We last inspected this service on 10 September 2015, when we found the service to be in breach of four regulations.
During this inspection we reviewed the action taken by the provider to meet the requirements of the regulations, these included; medicines management, environment safety and infection control. Person-centred care, Need for consent, Meeting nutritional and hydration needs and good governance.
At this inspection we found the provider was still in breach of Regulation 12 safe care and treatment, in relation to medicines management and Regulation 11 Need for consent. The provider was no longer in breech of the other regulatory requirements highlighted at the last inspection. However, we found the provider to be in breach of other regulations at this inspection, these included; Person centred care and Safeguarding service users from abuse and improper treatment. .
Alma Green is located in the village of Upholland. It provides accommodation for up to 29 people, who require help with their personal care needs. All bedrooms are of single occupancy with en-suite facilities, consisting of a wash hand basin and toilet. A wet room is available and there are a variety of bathrooms located throughout the home, which provide assisted bathing facilities.
There are a variety of amenities within the village itself, such as public houses, shops, a library, a church and post office. The surrounding areas of Southport, Ormskirk, Liverpool, Wigan and Skelmersdale are all within easy reach by public transport. The bus stops very close to Alma Green and there is a railway station nearby. Some parking spaces are available at the front of the premises.
At the time of the inspection there were 26 people who lived at the service. There was a registered manager in place. The registered manager assisted throughout the inspection.
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.
We looked at how the service protected people against bullying, harassment, avoidable harm and abuse. We found that staff had received training in safeguarding adults and demonstrated a good understanding about the meaning of abuse. However, we found that the service had not always made safeguarding referrals in line with their policy and procedure. For example, one person’s care records showed that they had been physically assaulted by another person who lived at the service. A safeguarding referral had not been made, risk assessments had not been reviewed in relation to the incident and the registered manager told us that they had not been informed about the incident.
We looked at people’s care records in relation to the prevention of accidents and injuries. We found examples of when people who lived at the service had fallen. However, their care plans and risk assessments for falling had not been updated to show how the service had assessed and mitigated the risk for further accidents to prevent injury.
During the inspection we observed staff using a hoist for a person who had fallen in their bedroom. We asked staff if the person had been assessed for the use of a hoist and staff could not confirm if an assessment had taken place. Staff assisting the person were unable to clarify what size hoist sling the person needed. This placed the person at risk of injury. We informed the registered manager who took immediate action.
Risk assessments were in place for the premises and these were audited on a regular basis.
We found variances in stocks of medicines. This suggested that medicines had not always been administered as prescribed. The service did not have a robust monitoring system in place to highlight when medicines had not been administered. We found that the service did not have protocols in place for the administration of medicines prescribed on an as needed basis. This meant that person centred medicine administration was not always provided for people who lived at the service. We observed medicines being administered at lunch time. Medicines were left with service users and the staff member responsible for administering medicines did not ensure that the person had taken their medicines as prescribed.
When employing fit and proper persons the recruitment procedures of the provider were robust in ensuring suitable people had been employed.
We found there were sufficient numbers of suitable staff during the day time to meet people’s needs and promote people’s safety. However, staff told us that night duty was not staffed according to people’s individual needs. We made a recommendation about this.
Improvements had been made around environmental cleanliness and infection control. We found the environment to be warm, comfortable and pleasant smelling. The premises were generally clean and some areas had been painted, decorated and flooring had been replaced. However, some improvements were still needed, particularly in the bathrooms and communal toilets.
We noted that the bed of one person was unsafe for use. The mattress was longer than the bed. Therefore, if the person sat on the end of the bed it was possible they could have fallen on the floor. We informed the registered manager that a new bed was needed straight away. We were told that this had been arranged.
The turnover of staff at Alma Green was extremely low. The last person to be employed started to work at the service in May 2011. This helped to promote good continuity of care.
Staff told us that they felt supported in their roles and had received training to help them understand their role and responsibilities. We looked at the training records and found that staff were provided with a wide range of training courses.
We found that the service had implemented consent care plans and mental capacity assessments since our last inspection. However, these had not always been completed in line with the principles of the Mental Capacity Act 2005. People who lived at the service and their representatives were asked to sign consent and agreement documents. The service had not always effectively recorded consideration of the person's mental capacity or evidenced sight of a Lasting Power of Attorney document, to show that the person’s representative had legal status to make decisions about the person’s welfare on their behalf.
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 of the service supported this practice.
We looked at three staff supervision records, these showed that two staff were last supervised in 2015. The third staff member did not have any supervision records on file. Staff told us they felt supervised by the registered manager.
Annual appraisals were available on one of the staff records we looked at. The most recent one being dated March 2016. Two further staff records did not evidence that appraisals had been undertaken.
People were assessed against the risk of malnutrition, however nutritional care planning was not person centred to show people’s preferences and individual needs. We looked at diet and fluid intake records and found gaps in recording. This meant that the service did not always monitor how much people had eaten and drank when they were at risk of malnutrition or dehydration.
People had access to external health care professionals including dieticians, occupational therapists and the speech and language team. During the inspection a visiting GP provided positive feedback about the standard of care and support provided for people who lived at the service.
During the inspection we did not see people being offered recreational activities, we asked to see the activity time table and we were told that this was not available. A notice board had information about a singing group and their schedule for visits. We made a recommendation about this.
We observed staff interact with people in communal areas. Some staff approached people in a caring way. However, we also observed two instances when staff disregarded people’s questions. For example, one person asked what medicines they had been handed, but the staff member walked away. When the staff member said what the medicine was, the person was unable to hear them. Another staff member mocked a person when they expressed that they were thirsty, the staff member replied, “No it is Friday”.
People told us they felt involved in their care and making decisions. However, when we looked at people’s care records we did not see that people had been involved in the care planning process. We asked the registered manager if resident and relative meetings had been undertaken; the manager confirmed that meetings had not been held.
We found that people’s care plans were not written in a person centred way. The provider had recently implemented a new electronic care planning system; staff told us they had received little training about the system. Care plans had been generated from the system and were generic in content. This meant that care plans did not describe the person as an individual.
Audits and quality monitoring systems were in place and completed on a monthly basis. The audits undertaken had not highlighted concerns found at this inspection. For example care plan audits showed ‘all care plans up to date’. This meant that quality assurance systems were not robust.
During this inspection we found several breaches of the HSCA 2008(Regulated Activities) Regulations 2014 otherwise known as the fundamental standards of care. Two of these were continued breaches from our previous inspection in September 2015.
We will ensure action is taken and report on this in due course.
Further information is in the