Asmall Hall

Asmall Hall is a care home providing personal and nursing care for up to 56 people. At the time of the inspection 50 people were living in the service. The service has 2 units one of which supports people living with a dementia.

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

Environment and individual risks had been assessed, incident and accidents were investigated and good evidence of lessons learnt were seen. People told us they felt safe and systems were in place to act on allegations of abuse. Staff were recruited safely. We saw plenty of staff during the inspection. Where agency was being used we were told they were regular staff. Staff told us, and records confirmed, training had been undertaken. Medicines were managed safely in the service.

MCA and DoLS assessments had been completed, staff were observed asking permission before undertaking any activity. 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. Admission assessments had been undertaken, and we saw evidence of the involvement of professionals in people’s care.

People received good care, their choices and likes were considered. Staff understood how to meet people’s needs. Policies and guidance was available to support good care delivery. The registered manager told us about the actions taken to investigate and address comments made in relation to people’s choice of staff member and the care provided.

Care plans had been developed recording people’s individual needs, including their communication needs. The registered manager took immediate action to ensure all records were up to date and reviewed. People’s end of life care needs were considered, where appropriate. Evidence of activities provided were recorded however, not all people were noted to have access to activities during the inspection. A system was in place to manage complaints, positive feedback was seen. Wi-Fi was available in the service.

We received very positive feedback about the registered manager and all of the staff team. We saw evidence of meetings taking place and surveys from people and professionals. Information was available on the actions taken from ‘you said we did’. A range of audits and monitoring was taking place. This included the findings and actions taken as a result. The provider had developed a detailed electronic system which supported the monitoring and oversight of the service.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 24 January 2020). 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.

At our last inspection we made recommendations about the management and oversight of safe staff recruitment as well as the management and oversight of the service. At this inspection we found the provider had made improvements.

Why we inspected

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

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

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

Follow up

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

Asmall Hall is a residential care home providing nursing and personal care for up to 56 adults, including those who are living with dementia. At the time of our inspection there were 43 people living at the home.

We found the following examples of good practice.

There were a wide range of policies and procedures in place, which provided staff with clear guidance about good infection control practices, including the management of Covid-19 and visiting arrangements during the pandemic. Relatives we spoke with were very complimentary about the visiting arrangements, which enabled them to safely spend some time with their loved ones.

Government guidance was being followed in relation to isolation criteria and testing programmes for service users, staff, visitors and visiting professionals. All employees had received both Covid-19 vaccinations and all relevant staff had completed specific training in relation to infection control and the management of Covid-19.

There were three domestic staff on duty plus a housekeeper at the time of our site visit and cleaning schedules were in place. The environment was clean and hygienic throughout and fully stocked PPE stations were provided in the entrance hall and at intervals throughout the home. We were told enough supplies of PPE were available and we saw staff wearing PPE correctly.

Asmall Hall is a care home providing personal and nursing care to 52 people aged 65 and over at the time of the inspection. The service can support up to 56 people. The home is divided into two units, one unit specialises in supporting people living with dementia, this is called the Mulberry Unit.

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

People’s medicines were not always managed in a safe and effective way. Staff did not always ensure people were accurately risk assessed and we found examples where staff failed to suitably record changes in people’s needs. The provider deployed suitable numbers of trained and competent staff. There were robust safeguarding procedures in place and improvements had been made in the way accidents and incidents were investigated and acted on. We made a recommendation about management oversight of safe staff recruitment. There had been significant investment throughout the environment and there was a good standard of cleanliness.

People were not consistently supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support best practice. People received nutritious meals and snacks however, staff did not always sufficiently risk assess when people had lost weight, this placed them at risk of avoidable harm. Staff received a good standard of training and told us they were encouraged to develop their professional skills. Staff felt supported and listened to. People had access to a wide range of external health care professionals and staff supported them to attend appointments. People were assessed before admission to determine if the service could meet their needs and expectations.

People received kind and compassionate support from staff they had built trusting relationships with. People and relatives told us they were happy with the standard of support provided. Staff promoted people’s independence and respected their background and culture. Staff demonstrated very good knowledge of how to support people living with dementia and how to de-escalate people when they became distressed by using a person-centred approach.

Staff did not always ensure people’s care plans contained person-centred information. This meant information to guide staff on how to support people was not always up to date and accurate. Staff demonstrated good understanding of people’s needs and preferences and had taken time to read about their past hobbies, interests and family connections. There was an activity co-ordinator and people told us they were encouraged to maintain links with the local community. People and visitors had access to the complaints procedure and told us they felt confident to raise any concerns.

The registered manager was transparent throughout the inspection process. We discussed the ongoing pressures of them managing three services and they confirmed plans were in place to ensure Asmall Hall was run by a full-time registered manager. We have made a recommendation about management oversight at the service. The provider had implemented a new IT system for quality assurance and this continued to be developed. Staff, people and relatives told us they felt involved in the running of the service and confident in the management team.

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

Rating at last inspection and update

The last rating for this service was requires improvement (Published 27 November 2018). The service remains rated requires improvement. This service has been rated requires improvement for two consecutive inspections, prior to that the service under the previous provider was in special measures and rated inadequate. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not enough improvement had been made and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

At this inspection we have identified breaches in relation to safe care and treatment, medicines management, person-centred care and consent.

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

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Asmall Care home is a large country manor type home set in its own grounds. The home is over two floors and supports people with nursing and residential care needs. There are two units one on each side of the home with their bedroom accommodation to the ground and first floor. One unit supports people with nursing and residential needs and the other supports people with nursing needs and people living with dementia.

Each unit has its own large lounge and dining room and there is a second quiet room on each unit.

There is a large kitchen providing food across the home and a large laundry in the annex to the side of the main building.

The home can support up to 56 people and at the time of the inspection there were 36 people living in the home. The new provider has undertaken a large investment programme updating and refurbishing the whole building. At the time of the inspection there were further works planned following planning permission.

Asmall Hall is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At the time of the inspection Asmall Hall had a current registered manager who was also the nominated individual. Following the inspection the nominated individual role was taken on by a director from the provider's company. The provider was currently recruiting to the registered managers post so the current manager could revert to managing another of their services. The provider’s third service was also looking for a registered manager to allow for each service to be managed by its own dedicated manager registered with the Care Quality Commission. A recommendation has been added to the report to prompt the provider to do this as soon as possible. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had begun to manage the service following the last CQC inspection of the home. The last inspection under the previous provider, rated the home as inadequate. The registered manager had been involved in the quality improvement programme implemented following the findings of the last inspection as many areas of concern were identified.

The new provider had bought the home as an ongoing business concern and had completed all the legal obligations of transferring staff from the previous provider to become an employee of Benridge care homes if they so wished. They had also recruited many new staff. We found recruitment procedures were fair and equitable. However, we were aware that the recruitment of staff had been difficult. This is in part because of the location of the home. We found the provider had been unable to suitably recruit enough staff with the competence and skills to deliver the nursing element of the service in line with the requirements of the regulations. We have found the service in breach of Regulation 12, safe care and treatment.

We have also found that suitable risk management plans had not been implemented. We identified risks which had not been addressed prior to their identification at the inspection. We also found where risks had been identified appropriate risk management plans had not been put in place. We found a further breach to Regulation 12, safe care and treatment, for the assessment and management of risk.

Care plans were in a period of development and there were some good documents used for assessment but these stood alone outside of the care planning system and had not been included appropriately when developing support to meet people’s needs. We found many care plans which were not reflective of people’s needs and were not updated with the involvement of the individual or the individual’s representative. This has led to a breach of Regulation 9.

We have also made nine recommendations in the report. We found where people had when required medications administered, protocols explaining what this meant were not always in place. They did not include the detail of what the medication was for and when it should be given. There were no clear guidelines for how staff could recognise when it was required, when the person prescribed it, could not verbalise their state of health and wellbeing. We have recommended clearer protocols were put in place.

We found some contradictions between assessments and the support provided. We saw some assessments specifically around food and drink were not followed. Reasons for this were ambiguous and we have recommended the provider ensures that appropriate documentation is completed to support people’s needs to be met.

We have also recommended some processes be formalised including complaints, the activity programmes and staff support including appraisals, supervisions and competency records.

We have recommended end of life assessments and care planning is reviewed and developed more comprehensively and assessments under the MCA are also reviewed and evaluated. This is to ensure they are accurate and are what is required. We have recommended the provider begins to hold resident and relative forums to gather feedback on the service delivered and lastly, we have recommended that the management structure is agreed and developed with greater clinical oversight.

People are supported to have maximum choice and control of their lives and staff attempt to support them in the least restrictive way possible; the policies in the service support this practice and work is being completed to embed systems to ensure this is implemented in line with the principles of the Mental Capacity Act.

Over the course of the inspection we saw the building interior and exterior had improved greatly since the last time CQC inspected. The provider had completed interior design based on best practice principles for homes supporting people living with dementia. We saw different dedicated space for quiet seating areas from one person to a group of people. Walls were decorated with memorabilia with a garden theme and we could see from pictures sent to the commission prior to writing this report that there were tactile and interesting objects for people to engage with.

Staff and people living in the home were all positive about the changes both to the environment and to the service delivered. We were told the food had much improved and there was a choice. Staff told us they felt better supported by each other and the new manager.

People living in the home were treated with dignity and respect and we received quotes showing that people appreciated the support provided to them.

The provider and registered manager had introduced a live action planning tool which was updated regularly. We noted that concerns identified by the commission were mostly known of by the provider and were on the action plan. Staff could influence meetings and suggest ideas for improvements which helped them feel part of a developing and improving team.

The overall rating for this service is ‘Requires improvement’

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