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We undertook an unannounced inspection on 15 October 2015. The inspection continued on the 19 October and this was announced.
The service provides accommodation and nursing care for 61 people but we were told the maximum occupancy is 58 people. On the day of our visit there were 52 older people living in the service. People can have a long term placement or short respite stays at the service. Rooms are single occupancy and over two floors. Each room has a call bell fitted so that people can call for help when needed. Each floor has three groups of bedrooms that share a kitchenette, specialist bathrooms, a lounge and dining room. A room on the first floor is available for when people and their families and friends want some quiet time together. There is a commercial kitchen and laundry.
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.
People told us they felt safe living at the service. We found that staff had a good knowledge of safeguarding and received regular safeguarding training. Safeguarding information was displayed in the reception telling people how to contact the local authority safeguarding team.
We found that risks were not always properly managed. Two of the four people’s records contained risk assessments and plans to reduce the risk of them choking. However, we found these risks were not safely managed. People’s risk in relation to other aspects of care such as moving and handling, skin integrity and falls were assessed and regularly reviewed. Plans were in place to reduce risk and we saw staff following the plans.
Medicines were stored safely and administered by a qualified nurse. Nursing staff told us their medication administration competency is checked annually. One person told us, “I have 11 tablets a day. I always get the right ones. I have a list. They are meticulous about the tablets”.
People and staff told us that there were enough staff on duty. We observed staff were unrushed and call bells were answered promptly. We looked at four staff files. Each file contained evidence that staff were suitable to work with vulnerable people and were eligible to work in the UK.
An individual fire evacuation plan was in place for each person. Staff training records showed us that staff received regular fire drill and evacuation training. We saw maintenance records and certificates showing us equipment was regularly serviced.
People felt that they knew the people caring for them. We saw photographs in peoples’ bedrooms of their named nurse and the care worker who was their keyworker. A care worker told us “We work as a team with the nurses”. One relative said, “Always the same staff when I visit. We feel involved in decisions”.
Newly appointed staff completed the care certificate induction programme. The care certificate is a national induction for people working in health and social care who have not already had relevant training. The service employs a trainer who ensures staff are up to date with training requirements. Nursing staff have regular clinical updates and competencies checked.
We saw evidence on files of mental capacity assessments being completed which included a best interest’s decision being made with families. The Manager and staff were aware of the Deprivation of Liberty safeguards legislation and how to apply it to their practice.
Care records contained risk assessments for malnutrition which were reviewed monthly. When the risk was high the GP and dietician had been contacted and actions taken stabilised the persons weight. Actions included fortifying food with high calories such as extra butter and cream. The kitchen practice was to fortify food for all the people unless they specifically had a low fat diet. Two relatives told us they were concerned about the amount of weight their relative had gained since admission. We discussed with the head chef the potential risk to a person’s health and well-being when being given excessive calories when risk assessments are not indicating a risk of malnutrition. We were told that the menus were currently being reviewed and they would include a review of this practice. We observed lunch being served in the dining room. The food looked appetising, people were supported in a respectful way, assisting one person at a time and encouraging people to be independent. The meal experience was relaxed and people chatted together.
People told us that they could access healthcare whenever they needed. Records showed us that people regularly received visits from health professionals such as dentist, chiropodist and physiotherapists.
We found the home clean and odour free. We observed staff using aprons and gloves appropriately when providing person care. There was a cleaning schedule in place and an up to date clinical waste contract. We observed the correct processes in place to avoid cross contamination when a person had a suspected contagious condition.
After our visit we spoke with a health professional about the quality of end of life care. They told us that the home were proactive in ensuring that anticipatory pain medication was always in place to ensure a person remained comfortable. They said “Very homely, level of care exemplary”.
During our time at the service we observed staff talking and laughing with people, their relatives and friends. We spoke with a person who said “I know the staff by name. They are quite friendly. They always want to help”. We observed care being provided in an unhurried way. A person told us “We have choice here with food, bed times and are allowed our own possessions in our rooms”. Staff understood the importance of respecting people’s wishes. We observed staff respecting people’s privacy and discreetly offering support. Activities were varied, one person told us “There are lots of activities here; card making, christmas pudding making, church services and we made Chinese lanterns for the Chinese new year”. Extra staff hours were available for social care. This was to provide support on a one to one basis for people who chose to stay in their rooms. People told us they were supported to keep in touch with their families and their local communities.
We found that people and their representatives were involved in planning and reviewing care. A nurse told us “Handovers are person centred. People’s needs are constantly being assessed and handed over to each staff team at the start of shifts. A call bell audit showed times calls were taking longer to be answered. Shift patterns had been changed so that additional staff was available to support people during these busy times. This showed us that the service is flexible and responsive to peoples changing needs.
A complaints procedure was displayed on the reception window. It gave details of other agencies people could take their complaint to if not satisfied with the outcome. Some of the information was incorrect. More clarity was needed of the complaints escalation process so that people understand their rights. The manager kept a log of complaints and recorded details of investigations, actions taken and outcomes. People, their visitors and staff all were aware of the complaints process and felt able if needed to make a complaint. Regular resident and relative meetings take place and minutes were displayed in the lounge areas.
The service has achieved the ‘Gold Standard Framework’. It is a model of care that enables good practice to be available to people nearing the end of their lives. The service completes regular audits to see how they have performed against the framework standards. The audits showed us that the service provided responsive care at the end of a persons’ life.
People using the service, visitors, staff and visiting health professionals all told us the service was well managed. We observed nurses and senior care workers visible on the floor supporting care staff. We spoke with a health care professional before our inspection who told us, “The manager is positive, pro-active and keen on staff training”.
Staff received regular supervision. The service has signed up to the ‘Social Care Commitment’. This is a national initiative that employers and employees of the care sector sign up to pledging to improve the quality of care standards. The six key commitments had been used as part of staff personal development through supervision.
The manager carried out regular quality audits. Any identified actions were noted and the outcome recorded. We saw evidence in staff meetings that audit findings were shared with staff to improve quality and learning.
The last CQC report, the local authority contracts monitoring report and results from the services quality survey were on display in reception. This demonstrated that the service had a positive culture that is open and inclusive.
We recommended the service consider how risks to individuals are managed so that they are protected whilst ensuring their freedom and choices are respected.