The Laurels Residential Home

We found the following examples of good practice.

¿ The premises were clean and well maintained. The home was undergoing a refurbishment programme to update and improve the premises.

¿ All staff had received training in infection prevention and control and their competency was regularly checked. Staff were seen to be following correct practice in this area.

¿ Relatives and friends were encouraged to keep in contact with their loved ones via telephone and video calls. A safe space had been created outside to facilitate face to face visits.

¿ All people living and working at The Laurels had been offered a vaccine and were regularly tested for COVID-19 in line with government guidance.

The Laurels is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home accommodates 28 people in one adapted building. On the day we inspected there were 22 people living in the home with one person in hospital.

There was a registered manager in post at the time of 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.

People told us they felt safe and the registered manager understood the principles of safeguarding well. They had responded to, and reported concerns appropriately, and also those concerns outside of their immediate responsibility, in a thoughtful and considerate manner ensuring people’s needs were placed at the centre and their wellbeing safeguarded.

Risks were appropriately managed with individualised plans to reduce the likelihood of harm and promote people’s independence. Accidents and incidents were responded to promptly and with full analysis to minimise repeat events. Staff were busy but always acknowledged people when they asked for assistance explaining they would be attending to them once finished with another person.

Medicines were administered safely and stored correctly. Records did not always show the time of PRN, or ‘as required’, medication but this was remedied before we left the home to ensure people did not receive medication too close together.

The home was clean and fresh, with rooms and equipment in good order.

The registered manager displayed in-depth knowledge of key practice and policy guidance and their knowledge was shared with staff who were able to explain and demonstrate the principles of best care practice.

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.

Nutritional and hydration needs were managed well as staff actively encouraged people to drink throughout the day and meals were well presented with people offered plenty of choice. Staff clearly worked as a team and showed appreciation of each other’s skills.

People were supported to access health and social care services as needed, and the registered manager showed where they had ensured decisions were always taken in people’s interests if they lacked capacity.

Staff displayed kindness, compassion and empathy in their relationships with people. They clearly knew people well and staff’s interactions demonstrated they appreciated people’s needs always came first. People’s dignity and respect was promoted and encouraged discreetly and sensitively, especially where people were resistive to support.

Care records remained person-centred and covered all aspects of a person’s care needs with direction and guidance for staff. People enjoyed a range of individual and group activities.

The home was well managed by an able and competent registered manager who led by example. They had a strong vision and this was embedded in all aspects of care delivery. Staff were well led and had sufficient guidance to ensure they met people’s needs well. The home was a happy and positive place where quality assurance systems ensured all aspects were reviewed regularly and any issues rectified promptly.

The Laurels provides accommodation and personal care for up to 28 people. Respite care is also provided. The home is over two floors with bedrooms on each floor. There is a secure garden easily accessible by the conservatory with a portable ramp to assist people using wheelchairs. On the days we inspected there were 19 people living in the home, four of whom were new admissions since the previous inspection. No one was currently sharing a room as all single rooms were being utilised first.

There was a registered manager in post on the days of 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 found people were happy and settled. They told us they felt safe and supported by the staff team who they had confidence in. We saw any safeguarding concerns had been reported appropriately and the registered manager was pro-active in supporting people where any issues were identified.

Risk assessments were more person-centred and focused on individual need. Staff displayed good techniques in relation to moving and handling practice which had improved greatly since the last inspection. This was supported by more robust documentation providing detailed guidance for staff to follow.

Staffing levels remained the same as before but there was evidence of clear leadership which meant staff understood their roles and liaised with each other more often. This meant people’s needs were responded to in a timely manner. Staff also displayed greater awareness of risk reduction measures such as falls prevention and conflict management, reinforcing positive interventions for people and reducing the risk of harm.

There were no issues with medication on this inspection and we found administration, storage and records all in line with stock levels and people’s requirements.

Staff had received regular one to one supervision as well as observations of their practice. This gave them the opportunity to develop their confidence and knowledge, and identify any areas they needed further training in. We saw all training was up to date and plans in place for regular updates.

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.

Nutritional and hydration needs were met pro-actively with staff offering regular drinks and snacks to people in addition to more organised mealtime experiences for people. People who were on bed rest had regular checks and appropriate levels of pressure care relief.

Staff displayed warm and friendly relationships with people, and it was obvious the needs of people living in the home were their first priority. This was a significant culture shift from the previous inspection where people had been ignored. There were many examples of positive interaction and it was highly evident staff knew people very well.

Although formal care plan reviews seemed limited, discussions with relatives and other visitors showed the registered manager was very knowledgeable about each person’s needs, which was mirrored in the conversations with staff. Staff were engaged and relaxed in their approach and this helped promote a calm and pleasant atmosphere.

Care records were relevant and reflected the needs of people. They were regularly reviewed and provided guidance to staff about how best to support people in the home. They were used frequently by staff to ensure information was current and any changes were made known.

Complaints were limited but the investigation and responses were handed well, and compliments were displayed in the home.

The registered manager had continued the transformation of the home through focusing on the small details such as people’s comfort, as much as the larger issues. This showed good foresight and skill. The quality assurance systems were more robust and aided the improvements in the home rather than being a task in themselves. The tools were appropriate and effective in highlighting key areas to monitor and provided sound evidence of where progress had been made. It was very clear from this inspection the registered manager and staff had worked incredibly hard to improve standards of care and drive up quality for people living in The Laurels.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The Laurels provides accommodation and personal care for up to 28 people. Respite care is also provided. The home has two floors, with bedrooms on each floor. There is a secure garden easily accessible via the conservatory with a portable ramp to assist people using wheelchairs.

There was no registered manager in post on the day we inspected, however there was an interim manager who had previously been the deputy manager. 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 previous inspection we had concerns with safeguarding, the premises, staff training and supervision, the implementation of the Mental Capacity Act and care records. At this inspection we found improvements in all of these areas.

People said they felt safe and staff were able to explain the signs of possible abuse, and how they would report this. This was evidenced in safeguarding records.

We found that although there had been significant progress in the development of person-centred care plans this was not always reflected in the risk assessments. We found some information was lacking and in parts contradictory. Staff did not always follow safe moving and handling procedures on the first day we inspected, but after receiving extra training by the second day we observed some improvement. The interim manager had plans in place to regularly review staff competence in this area.

We found staff responded as fast as practicable to call bells and were responsive, but there were times when staff were very busy. This was because most people in the home had high dependency needs.

We observed some issues with medicine administration. Most staff adhered to all expected guidelines but one staff member was seen to administer medication without first checking records or the pot into which they put people’s tablets. This lack of scrutiny meant people were placed at risk of receiving the wrong medication.

Staff had access to necessary personal protective equipment. We found there had been extensive improvements made to the property although there was still work to be completed.

People were supported throughout both days with regular food and drinks. However, mealtimes were not well organised as some people had to wait for food for long periods. We saw evidence of timely and appropriate referrals to health and social care professionals.

The service was acting in line with all requirements of the Mental Capacity Act 2005 and in close communication with the supervisory body for Deprivation of Liberty Safeguards applications which had yet to be authorised.

Staff had access to a supervision and training programme. This area was under constant review, with training arranged as needed. We observed all staff had positive interactions with people but sometimes they spoke about people, rather than to them. This showed a lack of respect towards them. On the second day of this inspection we saw several fizzy drinks bottles and half empty coffee mugs on the dado rail which did not aid the feeling this was people’s home.

Activities were limited as care staff did not have the time to arrange any and the activities co-ordinator was on annual leave during the week of inspection. We did see some evidence that events had taken place. The home had not received any complaints since the last inspection.

Care records had become more person-centred with individual needs and plans in place for the support people needed. Their evaluations showed changes were made as required but this did not always link across to people’s risk assessments.

The interim manager had promoted an ‘open door’ policy for people, relatives and staff alike so any issues could be raised. It was evident staff felt supported and valued. The registered provider had resourced improvements to the building and had visited regularly to obtain people’s views.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures.

CQC is now considering the appropriate regulatory response to resolve the problems we found.

The inspection took place on 22, 23 and 25 February 2016 and was unannounced. The service was last inspected on 9 November 2013, and was found to be compliant in all areas inspected.

This inspection was in response to concerns which had been raised. These concerns related in particular to the manager and their attitude towards people living and working at the Laurels. The Concerns also related to gifts being taken from people living in the Laurels by the manager.

The Laurels Residential Home provides accommodation and personal care for up to 28 older people. At the time of inspection respite care was also provided. The home was spaced over two floors with bedrooms on each floor.

The registered manager and deputy manager were on annual leave at time of our 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. Because of the multiple and serious nature of the findings of the inspection we spoke with the owner of the home, and they brought in staff from another organisation to support the leadership in the home. This would be in the short term while initial investigations could be completed into the suitability of the present management to fulfil their roles

We found the standards of care in the service had deteriorated significantly since our last inspection. There were multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014

Staff did not recognise safeguarding incidents that were occurring. There had been no safeguarding referrals made to protect vulnerable people living in the service until incidents were highlighted by CQC during the inspection.

There were very few risk assessments in place for people in the service and those that were in place were not adequate to identify and reduce identified risks to keep people safe. We found several people using equipment which was not identified in their risk assessments. And risk assessments for equipment which staff did not know should be use.

We found that DBS checks were used from other organisations for some staff. DBS checks were carried out when people commenced working at The Laurels but were not checked again which meant the provider was unable to confirm that ongoing suitability of staff is routinely monitored and verified to ensure they remain suitable to work with vulnerable people.

We found people in the service were not treated with dignity and respect. Staff alleged that some of the people living in the service had their rooms used as a treatment room for visiting professionals without their consent.

Staff alleged that gifts were routinely taken from people and locked away until decisions were reached about when people could access these. Staff did not recognise how people's dignity and fundamental human rights could be promoted.

We found people's care needs had not been adequately or accurately assessed and there was no care plan in place for any of the people on day care or respite care. People's care plans were out of date and the information did not reflect their current needs or describe the care which required by them or was being given to them.

The people living in the service were not asked for their consent for care to be carried out. The staff failed to recognise restrictive practices which were in place. Mental capacity assessments were not carried out for the people living in the service to measure whether they were able to make their own decisions and which decisions they were able to make. Where people's liberty was being restricted there were no Deprivation of Liberty Safeguards in place.

We saw that food records were inaccurate and were not filled in at mealtimes, which meant staff could not accurately monitor people's food and fluid intake. We found evidence of weight loss in some of the people living in the service, and people were not being weighed regularly to monitor their weight.

There were no processes in place to monitor the performance of the service or to maintain accurate records of the care which was being delivered. We found that there was no effective leadership within The Laurels. Staff alleged that they were spoken to in an unprofessional manner by the senior staff at the home. Staff were not empowered to make decisions and this impacted on the health and safety of the people living in the Laurels.

We found that staff supervision was not adequate and did not offer any opportunity for staff development Staff were not well trained and were not competent in all areas of their roles. There was no evidence of recent training the last documented training was October 2014.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose 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 time frame. 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 or 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 than12 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 looked at three people's care records and found these provided more detail, although the manager told us she aimed to make them more person centred. The manager told us the care records were put into place within the first 48 hours of a person moving into the home. We saw evidence which confirmed this.

We saw care plans had been put into place for people who had diabetes which specified how their diabetes was managed. Bed rail assessments were now in place and were signed by the person or representative to indicate their agreement. We spoke with two members of staff who told us they found people's care plans were sufficiently detailed and easy to follow.

Overall, we found people were protected from the risks of unsafe or inappropriate care and treatment.

We saw the care record audits documented which care record had been reviewed and whether any improvements were required. We looked at the complaint audit and saw this recorded information about any complaints received. This helped to ensure the management team identified any patterns and trends in relation to complaints.

People we spoke with were happy with the care provided at The Laurels. One person said; 'They do listen. They're pretty good.' Another person told us; 'I like living here. Some staff are better than others.'

Comments from relatives included:

'The staff are approachable. They listen to issues.'

'Staff are very good. Nothing is too much trouble.'

'I've seen carers treating people with care and respect. We're kept involved with my [relative's] care.'

We found people were involved with decisions regarding their care and treatment.

The three members of staff we spoke with told us they received regular supervisions and kept their mandatory training up to date. We saw documentation to confirm this. We found people were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

Overall we found that care and treatment was planned and delivered in a way that ensured people's safety and welfare. However, we found that one person had been living at The Laurels for over five weeks and did not have any care plans or risk assessments in place. Therefore they were not protected from the risks of unsafe or inappropriate care and treatment.