Chestfield House

Chestfield House is a residential care home providing personal and nursing care to up to 32 older people who may be living with dementia. At the time of our inspection there were 27 people living in one large adapted building.

People’s experience of using this service and what we found

People told us they felt safe living at the service and staff treated them with kindness and respect. However, potential risks to people’s health and welfare had not been consistently assessed and there was limited guidance for staff about how to mitigate the risks.

Medicines had not always been managed safely, records were not always accurate. Staff had been recruited safely but improvements were required to the documentation used such as references. Checks and audits had been completed by the registered manager and staff, but these had not been effective at identifying the shortfalls found at this inspection.

Staff were following current infection control guidance, and visitors were encouraged to visit people. The registered manager and staff understood their responsibility to protect people from discrimination and abuse.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People, relatives and staff were asked their opinions on the quality of the service and action was taken when suggestions were made. Relatives told us they were confident to raise concerns with the registered manager and they would take appropriate action.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 3 November 2017).

At our last inspection we recommended that the provider included checks on specific areas in the audits to drive improvements and deliver a consistent quality of care. At this inspection we found the areas identified had been included in the audits.

Why we inspected

We undertook this inspection as part of a random selection of services rated Good and Outstanding.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chestfield House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management, medicines and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

There was a registered manager employed at the service. A registered manager is a person who has registered with the 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. The registered manager was responsible for the day to day running of the service.

We carried out an unannounced comprehensive inspection of this service in May 2016 the service was rated Requires Improvement. There were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and we asked the provider to make improvements. We issued requirement notices relating to failing to collaboratively carry out an assessment of people’s needs and preferences, failing to mitigate risks to people, failing to assess and monitor the service effectively, failing to complete proper recruitment checks, failing to ensure staff were trained and failing to deploy sufficient numbers of staff. The provider sent us an action plan. We undertook this inspection to check they had followed their plans and to confirm they now met legal requirements. Improvements had been made and the breaches in regulation had been met.

Risks to people were assessed, identified, monitored and reviewed. However we found pressure relieving equipment that was not set correctly. Staff did not have clear guidance on the use of prescribed creams to make sure their skin was kept as healthy as possible. Other medicines were managed safely.

Some care plans had been rewritten and provided staff with more detail to help them provided people with personalised care. Other care plans remained generic and were in the process of being updated

Some audits and checks had not been consistently effective and shortfalls found during the inspection had not been identified. Other checks, such as the environment, had been completed and action taken to address any concerns. The area manager completed a ‘provider visit’ and audited the service The registered manager had taken action to address the shortfalls when they had been identified. We have made a recommendation regarding improving the audits.

People were protected from the risks of abuse, discrimination and avoidable harm. Staff knew how to report any concerns and felt confident that action would be taken. People’s money was safely managed. Staff knew how to keep people safe and understood their responsibilities for reporting accidents and incidents to the registered manager. People’s medicines were managed safely and they received them on time. The premises were maintained to help keep people safe.

People were supported by sufficient numbers of staff who knew them and their preferences well and who had been recruited safely. Staff had completed regular training and one to one supervision to keep them up to date with guidance and best practice.

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 mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People’s representatives and health professionals met to decide if the treatment was necessary and in the person’s best interest.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care services. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. DoLS applications had been made to the relevant supervisory body in line with guidance.

People were supported to have a balanced diet. Staff monitored people’s nutritional needs to help them stay as healthy as possible. Staff monitored people’s health and worked closely with health professionals to keep people as healthy as possible.

People were treated with compassion and kindness. Staff had developed strong, caring relationships with people and their relatives. Staff were patient and provided people with information in a way they could understand. People’s religious beliefs, ethnic and cultural needs were discussed and recorded to enable staff to provide the support people needed. People’s preferences and choices for their end of life care were discussed with them and their loved ones. People’s confidentiality, privacy and dignity were both promoted and maintained by staff.

People were supported to follow their interests and take part in social activities. People, relatives, stakeholders and staff were encouraged to provide feedback on the quality of the service. Concerns and complaints were investigated in line with the provider’s policy.

There was good communication between the staff team and staff felt supported by the management team.

The registered manager had submitted notifications about important events that happened to CQC in an appropriate and timely manner and in line with guidance. The latest CQC report and rating was displayed in the service and on the provider’s website in line with guidance.

Chestfield House provides nursing care and accommodation for up to 31 older people, some of whom may also be living with dementia. The service is an adapted detached building in Chestfield near Whitstable. The accommodation is provided on two floors, with bedrooms on both the ground floor and first floor, accessed by a lift and a staircase. There are three shared bedrooms and most bedrooms have ensuite bathrooms. On the day of the inspection, there were 28 people living in the service.

The service is run by a registered manager on behalf of the registered provider. 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 times insufficient staff were on duty to provide care safely. At other times, although people’s personal care needs were met, there were insufficient staff available to interact with people so they received stimulation and emotional support.

People’s care, treatment and support needs were assessed before they moved to the service and a plan of care developed. People’s care and treatment needs were not always recorded in full to guide staff on how to effectively support people in an individualised way. Assessment of risks to people’s safety and welfare had been carried out but lacked detailed guidance for staff to follow to ensure that safe practices were carried out. People were not always involved in care reviews and making decisions as their needs changed.

People were not fully protected by safe recruitment processes. The employment history of new staff was not explored thoroughly to ensure they were suitable to work with people.

Staff had completed some training to deliver care and support but this had not included all they needed to give them the skills or knowledge they needed to undertake their roles. Staff had regular supervision with a line manager to talk about training and development needs but staff appraisal requirements were not being met

The provider had quality assurance systems in place to ensure that care was given effectively, but where shortfalls had been identified, the action taken to address them was not always promptly completed. Policies and procedures were in place and in the process of being updated. Records were not all available for inspection.

Processes were in place to protect people from abuse. Staff understood how to protect people from the risk of harm and abuse. There was a safeguarding protocol in place that staff understood and said they would follow to help keep people safe.

Information had been gained about people’s likes, dislikes and history. People were spending long periods without stimulating activities and staff were currently too busy to spend time with people. External entertainers visited and special occasions were celebrated such as people’s birthdays. People were welcome to have guests to visit at any time, and to dine with them.

People had their health care, food and drink needs assessed and monitored and professional advice was sought as appropriate. People were offered choices at mealtimes, and where necessary support was provided to help people to eat and drink. People were not rushed and the dining room was welcoming so that dining was an experience to be enjoyed.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). The appropriate assessments and DoLS applications had been made for people to ensure that people were not deprived of their liberty unnecessarily. All staff had received training in the Mental Capacity Act 2005 and understood how to apply the principles of the Act.

Medicines were stored safely and administered to people when they needed them by registered nurses, in accordance with their prescriptions, and with current legislation.

Staff received regular training to make sure they had the skills and knowledge to support people.

The premises were clean and signage throughout the service supported people living with dementia in their movement around the service. Staff checked that the environment was safe and that equipment was in good working order. Accidents and incidents were monitored and actions taken to ensure these were kept to a minimum, such as people being referred to the GP or to the falls clinic if they had fallen.

People, their relatives and staff felt confident to approach the registered manager or other senior staff if they wished to discuss a concern. The registered manager was a visible presence in the service and led an established staff team who were well regarded by people and their relatives. They listened to what people had to say and took action to address any issues they had.

The service had developed positive relationships with external healthcare professionals and people had access to care and treatment support when they needed it.

There were systems in place to ensure complaints and concerns were fully investigated. People had the opportunity to say what they thought about the service and the feedback gave the provider an opportunity for learning and improvement. Relatives said they would or had recommended the service to other people.

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 the report.

This inspection was carried out by one Inspector, who visited unannounced on the 05 September 2014. During the visit we met and talked with people that used the service and their relatives/representatives, the manager, the nurse on duty and care staff. They helped answer our five questions;

Is the service caring?

Is the service responsive?

Is the service safe?

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 with people who used the service, their relatives, the staff supporting them and from looking at records. We found that action had been taken and improvements had been made by management and staff since our last inspection visit.

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

Is the service safe?

The service was safe. People told us that they felt safe. Safeguarding procedures were robust and staff understood how to safeguard the people they supported.

Records required to be kept to protect people's safety and wellbeing were maintained, held securely and available when required.

There were sufficient staff on duty at the time of the visit, to meet the needs of the people who used the service.

Staff training records showed that staff had completed essential training, which included subjects such as fire awareness, moving and handling, infection control and food safety. They had also completed training in relevant subjects such as dementia awareness.

Equipment at the home had been maintained and serviced regularly.

Is the service effective?

The service was effective. People's health and care needs were assessed with them and/or their representatives. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Staff referred people appropriately to their doctor and other health and social care professionals, so that they had the care and treatment they needed.

Is the service caring?

The service was caring. People were treated with respect and dignity by the staff. Staff interacted well with people and knew how to relate to them and how to communicate with them. People living in the home made positive comments about the staff, with remarks such as 'the staff are kind and helpful'.

Is the service responsive?

The service was responsive. Staff listened to people, and took appropriate action to deal with any concerns.

Action had been taken to address the area of non-compliance raised at the last inspection visit in January 2014.

Care staff noticed if someone was unwell, or needed a visit from a health professional such as a dentist or optician. The staff acted promptly to make appointments for people.

Is the service well-led?

The service was well-led. The manager had an open door policy, and was available to speak with people using the service, their relatives or staff.

There were systems in place to provide on-going monitoring of the home. This included checks of the environment, health and safety, fire safety and staff training needs.

Staff confirmed that they had individual supervision and staff meetings. This enabled them to share ideas and concerns.

Care records were detailed and well structured. When people moved into the service they had had their needs assessed quickly. Care records were regularly updated, there was good evidence of methodical recording. However, during the visit we observed unsafe moving practice which led to concerns about the quality of training for staff in moving people. We could not be sure that people were protected from bad moving practice.

A training schedule was in place and it was evident there was a wide range of training. Supervision and appraisal was in place. From speaking with staff and looking at records we felt that staff were supported, though raised issues with training. Staff were able to give a good account of safeguarding vulnerable adults, however not all staff had received training.

Medication was stored correctly. There were procedures in place to ensure that medication was handled, ordered and disposed of correctly. We had concerns about two medication errors in quick succession.