say if I want a male or female carer but it doesn't bother me", "I have my hair done every week" and "I was given a choice of bedroom".
There were some comments which may indicate that some staff do not always accommodate people's individual choices or promote privacy and dignity. Comments included "I wake up early and most carers assist me then fetch me a cup of tea but others say the kitchen isn't open yet so I cant have a cup of tea", "Most protect my privacy but some just walk straight in" and "Some times I feel rushed with the younger carers".
We received positive comments about the staff group which included 'staff are good', 'carers are very good', 'yes there are enough staff, they are always there to help you, they have time for people' and 'I have nothing but praise for the manager'.
However there were some comments which may indicate that there are times when there is not sufficient staff on duty. Comments included 'sometimes I have to wait for pain relief but it depends who is on', 'sometimes I have to wait as they are short staffed, staff say they are short staffed', 'sometimes you have to wait for the bell to be answered and there's no chance at meal times or change over' and 'bells are a nightmare, they don't come quick to answer the bells'.