Archived: Saltshouse Haven Care Home

The service had a registered manager in post as required by a condition of their registration. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Saltshouse Haven had a full comprehensive inspection in September 2015 and concerns were found regarding how people received person-centred care, dignity and respect, safe care and treatment, managing complaints, good governance, staffing and obtaining consent. We issued warning notices for staffing and consent and requirement notices for the other concerns. The service was rated as Inadequate and placed into special measures, which meant we were to follow up with another inspection within six months. A full comprehensive inspection to follow up the requirement notices and warning notices was completed in February 2016 and we found significant improvements had been made. The service was removed from special measures and rated as Requires Improvement. Although compliant with the requirement notices and warning notices at the February 2016 inspection, we wanted to make sure the improvements were sustained and we planned to return and inspect the service again within 12 months.

Findings specific to Coniston lodge:

Due to concerns raised by health professionals we inspected Coniston lodge 11 and 26 August 2016. As a result of findings, we decided to take urgent action and liaised with the local authority and Hull Clinical Commissioning Group to ensure the people who lived on Coniston lodge were found alternative placements at other services for their nursing care. The registered provider’s representative was informed of the decision. 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. Due to the level of risk and concerns found during the inspection, the registered provider agreed to a voluntary suspension on further admissions to Saltshouse Haven.

The concerns found on Coniston lodge resulted in us finding the registered provider in breach of nine regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches included, management of the service, providing person-centred care, the need for consent, safe care and treatment, safeguarding people from abuse and improper treatment, meeting nutritional and hydration needs, good governance and staffing.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’; this is the second time the service has been in ‘special measures’ in a 12 month period and the registered provider must take action to improve and sustain the improvements. 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 registered 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 inadequate staffing levels had impacted on the quality of care people received on Coniston lodge. People who used the service had sustained injuries due to a number of poor moving and handing incidents, staff had to be prompted to take action regarding one person’s health care needs, some people’s nutritional needs were not met and seating arrangements when people ate their meals was not always appropriate or safe.

There was a lack of robust risk management, staff had not always following guidance from health professionals and there was the use of improper physical interventions for one person.

Some people had not received their medicines as prescribed due to stock control issues, errors in administration and non-application of creams. Some people had poor hand and nail care and personal hygiene.

We found general concerns in documentation such as care planning and recording, advice from health professionals not transferred to care plans, risk assessments identified issues but lacked some control measures and care plans were not always updated following incidents. There was a lack of follow-through in recording of some issues so it was difficult to see if the care had been provided and the issue addressed. There were gaps in some people’s monitoring charts and wound care records, and re-dressing times were not always followed.

There were concerns with the management of infection prevention and control as some areas and equipment required cleaning.

We found specific staff lacked understanding about the Mental Capacity Act 2005, Deprivation of Liberty Safeguards, obtaining consent and carrying out care and support in people’s best interests. Documentation that showed best interest decision-making had not been completed appropriately.

Findings for the service as a whole:

There was a policy and procedure to guide staff in how to manage complaints and a record was held of investigations and outcomes. Improvement was required regarding a more customer focus approach and accuracy of the complaint letters sent out to people who had raised concerns.

There was insufficient induction, supervision and support to staff in lower management positions. There were shortfalls in how the service was managed overall and how care staff were overseen and supported when carrying out their roles. Some care staff had received formal supervision but others had not received any for some months. Staff had received a range of training but we were concerned some areas had not been fully understood.

We found audits had taken place regarding Saltshouse Haven as a whole, which highlighted specific issues, but there lacked analysis to ensure lessons were learned and incidents did not reoccur.

Findings specific to Bilton, Preston and Meaux lodges:

We decided to complete further inspection visits to Saltshouse Haven on 8 and 9 September 2016 to assess the care people received on the other three remaining lodges, Bilton, Preston and Meaux. On the days of the inspection there were 17 people who used the service on Bilton lodge, 18 on Preston lodge and 25 on Meaux lodge. During these two inspection days, the service was overseen by a regional director for the registered provider, BUPA. There were also other senior managers on site supporting staff with reviewing care plans and risk assessments.

We found there were sufficient staff on duty on each of the residential lodges as some members of staff had moved across to them when people moved from Coniston lodge to alternative placements. However, staff told us prior to the changes, there were days when there was insufficient staff on duty and this had impacted on the care and monitoring they were able to provide. The regional director told us they would complete a staffing review to ensure sufficient staff were on duty in line with people’s care needs.

We found employment checks were carried out prior to new staff starting work in the service. The recruitment process helped to ensure only suitable staff worked with vulnerable people. In one staff file we found gaps in their employment history had not been explored and documented.

There were policies and procedures to guide staff in how to safeguard people from the risk of harm and abuse. Staff had received safeguarding training and were able to describe the different types of abuse and how to report any issues of concern.

We saw people who used the service had assessments and care plans. The assessments did not always comment on the impact on people of their health needs and disabilities. Care plans did not always detail guidance for staff regarding the support people required to meet their assessed needs.

The care files included information about visits from professionals which helped to ensure people’s health and social care needs were

This inspection took place on 22, 23 and 25 February 2016 and was unannounced. The service was last inspected September 2015 and was found to be none compliant with the regulations inspected at that time. This inspection was undertaken to assess whether the registered provider had complied with the actions we told them to take following the last inspection of September 2015.

At the time of the inspection 78 people were living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Following the last inspection the registered provider was told to take action in all domains. This included:-

• Improving the way staff cared for people and provide them with person centred care.

• How staff ensured people’s dignity was respected at all times.

• How staff handled people’s medicines and ensured they received their medicines as prescribed by their GP.

• How people were supported and protected by the use of the Mental Capacity Act 2008 if they needed support with any decisions or choices, and the use of Deprivation of Liberty Safeguards (DoLS) if people needed protecting from the risk of harm.

• How complaints were handled so these were resolved and effectively investigated.

• How the service was monitored to ensure people lived in well run service and were not at risk.

• Improving staffing levels to ensure people received the care and attention they needed to meet their needs and keep them safe.

The registered provider sent us an action plan within the required time scale which outlined how they were to address all of the above requirements.

During this inspection we saw improvements had been made and have changed the rating of the responsive and safe domains from inadequate to requires improvement and the service is no longer subject to 'special measures'. However, we could not change the overall rating of the service any higher than ‘requires improvement’ because to do so requires consistent and sustained improvement over time and allows us to closely continue to monitor the service.

Improvements made included:

• More detail in people’s care plans which described their likes, dislikes and preference for care.

• Increased monitoring of people’s needs with regard to tissue and wound care, fluids and food.

• Dignity champions had been appointed whose role was to check staff were upholding people’s dignity on all the lodges.

• Medicine audits and checks of staff practise.

• Proper use of the Mental Capacity Act including holding of best interest meetings to ensure decisions made on people’s behalf were the right ones and least restrictive.

• Applications for DoLS where needed to ensure people’s safety if any restriction where made on them to keep them safe.

• Better recording of complaints and improved communication with complainants.

• Increased monitoring of the service to ensure people live in a safe, effective, caring, responsive and well-led service.

• Increased recruitment of staff and an increase of staff numbers around the lodges to ensure people’s needs were met.

Following the inspection of September 2015 the registered provider agreed a voluntary suspension of placements with the CQC and the local authority contracts department placed an embargo on all admissions. The local NHS Clinical Commissioning Group (CCG) agreed to support the service and provided daily supported through the nursing services. The provider put in place their recovery team to support the registered manager to improve the service. Following the last inspection of September 2015 the registered provider made the decision to close Sutton lodge, the high dementia unit. The people who lived on Sutton lodge were re-assessed by the local authority and the CCG and other accommodation has been found in other services or people have moved to the other lodges at the location.

Visitors whose relatives had moved from Sutton lodge to other lodges at the location thought this had been a positive move. They told us, “I have seen a great improvement especially since [relative’s name] has moved from Sutton lodge, there seems to more staff around and they are coping better”, “When [person’s name] was on Sutton lodge he was not looked after at all, it was awful, but since he’s moved he’s been looked after really well, I can’t praise the staff enough and what they have done for him”, “Mum is so much happier now, she is well looked after now”, “A doctor was called out to her recently, they notice more here [on this unit]” and “Things are so much better now.”

Since the inspection information has been shared with us from the local authority and the CCG of some concerns which have been raised with them. This pertains to some of the staff practise on Coniston lodge the nursing unit. This will be investigated and we will look at the findings of the local authority and the CCG.

This inspection was unannounced and undertaken on 30 November 2015 in conjunction with the local authority contract compliance team as a result of information received which gave rise to concerns about staffing levels on Sutton lodge which is one of the five units. We had previously inspected the whole of the location in September 2015; it was rated as inadequate overall and placed into special measures. Part of special measures does mean the service can be subject to further inspections if we receive any information of concern. The findings of this inspection have not changed the service’s overall rating.

The inspection focussed on Sutton lodge only. This lodge provides care and accommodation for people who need support and are living with high levels of dementia. We did not review any of the other lodges as this will be done when we return to undertake a full inspection of the service to establish compliance with the requirements set at the last inspection in September 2015.

We found staff were not deployed, lead effectively or provided in enough numbers to ensure people were safe or their needs were effectively met on Sutton lodge. Other agencies are now providing a support service to the location to ensure people’s needs are effectively met and they are safe. This was with the agreement of the registered provider. This will be for a limited period and we will review the situation in due course and consider whether we need to take further enforcement action.

The inspection was carried out by one inspector. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service responsive?

' Is the service caring?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking to staff who supported people who used the service, speaking with people's relatives and from looking at records.

During this review we only spent time on one of the units which make up the location as the concerns raised pertained to a person who resided on that unit. A further inspection will be carried out to look at the other four units as part of our ongoing inspection process.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was not safe because the amount of staff on duty was not enough to ensure people were kept safe and not exposed to unnecessary risk.

Is the service effective?

The service was not effective because systems in place did not effectively monitor people's nutritional intake.

Is the service caring?

The service was not caring because the lack of staff meant some people's needs were not fully met.

Is the service responsive?

The service was not responsive because systems in place were not adequate to ensure the right amount of staff were on duty at all times to meet the needs of the people who used the service.

Is the service well led?

The service was not well led because the systems in place for monitoring staffing levels and people's care and welfare were not effective and potentially put people at risk.

There was information for the staff to use and follow about how they should best care for people who used the service. There was also information about how the staff should keep people safe from harm. One relative told us 'The carers have been magnificent in what they do.'

People were protected by the way the staff handled and administered medication. Staff had also received regular training about how to handle medication safely.

People were cared for by staff who had received the relevant training for their role and who were well supported by the management of the home.

People were able to complain and their complaints were listened to and acted upon. One person told us, 'I would go to the Manager' another told us, 'I would tell the person in charge and they would definitely deal with it.' Relatives told us, 'Staff are always positive about any query and have offered in the most recent situation to search in the laundry for a particular item of clothing.'

We found that people's rights, choices and dignity were respected and considered. Working practises had changed and staffing levels increased to address the action we asked the provider to take.

We also found that the services offered at the home were audited and actions taken as a result of any shortfalls.

We could not ask people who used the service about their experience at the home due to their complex needs but relatives spoken with told us they were happy with the care and attention their relatives received and the services offered at the home.

The provider had sent us an action plan which detailed how they were to address the actions set at the last inspection.