Archived: Prestbury Court Residential Home

There was no registered manager for 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. An acting manager had been appointed in May 2017 and was in day to day control of the service.

This inspection took place on 18, 22 and 23 August 2017. The first two days of the inspection were unannounced. The service was last inspected in October 2016 when it was rated overall as Good, with the key question ‘Well-led’ being rated as Requires Improvement. Prior to the inspection in October 2016 the service had been inspected in December 2015 when we found significant improvements were needed. At the inspection in October 2016 Improvements had been made. However, at this inspection in August 2017 we found the improvements had not been sustained.

We carried out this inspection because we had received information that three safeguarding alerts had been made to the local authority in August 2017. The concerns had been raised about the care people received at the service. The local authority’s safeguarding team and commissioners were investigating the matters and working together to keep people safe.

The overall rating for this service is ‘Inadequate’ and the service was therefore placed in ‘special measures’ and enforcement action was considered. However, since this inspection the provider has applied to de-register Prestbury Court and asked for support from the local authority to help people move to other care services.. 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.

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.

We found the provider had not taken sufficient action to ensure people received safe and high quality care from well trained and competent staff. The quality monitoring systems were not effective and failed to identify and address the concerns we found at this inspection. The acting manager had been working with the local authority’s Quality Assurance and Improvement Team (QAIT) since May 2017 and a Service Improvement Plan (SIP) had been produced. Some work had been completed on the SIP. However, the report from the visit by QAIT on 2 August 2017 identified a quality assurance system needed to be reinstated, monitored and maintained.

People were not protected from risks to their health and safety. Risks associated with people’s specific health needs were not always identified or acted upon in a way that reflected the urgency of the situation. The gates fitted across some people’s doors were at a low height and there was a risk that people could fall over the gates. Risk assessments did not always contain sufficient detail to help keep people safe. There was no clear care plan or risk assessment to support staff in understanding the needs of people with diabetes or epilepsy.

People were not supported to receive their medicines safely. Staff did not have a full understanding of what people’s medicines were for or when people might need additional medicines, for example for pain relief.

People were not supported by sufficient staff at all times. However, involvement of the local authority’s safeguarding and commissioning teams had reduced the risks associated with this.

People were not supported by staff who received sufficient induction and supervision to ensure they were competent to meet people’s needs. Staff had not received recent relevant training to support people living with dementia, diabetes or epilepsy.

People were not always supported to receive sufficient food and fluids. There were concerns that staff had not made sufficient attempts to encourage one person to eat resulting in significant weight loss. When the weight loss had been identified professional advice had been sought and the person’s weight had increased. Fluid intake was not always recorded to ensure people remained hydrated.

People did not always receive care that was respectful and promoted their independence, privacy and dignity. We heard some staff talking about people in front of other people, breaching their confidentiality. We saw one member of staff assisting two people to eat at the same time, while also supervising other people who were eating independently.

People were placed at risk of not receiving the care and support they required to meet their dementia care needs. Staff did not always address people living with dementia by name when they spoke with them or ensure they made and retained eye contact with them. Care plans did not contain sufficient detail for staff. There were no instructions on what form reassurance should take in order to help people who became anxious due to short term memory problems. Care plans did not identify and plan to meet people’s social care needs. People's records did not always contain up to date and accurate information about the care they received. People did not benefit from an environment that supported those living with dementia.

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

People were supported to receive regular visits from healthcare professionals.

Complaints were well managed. One relative told us they felt able to raise any concerns they may have.

People and their relatives were supported to be involved in planning their care if they wished.

People were protected from the risk of abuse, because staff had a good understanding of how to recognise and report abuse. There were robust recruitment procedures in place.

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 this 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.

Prestbury Court Residential home is a care home without nursing providing care and accommodation for up to 48 people. People living at the home were older people, some of whom were living with significant dementia or long term health conditions. Some people were at the home for short term respite care. At the time of the inspection there were 35 people living at the home.

On the 25 and 27 March 2015 the Care Quality Commission (CQC) had inspected Prestbury Court Residential Home and identified concerns about the safety and well-being of people. On 8 and 9 December 2015 we returned to the home to see what had improved. We identified the concerns from March 2015 had not all been addressed and there were additional concerns over the management of the home. We identified breaches of Regulations12 (Safe care and treatment), 18 (Staffing), 9 (Person centred care), 11 (Need for consent) and 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014. We served warning notices on the provider and then registered manager for breaches of Regulations 11 and 17 of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014.

In December 2015 the home was involved in a series of complex safeguarding concerns with the local authority safeguarding team and the local authority was no longer supporting admissions to the home. The local authority quality team were supporting the service with a service improvement plan.

Following our inspection in December 2015 the home was rated as inadequate overall and placed in ‘special measures’. Services in special measures are 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 of the publication of the last report. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Following the inspection the provider told us what changes they intended to make. We received regular information on progress being made from the home’s management, through the safeguarding processes and from the local authority team.

During this inspection of 4 October 2016 we found that significant improvements had been made. Improvements were seen across all areas inspected, and the warning notices had been complied with. The home had managed to complete the action plans for the local authority, who were satisfied with the improvements made, and there were no open safeguarding concerns. People told us the changes at the home had been a “remarkable turnaround” and that it was like a ‘different home’ to visit. However as some of the changes made have been recent and we do not have a clear track record to show they have been sustained long term we have rated the key question for well led, previously rated as ‘inadequate’ as ‘requires improvement’ at this time. This will be reviewed at the next inspection.

The home is no longer in ‘special measures’.

Since the last inspection on 8 and 9 December 2015 the then registered manager had left the home. There was not a registered manager in post at the time of this inspection, however a new experienced manager had been employed and they had made application to CQC to be registered. 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. They are referred to throughout this report as the manager.

People living at Prestbury Court Residential Home received good quality, safe care. This was because systems were in place to ensure the quality and safety of services at the home. Since the last inspection there had been changes to strengthen the governance and leadership at the home. There was increased management oversight and clear systems for communication amongst the management team and with the staff. Action plans had been met and new targets set to continue the development of the home. The new manager and operations manager were enthusiastic and positive about the changes being made and potential for future development. People benefitted because the registered manager took advantage of learning resources to improve the services provided.

People’s rights under the Mental Capacity Act 2005 were being respected. Assessments had been made of people’s capacity where this was in doubt and decisions made in people’s best interests involved appropriate people to support the person’s wishes where these were known. Applications had been appropriately made for authorisations of Deprivation of Liberty Safeguards.

People received safe care because risks to their health and well-being were regularly assessed, and risks reduced wherever possible. Learning took place to reduce the risk of re-occurrences of incidents and accidents, and new systems in place helped ensure staff had clear pathways and guidance to follow when assessing incidents and knowing when they needed to be escalated.

People were protected from the risks of abuse because staff understood how to keep people safe, and through the provision of policies, procedures and staff training. The operations manager and manager had established open working relationships with agencies responsible for safeguarding people and had made all required notifications to the CQC. This helped to ensure that any concerns were properly investigated and addressed.

People received their medicines safely and as they had been prescribed. Safe systems had been put into place to ensure people received the correct medicines at the correct time, and that they had been stored securely. Clear protocols ensured staff understood when “as required” medicines were to be given. This included information for staff on how to assess people who may not be able to communicate verbally may benefit from medicines, for example pain relief.

People’s needs were met because there were enough staff on duty to support them. People were protected because a full and safe recruitment process had been followed for staff. People received good quality, safe care because staff received sufficient training and support to carry out their role. Staff were seen supporting people well; they were calm and confident when supporting an individual who had a sudden healthcare deterioration during the inspection, ensuring the person’s dignity was respected at all times. Staffing tools were used to assess the staffing levels at the home which were completed each week to identify where additional staff were needed.

People lived in an environment that was clean and well maintained. Infection control practices were well understood. Regular checks were carried out to make sure the home environment was safe. For example a recent fire inspection had indicated that changes needed to be made to some fire doors. This was being carried out at the time of the inspection. The environment at Prestbury Court was being further adapted to meet the needs of people living with dementia, with additional signage to help people find their way around.

People’s healthcare needs were supported and they had rapid access to medical and community healthcare support. Some people were living with dementia. We saw that the home obtained professional support and guidance from community psychiatric nurses to support people with distressed or risky behaviours. People’s nutritional needs were assessed to make sure they received a diet that met their needs and wishes. People told us they enjoyed the food. Choices were available and we saw people being given additional portions, cooked breakfasts and multiple desserts if they wished.

People were supported by staff who demonstrated a warm, respectful and caring approach. We saw staff supporting people well, addressing them respectfully and in ways that supported their communication where this had been affected by ill health or living with dementia. People’s care was delivered in private and their confidentiality was respected.

People received the care they needed and wanted. Good clear well maintained records ensured staff had the information they needed to support people and meet their needs. Care planning was individualised and people’s goals and wishes regarding their care were taken into account by staff. People living at the home were supported to follow their chosen lifestyle and take part in activities if they wished. Some people chose not to do so, and we identified one person who wanted more interaction on a one to one basis. We discussed this with the manager. Activities and stimulation were supported for people living with dementia, and the manager was looking further into targeting them at specific times of the day when people would benefit from additional distraction and occupation.

People could be confident that any concerns or complaints they had would be listened to and addressed. People told us they would be happy to raise any concerns with the manager, that they were approachable and would make any changes needed.

People and their relatives were consulted about their views on how the service could be improved, and kept informed about developments at the home. Questionnaires were being prepared to send out to staff, people living at the home, relatives and others to gather feedback about the home. Meetings had been held with relatives to explain the changes going on and the manager told us their door was “always open” if anyone had suggestions for improvements.

A single inspector carried out this inspection. The focus of the inspection was to 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 using the service, their relatives 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?

People who live at the home told us they were well looked after and were happy. One person we spoke with said "Everything here is fine'. Another person confirmed that living at the home was 'Lovely, I love living here'. Another person confirmed that they were "well cared for".

People had been protected against the risks associated with medicines because the provider had appropriate arrangements in place to safely manage medicines.

Recruitment practice was safe and thorough.

Policies and procedures were in place to make sure that unsafe practice had been identified and people were protected. Systems were in place to make sure that the manager and care staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

CQC monitors the operation of the Deprivation of Liberty safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made and how to submit one.

Is the service effective?

We found that people's consent had been obtained for care and treatment provided to them by the service. However this had not been consistently recorded when people had received treatment or when care plans had been reviewed.

People's health and care needs had been assessed with them or their representative, and those who wished to, and had been able to, had been involved in writing their plans of care.

Is the service caring?

We spoke with eight people who live at Prestbury Court. We asked them for their opinions about the staff that supported them. Feedback from people was positive, for example; "They are all lovely and all work so hard".

When speaking with and observing care staff during this inspection it was clear that they genuinely cared for the people they supported. They told us about people's individual health and social care needs and how these needs had been met in an individual way.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

We spoke with eight people who live at Prestbury Court. People we spoke with were satisfied with the care and support they received. We saw from records that planned care and treatment had been provided in line with people's individual care plans. Aspects of people's needs or care had been linked to risk assessments. Specialist health needs had been identified where required and appropriate health care professionals had been consulted and involved in providing care.

Is the service well-led?

The service had a quality assurance system, and records showed that identified problems and opportunities to change things for the better had been addressed promptly. As a result the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

People who live at the home had been asked to complete a satisfaction survey in May 2014. The manager, who was registered with the Care Quality Commission on the 11th June 2014, told us where shortfalls or concerns were raised these would be taken on board and responded to appropriately.

We observed that people appeared at ease and comfortable around care workers. People were treated with dignity and respect. They had opportunities to be involved in and shape their own care. Where people did not have the capacity to make decisions for themselves their rights were protected. People told us they felt safe and we found that the provider had systems in place to protect people from the risk of abuse. People told us the service was good. Comments included, "It's warm, great food, and the staff are fine."

We found that staff were well supported and had completed appropriate training. They knew people as individuals and were aware of each person's needs. They were assisted by care plans which contained clear assessments of needs and the strategies to meet those needs. Care records were reviewed and updated regularly. The service had good relations with health care professionals and acted upon their advice.

Systems were in place to monitor the quality of the service. We found that the provider was responsive when issues were raised and lessons were learnt from incidents.