Archived: Chiltern Court Care Home

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.

This unannounced inspection took place on the 13, 14 and 16 November 2017. During our last inspection in February 2017 we found breaches of Regulations 9, 10,12, 13,14 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 ( HSCA RA Regulations 2014) and Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 ( Registration Regulations 2009)

As a result we imposed conditions on the provider’s registration. This meant we asked the provider to supply us with information on a monthly basis to evidence improvements in these areas. They were legally required to do so and complied with these conditions. During this inspection we found improvements in regulations 13 and 14 HSCA RA Regulations 2014 and Regulation 18(Registration Regulations 2009).

However we found continued breaches in regulation 9, 10, 12 and 17 of the HSCA RA Regulations 2014 with additional breaches in regulation 19, 15 and 18 HSCA RA Regulations 2014.

The home had not had a registered manager in post since April 2017. Since the last registered manager left their post there have been three further managers covering the position, none of whom have remained in employment or applied to be registered with us.

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.

Chiltern Court Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single packages under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Chiltern Court Care Home is a nursing and residential home for older people. The home is registered to accommodate up to 53 people, at the time of our inspection 23 people were living in the home. The accommodation is spread over three floors. The bottom two floors have lounges and dining areas. Only one person was living on the third floor.

We found improvements had been made in some areas of the safe handling of medicines. However, records were not always up to date or used appropriately to prevent people from being harmed by medicines or lack of medicines. For example patches. This was a continued breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During our last inspection we found the provider had failed to notify us or the local authority of safeguarding concerns that had taken place in the home. During this inspection we found this had improved and there was only one outstanding safeguarding notification we had not received. Staff had understood the indicators of abuse and systems were in place to report concerns and to take appropriate action to keep people safe.

During our previous inspection in February 2017 we found failings in the recruitment practices of the service. During this inspection we found the same failings as gaps in employee’s previous employment histories had not been investigated and recorded. This placed people at risk of harm. This was a continued breach of regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During this inspection we found the standards of hygiene and infection control were of concern in some parts of the home. Some areas were not clean, and catering and domestic staff had not all received training in infection control. This was a breach of 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Health and safety checks had not been carried out continuously in the months since our last inspection. We found some areas of the building required attention to ensure the security and safety of the staff and people living in the home. This is a breach of regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Maintenance contracts and service checks on gas and electricity had been maintained and were up to date.

During our previous inspection in February 2017 we recommended to the provider they gave consideration to the deployment of staff. This was because staff were not always available when people needed them due to taking breaks at the same time. During this inspection we found improvements had been made and staff were more accessible and able to respond quickly when people needed assistance.

During our last inspection we made a recommendation for the provider to improve support to staff through appropriate training, supervision and appraisals. We found this area had improved and the rate of training had increased. However, we found staff that required specific training to carry out their roles had not all received training. Supervision and appraisals were not being provided in line with the provider’s policy. This was a breach of regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found during this inspection a continued breach in regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because records were not always available, up to date or accurate. The provider had failed to monitor the management of the home and address issues that affected the safe provision of care and support for staff.

Records showed people’s mental capacity had been taken into consideration when making decisions for themselves. Staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice. However, people were not always supported to have maximum choice and control of their lives. People’s dignity and privacy were not always protected by staff. This was a continued breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also observed good care practices from staff including how they communicated with people and their general caring attitude towards the people living in the home.

We found a continued breach of regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because care plans did not always consider how people could be supported with their mental health. They did not always reflect the involvement of people and did not always consider how to support people to be as independent as possible. People still remained at risk of social isolation as the provider had failed to improve the provision of person centred meaningful activities to people living in the home.

During our last inspection and this inspection we found people did not always know how to make complaints.

We have made a recommendation in relation to end of life care planning for people within the home, as this was not a consistent practice throughout.

Due to the lack of consistent management in the home, we found staff had been put under pressure to repeatedly change the way they were working, this had affected morale, and their understanding of what was required. The provider had failed to monitor the quality of the management in the home and this had resulted in a lack of progress with regards to the expected improvements. A new regional manager and acting manager are now in post and improvements have been reported from the local authority contracts team since our inspection.

We found a number of 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 the 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.

Chiltern Court Care Home is a registered nursing and residential home. It is registered to accommodate and care for up to 53 older people. At the time of the inspection they were providing care for 33 older people.

The home is required to have a registered manager in place. 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.

At the time of our inspection the registered manager was absent due to sickness, they had resigned from their post the week prior to our inspection, they were not returning to the service. As a result, the regional manager was covering for the registered manager until such time as a permanent or interim manager is employed.

During our previous inspection in October 2015 we had concerns the provider was not supporting staff with adequate training and supervision. We found during this inspection that this had improved, however we identified new areas that staff needed support and training in such as respect and dignity and skin care.

Medicines were not administered and recorded safely. Audits of medicines had not been completed accurately. There were inaccuracies in the records of the amount of medicines in stock. This placed people at risk of not receiving their medicines in a safe and appropriate way.

Systems used for the recruitment of staff were not robust. Gaps in applicant’s previous employment histories were not checked. This meant the provider could not be sure they were employing staff who were safe to work with people.

Although staff were knowledgeable about the process of identifying and reporting concerns of abuse, we found this process was not followed through by the registered manager. Incidents and concerns had not been reported to the local authority safeguarding team. The registered manager had not followed the multi-agency agreement on reporting safeguarding concerns. Notifications regarding incidents had not been sent to the Care Quality Commission (CQC). This placed people at risk of harm.

We were told there were sufficient numbers of staff working in the home to meet people’s needs. We found at various times, staff were not visible. The deployment of staff had not taken into account the fact that staff took breaks at the same time, leaving a lack of staff presence in the home. We have made a recommendation about the staffing.

Health and safety checks had been carried out regularly, and policies and procedures were in place to ensure sufficient checks were made on the premises and equipment to keep people safe.

We had concerns about the support offered to people to eat their meals, this was not adequate as the positioning of some people placed them at risk of choking and made eating difficult. Where people required support and encouragement to eat food this was not always evident. Records related to the intake of food and fluids had not always been completed accurately.

Not all staff were aware of how to apply the Mental Capacity Act 2005 to their role. One person was being un necessarily restricted, although the regional manager had intervened to stop this practice, as the person had the capacity to make their own decisions. We have recommended the service looks at training for staff in this area.

Staff did not always show respect to people or protect their privacy and dignity. Staff did not always knock on people’s doors or ask permission before entering. Staff were not always aware of the needs of people and therefore people were placed at risk of receiving inappropriate care.

Records did not demonstrate staff were carrying out the care people needed at the time they needed it. People complained they were not being washed regularly. One person told us their skin was sore because they were not being assisted to wash properly or regularly.

Although activities were provided in the home, these were not sufficient to protect people from the risk of social isolation and insufficient stimulation. People told us they were “bored”, and we saw very little in the way of activities for people.

People told us they did not know how to make a complaint. We saw documentation related to two complaints, but no information to demonstrate how they had been dealt with, and if any learning had taken place. We have made a recommendation about updating the practice of dealing with complaints.

Overall, we had found the home had not been well led. Standards had dropped since the previous inspection in October 2015. It was not evident the registered manager had monitored the day to day culture or the provision of care throughout the home. Information they had passed to the regional manager regarding the quality of care did not reflect what we found during our inspection. Positive feedback was given to us regarding the skills and knowledge of the interim deputy manager and the regional manager, and we were reassured by their presence in the home. They showed a commitment to improving the standards of care at Chiltern Court Care Home.

We found a number of 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 the report

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We set compliance actions for the provider to improve practice. The provider sent us an action plan which outlined the changes they would make to become compliant.

We returned to the service on 7 January 2015 to check whether improvements had been made. This was after the date the provider told us all actions to improve the service would be completed.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the questions we always ask:

' Is the service safe?

' Is the service effective?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

We found Chiltern Court Care Home provided a safe service.

There were enough staff to meet people's needs. One person said 'They're all good here, I love it.' Another person told us 'They're very good. I've got no concerns.' People said staff came within reasonable times when they called for them. We observed staff were attentive to people's requests for assistance during the course of the inspection.

Recruitment had taken place for nurses and care workers and most of these posts had been filled. This meant the home was less reliant on using agencies to provide staff cover and improved continuity of people's care.

Staff told us training had taken place since our last inspection, to provide them with the skills and knowledge they needed to support people appropriately.

Is the service effective?

We found Chiltern Court Care Home provided an effective service.

People were complimentary about the quality of their meals. We asked eight people what they thought of the lunch time meal. Each person said they had enjoyed it. Comments included 'It's pretty good,' 'Chef does a wonderful job' and 'He makes wonderful puddings.'

People's care plans identified their dietary needs. Management plans had been written where specific needs had been identified, such as diabetes. Each person had been regularly assessed for the risk of malnutrition and they were weighed monthly. We saw action had been taken where there were any concerns about people's weight. For example, referral to the dietitian or GP following weight loss. Any advice was then followed, such as fortifying meals with high calorie ingredients and introducing homemade milk shakes.

Is the service well-led?

We found Chiltern Court Care Home provided a well-led service.

The service had a new manager in post who was applying to become registered with CQC.

We found the service was providing improved standards of care. Monitoring was more effective in identifying areas of good practice and where changes needed to be made.

We saw various audits had taken place since our last visit. These included audits of care plans, medication practice, nutrition and use of bedrails. In each case, an action plan had been put in place where any shortfalls had been identified and when the actions had been achieved. There had also been visits on behalf of the provider by senior managers, to assess the quality of care.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

The provider sent us an action plan which outlined how they intended to become compliant.

We returned to the service on the 11 September 2014 to check if improvements had been made.

Below is a summary of what we found. The summary describes what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

We found improvements had been made to medication practices. We saw the provider had moved the drugs trolleys to a more appropriate room where temperatures did not exceed the required temperature within the provider's policy. We found people's creams and thickeners contained clear instructions and belonged to the person they were prescribed for. This meant people could be sure their medication was used and handled appropriately. We saw care plans now contained clear details of how people were to be supported with their care needs. This indicated people's needs were identified and provided guidance for staff on how the person was to be supported.

This meant the service was safe.

Is the service effective?

We saw the provider had arrangements in place to ensure all staff were trained and supervised properly to enable them to undertake their roles. Staff told us they felt the current management were supportive and approachable. We saw the current peripatetic manager was regularly on both floors throughout the day completing observations and checks. We saw the provider responded to concerns raised about medication. Care plans had now been updated to reflect people's current needs and food and fluid charts were filled in correctly.

This meant the service was effective.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.

Three inspectors carried out this inspection. The focus of the inspection was to respond to concerning information received and answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what people used the service and the staff told us, what we observed and the records we looked at.

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

This is a summary of what we found:

Is the service safe?

We found people were protected against the risk of harm in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards. Where people were assessed as lacking capacity, appropriate procedures were followed to ensure arrangements were in people's best interests and in line with the correct legal framework.

During our visits we found people were placed at risk from unsafe medication practices. We saw frequent gaps in Medication administration record (MAR) charts where medication had not been signed for as administered. We observed one person was given the wrong medication, and another person's medication was missed completely. One person had gone out for the day and staff could not tell us if they had been given their insulin or not. We found creams prescribed for specific people given to people who were not prescribed them. This meant people could not be sure that their medication was administered and handled safely.

We found care plans to not be reflective or people's current needs. For example, we saw people with specific nursing needs did not have specific guidelines or risk assessments around their nursing needs. We saw one person had not been offered a drink orally for 10 days as staff did not know if the person was deemed no longer nil by mouth by the doctor. We found information on changes to people's needs was not communicated and fed back into their care plans.

We saw people and staff were placed at risk as staff members were working without the appropriate training. For example, we found three members of staff had undertaken moving and handling tasks without training. We spoke with one staff member who could not tell us how they would handle an accusation of abuse in line with the provider's policy. They had not received any safeguarding training before working with vulnerable adults. This meant people could not be sure that they were cared for by suitably trained and competent staff.

This meant the service was not safe.

Is the service effective?

We found regular audits were undertaken and highlighted actions where improvements were needed. However, the ineffectiveness of these audits was highlighted during our visits when we raised concerns which the provider was not aware of. We found care plans did not reflect people's current needs and their care was impacted as a result. We found information from GP visits and advice from other healthcare professionals was not fed back to staff. This resulted in one person being being provided a liquidised diet when they could have had a moist soft diet.

This meant the service was not effective.

Is the service caring?

We saw some positive interactions between staff and people who used the service; however we also observed poor practices during lunchtime. Comments from relatives were overall very positive about the home and the staff. We found lack of social stimulation for people who used the service. We saw a high percentage of people stayed in bed and were provided with no social stimulation or interaction. We saw people were left in communal areas for long periods of time with no supervision. We were advised an activities coordinator was being employed and was starting after our first visit. By our third visit, we found no activities had taken place.

This meant the service was not caring.

Is the service responsive?

We found the service was not responsive to people's needs. Information from professionals was not always followed up or shared with staff members. We spoke with one person who told us they wanted more salt for their lunch. The staff member did not understand the person's request and it was not met.

We saw no contingency plans in place for the hot weather during our visits. We found people's creams were exposed to high temperatures with no risk assessment or plan in place. We saw the provider bought fans to help people cool down; however the rooms were still very hot.

The provider did act responsively when we raised concerns around medication practices; however, we had concerns around the effectiveness of staff training and competency checks.

This meant the service was not responsive.

Is the service well-led?

At the time of our visits, the registered manager was not present. We spoke with the regional manager who was covering for the registered manager. They showed us regular quality monitoring visits and action plans where the provider had highlighted areas for improvement, however we found these were ineffective as concerns were raised during our visits which management was not aware of. For example, we found three staff members were working without appropriate moving and handling training, care plans not reflective of people's needs and unsafe medication practices.

This meant the service was not well-led.

We found staff were respectful towards people. We saw people's needs had been assessed, recorded and reviewed regularly. Pressure area care was being managed well. There were systems in place to share information such as staff handover sessions at each shift. These helped ensure continuity of people's care.

Equipment had been provided to help meet the needs of people with disabilities. This had been serviced to ensure it was safe to use. Staff received training in moving and handling to assist people safely and prevent injury.

There were enough staff on duty to meet people's needs. The home had arrangements for obtaining staff at short notice to maintain staffing levels. Thorough recruitment procedures were used to ensure people were cared for by suitable staff.

The home had a procedure for making complaints. We saw people's complaints or concerns were responded to appropriately.