Archived: Whitchurch 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 inspection took place on the 17 and 24 January 2019 and both days were unannounced. The last inspection of the service took place in October 2017 and the service was rated Good.

At the time of this inspection the service was in a whole service safeguarding process and the provider had put in place a self imposed embargo on admissions. This meant the local authority safeguarding team were monitoring and working with the service to ensure people were protected from abuse and their rights safeguarded. A recent incident where a person had suffered a significant injury was being looked into by the statutory agencies.

At this inspection we found nine breaches of regulations. These include areas relating to safe care and treatment, safeguarding, treating people with dignity and respect, person centred care, staffing, complaints, statutory notifications and good governance. We will be asking the provider to send us a report of the improvements they will make.

The overall rating for the service is 'Inadequate' it will therefore be placed into special measures. The commission is now considering the appropriate regulatory response to resolve the problems we found.

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

There were widespread and systemic failings identified during the inspection. The quality and safety monitoring systems used by the provider were not fully effective. They did not ensure that there were the right resources in place to ensure the quality of service provision and mitigate risks to people.

The provider had failed to make appropriate statutory notifications; notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

The provider had failed to report and take prompt action as required regarding adverse safeguarding incidents appropriately.

There were not enough skilled and competent staff to meet peoples' needs. The staff team was unstable. The resulting high usage of agency staff had caused a lack of leadership for staff and confusion about who was responsible for people’s wellbeing and care needs.

Staff had not received regular meaningful supervision; the provider had not ensured that staff performance and progress was monitored effectively and that staff had an opportunity to voice their individual views. Staff training did not meet staff or peoples' needs. Staff recruitment procedures were not always followed appropriately.

Care plans were not consistently person centred. The guidance within peoples' risk assessments were not always followed by staff and records used to monitor peoples' health were not always completed. This exposed people to risks of neglect and unsafe or inappropriate care or treatment.

People had access to healthcare professionals however we were not assured that staff always identified when referrals were required. People did not always receive their prescribed medicines as required.

We received some positive feedback about the care staff and their approach with people using the service; however we observed occasions when people's dignity had been compromised.

The provider had a complaints procedure however not all complaints had been recorded as such or investigated following the procedure.

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, will be inspected 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 for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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.

You can read the report from our last comprehensive inspection, by selecting the 'All reports' link for Whitchurch Care Home, on our website at www.cqc.org.uk

Whitchurch Care Home is registered to provide accommodation for persons who require personal or nursing care for up to 50 people. The service cares for older people, some of whom are living with dementia. At the time of our inspection there were 35 people living in the service.

There was no register manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The current manager has submitted their registered manager’s application to the Commission for consideration.

At our last inspection in February 2017 we found that improvements were needed to make sure medicines were managed safely. Although areas of this work required further development sufficient improvements had been made.

At our previous inspection the provider had not consistently protected people against the risk of poor or inappropriate care as accurate records were not being maintained. The provider has been sending monthly progress reports on this issue of concern. At this inspection we found sufficient progress had been made.

At our previous inspection we found that care plans were not sufficiently detailed to help staff provide personalised care based on current needs. They were not consistently written in conjunction with people or their representative. At this inspection we found improvements had been made but this area of their work required further development.

At our previous inspection the provider did not have effective systems and processes for identifying and assessing risks to the health, safety and welfare of people who use the service. At this inspection we found sufficient improvements had been made.

A range of recruitment checks had been carried out on staff to determine their suitability for work. Staffing levels were maintained in accordance with the assessed dependency needs of the people who used the service. Staff were supported through a training supervision programme.

People were cared for in a safe and clean environment. Regular maintenance and equipment audits were undertaken. Where actions were required they are taken forward within a reasonable timescale and recorded in the maintenance log book.

People's rights were upheld in line with the Mental Capacity Act (MCA) 2005. This is a legal framework to protect people who are unable to make certain decisions themselves.

People told us that they thought the staff were caring and they were treated with dignity and respect. Staff were knowledgeable about people and understood their needs and preferences.

Advanced care plans were in place. Staff had documented their conversations with people and their relatives about people’s choices in relation to the care they wanted to receive towards the end of their lives.

Staff told us there had been “a lot of changes” recently, but in the main spoke positively about the new manager. Following the previous inspection a staff meeting was held to discuss the Commission’s report and the actions required to move the service forward. Staff said they attended regular staff meetings and were aware of plans for improvement.

People and their relatives provided positive feedback about the new manager. People were encouraged to provide feedback on their experience of the service. Actions were taken in response to the feedback.

We undertook an inspection on 1 and 15 February 2017 to check the provider was meeting the legal requirement of the regulations they had breached and had complied with the Warning Notice.

Whitchurch Care Home is registered to provide accommodation for persons who require personal or nursing care for up to 50 people. The service cares for older people, some of whom are living with dementia. At the time of our inspection there were 40 people living in the service.

There was a registered manager in place on the day of our inspection. 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.

In July 2016 we found that medicines were not managed safely. The provider sent us an action plan telling us what they were going to do to meet the regulations. During this inspection we found insufficient improvements had been made. This is the fourth inspection where we have found that the service has not managed medicines safely.

We served a Warning Notice relating to the breach of Regulation 17 [Good governance] of the Health and Social Care Act 2008. The warning notice required the provider be compliant by 13 December 2016. At this inspection we found that records were not consistently completed accurately to manage and ensure that people’s on-going needs were met. Systems were not being operated consistently effectively to assess and monitor the quality and safety of the service provided. This resulted in continued unsafe practice in some areas of the service.This is the fourth inspection there continues to be a breach of Regulation 17.

Staff were not consistently supported through a regular supervision programme. Supervision is where staff meet one to one with their line manager.

Care plans were not sufficiently detailed to help staff provide personalised care based on current needs. They were not consistently written in conjunction with people or their representative. People we spoke with had little or no knowledge of the content of their care plan.

Staffing levels were assessed by following the Care Home Equation for Safe Staffing (CHESS) dependency tool. Staffing rotas viewed demonstrated that staffing levels were in the main maintained in accordance with the assessed dependency needs of the people who used the service. There were mixed comments from staff and people and relatives about the levels of staff. The registered manager told us that at times when staff call in sick at late notice it has not always been possible to cover their absence with existing or agency staff.

Records showed that a range of checks had been carried out on staff to determine their suitability for work. This included obtaining references and undertaking a Disclosure and Barring Service (DBS) check. The DBS helps employers to make safer recruitment decisions by providing information about a person's criminal background and whether they were barred from working with vulnerable adults.

The staff we spoke with had a good awareness and understood their responsibilities with regard to safeguarding people from abuse.

People's rights were in the main being upheld in line with the Mental Capacity Act (MCA) 2005. This is a legal framework to protect people who are unable to make certain decisions themselves

At our previous inspection best practice had not been consistently followed in relation to infection control. Regular infection controls audits are now conducted by the service and actions plans were in place to take identified issues of concern forward.

People had access to healthcare services. Records showed that people were regularly reviewed by the GP, the tissue viability nurse, speech and language therapists and the hospice team.

Staff were knowledgeable about people's needs and told us they aimed to provide personalised care to people. Staff told us how people preferred to be cared for and demonstrated they understood the people they cared for. In the main people felt that the staff were caring.

The provider had systems in place to receive and monitor any complaints that were made. We reviewed the complaints received. Where issues of concern were identified they were taken forward and actioned.

We found three 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.

Whitchurch Care Home is registered to provide accommodation for persons who require personal or nursing care for up to 50 people. The service cares for older people, some of whom are living with dementia. At the time of our inspection there were 46 people living in the service.

There was a registered manager in place on the day of our inspection. 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.

In December 2014 we found that medicines were not managed safely. At this inspection the provider had not made sufficient improvements. This is the third inspection where we have found that the service has not managed medicines safely.

In December 2014 we found that people’s rights were not being upheld in line with the Mental Capacity Act 2005. We found sufficient improvements had been made.

The provider had not consistently protected people against the risk of poor of inappropriate care as accurate records were not being maintained.

The provider did not have effective systems and processes for identifying and assessing risks to the health, safety and welfare of people who use the service.

The provider had not ensured that people were protected from the risk of cross infection.

Staff were not consistently supported through an effective supervision programme.

Staff demonstrated kind and compassionate behaviour towards the people they were caring for. We received positive feedback about the staff and people thought they were caring.

Care records that we viewed showed people had access to healthcare professionals according to their specific needs.

Relatives were welcomed to the service and could visit people at times that were convenient to them. People maintained contact with their family and were therefore not isolated from those people closest to them.

We found two 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.

Below is a summary of what we found. The summary is based on our observations during the two day inspection, speaking with people using the service, their relatives and the staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service caring?

Everyone we spoke with praised the staff for their caring nature. Comments made included; 'staff are lovely, very caring.'

We saw care staff showed patience and gave encouragement when supporting people. Those people requiring assistance to eat were sensitively helped.

People's privacy was generally respected. Relatives told us they were able to visit their friend/relative when it suited them, and were able to see them in private.

All of the staff explained the numbers of staff on duty did not allow them to provide individual, personalised care. They were concerned they were not always able to maintain people's dignity in relation to continence care.

We saw, and everyone we spoke with said people's dignity was compromised by people waiting for staff assistance with personal care needs. Comments made included 'this is not dignified especially whilst I have a relative here, I am still in my night clothes.' Another person said 'they used to take me to the toilet, at least then I had some dignity and privacy.'

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring people's dignity is maintained.

Is the service responsive?

Before our inspection we received some information of concern regarding staffing levels and the negative impact this was having on people's care.

Every person we spoke with, their relatives and the staff all shared the same opinion, that there were not enough staff. Each person and relative made positive comments about the staff, saying staff were 'trying their best' and 'the staff are lovely, really kind and caring, there just aren't enough of them.' However, there were negative comments about the time it took staff to assist people with their personal care needs. There was a limited staff presence in certain areas of the home. The limited staff presence and the response times to call bells impacted upon the service some people received.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in terms of sufficient qualified, skilled and experienced staff to meet people's needs.

Is the service safe?

People told us they felt safe. Staff we spoke with understood how to safeguard the people they supported. However a recent incident was not investigated or reported to the local authority safeguarding adult's team.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Equipment was well maintained and serviced regularly, which reduced the risk of harm to people and staff. However we saw wheeled equipment which was not clean. Less visible areas of the home were not clean and hygienic.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in terms of cleanliness and infection control.

Is the service effective?

People looked well cared for. Each person had a lengthy care plan yet plans were not effective in informing staff about particular treatments or the management of certain health care conditions.

Visitors confirmed they were able to see their friend/relative in private and visiting times were flexible.

People were assessed for risk such as nutrition and pressure ulceration. However it was not clear how the overall level of risk had been identified.

The provider had not ensured all people who had a pressure ulcer risk, were being repositioned on a regular basis. This meant people were at increased risk of pressure ulceration.

Specialist dietary needs had been identified in care plans where required. However guidance regarding the use of fluid thickening agents was not available for staff until we identified this was required. We saw incomplete food records. There was no evidence to show when people who had been assessed as needing to be offered snacks in between meals, had been provided any.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring the appropriate assessment, planning and delivery of people's care.

Is the service well-led?

The Registered Manager applied to cancel their registration with us in December 2013. A new manager is in post and we have been told they are in the process of applying to register with us.

The service had a quality assurance system in place. However not all of the shortfalls we found during our inspection had been identified through the home's auditing process.

The home used a dependency tool in relation to staffing levels. Information from everyone we spoke with suggested the number of staff on duty did not reflect the current needs of people. This conflicted with the views of management team who said the tool used to determine staffing levels was effective.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to assessing and monitoring the quality of service provision.

The provider sent us an action plan outlining what actions they would take to ensure that they would meet this essential standard. During this inspection we checked the actions that the provider had taken and judged that they were now meeting this essential standard.

We did not speak to people during this inspection as we were checking on required improvements in the area of record keeping.

We found that the record keeping at the home had improved and records maintained were now accurate, complete and fit for purpose.

We saw that the provider had implemented procedures to monitor the quality of records and put actions in place to remedy any shortfalls.

All the people we spoke with told us they liked the home and were happy with the care and support they received. One person told us 'The manager see's me regularly, there is a family atmosphere here and I have good relationships with the staff'.

We saw that people's needs were assessed and in the majority of cases care plans were developed to meet these needs.

People told us they liked the food served at the home and their likes and dislikes were catered for. We found that people's needs in relation to nutrition were being met.

The home had designated domestic staff who kept the home clean and tidy. We saw that there were effective infection control measures in place and people were protected from the risk of cross infection.

Medicines were managed and administered safely by the home.

We found that staffing levels were appropriate to the needs of people living at the home.

During our inspection we saw that people's care records were not always being maintained appropriately. This meant that people were at risk of receiving inappropriate care or treatment.

The majority of people we met had positive views about life at Whitchurch care home Examples of comments we were told included, 'everyone of the staff is kind'. 'The food is quite good'. 'We have lots of activities". 'Not one of them is unpleasant there is always something to do'. 'The food is lovely'. 'They will do anything for you'.

Care plans partially showed how to meet people's needs. However some people were being cared for without a fully complete and up to date care plan to guide staff on how to effectively meet their needs.

People told us they felt safe at the home. They were cared for by staff who were trained to understand the signs of abuse and knew how to report concerns if they witnessed any wrong doing.

There were enough staff to support people with their physical care needs. Staff were caring in manner to people who used the service. However staff levels failed to meet people's full range of needs in a person centred way, which took account of the needs and preferences of each individual.

People were supported to make complaints about the service. People also benefited because complaints were properly investigated and learning took place to improve the service when necessary.