The White House

The White House is a care home that provides personal care for up to 22 older people. At the time of the inspection 20 people were living at the service. Some of these people were living with dementia. There were five self-contained flats attached to the service. People living in them were supported by the staff team and spent time in the communal areas of the main house if they wished.

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

Risks associated with people's care had been assessed and guidance was in place for staff to follow. A robust specialised risk assessment was completed before a person could move into the self-contained flats connected to the home. This was reviewed frequently to ensure it remained current and the person was able to continue living there safely. Peoples capacity had been assessed regarding the decision to live in the flats and best interest decisions made when required. Applications had been made appropriately to legally deprive people of their liberty. They were reviewed monthly.

Staff were recruited safely. There were sufficient staff employed and on duty to meet people’s needs and keep them safe over a 24-hour period. This allowed for effective monitoring of people’s welfare in the self-contained flats. Staff were very visible during the inspection, anticipating and responding to people’s need for support. A relative told us how a new member of staff had ‘taken the time’ to sing to their family member, telling us, “It’s the little things they do that make the difference.”

There were robust infection control practices in place. However, government guidance had not been fully understood regarding a member of staff unable to wear a mask for health reasons. The registered manager responded immediately to feedback, taking action to ensure peoples safety.

Care plans were detailed, person centred and reviewed frequently with people, and their relatives where appropriate. They gave staff the information they needed to support people safely in line with their individual needs and preferences. The electronic care planning system ensured information about any changes in people’s needs was shared promptly across the staff team.

Relatives spoke highly of the way the home kept them involved and informed about the service and welfare of their family member during lockdown. They could use the ‘relatives gateway’ to access their relatives’ information on the electronic care planning system. This meant they could see and monitor the care being provided in real time and raise concerns if they had any.

People received their medicines safely, and in the way prescribed for them. The provider had good systems to manage safeguarding concerns, accidents and environmental safety. The service worked alongside external health and social care professionals to support people. Safeguarding processes were in place to help protect people from abuse.

The provider and management team had worked to make significant improvements at the service. Feedback from a visiting professional stated, “I have seen significant improvements in the management, communication and professionalism over the last two years.”

A comprehensive quality assurance programme was in place. The management team were highly visible on the floor, supporting staff and monitoring practice. The providers visited the service weekly and attended monthly quality monitoring meetings.

There was a transparent and open culture at the service. Staff spoke highly of the improvements made and the way the service was managed. Comments included “It’s well managed. They listen. They take on what we are saying. It’s not hierarchical. We are all looking out for each other and work really well together.” Staff were supported to keep their knowledge and skills up to date and continue with their professional development.

Rating at the last inspection (and update)

The last rating for the service was Requires Improvement (published on 10 January 2020).

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

Why we inspected

We undertook this targeted inspection to follow up on conditions placed on the providers registration. These were imposed following our inspection in May 2019 and related to the self-contained flats attached to the service. At the time of our last inspection in December 2019 the provider had reduced risks to people by not using the flats. However, the flats were in use again and the provider had applied to have the conditions removed.

We inspected and found improvements across the whole service. We therefore widened the scope of the inspection to become a focused inspection which included the key questions 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.

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.

The White House is a care home that provides personal care for up to 22 older people. At the time of the inspection 11 people were living at the service. Some of these people were living with dementia. There was also five self-contained flats attached to the service that were currently not in use.

This service was registered for the current providers on 9 May 2018. The service was inspected on 4 and 5 December 2018, because of concerns we had received. At that inspection the service was rated as Inadequate overall and for the key questions of Safe, Responsive and Well Led. Breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the CQC (Registration) Regulations 2009 were found.

Following the inspection in December 2018, the service was placed in 'Special Measures' by the Care Quality Commission (CQC).

The purpose of special measures is to:

• Ensure providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made

• Provide a clear timeframe within which providers must improve the quality of care they provide, or we will seek to take further action, for example to cancel their registration.

We asked the provider to complete an action plan to show what they would do and by when to improve.

At the inspection on 22 and 23 May 2019 sufficient improvement had not been made. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the CQC (Registration) Regulations 2009. Some of these were repeated breaches from the previous inspection, although we found the seriousness and risks associated with the breaches had been reduced.

The overall rating for this service was 'requires improvement' and the service remained in 'Special Measures'. This is because one key question has been rated as 'inadequate'. This meant we would keep the service under review and if we do not propose to cancel the provider's registration, we would re-inspect within six months to check for significant improvements.

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 improvements had been made and the provider was no longer in breach of regulation. However, it had only been a short time since the last inspection and these improvements and changes needed to be embedded into the service. The services action plan confirms some issues remain ‘in progress’ and not yet completed. Therefore the service remains ‘requires improvement’.

This service had been in Special Measures since December 2018. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or any of the key questions. Therefore, this service is no longer in Special Measures.

The service had been working with the local authority Quality Improvement team to embed positive changes. A new manager has been employed since the last inspection and has been working alongside the Quality Improvement team. The manager was supported by senior management. New management systems had been implemented to better monitor care provision.

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

People told us they were happy living in the home and staff told us they particularly enjoyed working in the homely atmosphere. The manager and staff’s passion for caring for people was clear. Relatives and staff spoke highly of the new manager in post.

People and their relatives told us they were happy with the care they received and believed it was a safe environment. One person said; “Yes I feel safe here.” A relative said; “The staff are always about.” People looked happy and comfortable with staff supporting them. Staff were caring and spent time chatting and enjoying their time with people as they moved around 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.

Staff recruitment processes and staffing levels had improved to ensure people’s needs were met. There was time for people to have social interaction and activity with staff. Staff knew how to keep people safe from harm.

Improvements to the environment were still ongoing. However, the environment was safe, and people had access to equipment where needed. Staff received appropriate training and support to enable them to carry out their role safely, including safeguarding training.

Medicines management and practices had improved and were safer. People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.

Records of people's care were individualised and reflected each person’s needs and preferences. Risks were identified, and staff had guidance to help them support people to reduce the risk of avoidable harm. Staff were responsive to people’s requests and gave people choice and control over their care. Improvements were being made to the options available for how people spent their time.

People were involved in menu planning and staff encouraged them to eat a well-balanced diet and make healthy eating choices.

People received support from staff who cared about them. People were supported to express their views in the way they wanted to. People and their families were given information about how to complain and details of the complaint’s procedure were displayed at the service. The management and staff knew people well and worked together to help ensure people received a good service.

People, their relatives and staff told us the management of the service were hands on, approachable and listened when any concerns or ideas were raised.

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 requires improvement (published 29 June 2019) and there were multiple breaches of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.

This service has been in Special Measures since December 2018. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

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.

The White House is a care home without nursing and is registered to provide accommodation and support for a maximum of 22 people. At the time of the inspection there were 15 people living at the service. People living at The White House were older people, the majority living with dementia.

The service is set over three floors, with accommodation for people on the ground and first floors; office services are on the second floor. In addition, the service has six registered beds set away from the main accommodation but on site, offering a self-contained bedroom, and bathroom with kitchen area.

Since the last inspection a new manager had been appointed and had made application to be registered.

Enforcement

This service was registered for the current providers on 9 May 2018. The service was inspected on 4 and 5 December 2018, because of concerns we had received. At that inspection the service was rated as Inadequate overall and for the key questions of Safe, Responsive and Well Led. Breaches of regulation of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and and one breach of the CQC (Registration) Regulations 2009 were found.

Following the inspection in December 2018, the service was placed in ‘Special Measures’ by the Care Quality Commission (CQC).

The purpose of special measures is to:

• Ensure providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made

• Provide a clear timeframe within which providers must improve the quality of care they provide, or we will seek to take further action, for example to cancel their registration.

We asked the provider to complete an action plan to show what they would do and by when to improve. At this inspection sufficient improvement had not been made. We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the CQC (Registration) Regulations 2009. Some of these were repeated breaches from the previous inspection, although we found the seriousness and risks associated with the breaches had been reduced.

The overall rating for this service is 'requires improvement' and the service remains in 'Special Measures'. This is because one key question has been rated as ‘inadequate’. This means we will keep the service under review and if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

All information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

People’s experience of using this service:

We found risks to people’s safety were not always assessed and monitored. We found one person with significant dementia was living in one of the flats external to the main building. Staff were locking the person in at night to maintain their safety, and the person would not have been able to leave their room unaided or use a call bell to seek staff assistance. When staff needed to attend to this person’s personal care requiring a hoist, for example when getting up in the morning while the night shift were still on duty, both staff members were needed. This meant instances where both night staff had to leave the main building unattended to support the person. No risk assessments were in place, either to assess the vulnerability of the person or from the lack of staff in the main building. This had left people at risk.

Some other risk assessments, such as for the premises had not been completed, and a notification regarding allegations of unsafe or potentially abusive practice had not been notified to CQC as required by law. Systems for the safe recruitment of staff were not always being implemented properly.

New computerised systems for care planning had been introduced. However, care records could not always be relied upon. One person’s records showed they had not received appropriate care to manage their continence needs, including not receiving support for a period of ten hours. However, it was not clear if the person had not received care, or if the records had not been completed to record care given. Care plans were based on up to date assessments of people’s needs, and although there were some inconsistencies, contained guidance for staff on people’s wishes about their care.

Medicines practice was not always clearly recorded and had left people at risk of potentially poor care outcomes. Staff were not always clearly recording how much ‘as required’ medicine people had been given or why pain relief had been given at certain times.

We found an instance of a Deprivation of Liberty Safeguard authorisation which was inaccurately completed. This meant the person’s rights were not being protected.

Quality assurance and management systems were in place but had not identified all the concerns we found, some of which were issues that had been identified at the last inspection in December 2018.

Since the last inspection the environment of the service had been improved, to make it more dementia friendly. People were calmer and not showing signs of the distressed behaviours we had seen on the last inspection. Relatives and staff told us the home was improving. Staff had received training in positive support for people with dementia, which they told us had helped their understanding and confidence in supporting people. Some new staff had been appointed and further recruitment was taking place.

We saw some good practice when people were supported well, with kindness, effective communication and understanding. The service was working with the local Quality improvement team to embed positive changes. This was backed up by the service developing supervision systems and senior staff modelling good practice. New management systems had been implemented to better monitor care provision.

Risks to people from living with long term health conditions were assessed, along with other risks such as from falls, choking, poor nutrition or pressure ulcers, and actions taken to mitigate risks where possible. The service learned from incidents to prevent a re-occurrence and was taking advantage of opportunities to learn how to develop further, for example by visiting a similar service rated as outstanding.

We have made a recommendation about following best practice about recording pain management for people unable to discuss any pain verbally and to monitor the effectiveness of ‘as required’ medicines. These include medicines for pain relief.

The service was developing activities and opportunities for people to engage with the local community. Systems were in place for the management of complaints. Systems were in place to support people or their relatives to have a say in the way the service was being run. This included supporting relatives to have a greater understanding of the needs of people living with dementia.

More information is in the full report.

We identified five breaches of legislation as a result of this inspection.

Rating at last inspection: This service was last inspected on 4 and 5 December 2018, when it was rated as inadequate as an overall rating, and for the key questions of Safe, Responsive and Well Led. The service was placed in ‘special measures.

Why we inspected: This inspection was bought forward to allow us to review improvements that we were being told had been made.

Follow up: We will continue to monitor the intelligence we receive about the service. If any concerning information is received, we may inspect sooner.

• People were not always kept safe from harm. We were concerned that one person was not safe and made a referral to the local safeguarding authority and police as we were not reassured the service knew how to best support this person.

• There were not enough staff to meet the complex and changing needs of people. We saw people placed at avoidable risk of harm. There were not enough staff to support people to effectively prevent incidents such as falls.

• There were few activities for people to follow. People were not supported to lead lives that were meaningful to them. We saw three people with needs for positive behavioural and emotional support wandering around the home, showing periods of distress and confusion. They received minimal interaction from staff.

• Medicines were not always managed safely. Care staff were administering medicines in a patient and caring way and recording the medicines given with no gaps. However, there were no protocols in place for covert medicine administration or when it was appropriate to administer a medicine prescribed ‘as needed’. Some controlled drugs were not safely stored.

• Care plans and risk assessments were not up to date with people’s needs, placing people at risk of inappropriate care and treatment.

• People’s preferences were not being met. Choices were offered to some people but care staff did not always offer a choice to those people who might not be able to verbalise their preferences.

• Daily recording and monitoring frequency did not match up to care plans and there were gaps in records. We were concerned some people were not being repositioned as often as they should be and some people who required hourly monitoring to remain safe were not being checked on by care staff regularly enough.

• People were not empowered to have choice and control in their lives. They were not invited to contribute to the running of the home, either through their ideas or taking part in domestic tasks to introduce a feeling of purpose.

• There was insufficient manager and provider oversight into the day to day running of the home. There was a lack of senior staff presence on the floor. We had to intervene and ask for managers to assist after two incidents took place in a short space of time.

• Quality assurance was lacking and did not pick up on some of the issues we found during the inspection.

• The service had not always notified the Care Quality Commission of important events or significant incidents by sending in legally required notifications.

• People were supported by staff who cared about their welfare and spoke fondly of them. Relatives told us care staff were kind. We saw care staff approaching people gently and being patient.

• There had been some efforts to make the environment homely and there were planned redecoration and other maintenance works taking place during our visit.

• People had drinks within reach and were offered warm drinks throughout the day. There was a balanced diet on offer. Some people were not happy with the presentation of the food.

• Staff felt supported and informed by the provider on changes that were taking place. Supervisions were starting to take place. Training had been booked for future dates as there were gaps in staff knowledge and training relating to people’s needs.

• The provider, who had taken over in May 2018 was open to suggestions and had a programme of improvements for processes, the building and staff support planned.

• We found breaches of legal requirements in eight regulations relating to safeguarding, safe care and treatment, recruitment, staffing, consent, person centred care, good governance and notifying us of significant events.

• The service met the characteristics for inadequate in three of the five domains we inspected and the overall rating is inadequate.

• More information is in the Detailed Findings below.

Rating at last inspection.

This was the first inspection for this location under this provider.

About the service.

The White House is a 22 bed residential care home in the sea side town of Teignmouth, set over three floors. Five of these beds are away from the main accommodation but on site, offering a self-contained bedroom and bathroom with small kitchen area. The service supports mostly older people, some of whom may have advancing dementia, sensory needs and behavioural support needs. There were 17 people living in the service at the time of our inspection.

Why we inspected.

We inspected because we had received information of concern and wanted to see if people were safe

Enforcement.

Please refer to the end of the report to see the enforcement action we are taking.

Follow up.

We will be working with the service and local agencies to improve the care at this service.

The overall rating for this registered provider is 'Inadequate'. This means that it has been placed into 'Special Measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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 so 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.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.