Archived: Great Horkesley Manor

Great Horkesley Manor is a residential care home providing personal care. The service accommodates up to a maximum of 73 people across two units, each of which has separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of our inspection there were 44 people using the service.

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

Changes within the management team had led to a lack of leadership, management and oversight of the service. This, combined with high use of temporary agency staff had impacted on the quality of the service provided. The service does not always provide enough staff who have the right mix of skills, competence or experience to support people to stay safe, and meet their needs. Staff were not aware of the providers aims and objectives which sets out the values they should adhere to in their work. Staff morale was low. Staff were not working as a team which was impacting on the effectiveness of care delivery.

Risks to the health, safety and welfare of people using the service and staff had not always been identified and managed. NHS England raised a level 3 heat health watch alert in July, which required health and social care workers to pay attention to high-risk groups of people such as the elderly and vulnerable. On the first day of the inspection temperatures rose to 32 degrees and we found the central heating was on which could have had serious consequences to people’s health.

The premises were not clean or properly maintained. The providers approach to assessing and managing environmental and equipment related risks were inconsistent. This included trip hazards, fire doors being wedged open and poor ventilation in the kitchen and laundry.

Systems for managing infection prevention and control (IP&C) needed to improve. Staff were not always following current national guidance and standards in relation to infection control. Although staff had received training, they did not fully understand their responsibilities in relation to hygiene and did not consistently apply good infection control practices.

The provider did not have a system in place to assess the quality of training delivered to staff to ensure they had understood the content, test their skills, knowledge and competence to support people properly and safely.

Systems were in place to ensure people’s medicines were managed consistently and safely.

Peoples rooms were in the process of being redecorated and personalised with paint colours and bedding of choice. Appropriate equipment had been provided to meet people’s mobility and transfer needs and reduce the risks of pressure wounds occurring. These were in good working order and routinely checked.

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. Where people had been deemed to lack capacity to make significant decisions about their health, welfare and finances, relevant people including their Lasting Power of Attorney and health professionals had been involved.

People told us they were supported to see healthcare professionals when they needed them. Processes were in place to manage risks around people’s dietary needs, including risks relating to choking and weight loss. Where people had been identified as at risk, they had been referred to appropriate professionals. However, improvements were needed to ensure accurate records were kept to ensure people were receiving enough fluid to remain well and hydrated.

Although the area manager and the registered manager have worked well with other professionals to make immediate improvements, the governance systems to assess the quality and safety of the service had not always been effective in identifying where improvements were needed. These failed to identify and mitigate the risks to people and staff found during the inspection.

Complaints were not used as an opportunity to learn and drive improvement.

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

Rating at last inspection

The last rating for this service was good (published 16 October 2019).

Why we inspected

The inspection was prompted in part due to concerns received about a lack of staff, high numbers of unwitnessed falls, unexplained bruising, poor leadership and management of the service. A decision was made for us to inspect and examine those risks.

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. We have found evidence the provider needs to make improvements.

Please see the safe, effective and well-led sections of this full report. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Immediately after the inspection the registered manager told us they had employed extra agency staff to carry out a deep clean around the home, yellow bins had been purchased for clinical waste, closed toilet brushes and toilet roll dispensers had been ordered and additional training was being arranged for staff around use of PPE. They had also contacted the providers head office to request immediate action to improve ventilation in the laundry and install ramps over the thresholds to improve access to the home and gardens.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safe care and treatment and the leadership and management of the service. Governance systems failed to identify risks to people and staff, poor infection control practices, insufficient staff deployed to meet people’s needs in a timely way and a poor culture amongst the staff team.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

¿ The service was clean and hygienic. The unit had not been used previously and was planned to open for people who were tested positive for COVID-19. The unit was separate to the main house with its own entrance and exit for staff and professionals to use

¿ Any person who became COVID19 negative would be moved to another area of the main home to ensure that risks of re infection were minimised

¿ Food would be cooked within the main house and bought to the unit by one member of staff and would be left in a "airlock" between the main house and the unit. Staff delivering the food would be required to change PPE when delivering food. The registered manager told us this had been agreed with all kitchen staff who were aware of this need.

¿ The environment was in the process of being completed when we visited including new beds and cleaning equipment specifically for the unit. The scheme has its own entrance and exit. There are separate facilities for use by staff working in this area, all of which are contained within this area. The registered manager told us environmental risk assessments, including fire, would be updated prior to people coming into the unit

¿ There was enough Personal Protective Equipment (PPE) and current and any new staff would have training in Infection control and correct wear of PPE according to national guidance.

¿ The registered manager told us the service would be accepting of professional visitors to the service with robust infection control procedures in place.

¿ Risks to staff in relation to their health, safety and well-being had been thoroughly assessed. The registered manager told us when the unit opens individual risk assessments will be carried out for each person who was admitted.

¿ The provider had developed robust policies, procedures and guidance for the location which the registered manager.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Further information is in the detailed findings below.

Great Horkesley Manor is a residential care home providing personal care and accommodation for up to 73 older people in one adapted building. The service is located in the village of Great Horkesley. The premises are set out over two floors and consists of three units, Wing, Willow and Chestnut a dementia care unit. At the time of our inspection there were 37 people living at the service.

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

Since the last inspection there had been a change in manager. There was an improved open and transparent culture within the management team which was demonstrated throughout the inspection. The manager, provider and staff were enthusiastic and committed to further improving the service for the benefit of people using it.

We found a number of improvements had been made since the last inspection. Steps had been taken to protect people from risks associated with inadequate staffing levels, safeguarding people from abuse and improper treatment, staff's unsafe practice and the management of people’s medicines.

There were improved governance systems with regular quality assurance checks and audits in place. People's experience of care and support were at the core of these systems. Where issues were found, action was taken promptly to ensure improvements were made. Where external quality and safety audits had identified shortfalls, action plans were in place to rectify and reduce risk of harm.

We identified further improvements were still required to the standard of care plans to ensure planning for meeting the needs of people at the end of life and ensure effective monitoring for people at risk inadequate fluid intake and with a catheter in place.

Some aspects of the home environment had improved since the last inspection. There was ongoing refurbishment work to improve communal areas and improvements to sluice rooms completed. Further work was required to improve lighting in communal areas and replacement flooring. We were reassured these improvements were scheduled within the service improvement plan.

People told us they felt safe and staff knew how to identify and report concerns relating to people's safety. Risks were assessed and managed to reduce the risk of avoidable harm. People received support to take their medicines safely.

There were enough staff available to meet people's needs. Staff were safely recruited. Staff received training relevant to their role.

People were asked for their consent before care was provided. 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 were supported by a staff team who knew them well and understood their needs and preferences. People and their relatives were involved in the assessment and planning of their care. People were supported to participate in activities and follow their own interests. People knew how to raise a concern if they were unhappy with the service they received. Systems were in place to ensure complaints were investigated and where improvements were needed action plans were in place.

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

Rating at last inspection The last rating for this service was Requires Improvement (published 21 September 2018). There were multiple breaches of regulations 9, 12, 13, 17 and 18. Following our inspection we met with the provider to discuss our findings. The provider told us what they would do and by when to improve. They followed this up with an action plan which included timescales for compliance. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit

At the last inspection on the 19 and 20 July 2017, the service was rated ‘Requires Improvement’. Three breaches of regulatory requirements were identified in relation to Regulation 9 [Person-centred care], Regulation 15 [Premises and equipment], and Regulation 18 [Staffing].

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 key questions of ‘Safe’, ‘Effective’, ‘Caring’, ‘Responsive’ and ‘Well-Led’ to at least good. At this inspection, we found the service had improved in some areas but further work was needed to improve their rating which remains ‘Requires Improvement’.

Whilst we have acknowledged some areas of improvement, we found further work was needed to safeguard people from risks to their health, welfare and safety. For example, risks to people’s safety associated with inadequate staffing levels, safeguarding people from abuse and improper treatment, staff’s unsafe practice in supporting people with moving and handling, management of people’s medicines, catheter care and the monitoring of people at risk of inadequate food and fluid intake.

Whilst there was a number of management audits in place the overall governance systems did not always ensure the safety and quality of the service was maintained. The current arrangements were not as robust as they should be and improvements were required.

Great Horkesley Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates up to 73 older people including people living with dementia in one adapted building. At the time of our inspection there were 56 people living at the service.

The service is located in the village of Great Horkesley, in a large purpose built, building situated within a residential area. The premises are set out over two floors and consists of three units, Wing, Willow and Chestnut a dementia care unit.

A registered manager was 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.

Staff demonstrated a good understanding of how to recognise and report abuse. However, people were not always safeguarded from abuse and improper treatment.

Poor moving and handling practices and the lack of social interaction from agency staff did not support a caring experience for people.

There continued to be insufficient numbers of staff to meet people’s assessed needs. Newly employed staff did not all receive induction training before they were left unsupervised. Their competency to move people safely had not been assessed. Training was not provided to skill all staff in areas such as meeting the needs of people with in-dwelling catheters, people at risk of choking, pressure ulcers and support of people living with dementia.

Staff were trained in medicines management and their competency was regularly assessed. However, audits did not always identify when people had not received their medicines as prescribed, including oral and creams and lotions.

The registered manager understood their role and responsibilities with regards to the Mental Capacity Act [2005]. Staff sought consent from people before providing support. People's capacity to make decisions had been assessed.

People spoke positively about the food and drinks they were provided with. People were given choice of what they ate and drank on a daily basis. However, people at risk of not having enough to eat and drink did not always receive the support that they required and their food and drink intake monitored to maintain their health.

Care plans contained information about how they communicated and their ability to make decisions about their everyday lives. However, care plans did not always provide sufficient guidance to staff. People's records were not always securely stored and people’s personal information protected.

There was a system in place to respond to people’s concerns and complaints and to receive people's feedback about the service.

People had access to a range of activities including opportunities to access the local community.

Staff, people who used the service and their relatives were all complimentary about the management team. They told us they found them approachable, engaging and had clear, person- centred vision and values. People were comfortable to air their views and, provide honest feedback.

There was a more open and transparent culture than we found at the previous inspection. Whilst we identified some shortfalls at this inspection, the registered manager was open and transparent in their approach to implementing improved systems and learning from incidents.

Great Horkesley Manor provides accommodation and personal care support to 73 older people including some people living with dementia. During our inspection there were 59 people living at the service.

At our last inspection in July 2016 this service was rated as requires improvement as we found that the provider was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found that risks to people’s health, welfare and safety had not always been effectively managed to prevent them from the risk of harm. The provider did not have effective quality and safety monitoring processes in place with actions required to ensure continuous improvement of the service. The service did not always protect people’s human rights and ensure that people were supported to exercise choice and control as to their preferred daily routines and how they chose to live their lives. Following that inspection the provider sent us an action plan to tell us what improvements they were going to make.

At this inspection we found action had been taken to improve the quality and safety for people in a number of areas. However, we also identified areas that further work was needed to increase the service's overall rating and ensure that people are provided with good quality, safe care at all times. For example, we found continued shortfalls in relation to care planning, staffing levels, staff training and induction of new employees and deployment of staff to meet people’s personal care needs. Further renovation and refurbishment of the environment was needed.

There was a registered manager. 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.

Staff received a variety of training relevant to their roles. The Deprivation of Liberty Safeguards (DoLS) were understood by staff. However, not all staff received induction training. We also found safe moving and handling training including refreshers were not always provided in a timely manner to ensure staff had the up to date skills and knowledge to keep people safe.

Staff demonstrated a good understanding of how to recognise and report any signs of neglect and abuse. Risks had been identified but were not always consistently managed.

There were systems in place to ensure the safe management of people’s medicines. People were supported to receive their medicines in a timely and safe manner.

People were supported to maintain good health and had access to appropriate services which ensured they received on-going healthcare support. However, improvement was required in the monitoring of people’s food and fluid input and output.

People's nutritional needs were assessed and professional advice and support was obtained for people when needed. People told us that the food was good, they were offered choice and that they were supported to have enough to eat and drink. Dietary needs and nutrition were being managed and advice sought from appropriate health professionals as needed. Health care needs were met with access to and support from external health care professionals.

Relationships between people and staff were positive. Staff were compassionate and promoted people’s dignity and treated them with respect. However, we found some people’s personal belongings had their room numbers recorded on them instead of their names. We recommended this system be reviewed to ensure that people’s rights to dignity be considered and respected fully.

Staff did not always access to people’s care plans and so were not always provided with the most up to date, consistent information as to people’s health, welfare and safety needs. Further work was needed to ensure people were protected from the risks of social isolation due to the lack of planned group and individual social activities.

People’s views were surveyed through satisfaction questionnaires. There was also a complaints procedure in place to ensure people's comments, concerns and complaints were listened to. We saw these were addressed in a timely manner and used to improve the way the service was managed. However, given that a high number of people living at the service were living with dementia the provider did not have any effective observational tool currently in use which would assess the experiences of these people, particularly those with limited verbal communication.

Since our last inspection we found there had been a positive change in the culture of the service which was more focused on the needs of people who used the service. The management team together demonstrated an open culture. Plans were in place for implementing improvement of the service. However, further work was required to effectively identify and monitor the shortfalls we found at this inspection and ensure that people were provided with good quality, safe care at all times which would increase the service's overall rating.

During this inspection we identified two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

The inspection was completed on 7, 8 and 11 July 2016 and there were 49 people living at the service at the time.

A manager was in post but they were not registered with the Care Quality Commission. 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. This service has had managers in post, but there were times that they were absent for long periods and no one has been registered since April 2014.

The last inspection on 14 November 2014, found that the provider was not meeting the requirements of the Health and Social Care Act 2008 in relation to the management of complaints, the management of safeguarding concerns and the poor management of health care records. An action plan was provided to us by the provider on 29 May 2015. This told us of the steps they had taken and that the provider believed that they were already meeting the relevant legal requirements. During this inspection we looked to see if these improvements had been made.

We found that some improvements had been made in some areas but that there were other areas that gave us concern and were falling short of the respective regulations.

There was not always enough staff on duty to care for people when they wanted or needed it or to help keep people safe. Before our inspection, individual needs assessments had not been carried out to calculate the necessary staffing levels that people needed so that the necessary numbers of staff would be on duty. We have been informed that these were now being done.

Risks were not always managed in a way that kept people safe from preventable harm. Equipment was in use that were potential risks to people and no risks assessments had been done to determine what safeguards could be put in place to minimise risks to people. Fire risks were not recognised or attended to, there was no up to date fire risk assessment in place.

This service did not always protect people’s rights under the Mental Capacity Act. The Care Quality Commission (CQC) monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and are required to report on what we find. The MCA sets out what must be done to make sure the human rights of people who may lack mental capacity to make decisions are protected. The DoLS are a code of practice to supplement the main MCA code of practice. Where people lacked capacity to make day-to-day decisions about their care and support, we saw that decisions had been mostly made in their best interests, however there was an example where decisions had been made in relation to one person without making sure their legal rights were being protected.

People were not always given the choice of when to get up in the morning or when they could have their breakfast, sometimes they were got up earlier than they wanted and had to wait to have breakfast.

People’s care plans did not always reflect the current needs of the person. They had not been updated as their needs changed or their health had deteriorated.

Arrangements were in place to regularly assess and monitor the quality of the service provided.

However, the concerns and breaches to regulations that we have highlighted during our inspection were not identified or dealt with. This indicated that the service did not have an effective quality assurance monitoring process in place.

Effective arrangements were now in place to demonstrate that where safeguarding concerns were raised these had been responded to appropriately.

People enjoyed their meals and had enough to eat and drink to meet their needs and staff assisted or prompted people with meals and fluids if they needed support.

Staff treated people with warmth and compassion. They were respectful of people’s dignity and offered comfort and reassurance when people were distressed or unsettled. People’s privacy was protected at times like personal care, but their care notes were sometimes left unattended in open cupboards and could be easily seen by people not authorised to see them.

Staff showed commitment to understanding and responding to each person’s needs and made sure that people who were becoming unwell were referred promptly to healthcare professionals for treatment and advice about their health and welfare.

Outings and outside entertainment was offered to people and staff offered activities on a daily basis. People thought that changes in the way activities were presented meant they had less choice, but the manager had plans to make improvements and had introduced areas of interest around the service, such as a replica bar where people could spend time relaxing in a sociable area.

Staff understood the importance of responding to and resolving concerns quickly if they were able to do so. Staff also ensured that more serious complaints were passed on to the management team for investigation. People and their representatives told us that any complaints they made would be addressed by the manager.

People told us that they enjoyed their meals and had enough to eat, although the lack of sufficient numbers of staff sometimes had a negative effect on their mealtime experience. The management of medicines was suitable and people received their medication safely.

Staff felt supported and believed that the new manager would make changes for the better in the service. Staff received regular training opportunities. Staff received a robust induction and supervision and appraisal.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safeguarding and complaints management. You can see what action we told the provider to take at the back of the full version of the report.

This is the summary of what we found:

Is the service safe?

Staff received training in safeguarding vulnerable adults from abuse and the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The service had appropriate policies and procedures in place in relation to the MCA and DoLS although currently no applications had been submitted.

The entrance of the building was secure with a recently implemented keycode system in place.

We found medicines were stored safely for the protection of people who used the service. People were not provided with their medication in a safe manner. We were not assured that appropriate and effective monitoring arrangements were in place to identify and resolve medication errors promptly.

We found that there were not always sufficient numbers of staff on duty to safely meet the needs of people throughout the day and night. There was a high percentage of agency staff working in the service. People we spoke with told us staff did not always respond to their call bells promptly. One person we spoke with told us, 'I feel safe here but I do not think there is enough staff at night. Staff tell me they have lots to do and there is not enough of them.'

Is the service effective?

People's health and care needs were assessed in consultation with either the person themselves, relatives or their advocate. People had a plan of care in place that reflected their healthcare needs in conjunction with support from external professionals, where required.

Is the service caring?

The interactions we observed by staff were kind and we found the majority of staff responded appropriately to people's requests and needs. We spoke with relatives, one told us, 'The staff do their best but there has not been enough of them. Things are improving but the place is full of agency staff.' Another relative told us, 'The staff do their best. I have no concerns about their care of my (relative).'

Is it responsive?

People's care records showed that where concerns about an individual's wellbeing had been identified, staff had taken appropriate action that ensured people were provided with the support they needed. This included seeking support and guidance from health care professionals, including a doctor and community nurse.

People, who used the service and their relatives, told us that they considered staff were not always available when they needed them as staff did not always respond to their call bells promptly. One person told us, 'They are fairly quick during the day but at night they are not very quick, I think they are tired at night.'

People who used the service and their relatives involved in the service had completed monthly satisfaction surveys. Issues raised had been addressed with action plans implemented.

People were involved in participating in a range of activities both within the service and were also offered regular visits from outside entertainers. However, we found that activities provided for people living with a dementia were not always appropriate given some people's complex needs.

Is the service well led?

The registered manager was absent from the service and the service was currently being managed by an Interim manager.

The provider had quality assurance systems in place to regularly assess and monitor how the service was managed and to monitor the quality of the service. There was evidence that these systems had identified a number of shortfalls and some improvements had been made which would improve protection for people from inadequate standards of care and to identify any areas of non-compliance. However, we were not assured that the systems for identifying shortfalls, for example in supplying sufficient numbers of staff were always effective.

We spoke with seven people who lived at the home. One person said to us, "I've got no complaints or concerns; the staff are very kind." Another person commented, "I like the lovely views from my room." No one we spoke with raised any concerns with us.

The registered provider had undergone a complete change of management two months prior to the inspection. Since then the new management had implemented a range of quality monitoring systems to ensure that care was being delivered appropriately by staff in line with individual care plans, and that the service was continuously challenged to improve.

We saw that people's support plans and risk assessments reflected their needs and were up to date. Staff we spoke with were aware of the contents of the care plans, which enabled them to deliver safe care in line with those plans. The provider had systems in place that ensured the safe receipt, storage, administration and recording of medicines. Staff recruitment systems were robust.

The home was warm, clean and was personalised to the people who lived there. The accommodation was adapted to meet the needs of the people living there, was suited to caring for people with limited mobility and the provider had a suitable maintenance and renovation plan in place for the future.

We spoke with staff and looked at staffing records. Staff were supported and appropriately trained to meet people's needs. Staff were employed in sufficient numbers to meet people's needs. The service had safe systems for staff recruitment, which meant that people were supported by staff who had been properly vetted.

Standards of cleanliness and maintenance in the home were high which meant the premises were safe and comfortable.

Care records examined clearly described how to meet people's needs and we saw that people's needs were being met appropriately. We were concerned about the lack of social activities taking place in the dementia care unit which staff told us were difficult to provide due to their dependency levels.