This inspection took place on 05, 06 and 08 of December 2016 and was unannounced on the first day. We last inspected Bowerfield House on 19 and 22 October 2015 when we rated the service as requires improvement overall and identified breaches of three regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found sufficient improvements had not been made and the service remained in breach of the regulations. Since our last inspection we had received a number of concerns that related to areas including sufficient staffing, staff turnover, activities and management of the home. We identified breaches of seven of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which were in relation to person centred care, dignity and respect, need for consent, safe care and treatment, meeting nutritional and hydration needs, good governance and staffing. We made one recommendation, which was in relation to how the provider handles informal complaints.
Due to the concerns we identified during our inspection, we wrote to the provider and requested they take a number of voluntary actions. This included ensuring all care plans and risk assessments be reviewed by the end of January 2017, reviewing staffing levels, assessing staff competence, keeping CQC informed about the recruitment of a suitable deputy and sending CQC an action plan. The provider agreed to take these actions. We requested the provider sends us evidence of these completed actions, and will review this to inform our decision making as to whether any formal enforcement action is required. We will update the section at the end of this report once any enforcement action has concluded.
Because of our concerns, we also raised a number of safeguarding alerts with the local authority. These were not progressed formally under safeguarding, but were passed to the local authority’s quality assurance department to follow-up.
Bowerfield House is a purpose built care home owned and operated by Maria Mallaband Group. The home provides nursing and personal care for up to 26 older people living with dementia. It is a two storey building situated adjacent to a larger sister building on the same site. All bedrooms are single occupancy and some have en-suite facilities. There is a passenger lift providing access to the first floor, an enclosed garden area to the rear of the building and car parking is available within the grounds. At the time of our inspection there were 23 people living at the home.
We found medicines were not being kept safely, which presented a risk to people living at the home. On our arrival at the home we found a large quantity of medicines received from the pharmacy had been kept in the conservatory area of the home, which was accessible to people living at the home. We also observed one occasion when the medicines trolley was left open and unsupervised in the clinic room. Entry to this room was restricted only by a door guard that some people living at the home may have been able to release. We also found thickening agent was kept in an unlocked cupboard in the ground floor lounge/dining area, which presented a risk of asphyxiation if people inadvertently consumed this.
Staff had not regularly reviewed risk assessments in relation to areas including malnutrition, falls, and pressure sores. This meant the provider could not be certain that appropriate measures were in place to reduce such risks. We also found staff were not following guidance in one person’s care plan in relation to reducing their potential risk of choking.
Numbers of staff providing direct care and support to people had not increased since our last inspection, despite the interim manager at that time recognising that staffing levels at particular times of the day required review. The provider had started using a dependency tool, which indicated there were sufficient numbers of staff. However, this tool did not consider factors such as the layout of the building, or the times of the day when additional staff support might be required. We observed that people did not always receive the support they needed in a timely manner, including support to get up in the morning, use the toilet, and to eat and drink. Staff and relatives expressed concerns that staffing levels did not always allow for sufficient supervision of people who may be at risk of falls.
We observed that people who required encouragement or prompting to eat and drink did not always receive the support they required as staff were engaged supporting people on a one to one basis or providing other care to people who required two staff to support them. On one occasion we observed two people had been sleeping with their meals in front of them uneaten, which were then removed by staff with no apparent encouragement or prompting provided for them to eat and drink. The provider changed the process for mid-day meals during the inspection to provide two sittings, which meant additional staff were available to provide support. However, we found there were on-going issues around the provision of support at breakfast and in the evening.
Care plans, including a care plan for a person receiving end of life care had not been regularly reviewed, and were not always reflective of peoples’ current support needs. The provider was in the process of carrying out comprehensive reviews of the care plans that had been completed for two people. However, this meant other care plans had not been regularly reviewed, which meant there was a risk care would not be planned to meet individuals’ needs and preferences.
We observed staff interactions with people living at the home were caring, patient, and empathetic. However, due to pressures on staff members’ time, interactions were often task based. Other than a pantomime on the first day of the inspection, we did not observe any attempts by staff to engage people in activities or other stimulation.
Systems and processes in the home were not always effective at ensuring people were treated with dignity and respect. We found one person was left for at least one hour without access to a call bell with their finished meal in front of them and wearing a clothing protector. We were informed by relatives that another person had been left without a duvet on their bed overnight as this had been taken to the laundry and not returned. Another relative told us that despite improvements in the laundry service, they would still find their family member wearing other peoples’ clothes.
Since our last inspection staff had started to receive regular supervision, and we saw training was carried out in a range of areas including safeguarding, moving and handling and infection control. The registered manager had identified areas where additional training was required, and had taken steps to ensure training that met specific learning needs was provided.
Relatives told us there had been a large turnover of staff, and this was also reflected in the information shared with us by the provider. Although relatives felt longer-term staff knew their family members well, it was felt that the regular use of agency staff and the turnover of staff had effected the consistency of care provided, as well as effective communication within the home.
Since our last inspection a registered manager had been appointed who was responsible for the management of Bowerfield House and the neighbouring care home, Bowerfield Court. 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.
Staff and relatives were positive about the registered manager’s management of the home. They told us the registered manager appeared to be working very hard to try to improve the home. We received mixed reports about effective communication between relatives and staff at the home. Whilst some relatives were confident to approach staff or the registered manager, other relatives told us due to the registered manager managing two homes they felt they were not always accessible.
Record keeping at the home was poor. We found gaps in records of care provided and records, including records of food and fluid intake were not always updated in a timely manner. Record keeping in relation to wound care was poor, and although there was no evidence of actual harm as a result of this, we found staff were not clear about the care needs of one person with a wound.
There were systems and processes in place to help the registered manager and provider monitor and improve the quality and safety of the service, but these had not always been completed consistently and had not been effective at addressing identified concerns in a timely way. For example, we saw issues in relation to meal-time support had been identified in audits by both the registered manager and provider, and this issue had also been discussed at a relatives meeting. However, we found no effective actions had been taken to address this area of concern at the time of our inspection.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. 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 be