Piper Court

Piper Court is a residential care home providing personal and nursing care to up to 60 people. The service provides support to adults including older people, people living with dementia and people with mental health conditions. At the time of our inspection there were 38 people using the service.

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

Medicines records were not always accurate or up to date. The management of risk around people’s dietary requirements was not always clearly documented. Records around maintenance and safety checks were not always completed. Night staff had not taken part in recent fire drills and we have made a recommendation about this.

People told us they felt safe living at Piper Court. The manager handled safeguarding concerns appropriately. A safe recruitment procedure was in place. We received mixed feedback from people and their relatives about staffing levels. Some people were happy there were enough staff but others felt they would benefit from more staff at certain times of day. We shared this feedback with the provider. The provider was recruiting for new staff so at times agency staff were used to cover shifts to ensure sufficient staff were always available.

The provider had appropriate measures in place to minimise the spread of infection. Lessons were learned following accidents and incidents.

The manager and staff liaised with external professionals to ensure people had access to the support they needed.

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.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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 12 January 2022). At this inspection we found the service remained rated requires improvement. This is the third consecutive inspection where the provider has failed to achieve a good rating.

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 some improvements had been made but the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced inspection of this service on 25 November 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 remains requires improvement. This is based on the findings at this inspection.

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 Piper Court on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to good governance, specifically relating to quality assurance and record keeping.

We have made a recommendation about fire safety, specifically around fire drills.

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

Follow up

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.

Piper Court is a residential care home providing personal and nursing care to a maximum of 60 people. 30 people were using the service at the time of the inspection. Piper Court is purpose built and accommodation is spread across three separate wings, each of which has adapted facilities. Some people are living with dementia and one of the wings provides care to people living with mental health conditions.

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

Medicines were not always managed safely. Quality assurance processes were in place, but audits had not picked up on all of the issues we identified.

Risks to people’s health and wellbeing were assessed but records did not always contain sufficient information to help staff minimise risk. People were safeguarded from abuse. Accidents and incidents were monitored. Effective infection prevention and control measures were in place. There were sufficient staff to meet people’s needs.

Feedback from people who used the service, relatives and staff was sought and acted on. People and staff spoke positively about the management of the service. Staff said they were supported in their roles.

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 inadequate (published 26 June 2021) and there were breaches of two regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, although we found some improvements had been made there were still areas where further improvement was needed, and the provider was still in breach of regulations.

This service has been in Special Measures since 16 June 2021. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We previously carried out an unannounced inspection of this service on 18 and 19 May 2021. Two breaches of legal requirements were found. After the last inspection we imposed conditions on the provider’s registration requiring urgent action to be taken to improve the service. This was in response to the concerns we found with infection prevention and control. The provider also completed an action plan to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check whether required improvements had been made in relation to infection prevention and control. We also checked whether other areas of regulations 12 and regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. We checked whether they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe and well-led which contain those requirements.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. This is based on the findings at this inspection.

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

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a breach in relation to the safe management of medicines.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Piper Court is a residential care home providing personal and nursing care to a maximum of 60 people. 43 people were using the service at the time of the inspection. Piper Court is purpose built and accommodation is spread across three separate wings, each of which has adapted facilities. Some people are living with dementia and one of the wings provides care to people living with mental health conditions.

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

People we spoke with told us that they felt safe living in the home. However, we identified concerns in relation to people's safety and the leadership of the home.

Staff did not follow infection prevention and control procedures despite evidence which showed they had completed training in this area. PPE was not always worn correctly, and some staff were travelling to and from work in their uniforms. Medicines were not being managed safely. There were no fire drills taking place and regular health and safety checks had not been done since the beginning of 2021. All staff we spoke with had concerns about safe staffing levels. Some of the people who used the service also felt there was not always enough staff on duty. We have made a recommendation about this.

Management checks had not identified the issues we found. Care records were not always comprehensive or up to date and therefore did not accurately reflect people's needs. We received mixed feedback from staff. Some staff told us they did not feel well supported and they did not feel confident in approaching the manager. Surveys and meetings had been affected by the pandemic. We have made a recommendation about this.

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 7 June 2019).

Why we inspected

The inspection was prompted in part due to concerns received about the management of medicines. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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.

The overall rating for the service has changed from good to inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe 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.

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

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to safe care and treatment, including the safe management of medicines, and good governance at this inspection.

In response to the concerns we found with infection prevention and control, we imposed conditions on the provider's registration requiring urgent action to be taken to improve the service.

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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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’s experience of using this service: At this inspection we found the management of medicines had improved and risks to people were assessed with information to support staff on how to mitigate the risks. Further work was needed to show action had been taken when people lost weight. Where people were at risk of dehydration, fluid charts were not always completed. The provider had recognised this in an audit and arranged further training for staff. There were no concerns with staff recruitment or staffing levels. People said they felt safe living at Piper Court.

Staff now received training and adequate supervisions. People were supported to have choice and control of their lives and staff did support them in the least restrictive way possible; the policies and systems in the service supported this practice. People were happy with the food provided and were offered plenty of choice. Work was in place to improve the meal time experience.

People’s needs were met by knowledgeable staff who were kind and caring.

Care plans had person-centred information recorded. People were happy with the activities provided and enjoyed them. Complaints were acted on with an outcome documented.

People and staff said the service was well led. Audits were taking place to monitor the quality of the service and concerns were raised had already been addressed following the audits. Staff said the new manager was committed to driving improvements and they felt supported and listened to.

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

Rating at last inspection: At the last inspection the service was rated requires improvement (published 1 June 2018).

Previous breaches: At the last inspection in August 2018 we found the systems in place for the management of medicines and personal risks did not always keep people safe. Staff were not supported with supervisions and did not receive training. The provider did not have systems in place to enable them to identify and assess risks and records relating to the care and treatment of people were not complete, legible, accurate or up to date. We asked the provider to complete an action plan to show what they would do to improve and by when. 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 return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

Piper Court 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. The service is registered for 60 people and at the time of inspection there were 57 people living at the service. The service had three units, nursing, residential and a mental health unit.

A registered manager was in post at the time of the inspection visit. They were registered with the Care Quality Commission in December 2004. 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 last inspection of the service was carried out in April 2017 and found that the service was not meeting all the requirements of Health and Social Care Act 2008 and associated Regulations. We found concerns relating to the storage of medicines and the administration of controlled drugs. There were not enough staff, staff recruitment records were not adequate, records were not accurate, updated to reflect current needs or dated, audits had not picked up any of our concerns and had no actions plans. Following this inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least good.

At this inspection we found that the provider had made some improvements however we found further improvements were required to become fully compliant with the Fundamental Standards of Quality and Safety. This is the second time the service has been rated requires improvement.

We found concerns with the safe administration of medicines.

Not all accidents and incidents were recorded.

Staff training was not up to date. Supervisions were taking place but the records were not available to evidence this.

Audits were taking place; however, they were not robust enough to highlight the issues we found during our visit. Records, such as records to evidence training, could be difficult to follow

Feedback on the quality of the service had not been sought. We have made a recommendation about this.

People enjoyed the food provided. Specific cultural diets were provided if needed.

People were supported to continue with their preferred religious needs.

People who lived at the service were safeguarded from abuse. People told us that they felt safe at the service and that they trusted staff. Staff had received training in the safeguarding of vulnerable adults and said they would not hesitate to report concerns.

A number of recruitment checks were carried out before staff were employed to ensure they were suitable to work with vulnerable adults.

The registered manager understood their responsibilities in relation to the DoLS. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; policies and systems in the service supported this practice. Evidence of consent was sought.

We found there was sufficient staff employed to support people with their assessed needs.

Staff demonstrated a person centred approach to care, they knew people well. However we found that not all staff knowledge was recorded in people’s care files. Care plans had information of people’s wishes, preferences and life histories.

We saw evidence of activities taking place and people we spoke with enjoyed them.

The service had a complaints policy that was applied if and when issues arose. People and their relatives knew how to raise any issues they had. The service had received one complaints since the last inspection.

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

Piper Court is a 60 bedded purpose built care home. It is part of Akari Care Limited. Personal care is provided within the ground floor unit. Personal care for people with functional mental health needs is provided in a small unit on the first floor and there is a further unit providing both general nursing and dementia nursing on the first floor. Functional mental health is for people with a type of illness that has a predominantly psychological cause. It may include conditions such as depression, schizophrenia, mood disorders or anxiety

The service had 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.

Risks to people arising from their health and support needs were not always assessed, and plans were not always in place to minimise them. Risks to the environment were not all in place. On the second day of inspection a notice was on the lift to state the doors were not always aligning with the floor. We asked to see the risk assessment and there wasn’t one in place. The registered manager agreed to put one in place immediately and send a copy to CQC after the inspection. We received this on the 25 April 2017.

There were not enough staff to meet people's needs; there was only one nurse on duty to care for 21 people who required nursing care, on the first day of inspection one person who was requiring nursing care resided on the ground floor. Therefore the nurse had to keep going downstairs to check on this person.

Robust recruitment and selection procedures were not in place. Although appropriate checks had been undertaken before staff began work, where concerns were raised no risk assessments were in place. Staff did not receive training to ensure that they could appropriately support people. The clinical lead job description stated they should be a registered general nurse (RGN). However, the service employed a registered mental nurse (RMN) and provided no training to support this person. Nurses employed were not trained on the use of syringe drivers. A syringe driver helps reduce symptoms by delivering a steady flow of injected medication continuously under the skin.

Medicines were not administered safely. An agency nurse administered a controlled drug subcutaneously [via injection] however the prescription stated that this drug was to be administered via a syringe driver only. We raised asked the registered manager to raise a safeguarding alert regarding this. CQC also raised a safeguarding alert.

People’s care plans contained a record of assessment, care planning, reviews and evaluations, daily records and external healthcare professional input. However, we found the care plans were not person centred, and did not reflect people’s current needs.

Audits were taking place, however were not robust enough to highlight the issues we found during our visit. Many audits did not have action plan in place.

Staff understood safeguarding issues and felt confident in raising any concerns they had, in order to keep people safe.

Staff had received online Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) training and demonstrated a very basic understanding of the requirements of the Act. The registered manager understood their responsibilities in relation to the DoLS.

On the first day of inspection the lunchtime experience was not dignified for all the people using the service. Where people needed a pureed diet the ingredients were all blended together. On the second day of inspection improvements had been made.

The service worked with external professionals to support and maintain people’s health. Staff knew how to make referrals to external professionals where additional support was needed. Care plans contained evidence of the involvement of GPs, care home liaison nurse and other professionals. Feedback we received from health professionals was positive.

The interactions between people and staff were cheerful and supportive. Staff were kind and respectful. We saw staff were aware of how to respect people’s privacy and dignity. People and their relatives spoke highly of the care they received.

Procedures were in place to support people to access advocacy services should the need arise.

People had access to activities, which they enjoyed. The service employed two activity coordinators, who worked alternate days.

The registered provider had a clear complaints policy that was applied when any concerns were raised. People and their relatives knew how to raise any issues they had. The majority of complaints were documented, with an outcome recorded to show if the complainant was satisfied. However we found some complaints had not been recorded correctly.

We identified 4 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Regulation 12 Safe care and treatment, Regulation 17 Good governance, Regulation 19 Fit and proper persons employed and Regulation 18 Staffing. You can see what action we told the registered provider to take at the back of the full version of the report.

We looked at a six sets of care records; spoke with the regional director, manager and deputy manager. Throughout the inspection visit we also spoke with four care staff of varying roles and we spoke with three people who used the service and one relative.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the manager and staff.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service had discussed the new judgement regarding DoLS with the local authorising body. They were completing DoLs applications where needed in a staggered process as requested by the local authorising body.

We found that the service was not safe because people were not protected against the risks associated with the use and management of medicines.

People did not receive their medicines at the times they needed them and in a safe way. Medicines were not administered and recorded properly.

Is the service effective?

People who used the service were clean and well-cared for and we observed staff being attentive to their needs. Although the lack of up-to-date care records and assessments put people at risk of receiving poor care.

Is the service well led?

We saw that audits in place to check medication was being administered correctly were being carried out, but action was not being taken to address the issues found such as missing signatures or incorrect stock figures. This led to the audit being a 'tick box' process with no actions or analysis being used to improve the medication process.

Other audits for care plans had not been completed on a consistent basis since our last visit at the end of March 2014. Care plans were not always reviewed consistently and audits had picked up issues in one file in June and July and these stated they should be addressed within 24 hours but they had not been completed by the time of our inspection. We found omissions in reviews for care plans, assessments and audits in four of the six care files we viewed.

From our last visit the service said they would provide 'NCFE Level 3 training for all staff including nurses'. We saw from staff personnel files that although one nurse and four care staff had received safe handling of medicines training from the pharmacy, the more in-depth training at NCFE level had not taken place. We also saw that of the three nurse's files we viewed that none had been assessed as competent to administer medication and only three senior care staff had received one assessment of their competency. Four new staff who were two nurses and two senior care assistants had no specific training in medicines or had received an assessment of their competency from commencing their employment with the home. This could mean that people were at risk of staff handling medicines who did not have the competency and skills needed to perform this task.

What people told us: We spoke with three people who used the service, one relative and nursing and care staff.

One relative we spoke with told us; 'Generally they are very kind, we had a complaint last week but it was dealt with'. They take any concerns on board and deal with them quickly'. They also told us that they had mentioned to management about one member of staff's attitude that wasn't pleasant and said; 'I think this has been dealt with'.

One person who lived at the service told us; 'It's a beautiful place with a good choice of food and there is plenty of it'.

One staff member told us; 'People are more at ease now and the new manager is lovely'.

At our last inspection of Piper Court of November 2013 we identified some concerns about staffing within the service and also with some of the record keeping.

At this inspection we found that improvements had been made to both staffing arrangements and record keeping within the service, however there was still some further development needed. We were satisfied that the provider was taking appropriate action to address this.

Prior to this inspection there were also concerns in regard to the medication systems, as such we included this outcome as part of this inspection. During this inspection we identified a number of concerns regarding the way in which medication was managed within the service and have asked the provider to make improvements. Immediate action was taken by the provider to start addressing this.

We spoke with three people who used the service, two relatives and ten staff. We spent time observing the interactions between people living at the service and staff on each of the three units. We saw people being treated kindly and with respect.

All of the people we spoke with were satisfied with the care they received. Comments included, "They look after me very well.' 'They are a nice lot of staff, they are lovely, I cannot fault any of them.' 'Anything I want I just ask and I get it.

We found that people had nursing and care plans in place that were up to date. We did however find that more detail was required for specific needs.

We also found that staff worked in collaboration with other health and social care professionals.

We found that effective systems were in place for the maintenance and servicing of equipment and for monitoring the quality of the service.

We did identify some concerns about the staffing levels and skill mix. This was a particular concern within the newly developed EMI nursing unit.

We also identified some gaps and lack of information within records.

We were able to observe the experiences of people who used the service. We saw that staff treated people with dignity and respect. Staff were attentive, when interacting with people and explanations of care were given in a way that could be easily understood.

We saw that there were times when staff were not available within lounge areas and there were mixed views about the sufficiency of staffing. An assessment of dependency is carried out on all people who used the service; however, this information isn't used as a basis for deciding sufficient staffing levels, which could impact upon people's care.

We found the actual premise was in need of some repair and refurbishment and identified areas of potential risk to people.