Snapethorpe Hall

Snapethorpe Hall is a residential care home providing accommodation for persons who require personal care for up to 62 people. The service provides support to people who have physical health needs and conditions such as dementia. At the time of our inspection there were 47 people using the service.

The home is set out across 2 floors, each of which has adapted facilities. Each bedroom has an en-suite facility. One floor focused on providing care to people living with dementia.

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

People and their relatives mostly told us they felt people were safe. We found people were at risk of harm as medicines were not managed safely and risks to people were not always well-managed. Risk assessments and care records for people were not always up to date and reflective of people’s current support needs and we found staff were not always following risk assessments in place.

Recruitment for permanent staff was managed safely; however, assurances in respect of agency staff were not always robust. The provider was actively recruiting more permanent staff.

People, relatives and staff raised concerns about staffing levels and consistency of staff. Staff were trained in safeguarding and knew the procedure to follow if they suspected people were at risk of harm.

During the inspection, the service had an infection outbreak. We found staff had not been appropriately deployed and the outbreak management was not robust. We saw some positive interactions between staff and people, however there were not enough staff available on one unit to respond quickly when people needed care, support or reassurance.

Governance processes were in place but were not being used effectively to identify shortfalls and drive service improvement. The registered manager required support around governance processes but the governance and delegation process was not always clear. Feedback from staff was mostly negative about the culture of the service and the management team. However, we found the provider challenged poor practice in the service.

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 service had recently had a refurbishment and the home was very well maintained, providing luxurious and spacious accommodation for people. Most people spoke positively about the care provided by care staff.

The regional management team were responsive to our inspection findings and responded after the inspection. We received updates about what action they were taking, including an action plan in respect of medicines management. The registered manager was new in post and was being supported by the area director to effectively communicate and respond to their regulatory responsibilities.

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 9 April 2020) and there were breaches of regulation. At this inspection we found the provider remained in breach of regulations and the rating remains requires improvement. This service has been rated requires improvement for the last 2 consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service. We received concerns in relation to medicines management, appropriate staffing and management practice and oversight. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. The provider has taken action to mitigate some of the risks identified at this inspection. Please see the safe and well-led sections of this full report.

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 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 comprehensive inspection to calculate the overall rating.

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

Enforcement

We have identified breaches in relation to the safe management of medicines, staffing and governance. We issued warning notices against the registered manager and provider relating to the breach of regulation 17. The provider and registered manager did not submit an appeal or representations against the warning notices.

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.

Snapethorpe Hall provides residential and nursing care for up to 62 older people, some of whom are living with dementia. Accommodation is provided on two floors. The home was split into three units, with the ground floor having a residential unit and a separate dementia unit. The first floor had a mix of residential and nursing care beds. Six beds were used for short-stays. On the first day of our inspection there were 45 people living in the home. On the second day this number was 46.

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

Medicines were not safely managed at this inspection. We identified three people whose pain relief was not available on the first day of our inspection. We observed people not being offered medicines which were prescribed ‘as required’.

There were insufficient numbers of suitably deployed staff. Staff described covering areas of the home they were not allocated to in order to meet people’s care needs. This meant the area they were supposed to work in was at times not staffed.

Governance checks were taking place, although these were not robust as the above issues were not identified. Management spot checks were taking place on all shifts to assess quality oversight through both day and night. Meetings for people, their relatives as well as staff were taking place.

Feedback was actively encouraged through several systems. The most recent satisfaction survey for people and relatives showed mostly positive feedback was received. An action plan had been created and put on display. Relatives knew how to complain if they were dissatisfied and when this happened, this was managed appropriately.

Feedback we received showed staff were kind and caring. We observed positive interactions between staff and people. Staff were familiar with people's preferred routines and their care needs. Privacy and dignity was maintained and people’s equality, diversity and human rights were met.

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.

Risks to people were assessed and action was taken to reduce levels of risk. Care plans were person-centred and contained sufficient detail for staff to follow. Activities were taking place both inside and outside of the home.

Staff received a programme of induction, training, supervision and appraisal. Staff spoke positively about a recent change in the registered manager.

We have made a recommendation about the recording in food and fluid charts.

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 Good (published 28 July 2017). There was also an inspection report published on 12 April 2019. This was withdrawn as there was an issue with some of the information that we gathered.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to the safe management of medicines, governance and staffing . You can see what action we have asked the provider to take at the end of this full report.

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.

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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We had previously inspected the home in April 2016. At the previous inspection, we found staff did not have access to written instructions for the safe moving and handling of people. This was a breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also found there was no consistent recording or understanding about people's ability to consent to care. This was a breach of Regulation 11 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During this inspection we checked whether there had been any improvement in the service. We found there had been and the provider was no longer in breach of the regulations.

We saw safeguarding matters and accidents and incidents were responded to appropriately. We checked staff files and found all recruitment checks had been carried out as required. Staff felt supported and had regular training and supervision.

We checked staff rotas and saw all shifts had been covered up to two weeks in advance where gaps had been identified, particularly in the nursing staff. We observed call bells were responded to in a timely manner. We observed a number of people who needed assistance to eat would have had to wait some time if relatives had not been available. We recommend that the provider assesses the staffing levels around mealtimes.

We saw systems were in place for the ordering, recording and disposal of all medicines received into the home. Medication Administration Record sheets (MARs) were completed with the detail and the amount of the medicine received. We were concerned medicines which needed to be taken before food were not always administered in line with the manufacturer’s instructions. The registered manager rectified this issue on the day of inspection.

Staff understood the basic principles of the Mental Capacity Act (2005). 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.

We observed most bedroom doors in the home were open, although we checked with the people we spoke with and they did confirm this was what they wanted. We recommend that the provider needs to evidence people’s choice to have their bedroom doors open permanently or whether it has become standard practice.

We found people were appropriately supported to eat and drink. People’s weight was monitored, some on a weekly basis where concerns had been identified. People had access other healthcare professionals when required.

The people we spoke with told us staff were caring and friendly. They also told us staff knew them well and understood their needs. People’s independence was promoted well and staff encouraged people to do as much for themselves as they were able.

People’s care records were detailed and person-centred. Care plans were in place for communication, personal care, mobility, eating and drinking, safety, medication, activities, sleeping, continence and skin care.

The provider monitored the quality of the service. Regular audits took place in areas such as; care records, medication, health and safety, infection control and catering. We saw complaints were recorded and responded to appropriately. The complaints were reviewed by the provider’s head office to ensure they were actioned within a timely manner.

Snapethorpe Hall provides personal care and nursing care for up to 62 older people, some of whom are living with dementia. Accommodation is provided on two floors with lift access between floors. Communal lounge and dining areas are provided on both floors. On the day we inspected there were 48 people living at the home; 12 were in the specialist dementia unit, 14 in the residential area and 22 in the nursing section upstairs in the home. The home had recently changed the nursing unit to upstairs to create a more secure and cosy dementia unit downstairs.

The home had recently appointed a new manager who was undergoing the required checks before being registered. They had been in post since 8 March. 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 living in the home felt safe and had confidence in the staff caring for them. Staff were able to explain what action they would take if they were concerned about someone and knew the procedure to report such concerns.

Some people living in the home did not feel there were enough staff and this was also reflected by some staff comments. We did not witness any major impact on people in the home but were aware that staff were working in a pressured situation for much of the time we were there, and that in the dementia unit some people required one-to-one care which restricted the flexibility of the staff team to respond at times.

Medicines were administered safely although we found issues with the lack of fridge temperature monitoring in the treatment room and for some people, a lack of specific instructions in how they took their medication. There were no specific capacity assessments or best interest decisions detailing how to support someone who was resistant to taking medicines.

Risk assessments were in place for factors such as choking, skin integrity and falls but not all of the risk assessments were detailed and some contained conflicting information. We could not find any reference to safe moving and handling instructions for staff when using equipment such as a hoist. This was a breach of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as staff did not have access to written instructions for the safe moving and handling of people.

People in the dementia unit were supported well with their nutrition and hydration needs but this was not reflected in all areas of the home. Food and fluid charts were kept but not always used to their full potential. However, the new manager had implemented further training and detailed care plans in relation to supporting people with weight loss. People had timely access to health and social care services.

Staff had received supervision from the new manager since they had started but there were gaps in the training schedule for some staff. The manager was aware of this and addressing these gaps. It was evident from conversations with staff that understanding around the requirements of the Mental Capacity Act 2005 and its associated Deprivation of Liberty Safeguards was limited. We spoke with the manager about this and they agreed to look at this issue promptly. This was a breach of Regulation 11 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 need for consent as there was no consistent recording or understanding about people’s ability to consent to care.

People were supported by staff who were kind, caring and friendly. We observed people being acknowledged throughout the day which was an improvement from our previous inspection. Staff were discreet in offering support and worked well with colleagues to ensure people’s needs were met in a timely manner.

People had access to a wide range of activities, especially in the dementia unit. These were varied according to people’s needs and interests.

The home focused on person-centred care giving people as much choice as possible, such as when to get up, and most records were reflective of individual needs. However, not all the information was current and some records needed further scrutiny. We were concerned as some staff told us they did not have time to read the records which could have meant incorrect care was delivered.

We saw a detailed complaints log with in-depth investigations, apologies where required and learning from situations which was shared with staff at team meetings.

People and staff all said they liked working at the home but for staff there had been a long period of instability due to the lack of a registered manager. The home had been supported by relief and turnaround managers in the interim. The new manager had been pro-active since starting only one month previously and had already implemented some changes which were taking effect. Communication was a key area and staff had access to detailed information through meetings and supervisions.

The home had a quality assurance process in place and we saw the audits were in detail with action points completed. However, the lack of effective care plan auditing over the past six months meant there were issues in people’s records and the lack of evaluation about staff’s training had resulted in problems with the understanding of mental capacity.

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

Is the service safe?

We found the systems for managing medications were safe. There were sufficient staff on duty to meet people's needs safely.

Is the service caring?

We found staff were kind and caring. People received care that was planned and delivered to meet their individual needs.

Is the service effective?

The service had made improvements since the last inspection to ensure people received good care. Staff had a good understanding and knowledge of people's needs, which meant they were able to provide effective care for them.

Is the service responsive?

We found the service had responded and improved the mealtime experiences for people. Increased staffing levels meant people were receiving the care and support they needed.

Is the service well led?

We found management structures had been strengthened to enable the effective maintenance of staffing levels and staff deployment.

We carried out this inspection in response to concerns raised at recent safeguarding meetings regarding the care provided to people who lived on the Kirkgate and Westgate units. Both units provided care and support to people with dementia. We visited late in the afternoon as concerns had been raised about the staffing levels on these units, particularly over the tea time period. We also reviewed the care provided to people and the management of medicines as concerns had been identified. We focused our visit on the first floor and did not spend time on Northgate and Southgate units at this inspection.

During the inspection we spoke with the Quality Assurance Manager, the registered manager, three relatives, three people who lived in the home and six members of staff. We spent time observing the care being delivered and how staff interacted with people.

We found there were shortfalls in the care records, which meant it was not clear what people's current needs were or how they were being met. We identified some areas where people's dignity was not respected. People we spoke with gave mixed views about the care. One person said: 'I like it here. The girls are nice'. Another person said: 'I'm fed up and so bored. Nothing to do'. A further person told us: 'It's good here, not a lot going on but happy watching telly'.

We observed the tea time meal was disorganised, which meant people were not provided with the support and supervision needed to ensure they received adequate food and fluids. The menu displayed did not reflect the food served and pureed diets were not presented in a way that enabled the person to distinguish the different tastes or textures of the meal.

We found discrepancies in the medicines administration records, which meant we could not determine if some people had received their medicines as prescribed.

We found although the staffing levels may be considered sufficient for the number of people living on the first floor, the layout of the units and the dependency levels of the people accommodated meant more staff were required to ensure people's needs were met at all times.

We saw that people were treated with dignity and respect by staff. We saw that staff were caring and kind in their interactions with people and offered them choices in all aspects of their daily lives. People who used the service told us staff were 'very good' and relatives said they were satisfied with the care and support provided.

People looked well care for and staff we spoke with had a good understanding of people's needs. New care documentation was being implemented in the home. We saw evidence that people who used the service and their relatives were involved in planning care.

People told us they enjoyed the food. One person described the food as 'brilliant'. We saw that people were offered a choice and nutritional needs were assessed and monitored by staff.

We found the home was clean and well maintained. We were told there is an ongoing refurbishment programme to improve the environment.

We observed that there were sufficient staff to meet people's needs.

We saw there were systems in place to monitor and audit the quality of service people received.