The Warren

This unannounced inspection was carried out on 18 June 2018.

At the time of the inspection there was not a registered manager in place. However, a new manager had been appointed and planned to apply to become registered with the Commission when they commenced working in the home. 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 last inspection in February 2017 the service was rated requires improvement. We asked the provider to make improvements to reducing risks to people, safe administration of medicines, ensuring people receive the support they required in a timely manner. We also asked them to ensure that there was effective monitoring of the quality of the service being provided.

At this inspection we found the provider had made the required improvements and the service is now rated as Good.

Staff were aware of how to keep people safe from harm and what procedures they should follow to report any harm. Action had been taken to minimise the risks to people. Risk assessments identified hazards and provided staff with the information they needed to reduce risks where possible.

Medicines were managed safely. Staff received training and competency checks before administering medicines unsupervised. Medicines were stored securely. The records were an accurate reflection of medicines people had received.

Care plans gave staff the information they required to meet people’s basic care and support needs. People received support in the way that they preferred and met their individual needs.

There was an effective quality assurance process in place which included obtaining the views of people that lived in the home, their relatives and the staff. Where needed action had been taken to make improvements to the service being offered.

Staff were only employed after they had completed a thorough recruitment procedure. Staff received the training they required to meet people's needs and were supported in their roles.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice and worked within the guidance of the Mental Capacity Act 2005.

Staff were motivated to provide care that was kind and compassionate. They knew people well and were aware of their history, preferences, likes and dislikes. People's privacy and dignity were respected.

People were supported to maintain good health as staff had the knowledge and skills to support them. There was prompt access to external healthcare professionals when needed.

People were provided with a choice of food and drink that they enjoyed. When needed staff supported people to eat and drink.

There was a varied programme of activities including activities held in the service, trips out and entertainers that came into the home.

There was a complaints procedure in place. People and their relatives felt confident to raise any concerns either with the staff or manager.

The Warren provides residential care for up to 44 older people, some of whom may be living with dementia. The home is purpose built and accommodation is on one floor. Communal areas include a number of lounges, a dining room, a conservatory and a hairdressing salon. The home has access to garden areas. At the time of our inspection there were 41 people living within the home.

There was a registered manager in post. 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 previous inspection carried out in January 2016, the home had been rated as good. At this inspection, completed in February 2017, we identified a number of issues that resulted in three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to staffing levels, the management of risks and medicines and the governance of the home. You can see what action we told the provider to take at the back of the full version of this report.

We have also made a recommendation to the service in relation to their compliance with the MCA.

There were not enough staff to meet people’s needs in a timely and individual manner. People told us that they did not consistently receive support in an appropriate time and were sometimes left waiting. Staff agreed there were not enough staff to meet people’s needs.

Whilst staff knew people’s needs, they did not have time to meet these in a person centred way. People’s preferences were not always met. Care plans lacked guidance for staff to meet people’s needs in a safe and individual manner. They did not always contain accurate and up to date information or reflect people’s current needs. Care plans did not demonstrate that people had been involved in the planning or regular review of their care needs. People’s dignity was not consistently maintained and their privacy was compromised at times.

The risks to people had not always been managed in a way that fully protected them. Where risks had been identified, appropriate control measures had not been consistently applied. The risk to the environment and those associated with adverse events had been identified but required review. Regular maintenance and serving of the building and equipment had taken place.

The service had a comprehensive quality monitoring system in place but this had been ineffective at driving timely improvement. Whilst most of the issues highlighted in this report had been identified by the service, actions had failed to rectify them in good time and were still evident. The registered manager did not have a full overview of the service and the needs of the people who used the service.

Staff morale was low and staff told us that they did not feel supported or appreciated by the manager or provider. They told us this was due to being short staffed and that they felt their concerns were not listened to.

Most people told us that they had confidence that any concerns they may have would be addressed by the service. However, one relative had had a negative experience in relation to the concerns they had raised and the service had taken some months to respond.

The service was in the process of recruiting additional staff to fill vacancies. Recruitment processes were in place to help reduce the risk of employing staff not suitable to work in the home. New staff received an induction and ongoing training and did not begin work till appropriate checks had been carried out.

Processes were in place to help reduce the risk of people experiencing abuse. Staff had received training in how to prevent, protect, identify and report potential abuse and knew where to go to report any concerns they may have. Accidents and incidents were recorded and a clinical governance system ensured that an overview and analysis of these was in place to help mitigate future risk.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. People’s human rights had not been compromised but the service had not consistently worked within the principles of the Act. Staff were able to demonstrate that they assisted people to make choices and that they gained consent before providing support. However, documentation around the recording of people’s capacity did not demonstrate adherence to the MCA.

People’s nutritional and healthcare needs were met. People received enough to eat and drink and had a choice. They told us they enjoyed the food provided. The service had assisted people to access a wide variety of healthcare professionals to aid health and wellbeing.

Independence was encouraged and people told us that the service was good at promoting this. Confidentiality was maintained and people told us that most staff demonstrated a kind and respectful approach. People enjoyed and appreciated the varied and regular activities the service assisted them with.

The service regularly and actively encouraged people’s views on the service. People thought the service strived for improvement and would recommend the service. However, they told us that some improvements were required in relation to staffing levels, staff retention and call bell response times.

This inspection took place on 13 and 18 January 2016 and was unannounced. At the last inspection on 14 January 2014 the service was meeting the legal requirements.

The Warren is a service that provides accommodation for up to 44 people. It offers residential care and support for older people, some of whom may be living with dementia. On the day of our inspection 39 people were living in the service.

The service had a registered manager in post. 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 living in the service were safe. However, there were times when there were insufficient numbers of staff available to meet people’s needs in a timely way. Staff and the management team understood their responsibilities in safeguarding people from harm. Identified risks to people’s safety were recorded on an individual basis and there was guidance for staff to be able to know how to support people safely and effectively.

Appropriate recruitment procedures were followed and pre-employment checks were carried out to ensure staff were suitable to work with people receiving care and support. There were occasions when staffing levels were lower than the provider had identified as being required. However people’s needs continued to be met and staff provided good support to people.

Medicines were managed and administered safely in the home and people received their medicines as the prescriber had intended.

Staff were skilled and motivated to support and care for people. Staff also knew people and their needs well. New members of staff completed an induction and all staff received appropriate training and were supported well by the manager.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack the mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The service was working within the principles of the MCA.

People had enough to eat and drink and the cooks provided good quality food and catered for individual preferences. The cooks and all staff tried to make mealtimes a pleasure rather than a necessity and these occasions were treated as a special event.

People had regular access to healthcare professionals and were supported to attend appointments if needed.

All staff at the service were caring and supportive and treated people as individuals. The care provided was sensitive and person centred and people’s privacy, dignity and wishes were consistently respected. Friends and relatives were welcome to visit as and when they wished and people were supported to be as independent as possible.

People were happy living in The Warren and their interests and hobbies were encouraged by staff. There was a positive atmosphere in the service and people had access to the community if this was important to them. Assessments were completed prior to people moving into the home, to ensure their placement would be appropriate for them and would meet their needs. People were also involved in planning their care.

There was an open and positive culture at The Warren. People using the service and their relatives were given opportunities to raise issues about the quality of the care provided and knew how to make a complaint if needed. People’s comments were listened to, with appropriate responses and action was taken where possible.

The service was being well run and people’s needs were being met appropriately. The manager was approachable and communication between the manager and staff was frequent and effective.

There were a number of systems in place to ensure the quality of the service was regularly monitored and maintained. The manager carried out regular audits to identify and take action on any areas that needed improvement.

The people we spoke with all said that they were involved in making decisions about how they wished to be cared for and supported. This was reflected in people's care plans. We noted that people were involved in reviewing their needs on an ongoing basis.

Care plans were detailed and accurate. People had risk assessments which were appropriate to their needs.

There were different activities for people to join in with on a daily basis. The people we spoke with all said how much they enjoyed these. One person said, 'There's always plenty to do and join in with. I have been doing a word game this morning which was good fun'.

The premises of The Warren were safe and suitable for the people who lived there. We noted that appropriate adaptations had been made for people with mobility problems.

We saw that there were enough suitably trained and experienced staff to meet the needs of the people who used the service. The people we spoke with all felt that there were enough care staff and that they were attended to in a timely manner.

The staff we spoke with said that they felt well supported. There was an effective training and education schedule in place for staff. This included staff induction, mandatory and specialist training. Some staff had not received their supervisions or appraisal. The manager told us that this was being addressed.

The service had various methods that were used to ensure the quality of the service was monitored and audited. Meetings, reviews and management audits were in place and records were available.

On 28 March 2013 we visited the service to check that they had complied with the warning notices. We found that they had.

Following our concerns about the maintenance of accurate records, we found that care plans had been reviewed and new assessments had taken place where this was applicable. We saw that in all of the plans monthly monitoring of people's needs had taken place. This included assessments for a person's risk of developing a pressure sore, or suffering from a fall. We also saw that weight monitoring had been taking place on monthly basis since January 2013.

During our inspection in January 2013 we also identified concerns with regard to the lack of training available to staff employed at this service. Training was not being provided to enable staff to care for people who had specific needs associated with dementia. Again, during this inspection, we found that improvements had been made. We saw that a variety of training had been provided. The four members of staff who we spoke with confirmed that they found the training provided enhanced the way in which they were now able to care for the people living at The Warren.

However, we received mixed feedback from the people using this service. All of the people agreed that staff maintained their dignity with one person commenting 'I am always made to feel comfortable'. Other positive comments received included 'You get the attention you need' and 'I get support when I want, how I want and when I want'.

However, other comments received indicated that there was not always enough staff to deal with people's needs. One person said that they would like more support from the carers and commented that they felt the service was, 'Mediocre'.

People were provided with a choice of suitable and nutritious food and drink. During our inspection we noted that the daily menu was on display throughout the home. We saw that there was a choice of main meals and desserts.

There were appropriate systems in place to deal with medicines.

Whilst appropriate recruitment procedures were in place, we found that staff were not appropriately trained to meet the needs of the people they were caring for.

We also found that errors and omissions in record keeping put people living at the Warren at risk of receiving inappropriate care or support.