Enstone House

Enstone House is residential care home providing personal and nursing care to up to 36 people in an adapted building. The service provides support to older people, some of whom live with dementia. At the time of our inspection there were 26 people using the service.

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

Medicines were not always effectively managed, and the auditing system did not always cover all areas of medicine safety such as stock control, storage and safe disposal. We found there were gaps on medicine administration records (MARs), and we were not assured people received their medicines as prescribed.

Risks to people's safety and well-being were not always managed safely and there was an inconsistent approach to the risk management process. We found 2 broken window restrictors and an electrical heater which had not been risk assessed.

The environment was not always maintained to good standards. On the first day of the inspection there were malodours in the home. There were no clear cleaning schedules and there were gaps on cleaning records. The provider’s auditing systems had identified the shortfalls but there were no actions completed in relation to this.

Some people’s records contained conflicting information. The provider’s quality assurance systems were not always effective or used to drive improvements. We also found there was no clear provider oversight of the service.

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. Staff had a good understanding of when the principles of the Mental Capacity Act should be applied. However, the mental capacity assessments did not cover all areas where decisions needed to be assessed.

People’s needs were assessed before they came to live at Enstone House to ensure staff could meet those needs. People were supported to have a positive dining experience in a dignified manner.

Staff completed an induction which included mandatory training and shadowing an experienced member of staff and had access to supervisions and appraisals. People and relatives told us staff were skilled and knowledgeable.

The home was well-led by a long-standing registered manager who had support from a deputy manager. There was a management structure in place and a group of staff who worked well as a team. Staff worked well with external social and health care professionals.

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 11 June 2021). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

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.

We carried out an unannounced comprehensive inspection of this service on 11 May 2021 and rated the service requires improvement. We undertook this focused inspection to check they had made improvements. This report only covers our findings in relation to the Key Questions Safe, Effective 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 has remained 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 Enstone House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified 2 breaches in relation to risk management, records keeping and auditing systems at this inspection. 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Enstone House is a residential care home registered to provide accommodation and personal care to older people some of whom may be living with dementia. The service can accommodate up to 36 people and there were 15 people living at the service at the time of the inspection.

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

People were safe at the service and benefitted from a sufficient number of consistent and safely recruited staff. People were supported to have their medicines safely and as prescribed. Risks to people's individual conditions had been assessed and known to staff.

Staff followed good practice around infection control and had access to protective personal equipment (PPE). People were safe from risks surrounding the environmental, including fire and water safety.

Staff supported people with meeting their nutrition and health needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the records surrounding assessments of people’s capacity needed improving but this had no adverse impact of the care people received.

There was an improved, caring culture at the service that emphasized staff using appropriate language and ensuring people received dignified support. People’s confidentiality and privacy were respected. Staff told us the team worked better and throughout the day we observed a positive and a warm atmosphere.

The management team had introduced a number of governance systems since our last inspection. These systems needed embedding and to ensure they were fully effective.

There was a long-standing registered manager who was now supported by a deputy manager. The staff reported the teamwork had improved and staff told us they were listened to and supported. The management team praised the team for their hard work throughout the pandemic.

Staff worked with various external professionals to ensure people had access to health care services. An external professional complimented the improving standards at the service.

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 13 April 2020) and there were multiple breaches of regulation. The provider was found to be in breach of the following regulations: Regulation 9 HSCA RA Regulations 2014 (Person centred care), Regulation 10 HSCA RA Regulations 2014 (Dignity and respect), Regulation 11 HSCA RA Regulations 2014 (Need for consent), Regulation 12 HSCA RA Regulations 2014 (Safe care and treatment) and Regulation 17 HSCA RA Regulations 2014 (Good Governance). As a result, we issued the provider with five requirement notices.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations. Some aspects of the care documentation needed further improving and the quality assurance systems needed embedding.

Why we inspected:

This was our scheduled, planned inspection based on previous rating.

Follow up:

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

More information is in detailed findings below.

Enstone House is a residential care home registered to provide accommodation and personal care to up to 36 older people living with dementia. There were 31 people living at the service at the time of the inspection.

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

People did not always receive care that was personalised to them. Where people had support with personal care it was planned to be delivered in an institutionalised, regimented and a structured way.

People did not always receive care in a dignified manner. We observed staff using inappropriate and undignified language when speaking with people and in people's care plans. Staff reported being tired, overworked and told us as a result, they were “snappy” with people.

People were not always protected from risks surrounding the environment. We observed cleanliness and malodour concerns at the service and found people were not always protected from risks surrounding the environment.

People commented there was the lack of activities of their choice, there was no evidence activities provision planned considered people’s life history and individual wishes. Staff had poor understanding of dementia including how to manage people’s distressed behaviours. A staff member referred to people’s behaviour that may challenge as “violence”. This was derogatory and labelling.

People were not supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

The registered manager reported safeguarding concerns where required. However, staff were not always aware of the importance to follow the provider’s safeguarding policy. Where risks to people had been assessed the guidance on how to manage these risks was not always current and did not reflect where people's needs had changed. There was no evidence accidents had been audited for trends and patterns, to prevent reoccurrence and establish lesson learnt.

The systems to monitor and improve the quality of the service deteriorated further. Where a feedback from satisfaction surveys had been gathered or an area for improvement identified, these had not been actioned effectively. There was no evidence of the provider’s overview of the quality of the service at Enstone House.

Staff reported they were not valued and there were low staff morale. Comments from external professionals reflected staff were kind but the environment and the management were poor.

People’s dietary needs were assessed, and people were encouraged to eat well. and meet their healthcare needs. People had their medicines as prescribed.

People’s privacy was respected, and people’s relatives were positive about the care at the service.

Rating at last inspection and update:

The last rating for this service was requires improvement (published 23 March 2019). At this inspection we found not only no improvement had been made, but we found further concerns and the provider was found in breach of regulations.

Why we inspected:

This was our scheduled, planned inspection based on previous rating.

Enforcement

We have identified five breaches in relation to the management and governance of the service, dignity, safety, person-centred care and need for consent. You can see what action we have asked the provider to take at the end of this full 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.

More information is in detailed findings below.

Enstone House is a residential care home. People in care homes receive accommodation and personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The service can provide accommodation and care to 36 people. At the time of the inspection 32 people lived there.

People’s experience of using this service:

People received safe care and treatment. There was sufficient staffing to keep people safe. People received their medicines safely and as prescribed. Risks to people’s individual conditions and well-being were assessed, recorded and updated when needed. The registered manager reflected on where things could be improved to benefit the service operations and people.

People’s needs were assessed to ensure people’s care was delivered in line with their care plans. People were cared for by staff that received relevant training and told us they were well supported. People told us and we observed people’s rights to make own decisions were respected. We however found the documentation around decision making needed improving. We identified for example, Deprivation of Liberty applications were made for people who were not being deprived of their liberty. People were encouraged to maintain good diet and access health services as required.

People continued to be cared for by caring and kind staff. People complimented staff and the positive caring relationships they had with the staff. We identified staff did not always refer to people in a dignified way as a labelling comment made by staff could be interpreted as belittling. The registered manager reassured us this was not intentionally derogatory and that they were going to address it with the team. Privacy, including people’s diverse needs and individual communication needs were respected.

People’s care plans gave details of how people liked to be supported. The staff knew people’s needs well and how to best support them. We however found people’s support was not always delivered in an appropriate manner. The feedback received from people, relative and professionals as well as the records demonstrated people did not always received meaningful activities in line with their choices, preferences and assessed needs. People knew how to make a complain but told us they never needed to and there was a system to record any complaints received. No people received end of life care at the time of our inspection.

There was a registered manager in post and a clear staffing structure. We found the quality assurance processes were not always effective as did not identify concerns we found during our inspection visit. People, staff and relatives were involved and told us they felt listened to. The team at Enstone House worked well in partnership with other agencies and the local social and health professionals.

Rating at last inspection:

Good (report published 26 July 2016).

Why we inspected:

This was our scheduled, planned inspection based on previous rating.

Follow up:

We will monitor all intelligence received about the service to inform the assessment of the risk profile of the service and to ensure the next planned inspection is scheduled accordingly.

More information is in Detailed Findings below.

There was a registered manager in post at the service. 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 our last inspection on 12 May 2015 we found that not all relevant checks had been completed for one individual before they worked unsupervised and there was no risk assessment for this staff member in place. This was a breach of Regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found the registered manager had no system in place to audit incidents which would enable them to identify trends or concerns across the service. We also identified there was no evidence of the actions which had been taken following the satisfaction survey. Additionally there were no audits of medicines, care plans or other measures of how the registered manager or provider monitored the quality of the care people received. This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection we found the provider had addressed the above concerns. We saw the risk assessments for staff had been put in place where required. The registered manager ensured the safe recruitment practices were followed. We noted accident and incident recording procedures were in place and appropriate action had been taken where necessary. A number of audits was introduced and carried out regularly. This included care plan audits, medication audits, monthly house audit and a cleaning audit. We noted a responsive action was taken if required. The registered manager also ensured any action arising from satisfaction surveys were followed up promptly.

People and their relatives told us they had no concerns about people’s safety at the home. There were safeguarding procedures in place and staff received training on safeguarding vulnerable people. Staff had the skills and knowledge to recognise and respond to any safeguarding concerns.

Risks to people were identified and managed well. A range of detailed risk assessments were in place and identified how to manage the risk of injury or harm to people during the provision of support.

Medicines were administered in line with safe practice. Staff who assisted people with their medicines received appropriate training to enable them to do so safely. People were supported to maintain a balanced diet. People were also supported to access health care professionals when required.

We found there were sufficient staffing levels to meet people's needs effectively. The staff team worked well together and were committed to ensure people were kept safe and their needs were met appropriately.

There was an on-going training programme to ensure staff had the skills required to carry out their roles. Staff received appropriate support through induction and supervision. Staff told us they felt able to speak with the management team or senior staff at any time.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and report on what we find. Staff and the registered manager understood the MCA and DoLS and the provider followed the legal requirements.

People were cared for by caring and compassionate staff that knew them well. The staff treated people with dignity and respect. People were encouraged to be involved in decisions about their care. There were a range of activities on offer for people to participate if they chose to do so.

People had care plans in place that documented their needs and preferences for how they wished to be supported. These were reviewed and took into account any changes in people's needs over time. The provider had a system in place that ensured they listened and learned from people's feedback and complaints. People and their relatives told us they knew how to complain and felt their concerns were addressed promptly.

People told us they were happy at the home. One person told us, 'I can't complain. I'm looked after. We have a bit of humour with the staff. The manager is very good'. Another person told us, 'they look after me, it's nice here'. While one person told us, 'I like it here, it's very nice. I like the carer's, it's alright'.

Audits were conducted on peoples' medication on a monthly basis by the deputy manager and the home's pharmacist conduct a yearly audit of medications. This meant that peoples' medications were stored securely and appropriate systems were in place to ensure medications were kept safe.

People who used the service felt that staff were knowledgeable and received appropriate training. One person told us 'staff are lovely, they know what assistance I need'. One told us, 'Staff are very good. If you want something, they'll help. They give as much time as they can'.

The provider conducted care reviews every three months with people and their representatives. These reviews showed that the provider took into consideration peoples' and their representatives views. We saw one person's family member attended their relative's review, which was arranged at their convenience.

We observed that staff respected and involved people. Some people's needs were not accurately assessed and reflected in their individual care plans. Staff in the home had received adequate training on safeguarding vulnerable adults. They were aware of how to respond and what to do if there were concerns about a person's safety. We saw staff co-operated with each other and worked together. The provider assessed and monitored the quality of care provided.