Archived: Beech House - Salford

Beech House 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.

At the last comprehensive inspection of Beech House in January 2017, we rated the service as ‘Requires Improvement’ overall and in four of the five key questions we inspected against (Safe, Effective, Responsive and Well-led). The Caring domain was rated as Good. During that inspection, we identified breaches of the regulations with regards to person centred care, safe care and treatment, nutrition/hydration and good governance. We also issued two warning notices regarding nutrition/hydration and good governance following the inspection telling the home they must improve. The provider then sent us an action plan, informing us of the planned improvements they intended to make. We also held meetings with the provider to discuss the concerns, with the local authority also in attendance.

To follow up on these concerns and due to receiving a number of safeguarding alerts about the home, we undertook a further comprehensive inspection on 13, 14 and 20 February 2018. The first day of the inspection was unannounced, however we informed staff at the home we would be returning for a second and third day to complete the inspection. At this inspection, we identified multiple breaches of the regulations regarding person centred care, safe care and treatment, safeguarding people from abuse and improper treatment, nutrition/hydration, good governance and staffing. You can see what action we have asked the provider to take at the back of the full version of this report.

Medication was not being administered to people safely. We identified multiple instances where people did not receive their medication because it was not available in the home to be given to them by staff as prescribed.

People’s skin integrity was not always being well managed and we found guidance from district nursing staff was not being followed. We also observed one person sat in a chair without appropriate pressure relieving equipment in place which could have placed their skin at risk.

We found people were being placed at risk because they were not always receiving food and drink of correct consistency which could place them at risk of choking/aspiration.

We found several environmental risks around the home such as the kitchen area not being secure and people’s thickened drinks left unattended in the lounge area.

People were not always referred through to the falls service for further assessment when necessary. The deputy manager told us people were referred once they suffered two falls or more, however we found this had not been done for one person living at the home in a timely manner. The deputy manager made this referral during the second day of the inspection.

Staff did not always receive the appropriate training, supervision and appraisal to support them in their role.

We identified concerns relating to people’s nutrition and hydration needs with advice and guidance from other health care professionals not being followed. Drinks were not easily accessible for people in communal areas who were at risk of dehydration and one person had run out of their nutritional supplements, despite needing them following weight loss.

The home did not have a system in place to monitor which people were currently subject to deprivation of liberty safeguards (DoLS) authorisations. We found instances where mental capacity assessments had not been undertaken, despite their being concerns about people’s capacity during social work assessments. Applications for DoLS for these people had therefore not been made at the time of the inspection by staff. Staff said these people wouldn’t be able to leave the home freely as it would not be deemed safe for them and would be a restriction.

People living at the home spoke favourably about the staff and the care they received. However we observed several missed opportunities for interaction between staff and people living at the home, such as staff leaning over the barrier near the entrance to the lounge area and watching people who were up early in the morning as opposed to interacting and speaking with them.

People’s dignity was not always preserved and at times we heard staff talking loudly about taking people to the toilet and on one occasion, how one person living at the home had suffered continence issues during the night.

We observed there to be a lack of activities and things for people to do during the inspection. We were informed the activities co-ordinator had recently left the home, which was the reason why none were taking place.

Not all people living at the home had an appropriate care plan in place which meant staff did not have access to information about the care people required.

Confidential information was not being stored securely, with care plans left on the top of cabinets in a room which was not locked and could be accessed by unauthorised personnel.

Quality assurance systems were in place, however were not robust and had not identified the concerns we found during this inspection. There had also been a failure to improve standards despite two warning notices being issued following our last inspection in January 2017.

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, we will be inspecting 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 in 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.

Beech House is a residential care home which provides care for up to 36 older people and is owned by Akari Care Limited. The home is situated in Salford, Greater Manchester and is located near to local transport routes. Car parking is available at the front of the home or in nearby side streets a short distance away.

Our last inspection of Beech House was in March 2015. Although no regulatory breaches were identified, the home was rated as ‘Requires Improvement’ overall and in the ‘Safe and ‘Effective key questions. This was due to concerns regarding the length of medication rounds, safety gates on stairwells being left open and unlocked and also a lack of dementia friendly environments to help people orientate themselves around the building. The domains for ‘Caring, ‘Responsive’ and ‘Well-led’ were rated as ‘Good’.

During this inspection we identified four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to person centered care, safe care and treatment, meeting nutritional and hydration needs and good governance. We are currently considering our regulatory response to these issues.

We identified concerns with how risks were mitigated at the home. For example, risk assessments were not reviewed on a consistent basis and trends analysis following accidents and incidents had not been completed since October 2016. Two people, who had been admitted to home in recent months did not have any risk assessments in place. This meant staff did not have sufficient information available to them about how to keep people safe.

We also observed one bedroom door was propped open with a chair which presented the risk of the door not closing in the event of a fire. We raised this with the manager on the first day of the inspection, however we observed the door to still be propped open the following day. We also checked upper level bedroom windows to see if window restrictors were used. We found one bedroom and two corridor windows did not have window restrictors on, with two of the windows opening a considerable length, presenting the risk of a person potentially leaving in an unsafe manner or falling. The provider immediately ordered window restrictors to be fitted and we checked these on the second day of the inspection. However we noted from looking at the maintenance book that the bedroom window restrictor was noted in July 2016 as being missing. This still had not been replaced at the time of our inspection in January 2017.

One person’s care plan also identified them as needing to be sat a pressure relieving cushion during the day, however staff did not ensure this was provided for this person on both days of the inspection. Although this person was mobile, there was a lack of oversight in communal areas to ensure this task was completed.

People living at the home told us they felt safe living at the home. The staff we spoke with had a good understanding of safeguarding, whistleblowing and how to report any concerns.

We found that medicines were given to people safely, with staff receiving appropriate training. Medicines were stored in a secure treatment room, with only staff responsible for administering medicines having access to the room.

Staff were recruited safely with references from previous employers being sought and DBS (Disclosure Barring Service) checks undertaken.

We had concerns about how the service monitored and responded to people who were at risk of losing weight. For example, one person who had suffered recent weight loss had been referred to a dietician in December 2016. This person was noted to have lost 9 kilograms between August 2016 and November 2016. Whilst waiting to be assessed, the dietician service had sent an action plan to the home, with specific instructions about how to monitor this person’s weight. This included accurately monitoring this person’s food/fluid intake, carrying out weekly weights and encouraging a high calorie diet. From looking at the records, we were unable to see that these care interventions were carried out by staff. The manager acknowledged that it looked as though the action plan had been put in this person’s care plan but had not been followed by staff. This placed this person at risk of suffering further weight loss.

We identified a second person, who had also suffered weight loss between October 2016 and January 2017, with gaps in weight records also noted. This person weighed 80 kilograms in October 2016 and was then weighed as 69 kilograms in January 2017. This persons risk assessment was reviewed, however this significant drop in weight had not been taken into account or considered to be a risk and a referral to the dietician service had not been made.

We noted from reading a third person’s care plan that they suffered from a condition known as Oedema which caused them to retain water. Their care plan stated staff should encourage them to drink 2 litres of water each day and that due to living with dementia, they may forget to have a drink. We did not observe this person being encouraged to drink any additional fluids during the inspection and the sample of fluid intake records we looked at showed this person consumed a maximum of one litre and as little as 250 millilitres on other days. This meant we were unable to ascertain that staff were providing this person with the fluids they needed to help them maintain good hydration and keep them safe.

Staff received an induction when they started working at the home, as well as receiving appropriate mandatory training and supervision to support then in their role.

The home worked within the requirements of the MCA (Mental Capacity Act), with the manager completing appropriate assessments if there were concerns about a person’s capacity. The home also worked within the requirements of DoLS (Deprivation of Liberty Safeguards) and made referrals as necessary.

The people we spoke with told us they were happy with the level of care provided. People told us they liked the staff, who were kind and caring. Two visiting relatives we spoke with expressed their satisfaction with the care provided, however a third told us they felt the level of care had declined in recent months.

People told us they were treated with dignity and respect and that staff promoted their independence.

We saw complaints were responded to appropriately. The home also collated various compliments which had been made about the home.

The home held meetings for staff and people who lived at the home. This meant concerns or areas for improvement could be discussed.

At the time of the inspection, the did not have an activities co-ordinator, although the manager told us this was something that was being looked into. Due to this we observed limited activities taking place during the inspection. A visiting relative also told us activities and trips out had decreased in recent months.

We found two people living at the home did not have care plans in place, despite being at the home for over a month. This meant staff did not have access to guidance about how people needed their care to be delivered. During the inspection we observed staff asking each other what the moving and handling requirements were for one of these people. The care plans we did look at contained a section for annual reviews, however we were unable to see that these had taken place. The manager acknowledged this and said they were holding a review with one person living at the home the week following our inspection, with the intention of doing these for each person. We also found gaps and inconsistencies with monthly care plan evaluations.

Poor record keeping was also identified during the inspection. This was in relation to turning/re-positioning charts and fluid intake sheets. This made it difficult to establish if the care was being delivered due to accurate records not being maintained. When asked for, these records could either not be located, or took a long time to find.

Confidential information was not stored securely. For instance, daily records detailing information about when people had been to the toilet was left in files in the main lounge. We were told a suitable storage place was being sourced, however interim measures had not been taken such as moving the files to somewhere more secure, such as the managers office.

The manager and provider conducted audits at the home, however these were in effective due to the concerns we had identified in relation to risk assessments, care plans, nutrition, monitoring of weights, fire doors, window restrictors, record keeping and storage of confidential information. Some of these concerns had also been raised during social week reviews the week prior to our inspection, however no action had yet been taken.

At our last inspection we had some concerns in relation to referrals being made to external agencies such as General Practitioner (GP's), dieticians and the falls team, as we couldn’t see any evidence that these referrals had been made. During this inspection we saw improvements in this area and we were shown documentation to show that people had been referred appropriately when there had been any concerns.

We looked at how the home ordered, stored, administered and disposed of people’s medication and we found that this had been done safely and effectively.

At our last inspection we had some concerns in relation staff not being appropriately supported to carry out their job role effectively. This was because not all training and supervisions were up to date and there was no overall training matrix to identify training requirements for staff. We saw improvements during this inspection.The area manager told us that mandatory training will be completed for all staff by September 2013 and we could see that this had been pre-planned.

We found that the home had appropriate systems in place to monitor the quality of service provision effectively.

People told us what it was like to live in Beech House and how the staff cared for them and supported their needs. One person told us, “This is a nice place to live. The staff are really very good and they help you when you need it”. Another person said “I am treated really well by all the staff here” and, “They always check with me before they do something”.

We found everywhere to be clean, tidy and comfortably furnished, although all areas and furnishings were showing significant signs of wear and tear. The manager told us that a full re-furbishment programme was due to start in early January 2013.

Each person using the service had a care plan in place. These were person centred and the staff had made an effort to create a ‘This is my life’ section for each person by capturing background information such as hobbies and interests, work background and family information.

The manager told us that the ratios of night staff had recently been increased to make sure people’s needs were met by sufficient numbers of appropriate staff at all times.