Rosehill Rehabilitation Unit is a care home without nursing, providing neuro-rehabilitation services for people with an acquired or traumatic brain injury, or long term health conditions such as motor neurone disease. The service provides accommodation for up to 16 people. The service is owned and operated by Speciality Care (Rehab) Limited, which is part of the Priory Group. The Priory Group have 420 services across the UK, of which 13 are registered with the Commission to provide neuro-rehabilitation services. The service had last been inspected in October 2015 and had previously been rated Good.
We carried out this unannounced comprehensive inspection on 11 and 15 June 2018. On the day of our inspection there were 10 people living at the service.
There was a new management structure in place. This consisted of, a manager who was in the process of applying to be registered with the Commission. 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. As well as a deputy manager and a senior occupational therapist. The management team were supported by the senior management, which included an operations manager, quality improvement facilitators and Priory regulatory inspectors.
Prior to our inspection we had received concerns about the management, leadership and culture of the service. So as part of our inspection we looked at the concerns which had been raised.
The vision and strategy for the service was in the process of being reviewed by the provider. We were told by the manager that Rosehill Rehabilitation Unit had in the past not always delivered its purpose, of enabling and empowering people in their recovery. Therefore a new management team had been recruited to drive improvement and fulfil its purpose.
Whilst the new management team displayed a commitment to improving and developing the service, the provider had not ensured that those in charge of the service had knowledge of the Health and Social Care Act 2008. In addition, the provider had not ensured the management team had been given an induction to the organisation. This meant they were not aware of important policy and procedures.
People lived in a service which was not effectively monitored by the provider to help ensure its quality and safety. The most recent quality audit which had been carried out by the provider in May 2018 had not identified the areas which we had found requiring improvement, as part of our inspection.
The provider’s organisational values were not known by the management team or by the staff. This meant the staff had not been effectively told of what the culture of the service was expected to be, in line with the provider’s philosophy and ethos.
Overall staff, relatives and professionals spoke positively about the new manager, however some staff felt the manager’s individual approach to staffing matters, did not always create a positive culture.
People were not always protected from risks associated with their care, because records were not always accurate or in place, to help provide guidance and direction to staff, about what action to take. Staff had not received the appropriate training when risks were associated with people’s care. The management team took immediate action to update people’s care records, and arrange for staff to receive relevant training.
People lived in a service whereby the environment was assessed and reviewed to help ensure ongoing safety. The providers own internal health and safety audit had identified some areas required improving, such as improving the Environmental Health kitchen rating. Fire checks were carried out on a weekly basis to ensure the fire alarm worked.
People were supported by sufficient numbers of staff. The manager told us a staffing dependence tool was used which helped to calculate the correct staffing levels, but expressed there was always flexibility. The manager explained there were some staff vacancies, but recruitment was ongoing and they had recently been successful in appointing three new members of rehabilitation staff.
People were supported safely with their medicines. People’s medicines were stored safely and records were accurate. Learning from mistakes, was used to help improve the service. However, the management team were not aware of the National Institute of Clinical Excellence (NICE) guidelines for managing medicines in care homes, this meant they were not up to date with best practice requirements.
People were protected from abuse. The management team and staff had a good understanding of what action to take if they were concerned a person was being abused, mistreated or neglected.
People were protected by infection control procedures. Staff wore personal protective equipment (PPE) as required and the service was clean and odour free.
Overall, people had a care plan in place to help provide guidance and direction to staff about how to meet their health and social care needs. However, people’s care plans were not always specifically detailed about their individual needs. For example, one person had dementia, but did not have a care plan regarding this. The management team told us they were in the process of updating care plans to a new format, and had recognised that documentation was not always available or accurate.
People’s care records did not always demonstrate they were being supported to eat and drink enough to maintain a balanced diet. However, following our first day of inspection, the manager told us they had taken immediate action to implement new records, and that monitoring processes were now in place by the management team, to ensure records were being completed as required.
Staff described how they had made a positive impact on people’s lives, by explaining how people’s mobility and mental health had made steady improvements. Relatives were complimentary of how staff recognised people’s limitations, but still offered encouragement and empowerment when appropriate. Relatives told us they felt involved in their loved ones care.
Opportunities for social engagement were being reviewed because the management team had recognised people were not always being socially stimulated. Therefore, a new activity co-ordinator had been employed to help ensure people’s interests were taken into account and social activities were tailored to people’s individual needs.
People’s wishes for the end of their life were not always recorded, which meant people’s preferences may not be respected. Staff had also not received training in how to support people at the end of their life, which meant, people may not receive effective support.
People’s complaints were positively listened to and used to improve the quality of the service. Relatives told us they felt confident to complain or raise concerns, and explained how the manager always tried to deal with things promptly.
People were not always supported by staff who had received training in subject’s relating to neuro-rehabilitation, acquired or traumatic brain injury. Staff had received training the provider had deemed to be ‘mandatory’, in subjects such as fire, first aid, manual handling and data protection and confidentiality, however this had not always been completed.
Staff, were complimentary of the support they received. The manager told us, supervision of staff practice, and one to one meetings had not been carried out for over two years. But there were plans in place to implement these again. Unlike management staff, all other staff received an induction into the organisation.
People’s consent to care and treatment was sought in line with the Mental Capacity Act 2005 (MCA). DoLS application had been made when required and Best Interests meetings had taken place when a person lacked the mental capacity to make a decisions, for example having their medicines covertly (hidden in food). However, such decisions had not been reviewed regularly, for example one had not been reviewed since 2014. It is important decisions are reviewed regularly to ensure people’s human rights are protected.
People and their families were being actively encouraged to be involved in decisions relating to care and support. One relative was highly complimentary of the way they were kept informed and involved in their loved ones care.
The service worked positively with health and social care agencies to help ensure people received effective care and treatment, and lived heathier lives. People’s records demonstrated how psychology and physiotherapy reviews had prompted changes to how people were supported. An external professional told us, they found staff to be helpful and responsive to any advice given, and staff generally, had a good knowledge of people.
People lived in a service which had been suitably adapted to meet people’s individual needs. People’s communication needs were known by staff and effectively met. However, whilst there was some pictorial signage through the service, to help ordinate people, the provider had not fully considered the Accessible Information Standard (AIS), because people’s care plans were only available in a written format. The Accessible Information Standard (AIS) states that people with a disability or sensory loss are given information they can understand, and the communication support they need.
People received care and support from staff who displayed kindness. People and relatives expressed staff were always kind and compassionate. Staff and the management team, spoke incredibly fondly and passionately about the people they cared for, and described them “As an extension of their own family” and as “Special people”.
Overall, people’s privacy and dignity was respected. Interactions relating to personal care were carried out in the privacy of people’s bedrooms. However, people’s personal information relating to their weekly social