Archived: Durham Care Homes

People’s experience of using this service: The quality of care had deteriorated since the last inspection. People’s safety had been placed at risk due to safeguarding policies and procedures not being followed. The provider and manager had not assessed and managed risk, which placed people at risk of harm. Some people had not received their medicines as prescribed. Staff recruitment continued to be poor. There was insufficient staff to meet people’s needs. There were concerns with staff practices regarding infection prevention and control.

Some people’s nutritional and hydration needs had not been fully assessed and met; the meals provided were repetitive and gave limited choice to people. The meals and snacks for people on soft diets were inadequate. Staff contacted health professionals when required, although during the inspection, staff had to be prompted on two occasions to seek medical assessment for people.

Staff did not have the right skills, experience and knowledge to care for people safely. There was partial understanding from the manager regarding mental capacity legislation, the need for people’s deprivation of liberty (DoLS) to be authorised and the need for people to consent to their care. However, some people’s DoLS had expired and applications had not been resubmitted. Three people met the criteria for DoLS but applications had not been made to the local authority for authorisation.

We observed episodes of care and staff interaction with people and each other that was poor and required improvement. There were also some interactions between staff and people who used the service that was kind and considerate. There were times when people’s privacy and dignity were compromised. There was very little social stimulation provided to people, especially those people who remained in their bedrooms.

People had assessments and plans regarding their care and support needs. However, the care plans lacked important information, were not always kept up to date when changes occurred and had limited direction for staff in how to deliver care in a person-centred way.

The service was not well-led and there continued to be a lack of effective governance and oversight by the provider and manager. The day to day shifts lacked organisation and the culture in the service required significant improvement; there was institutional and unsafe practices, which went unnoticed and unchecked by management. Records were not always accurate and up to date.

More information is in the full report.

Rating at last inspection: Requires improvement; published 19 February 2019.

Why we inspected: We received information from the local authority regarding an escalation of concerns about the service; they had been completing monitoring visits. We completed this inspection based on these concerns. At the time of the inspection, we were aware of incidents being investigated by another agency.

Enforcement: The service met the characteristics of Inadequate in four key questions of safe, effective, responsive and well-led and Requires Improvement in caring. We are taking enforcement action and will report on this when it is completed.

Follow up: We will continue to monitor the service closely and discuss ongoing concerns with the local authority.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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. Where necessary, another inspection will be conducted within a further six months, and 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.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

Durham Care Homes 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. Durham Care Homes is registered to provide care and accommodation for 20 older people, some of whom may be living with dementia. There was a lounge and dining room on the ground floor. Bedrooms, bathrooms and toilets were located on both the ground and first floor. The first floor was accessed by a chair lift. At the time of our inspection 16 people were using the service.

At the time of the inspection, a registered manager was not in place. 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 last inspection on 2 October 2017, we rated the service as 'Requires Improvement'. This was because we had concerns about recruitment processes potentially placing people who used the service at risk. There were also concerns that the provider did not have effective systems and processes in place to identify shortfalls and maintain the quality and safety of the service.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the ratings for the key questions; ‘Is the service safe? ‘Is the service effective?’ and ‘Is the service well-led?’ to at least good. We found that actions taken had not resolved the issues identified at our last inspection.

Prior to this inspection, we received information of concern regarding staff recruitment, training, lack of meal choice, food quality and set times for people to get up and go to bed. We considered and explored these concerns at this inspection.

We found concerns with how the service was managed and governed. Quality assurance processes were ineffective at identifying and addressing quality shortfalls. Accidents and incidents were being recorded but there was a lack of analysis and lessons learned to prevent reoccurrence.

There were concerns with the safe and proper management of medicines. This had led to some people not receiving their medicines as prescribed and there was a lack of guidance for staff when administering medicines prescribed for use 'when required'. Medicine recording errors continued to be made.

There was a lack of robust risk management; areas of risk in the service had not been identified and there was a lack of monitoring and reviewing of risks. This related to the environment, equipment used in the service and people's individual risk assessments. This had placed people at risk of potential or actual harm.

Infection prevention and control had not been managed appropriately. Areas of the service and some items could not be appropriately cleaned. This placed people at risk of infections.

Staff had not received regular training, supervision or appraisals and the provider had not assured themselves that staff had the skills and knowledge required to meet people’s needs. As a result, staff did not always promote people’s privacy, dignity and independence.

People who used the service had assessments and care plans in place but these did not always contain the most up to date information about their needs. This meant there was a risk that staff could deliver care that did not meet people’s needs due to inaccurate information.

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. However, records did not always evidence this. We have made a recommendation about this.

People were supported to have pain-free, dignified deaths and their health care needs were met. Where necessary staff made referrals to community health care professionals who visited the service to provide treatment and advice.

People’s nutritional needs were met; however, people did not always feel there was a wide variety or quality of food. People were offered snacks and drinks throughout the day.

In-house activities were provided and people could spend their time as they wished.

People knew how to raise concerns and these were logged by the provider. However, they did not follow their own policy and procedure when attempting to resolve these complaints. We have made a recommendation about this.

At this inspection, we found the provider was in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, namely Regulation 12, safe care and treatment, Regulation 17, good governance, Regulation 18, staffing and Regulation 19, fit and proper persons employed.

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

Durham Care Home is registered to provide care and accommodation for 20 older people, some of whom may be living with dementia; there are 14 single and three shared bedrooms. There was a dining room and a lounge on the ground floor and sufficient bathrooms and toilets. The first floor was accessed by a chair lift. The service had good public transport links to Hull city centre and is situated close to local facilities and amenities. At the time of our inspection there were 18 people living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found the provider did not always have effective systems and processes in place to identify shortfalls in the service. Audits were not always completed and action plans were not always followed through. Quality assurance systems were being developed but we found information in the audits was not consistently recorded. For example, medication audit had not identified the lock on the medicines fridge had broken. Also a food safety audit had not identified the temperatures of the food refrigerators were not recorded on a daily basis. This meant people could potentially access medicines and also the provider could not be assured food was stored at the correct temperature. Quality assurance systems and processes lacked consistency and some policies were not available to staff at the time of the inspection.

There were shortfalls in the staff recruitment process. References for two members of staff had not been obtained and one disclosure and barring service (DBS) check had been carried out by a previous employer. This meant the provider was not assured staff were of a good character. The provider had also not always assured themselves new staff were competent prior to allowing them to work unsupervised.

You can see what action we told the provider to take regarding quality monitoring and staff recruitment, at the back of the full version of the report.

We found the environment had some potential hazards for people such as uneven floor covering connections between communal rooms. During the inspection, the provider started to address these trip hazards and assured us these would be rectified. After the inspection, the provider confirmed the work had been completed.

People told us they felt safe living at the service. Staff were clear about their responsibilities to protect people from the risk of harm and abuse, and had completed safeguarding training.

Staff had completed risk assessments for people to ensure there was guidance in how to minimise the risks. These included risks associated with falls, moving and handling, nutrition, pressure areas and plans for emergency evacuation of the building.

People’s health care needs were met. Records showed they had access to community health care professionals in a timely way and when required.

People’s nutritional needs were met. The menus provided choices and alternatives to people and catering staff were aware of their special dietary needs. We observed people were offered choices for meals, snacks and drinks, and the food served looked appetising and healthy.

The registered manager was aware of their responsibilities regarding the Mental Capacity Act 2005. For example, when people were assessed as lacking capacity to make their own decisions, people involved in their care were consulted or invited to meetings. There was also Deprivation of Liberty Safeguards (DoLS) in place for thirteen people who used the service.

People received person-centred care, which was responsive to their individual needs. People’s care records were detailed and risks to their wellbeing were identified. People were supported to be as independent as possible and staff supported them to attend appointments in the community.

Although entertainers were sometimes invited to the service and people could participate, if they wished, there was no structured activity programme. Most people were happy with this arrangement but we spoke with the registered manager about enhancing the provision of activities for people living with dementia. Visiting was not restricted and relatives were invited to attend events and to have meals with their family member.

We found staffing levels had recently been reduced. However, people told us there were sufficient staff to meet their individual needs. We observed staff were caring and patient with people, and their dignity and privacy were respected. Staff had a good understanding of people’s individual needs. Staff received training, supervision and appraisal to develop their knowledge and skills.

Staff told us they were well-supported by the registered manager. People who used the service said the registered manager and provider were approachable. Regular residents meetings were held and people’s requests were acted upon, for example, liver had been added to the menu.

The service was clean and tidy. Staff had access to personal protective equipment. Equipment used in the service was maintained appropriately.