Larkhill Hall

Larkhill Hall provides accommodation and personal care to up to 66 older people; including people with dementia. At the time of our inspection there were 63 people living in the home.

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

At the last inspection areas of improvement were needed to the management of people's prescribed medicines. At this inspection we identified further concerns with the management of medicines and governance.

Medication practices observed placed people at risk of harm through not receiving their medicines as prescribed or on time. We had concerns about medication management for some people, so we referred our concerns to the Local Authority Safeguarding Team to investigate. After the inspection, the provider submitted an audit of all medication within the service and outlined the immediate improvements they intended to take with regards to medicines.

The provider's governance systems were mostly effective at driving necessary improvements however, audits had failed to identify some of the issues we found in relation to medicines management. We have made a recommendation in relation to this.

People's care plans contained inconsistent information in relation to planned care. Some people were at risk of weight loss and required weekly weight monitoring and records did not evidence this. We identified inconsistencies with the recording of modified diets and were not assured people were in receipt of the correct modified diets in accordance with their assessed care needs.

Feedback we received from staff, people and relatives we spoke with during the inspection was positive. We were told by the relatives we spoke with that the care staff communicated with families regularly. There were enough staff on duty to support people, and staff were recruited safely. Care staff were friendly, and treated people kindly. People's relatives confirmed this and felt their loved ones were well looked after.

Infection control standards were monitored and managed appropriately. Accidents and incidents were recorded and reviewed in order to minimise the risk of reoccurrence.

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.

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

Rating at last inspection and update

The last rating for this service was Requires improvement (published 21 December 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

This inspection was prompted by a review of the information we held about this service. As a result, we undertook a focused inspection to review the domains of 'safe’, and' well-led’.

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.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, and good governance.

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

Larkhill Hall provides accommodation and personal care to up to 66 older people; including people with dementia. At the time of our inspection there were 56 people living in the home.

People's experience of using the service and what we found

We identified some areas of improvement needed to the management of people's prescribed medicines and records associated with medicine administration. We found no evidence people had been harmed, however the issues we found placed people at risk of avoidable harm.

The provider's governance systems were mostly effective at driving necessary improvements however, audits had failed to identify some of the issues we found in relation to medicines management. We have made a recommendation in relation to this. Where audits and checks had identified issues, clear action was in place to address these and make improvements.

Risks to people's health, safety and well-being had been assessed and staff knew people well and how best to support them. People told us they felt safe and family members were reassured their relatives were well-looked after.

Accidents, incidents and safeguarding concerns were acted upon appropriately and incidents were subject to regular review and analysis to prevent them occurring in the future. Safe recruitment processes were in place to make sure new applicants were suitable to work for the service. Staffing levels were sufficient to support people safely.

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.

The home and equipment used by people to support with their mobility was visibly clean and hygienic; staff responsible for the cleanliness of the home completed regular cleaning tasks to prevent the spread of health care related infections. Staff were observed following correct guidance in the use and disposal of PPE. The home was open to visits in line with current covid-19 visiting guidance.

The manager was open and transparent during the inspection process and receptive to feedback given about issues we found. Family members were happy with the service provided and the level of care their relatives received. One family member said, "She [relative] is so much better already. I feel she is safe here. She is more chatty, she smiles more and she recognises me and family more frequently. She appears content.”

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 25 January 2021).

Why we inspected

We received concerns in relation to the management of medicines and staffing levels. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

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.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. 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 Larkhill Hall on our website at www.cqc.org.uk.

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.

Larkhill Hall is a residential care home providing personal care for up to 66 older people. The service was supporting 33 people at the time of the inspection. Larkhill Hall accommodates people across three floors.

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

People had personalised risk assessments which gave staff the information needed to safely manage the risks associated with people’s care. There were some inconsistencies with the recording of some of this care being delivered, however we were assured people were having their needs met safely. The provider told us they would address the recording concerns immediately.

Concerns regarding communication with external healthcare professionals had been received prior to the inspection. We found the registered manager and provider had taken appropriate actions to address these concerns and improvements had been made.

Accidents and incidents were recorded, and actions were in place to ensure people were safe. Referrals were made to healthcare professionals when needed to ensure good outcomes for people.

The environment was safe and well-maintained. The home was clean and effective infection prevention and control measures were in place.

People were safeguarded from the risk of abuse. Staff had received safeguarding training and understood their role in recognising and reporting safeguarding concerns. The provider had appropriate systems in place to manage concerns of a safeguarding nature.

Audits and checks were completed regularly to monitor the quality and safety of the service. There were clear processes in place to drive improvement and to continually develop the service in line with people’s needs.

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 26 January 2021).

Why we inspected

We undertook this targeted inspection to check on specific concerns we had about the management of people’s health conditions, risk assessments, infection and prevention control concerns, safeguarding concerns and a lack of appropriate referrals to professionals regarding people’s deteriorating health. A decision was made for us to inspect and examine those risks. The overall rating for the service has not changed following this targeted inspection and remains good.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Larkhill Hall is a residential care home providing personal care for up to 66 older people. The service was supporting 33 people at the time of the inspection. Larkhill Hall accommodates people across three floors.

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

Since the last inspection, a new manager had been appointed. People, their relatives and staff spoke positively about the new manager. They told us the manager was on hand to provide support and how communication within the home had improved.

The manager had quickly identified issues which had developed at the service and had put an action plan in place to address those issues and improve practices. The manager was keen to tell us how improvements to the culture of the home were being made to ensure that the best possible care and support was being delivered to people.

Although we highlighted some minor areas of improvement around the issue of medicines management, these were immediately acted upon by the management team.

The manager participated in daily meetings with senior staff and undertook daily walkarounds of the service to help identify any issues and to make improvements as a result.

Staff knew the needs of the people they supported well. We observed warm and positive interactions between staff and people living at the service.

There was a calm and welcoming atmosphere and people appeared relaxed and at home in their environment.

The service appeared clean and well maintained. Infection prevention control practices, including those against Covid-19, were adopted and practised by staff.

Regular checks to monitor the safety and quality of the environment were in place.

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 12 March 2019).

Why we inspected

The inspection was prompted in part due to concerns received about medicines, infection control and staffing. A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe and well-led sections of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has remained as Good. This is based on the findings at this inspection.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

• People were admitted to the service safely. People were cared for solely in their rooms for 14 days on arrival. A designated staff member known as a 'buddy' was allocated to the person, to provide one to care and to help reduce any feelings of anxiety or isolation.

• A safe visiting procedure was in place and followed. Any visitors to the service had their temperature taken and completed a health screening questionnaire. Window visits for people's relatives were facilitated by appointment. People's relatives could physically enter the home if visiting in times of exceptional circumstances, such as end of life care.

• The service was registered for regular testing to ensure people and staff were tested frequently. At the time of the inspection, the service did not have any positive cases of COVID-19.

• Policies, procedures and equipment were in place to maintain infection control and support the needs of the people using the service. Risk assessments specific to people's needs were also in place to help reduce the risk of infection.

Further information is in the detailed findings below.

People’s experience of using this service: People told us they felt safe living in the home due to the support they received from staff. Staff understood the risks to people and the measures were in place to keep them safe. Safeguarding procedures were followed and incidents were raised with the appropriate professionals.

Some care plans lacked detail. We did see other care plans that were very detailed and supported staff in providing person centred care. The registered manager had reviewed care plans for the second day of inspection.

There were some inconsistencies with record keeping. We saw the amount of fluids people had been offered and drank wasn’t always accurately recorded.

Staff were supported in their role and had access to relevant training to help ensure they had the necessary skills to meet people's needs.

People’s medicines were managed safely. Improvements had been made to medicines audits since the last inspection.

Measures were in place to reduce the risks associated with the spread of infection. We found the home to be clean and well maintained. Environmental risks were assessed and well managed to prevent any harm to people.

Sufficient numbers of staff were employed to meet people’s needs. Staff were caring and always promoted people’s dignity and independence.

A system was in place to monitor applications and authorisations to deprive people of their liberty and any conditions attached to them. Consent to care and treatment was sought and recorded in line with the principles of the Mental Capacity Act. Staff supported people in the least restrictive way possible.

People received the support they needed to eat and drink and maintain a healthy and balanced diet. Staff knew people's dietary needs and people told us they enjoyed the food available to them. People could enjoy snacks throughout the day, and were able to choose alternative meals if they did not like what was on the menu.

People were given the opportunity to have interesting and fun activities to do.

Staff worked with other health professionals to ensure people’s health outcomes were met.

The registered manager notified CQC about some important events which happened at the home, so they could be sure they were consistently meeting their legal obligations.

Staff understood their role and had confidence in the manager. Staff told us they worked well together as a team, and there was good morale amongst them. People, staff and relatives were highly complimentary about the managers. We were told the management team were approachable and responsive to any issues. Systems were in place to gather feedback from people.

There was good oversight from the provider and the registered manager was well supported.

People told us they would recommend the home to others.

Rating at last inspection: Requires improvement (Report published 28 March 2018).

Why we inspected: This was a planned inspection based on the rating at the last inspection.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

When we conducted a previous inspection on 14 and 15 March 2017, the service was rated Requires Improvement with breaches of regulations in relation to; need for consent, safe care and treatment, good governance and staff support. This is the second consecutive time the service has been rated Requires Improvement. Following the last inspection we asked the provider to complete an action plan to show what they would do to address the issues identified.

During this inspection we looked to see whether improvements had been made to ensure that the provider was meeting the fundamental standards of care. We found that the service had made significant improvements to address the issues found in the last inspection and had met some breaches of the regulations.

Larkhill Hall is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

The home is a purpose built three storey residential care home in north Liverpool, providing specialist services for up to 66 people living with dementia. During the inspection, there were 60 people living in the home.

A manager was in place and were applying to be registered with us at the 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.

We observed a member of staff while they administered some medicines. We also checked records, storage arrangements, stocks and audits - We found that medicines were not always managed safely.

We checked for risks to people regarding the environment and equipment and found whilst safety checks were completed regularly, risk was not always identified and minimised effectively.

The provider remained in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; safe care and treatment.

During the last inspection it was identified that whilst systems and processes were in place to monitor the quality and safety of the service actions had not been taken to address all the concerns raised. During this inspection we saw evidence that improvements had been made in the monitoring of the quality and safety of the service, however some areas were still not being monitored effectively.

From the improvements that were made we found the provider was no longer in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014;Good Governance.

During the inspection we recommended that the manager delegate tasks within the management team to allow the manager to effectively address the issues highlighted in relation to quality assurance audits to improve the systems currently in place.

We checked four staff recruitment files and found they reflected safe recruitment processes.

Staff were aware of different types of abuse and how to report safeguarding incidents. Those that were reported had been done so appropriately. Staff had received appropriate training in safeguarding and were able to explain how to keep people safe from abuse - Staff were also aware of the whistleblowing policy.

Individual risks to people living in the home were accurately assessed and reviewed regularly with measures in place to reduce the risk in order to keep people safe.

Staff had received training in areas such as infection control, health and safety and manual handling.

Accidents and incidents were reported and recorded. They showed evidence of analysis, review and action taken where needed.

People that we spoke to told us they felt safe living at Larkhill Hall Care Home.

During the inspection we observed appropriate levels of staff on duty and people that we spoke to told us there were staff available if they needed them.

Principles of the Mental Capacity Act (MCA) 2005 legislation were being followed and Deprivation of Liberty Safeguard (DoLS) applications were completed correctly and in line with current legislation. Staff showed a basic knowledge and understanding of both MCA and DoLS. Best interest decisions were being made appropriately. Consent for care was gained in line with the principles of the MCA.

We found the registered provider was no longer in breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; need for consent.

Staff had received appropriate training to carry out their role. Staff that we spoke to told us they felt they had been given the right skills to care for people living in the home.

Staff were supported in their role through supervision and appraisals. Although we found that not all staff had received an annual appraisal the manager was able to show us a record of when outstanding appraisals were due. Staff that we spoke to told us they felt supported in their role through regular supervisions.

We found the provider was no longer in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; staffing.

We saw from the care files that people living in the home were supported to receive appropriate medical and health care when needed; such as GP, district nurse, occupational therapists and dietician.

People living in the home spoke positively about the food provided. There was a choice of meals and drinks and snacks were available if requested. People were supported to eat and drink where needed.

People that we spoke to told us that staff were caring and kind and treated them with respect. During the inspection we observed positive interactions between staff and people living in the home. Staff were seen to be kind and patient with people.

Staff were observed showing dignity and respect to people living in the home. People that we spoke to told us that their privacy and dignity was respected at all times.

From the care files we looked at we saw evidence of people receiving care that was person centred and based on individual needs and risks. Care files showed that people (and their relatives) were involved in their care planning and they were provided with choices and were listened to. Care files were reviewed regularly.

The home had a detailed complaints procedure. We saw evidence that complaints were dealt with effectively by the manager and in a timely manner.

During the inspection we saw evidence of activities being provided for people living in the home. An external activities coordinator visited the home during the inspection and we observed people engaging in the activity being provided. People spoke positively about the activities provided in the home.

We saw from training records that staff had been trained to support people with end of life care and records provided the opportunity for people living in the home to express their wishes and views about the care provided at the end of their lives.

Throughout the inspection the management team and staff were open and responsive. They were able to provide information on request and showed a desire to improve on the quality of their service.

Larkhill Hall is a purpose built three storey residential care home in north Liverpool, providing specialist services for up to 66 people living with dementia. During the inspection, there were 64 people living in the home.

There was no registered manager was 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A new manager had commenced in post in September 2016 and was in the process of registering with CQC.

Records showed that not all staff had completed recent training in relation to safe medicine administration and not all staff had had their competency assessed each year. Since the inspection the manager has confirmed that all staff who administer medicines has had a competency assessment completed.

We found that medicines were not always stored safely. Medicines were stored in two clinic rooms within the home; however they were not always secure. We observed one clinic room door to be unlocked during the inspection and on another floor, we observed keys to the clinic room to be left unattended in a dining room. We found that records regarding administration of medicines were not always accurate and there were gaps in the recording of medicines that had been administered.

The care files we looked at showed staff had completed risk assessments to assess and monitor people’s health and safety. Most were completed accurately and reviewed regularly. We found however, that not all assessments reflected people’s needs accurately.

We looked at the environment and found that risks to people were not always minimised. For instance, we observed unlocked bathroom cupboards which contained creams and razors. The manager rectified these issues straight away. A fire risk assessment of the building was in place and regular internal checks of the environment were completed, as well as external contracts to ensure the building was properly maintained.

People told us they felt safe living in Larkhill Hall and their relatives agreed. Staff were aware of safeguarding procedures and how to report any concerns they had.

We looked at how the home was staffed. Prior to the inspection we had received concerns regarding staffing levels within the home. We had written to the provider regarding this and they told us a number of new staff were being recruited. We found that a number of care staff had commenced earlier in the week and were now in post. Our observations showed us that there were sufficient staff on duty and people we spoke with agreed.

We found that safe recruitment procedures were followed.

Records showed that applications to deprive people of their liberty had been made appropriately.

The principles of the Mental Capacity Act were not always adhered to when seeking and recording people’s consent to their care and treatment. For example, one person's care file contained consent that was signed for by a relative who did not have the legal authority to provide consent on the person's behalf and there was also no evidence that the person lacked capacity to consent themselves.

Staff were provided with an induction that reflected the requirements of the care certificate when they started in post. All of the staff we spoke with told us they received regular supervision and records we viewed reflected this. There was however, no evidence that annual appraisals had taken place for all staff, although the manager had taken steps to address this. Training records showed that staff had completed training in a variety of areas, however not all staff had completed training that the provider considered mandatory, such as safeguarding.

A fire risk assessment dated July 2016 identified that staff required fire marshal training, however the manager told us that this training had not yet been completed. Since the inspection the manager has told us that head office are arranging this training for all senior carers, so that one staff member will be trained on each floor at all times.

People at the home were supported by the staff and external health care professionals to maintain their health and wellbeing. A visiting health professional told us that they received relevant and timely referrals from staff at the home and that any health advice they gave, was always followed by staff.

When asked about the food available, people told us they enjoyed it. We found that people had easy access to snacks and drinks throughout the day. People were offered a choice of meal and food was served hot and presented well. Staff were available to support people when required and this was done in a discreet way and people were not rushed with their meals. All staff we spoke with were aware of people’s dietary needs and preferences and this information was also available in the kitchen.

We observed the environment of the home and found that although the manager had taken some steps towards the environment being appropriate to assist people living with dementia with orientation and safety, this could be further developed.

People living at Larkhill Hall told us staff were kind and caring and treated them with respect. We observed positive and kind interactions between people living in the home and staff members during the inspection. We saw people’s dignity and privacy being respected by staff in a number of ways and staff described how they protected people’s dignity and privacy when providing care. One person however described care that was not provided in a dignified way.

Records containing people’s personal information were not always stored securely to ensure confidentiality was maintained.

Care plans we viewed were written in such a way as to promote choice and independence. Staff we spoke with told us they were aware of the importance of people maintaining as much independence as possible.

We observed relatives visiting throughout both days of the inspection. The manager told us there were no restrictions in visiting, encouraging relationships to be maintained. For people who had no family or friends to represent them, contact details for a local advocacy service were available.

We found that there was a variation in the quality of person centred information within care files we viewed. For instance, one person’s care file contained information regarding the person’s preferences in relation to their care and this helped staff get to know the person and provide care and support based on their preferences. Another care file however, contained little information that was specific to the individual and their needs. There was no evidence that people or their families had been involved in the creation or reviews of care plans.

People told us they were not always happy with the laundry system and records showed that these concerns had been raised with the manager. One relative told us their family member regularly had clothes go missing and that they had no socks on the day of the inspection as they were all in the laundry. The manager told us they had received complaints regarding the laundry and had recently increased staffing numbers so that dedicated laundry staff were on duty each day.

Staff we spoke with demonstrated a good knowledge of people’s individual care, their needs, choices and preferences.

There was no activities coordinator employed, but all staff were responsible for providing activities on a daily basis and a Programme of activities was in place. The manager also told us that external entertainers visited the home three times per week. People we spoke with were satisfied with the activities available and we were told that the home also arranged trips and outings to local places of interest. One person living in the home told us they were supported to attend a local church service and that a priest also visited the home and offered people communion.

Systems were in place to gather feedback regarding the service and listen to people’s views, such as resident meetings and regular quality assurance questionnaires.

People had access to a complaints procedure and this was displayed within the home. The manager maintained a log of all complaints received and we found that those we viewed had been dealt with appropriately and in line with the provider’s policy.

Systems were in place to monitor and assess the quality and safety of the service. We found however, that not all identified actions had been addressed. Although the manager was aware of some of the issues we identified during the inspection, the governance systems in place had not highlighted all of the issues we identified during the inspection. This meant that systems in place to monitor the quality and safety of the service were ineffective.

We asked people their views of how the home was managed and feedback was positive.

Staff were aware of the home’s whistle blowing policy and told us they would not hesitate to raise any concerns they had. A range of policies and procedures were in place to help guide staff in their role and ensure they were clear of their responsibilities and aware of the culture of the service.

The manager had notified CQC of events and incidents that occurred in the home in accordance with our statutory notifications. This meant that CQC were able to monitor information and risks regarding Larkhill Hall.

You can see what actions we have told the provider to take at the back of the full version of this report.