Lent Rise House

Lent Rise House is a nursing home which can provide care for up to 60 people. Thirty six people used the service at the time of our inspection. The building was purpose-designed and divided into four units, known as ‘houses’. Each house contained en-suite bedrooms, shared bathrooms, shared dining and lounge areas and small quiet areas. Ground floor houses provided care to people with dementia; first floor houses provided care to people with general nursing needs. There was a shared lounge on the ground floor used for activities and other events. There were well-maintained enclosed gardens with seating areas for people to enjoy

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

People were protected from the risk of injury or harm at the service. Staff understood about safeguarding people from abuse and undertook training to ensure they followed safe working practices. People were assisted by staff who had been suitably recruited and received good support to be able to meet their needs. Medicines were managed safely and people received support to access healthcare services as and when they needed them. End of life care was managed sensitively.

People’s nutritional needs were met and any weight loss concerns were managed appropriately. People were protected from the risk of infection and the premises were kept clean and odour-free. There was appropriate maintenance of the building to ensure people were kept safe. The landlord had carried out a survey of all fire doors at the home. The survey report identified actions were needed but it was not known whether all of these had been completed. We have made a recommendation about this.

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.

People could take part in a range of activities and there were good links established with the local community.

Managers monitored the service to make sure it met people’s needs in a safe and effective way. Staff worked well together. They treated people with compassion and kindness, respected their privacy and dignity and took account of their individual needs. People were supported to be as independent as they could be. Staff understood about people’s communication needs and provided appropriate support to them where required. People’s equality and diversity needs were well met at the service.

The provider kept us informed of any significant events and worked well with us and other external agencies to monitor and improve people’s care. Action was taken when things went wrong or people made complaints.

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 (report published 22 June 2018). There were no breaches of regulations at that time but the provider needed to show they could sustain improved practice in the Safe, Effective, Responsive and Well-Led domains. At this inspection we found improvements had been made.

Why we inspected

This was a planned inspection based on the previous rating.

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

Lent Rise House can accommodate 60 people within four units, each of which has separate adapted facilities. The service cares for adults, including people living with dementia. The premises are modern and purpose-built. People live in their own bedrooms and have access to communal facilities such as a dining and lounge areas. At the time of our inspection, 44 people used the service.

Our inspection took place on 17 May and 18 May 2018 and was unannounced. This was a comprehensive inspection. Our prior inspection was completed on 31 January and 1 February 2018. It was a focused inspection to establish whether the service had made sufficient improvements after our inspection in December 2017. We found that the service had not improved and there were continued breaches of seven regulations. The service remained rated inadequate overall and therefore in ‘special measures’. We took no further enforcement action after this inspection, but the service was not permitted to accept admissions and was required to submit weekly action plans.

The overall rating for this service is now requires improvement. This service has been in ‘special measures’. Services that are in ‘special measures’ are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection, the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of ‘special measures’.

The provider is required to have a registered manager as part of their conditions of registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection, there was a manager registered with us.

People were better protected against abuse and neglect. Staff had received more training in how to protect people against harm and reporting of incidents had increased. People’s medicines were managed in a safer way, with increased monitoring by nurses and management. Recruitment checks of new staff were improved, which ensured only fit and proper persons were employed. We made a recommendation about infection prevention and compliance.

People’s risk assessments were more detailed and contained increased relevant information. Extensive staff training was completed to ensure people were care for by workers with sufficient knowledge and skills. The assessment and management of people at risk of malnutrition had improved significantly. We made a recommendation about the service’s environment for people living with dementia.

People and relatives told us staff were caring and compassionate. They said there were improvements since our prior inspection. People and relatives were more involved in the care planning and review process. People’s dignity and privacy was maintained.

Some care remained task-focused instead of person-centred. At times, there was a lack of engagement with people by staff. During routine care, staff effectively communicated with people and included them in the process. People and relatives had an improved opportunity to have a say in how the service operated. They felt there was more information from the management team and provider. People’s end of life preferences were assessed and respected. We made a recommendation about the Accessible Information Standard.

The governance of the service had improved. Additional time is required to demonstrate sustained monitoring and improvement of the care safety and quality. A better management structure was implemented. This fostered better scrutiny of care practices. A range of existing and new audit tools were used more routinely to examine strengths at the service and any areas for improvement. The workplace culture had improved for staff, and they were progressively filling vacant posts. The service worked closely with community partners to improve the safety and quality of people’s care.

The service has achieved compliance with all breaches of the regulations from our previous two inspections. Further improvement is required in a number of areas.

Lent Rise House can accommodate 60 people within four units, each of which has separate adapted facilities. The service cares for adults, including people living with dementia. The premises are modern and purpose-built. People live in their own bedrooms and have access to communal facilities such as a dining and lounge areas. At the time of our inspection, there were 54 people living at the service.

Our last inspection was completed on 25 July 2016 and 26 July 2016. We found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s medicines were not safely managed. The storage of medicines exceeded safe temperature limits and the provider had failed to ensure appropriate action was taken. The rating for key question safe was subsequently requires improvement. Following our last inspection, we asked the provider to complete an action plan to show what they would do and by when, to improve key question safe to at least good. We received the action plan on 31 August 2017.

We undertook an unannounced focused inspection of Lent Rise House on 13 December 2017. This inspection was done to check that improvements to meet legal requirements planned by the provider after our comprehensive July 2016 inspection had been made. We completed this focused inspection because we had received concerning information from the local authority, police and clinical commissioning group. Information we received included allegations that people had sustained avoidable harm, that medicines were not properly managed, that people had experienced abuse or neglect and that there were ineffective management. The team inspected the service against two of the five questions we ask about services: “is the service safe” and “is the service well-led?” This is because the service was not meeting some legal requirements. The ratings from the previous comprehensive inspection for these key questions were included in calculating the overall rating in this inspection.

The provider is required to have a registered manager as part of their conditions of registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection, there was no manager registered with us.

The overall rating for this service is inadequate and the service is therefore in ‘special measures’. Services in ‘special measures’ will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

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.

We found people had either sustained harm, or were at high risk of enduring harm. The safety of people’s care and treatment was unsatisfactory. Avoidable incidents and accidents had occurred, including slips, trips, falls and fractures. People had unexplained injuries, such as bruising which were not adequately reported or investigated. Local authority and police enquiries were commenced in an attempt to determine what the causes of some of the injuries were, and where appropriate, any staff responsible. Multiple staff were suspended from duty and under investigation at the time of our inspection. The provider had not made referrals to other regulators, but completed these when we asked.

People’s risk of harm and actual harm sustained was increased by poor risk assessments, nursing care plans and a lack of regular reviews. Advice and guidance from community healthcare professionals was often not incorporated into the care people received. Some documentation was inaccurate and other care documentation was missing or never completed.

People’s medicines management was unsafe. There were numerous errors in medicines processes. These included ordering, storage, administration, documentation and reporting of incidents.

Staff described a challenging workplace environment. Many staff deployed at the service were from agencies and did not have adequate knowledge of the people who lived at Lent Rise House. People and relatives were sometimes unaware of the management of the service and explained their opinions were not always considered.

The provider had identified the service required improvement and commenced an action plan in August 2017. However, interventions to address shortcomings were not measured regularly enough to ensure they were sufficient or sustained. The lack of effective oversight of the service had led to poor governance of the systems and process meant to be in place to provide safe, quality care for people.

We provided information about our findings to the local authority, commissioners of people’s care, the district council’s environmental health office and the local fire inspectorate.

We found seven breaches of the regulations.

You can see what action we told the provider to take at the back of the full version of the report.

Full information about our regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We previously inspected the service on 13 December 2017 and looked at the ‘safe’ and ‘well-led’ domains. This was in response to concerning information about allegations people had sustained avoidable harm, that medicines were not properly managed, that people had experienced abuse or neglect and that there was ineffective management of the service.

At that time we found multiple breaches of the regulations related to medicines practice, safeguarding people from abuse or harm, acting in an open and transparent way (duty of candour), assessing and mitigating risks to people’s health and safety, recruitment of staff, providing person-centred care and effective governance of the service.

The overall rating for the service was assessed as ‘Inadequate’ and the service was placed in ‘special measures’. We took urgent enforcement action following our last inspection and required the provider to send us a report each week of the actions they were taking to improve the service. We also imposed conditions on the provider’s registration to prevent any admissions to the home.

This inspection took place on 31 January and 01 February 2018. It was an unannounced responsive inspection to follow up on our previous findings. We returned on this occasion to check whether people were safe and that the provider was taking the necessary action to improve the quality of care and reducing the risks to people.

The service did not have a registered manager in post for over a year. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. At the time of our inspection, a manager was appointed who intended to apply for registration.

The overall rating for the service from this inspection is ‘Inadequate’ and the service remains in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

People continued to be placed at risk of harm. We found continued breaches of the regulations. Where improvements had been made, it was too early to see that these were sustained and that regulations were fully met.

The provider was taking action and had put in extra staffing resources to make improvements at the home. However, progress was slow in a number of areas such as updating people’s care plans and improving fire safety. Improvements were being made to ensure people were assisted to move safely and had the right equipment in place.

The majority of people we spoke with told us they felt listened to and were involved in their care. They said staff were kind and caring. Their comments included “So far no problems. Staff are very attentive,” “They look after me very well,” “Very nice, kind, compassionate” and “Very kind, running backwards and forwards, always willing.”

People and relatives told us about the impact of staff changes and high use of agency staff. Comments included “Used to be very good, was perfect initially couldn’t fault anything. Now staff change so much, new people don’t get enough training and don’t stay for any length of time.” Another person said “There are a new series of staff, lots of younger people, (we) have to tell them what you want.” A relative told us “There are many agency staff who don’t know the residents. All the experienced staff have been suspended. (This) can be quite challenging to the residents.”

Improvements had been made to the storage and recording of people’s medicines. However, we found a discrepancy in the disposal records of one controlled medicine which we asked the provider to look into. They did this and attributed the discrepancy to a recording error.

The home had been visited by the environmental health officer since our last inspection. They served hygiene improvement notices in response to their findings. We found the home was making improvements to food hygiene measures and the chef managers were keen to put matters right.

Governance systems and processes were not robust enough to ensure there was a co-ordinated approach to implementing improvements. There were inconsistent checks to ensure staff completed work delegated to them. This meant some actions in the provider’s improvement plan were marked as completed when they were still not implemented.

People were placed at risk of harm and inconsistent care by the standard of record-keeping at the home. For example, staff had not followed good practice in the management of injuries and pressure wounds. Other important records such as recruitment files did not contain all required checks.

We found continued breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found a continued breach of the Care Quality Commission (Registration) Regulations 2009.

You can see what action we told the provider to take at the back of the full version of this report.

We previously inspected the service on 03 April 2014. The service was meeting the requirements of the regulations at that time.

Lent Rise House provides nursing care for up to 60 older people, including people with dementia. Fifty nine people were living at the service at the time of our visit.

The service did not had a registered manager in post. The registered manager left the service shorty before our inspection. 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. Arrangements were in place to make sure there was appropriate management cover at the service.

We received mixed feedback about the service. Comments from people included “Excellent end of life care…I cannot thank the home enough for all they did for not only my mother, but in supporting my sister and I,” “We’re very pleased with mum’s care” and “They’re a smashing crowd, I’m well looked after.” Some people were critical of agency workers. For example, we were told “The agency staff don’t engage with the residents and they don’t even attempt to get to know them.” Our observations of care provided by agency staff during the inspection did not support this view.

Some people were critical of the food provided for them. A new chef started working at the home on the first day of our inspection and improvement was seen.

There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. Risk was managed well at the service so that people could be as independent as possible. Written risk assessments had been prepared to reduce the likelihood of injury or harm to people during the provision of their care. People’s medicines were handled safely and given to them in accordance with their prescriptions. However, medicines were not always stored at safe temperatures. This could affect how effective they were.

We found there were sufficient staff to meet people’s needs. They were recruited using robust procedures to make sure people were supported by staff with the right skills and attributes. Staff received appropriate support through a structured induction, regular supervision and an annual appraisal of their performance. There was an on-going training programme to provide and update staff on safe ways of working.

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. These had mostly been kept up to date to reflect changes in people’s needs. Staff supported people to attend healthcare appointments to keep healthy and well.

People spoke positively about staff who provided activities. For example, one person told us “This place is beautiful thanks to the contribution of the activity co-ordinators. The flowers, the plants, the chickens and all activities are organised by the activity co-ordinators. They work tirelessly and when they are not here you notice it.”

The building was well maintained and complied with gas and electrical safety standards. Equipment was serviced to make sure it was in safe working order. Evacuation plans had been written for each person, to help support them safely in the event of an emergency.

The provider regularly checked quality of care at the service through visits and audits. Records were maintained to a good standard and staff had access to policies and procedures to guide their practice.

We found a breach of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to medicines practice. You can see what action we told the provider to take at the back of the full version of this report.

We returned to the service on 3 April 2014 to check whether improvements had been made. This was after the date the provider told us all actions would be completed to improve the service.

We considered the evidence we had gathered under the outcome we inspected. We used the information to answer the question we always ask: Is the service safe?

This is a summary of what we found-

Is the service safe?

We found improvements had been made in the laundry. Large storage bins had been provided to store laundry waiting to be washed. This kept the floor and other areas clear and easier to keep clean. Laundry trollies no longer blocked the exit. This meant staff could now use both doors, keeping clean and dirty areas separated.

We noted walking frames, wheelchairs and boxes of supplies were no longer stored in any of the bathrooms. This reduced the risk of cross infection and ensured housekeeping staff could now clean the whole floor area.

Training on infection control had taken place for some of the staff who needed to attend it. The manager told us there would be further training in-house in the next two weeks. This would ensure all staff had the necessary skills and knowledge to prevent the spread of infection at the service.

We were satisfied the provider had made sufficient improvements to ensure there were effective systems in place to reduce the risk and spread of infection.

We spoke with five visitors. Each person expressed positive comments about the standards of care their relative received. One visitor told us the premises were 'Always kept clean' and that 'Staff are good.' Another said 'My mum's blossomed since coming here' and added 'Staff are wonderful.' Three visitors praised the standard of nursing care and the improvements they had seen in their relatives. One visitor said their relative 'Wouldn't have survived without staff here.' A second visitor described how their relative was now walking independently. The third visitor told us 'It's better than the other home mum was at. They manage incontinence and night time wandering without any problem here. I'm very pleased with the care.'

We found people received effective care. Care plans outlined the support people needed. Risk assessments had been written to reduce or control the potential for people to experience harm. People had access to external healthcare professionals to keep them healthy and well.

The building was generally clean and malodours were managed well. We had some concerns about infection control practice. This was because effective hygiene measures were not being followed in the laundry and one of the bathrooms. This placed people at risk of cross infection.

There were enough staff to support people who lived at Lent Rise House. We observed staff were attentive to people's needs and answered call bells promptly.

The provider had an effective system to regularly assess and monitor the quality of service that people received. This included regular visits to the service and auditing of practice.