Wiltshire Heights Care Home

Wiltshire Heights Care Home is a residential care home providing accommodation, personal and nursing care for up to 63 people. The service provides support to adults over and under 65yrs and people with dementia. At the time of our inspection there were 53 people using the service.

Accommodation was provided over 3 floors accessed by stairs and lifts. People had their own rooms which were en-suite and communal areas such as dining rooms, a library, and lounges. People could also access secure gardens from the ground floor.

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

Medicines were not always managed safely. People had not had their medicines as prescribed and ‘as required’ guidance was not detailed. The provider had taken action to improve medicines management, however, we have made a recommendation about medicines policy. Staff received medicines training and had annual competence assessments.

We observed there were enough staff available to meet people’s needs however, feedback from people and staff was at times there was not enough staff available. The provider used a dependency tool to calculate staffing numbers and used agency staff to fill gaps in rotas. We have made a recommendation about using feedback from people and staff to help calculate staffing numbers.

People who experienced distress did not have detailed guidance in place to help staff to understand how to provide support. We observed 2 occasions where people were not responded to in a timely way. Other risks to people’s safety had been assessed and guidance was in place to help staff manage those risks.

Care plans were in place, but some were conflicting. The provider had changed systems prior to our inspection which had been a challenge and were carrying out monthly checks on the quality of recording. Senior staff also reviewed care plans monthly to make sure they were up to date. People had been given the opportunity to record their wishes with regards to end of life care.

People enjoyed the food and could have family and friends to eat with them if they wished. Menus were available informing people of choices. Systems in place for people choosing their meals were not effective for people with short term memory loss. The provider recognised this and gave assurance they were reviewing mealtimes across all their services. Despite this area for development, we found people were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People and relatives told us people were safe at the service. Staff had been provided with training on safeguarding and understood how it applied to their role. New staff had been given a comprehensive induction which gave them knowledge and skills needed for their roles. Refresher training was provided in a range of areas and staff told us they could ask for training if needed.

The home was clean and cleaning schedules were in place to record what was cleaned and when. Personal protective equipment was available for staff, and we observed them using this safely. Staff were provided with guidance and training on infection prevention and control. Health and safety checks were carried out across the building and for all equipment. We did find rooms that needed to be locked were open and shared this with the provider. They gave assurance these rooms would be kept locked.

People, relatives and professionals told us staff had a kind and caring approach. We observed some positive interactions between staff and people. We also observed some interactions that were not person-centred and shared that feedback with the registered manager. The provider told us their head of dementia care was working with the service to develop staff skills and knowledge to provide good dementia care.

People had a range of activities to choose from if they wished. During our inspection we saw a variety of activities taking place to cater for a wide range of interests. The service had a minibus which was used to take people out to the local community or access local services.

Staff worked with healthcare professionals to meet people’s health needs. Local GPs visited the home weekly and other professionals were contacted if needed for advice. Staff had daily handovers and regular meetings to keep updated with people’s needs. Staff told us there was good communication amongst the team and good teamworking. Feedback from professionals confirmed this.

Quality monitoring systems were in place and shortfalls found during this inspection had already been identified by the provider. There was a service improvement plan in place to identify actions needed to make improvement and who was responsible for this action. Incidents and accidents were recorded, and any necessary actions carried out. Analysis of incidents, falls and other data was completed by the registered manager and the provider to identify any patterns or trends.

People, relatives, staff and professionals told us the registered manager was visible and approachable. People and relatives felt able to complain if needed and we saw complaints were well managed. People thought the service was well managed. Relatives told us they felt able to visit any time and were always made to feel welcome.

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 outstanding (published 10 April 2019).

Why we inspected

The inspection was prompted to seek assurances about the safety and care of people following information received as part of ongoing safeguarding concerns and medicines management incidents. As safeguarding investigations were ongoing, the inspection did not examine the circumstances of those particular incidents. We wanted to seek assurances about the wider safety measures for people at the service. We inspected and found there was a concern with medicines management and the approach of some staff, so we widened the scope of the inspection to become a comprehensive 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.

The overall rating for the service has changed from outstanding to good based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe key question section of this full report.

Recommendations

We have made 2 recommendations about medicines management and seeking feedback from people and staff to help calculate staffing numbers.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice

¿ The provider had made changes to the layout of the home and how parts of the building were used to help control the spread of infection. The library was being used as a visiting room. Visitors were able to enter this room from the outside, which reduced the number of people entering the main part of the building. A booking system had been introduced to ensure people had fair access to the visit appointments that were available. The registered manager had deployed staff to specifically facilitate visits, ensuring infection prevention and control procedures were followed and people were given the support they needed.

¿ People had been supported to continue with activities and hobbies they enjoyed. These included arts and crafts activities, discussion groups and entertainment. Events had been organised in ways to maintain social distancing and meet infection prevention and control measures. People told us this was very important to them and a relative gave positive feedback about the input from the activities and wellbeing team. The service had maintained links with the local community and exhibits from their recent 'National Day of Arts in Care Homes' was being displayed in local shops.

¿ The provider had set up clear procedures to support people to move into the home safely, including periods of isolation and COVID-19 testing. A relative told us "I could not have been more impressed with the process; from Covid precautions to the friendly way [my relative] was greeted by all staff on her orientation walk. The staff were exceptional."

¿ The registered manager had set up infection control 'hubs' on each floor of the home. These were areas where staff could access additional personal protective equipment (PPE) when they needed it. The hubs contained the most recent guidance on what PPE to use and how to use it safely. Staff told us the systems were working well and they had access to all the equipment they needed. Staff said they had received training in infection prevention and control and had received good support from the management team throughout the pandemic.

Further information is in the detailed findings below.

Wiltshire Heights is a care home which provides accommodation and nursing care for up to 63 older people, including people living with dementia. The home is arranged over three floors, Robin, Willow and Poppy. At the time of our inspection 54 people were living at the home.

People’s experience of using this service:

People received an outstanding leisure and wellness service which catered to individual interests and abilities. People had a comprehensive and varied menu of activities to choose from and were involved in the development of clubs and programmes for the home.

People received outstanding end of life care which was compassionate, holistic and sensitive. Families were generously and respectfully supported during this time and were able to stay with their relative or visit around the clock.

People received an outstanding caring service. People told us they received very kind and respectful support from staff who promoted their abilities. Staff promoted people’s privacy and dignity and enabled them to make choices and have as much control and independence as possible

The registered manager had made improvements since the last inspection to ensure people always received safe care and treatment. People told us they felt safe.

People benefited from the development of closer links to their local community which included intergenerational events.

People were cared for by well trained and skilled staff who knew their needs and how they liked to be supported. The whole staff group worked as a team to support people in a person centred way.

People had access to plenty of food and drink throughout the day and were served by a hostess. People told us the food was very good and there was plenty of choice. Meals were appetising and served in a calm and organised manner.

The service was well-led. The provider’s quality assurance processes were effective and there was a focus on continuous improvement. The registered manager provided good support for staff to be able to do their job effectively.

More information is in Detailed Findings below.

Rating at last inspection:

Good overall, Requires Improvement in Safe (report published 6 July 2016).

Why we inspected:

This was a planned inspection based on the rating at the last inspection.

Follow up:

We will monitor all intelligence received about the service to inform when the next inspection should take place.

This inspection took place on 16 May 2016 and was unannounced. We returned on 17 May 2016 to complete the inspection.

At the last comprehensive inspection in August 2015 we identified that the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because medicines were not always managed safely, staff did not always take action to safely manage risks people faced, some nursing staff did not have the necessary skills to provide care that met people’s specific needs, the home had not followed the principles of the Mental Capacity Act 2005, people were not always given the help they needed to eat and drink, people’s private information was not securely stored, care records were not accurate and the service was not well managed. We served a warning notice to the provider as a result of the concerns we identified and the service was placed into 'special measures'. We completed a focussed inspection in December 2015 and found that the provider had taken the immediate action necessary to improve the service. During this inspection we found that the provider had sustained and built upon these improvements. The home was providing a good service, but some action was needed to ensure the support staff provided to keep people safe was always recorded accurately. As a result of the improvements made, the service has been removed from 'special measures'.

Medicines people had been prescribed were available and were safely managed. People received support to take their medicines but further work was needed to ensure staff recorded when they had supported people with topical creams.

Risks relating to malnutrition were well managed and people were supported to take nutritional supplements and fortify their meals where needed to minimise risks. Further work was needed to ensure staff always recorded the nutritional risk assessments accurately.

People told us they felt safe living at Wiltshire Heights. Comments included, “Of course, I’ve only got to press my button and they are there for me, no waiting, and they can’t do enough for me” and “I’m as safe as houses living here”. We observed people interacting with staff in a confident way and people appeared comfortable in the presence of staff.

There were enough staff, with the right skills, available to meet people’s needs. Comments included, “There are always enough staff available. They come quickly if you use the call bell” and “There are sufficient staff and they have the right skills”. During our observations we saw that staff were available to provide support to people when needed, including support for people to eat, drink and move around the home safely. Call bells were answered promptly and staff responded to verbal requests for assistance from people.

Staff understood their responsibilities under the Mental Capacity Act 2005 and had taken appropriate action where people did not have capacity to consent to their care. Staff were well supported and received training that was relevant to their role.

People who use the service, their relatives and visiting professionals were complimentary about the caring nature of staff. Comments included, “They always treat us well. They ask me what I can / want to do and how much help I need. They always encourage me to be as independent as possible”, “I had pneumonia but I have got better, you are so well cared for here you can’t help but get better” and “Staff are very kind and provide all the care and help I need”.

People had been supported to develop care plans which were personal to them and told us staff provided care in line with their plan. People were confident any concerns or complaints they raised would be responded to and action would be taken to address their issue. Comments included, “The manager acts very quickly on any complaints. I would be happy to raise a concern or make a complaint knowing that people would listen and something would be done about it” and “If I had a real concern I would go to (the registered manager) and I know she would listen”.

People told us the home was well managed and there was good leadership. Comments included, “(The registered manager) comes round every day so we can speak to her if we need to. We are confident she will resolve any problems”, “I’m confident (the registered manager) would sort out any problems. She comes round every day and speaks to us” and “The manager listens to concerns and takes action”. The registered manager had developed detailed plans to address shortfalls in the service and improve the quality of care being provided.

This inspection was carried out to assess whether the provider had taken action to meet the warning notice we issued. This report only covers our findings in relation to the warning notice we issued and we have not changed the ratings since the inspection in August 2015. The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for Wiltshire Heights Care home on our website at www.cqc.org.uk.

We will carry out a further unannounced comprehensive inspection to assess whether the actions taken in relation to the warning notice have been sustained, to assess

whether action has been taken in relation to the remaining breaches, and to review the rating for the service.

At this inspection we found the provider had taken action to either fully address the issues highlighted in the warning notice or to make sufficient progress. Nursing

staff had the required core skills to be able to offer individualised care safely. There was a training programme in place to ensure competency in these core

skills and the training for the safe administration of medicines. There was a clear structure in place for clinical direction and supervision of nursing staff.

Improvements had been made to record keeping, in the level of detail care plans included and the guidance to staff on how to support people with behaviours which

may challenge. Staff were receiving training on managing behaviours in a positive way and in dementia awareness. Risk assessments clearly identified the possible triggers people may display prior to an incident, thereby enabling staff to take more preventative measures. Monitoring charts contained more information and were being more closely reviewed, however, there was still room for improvement in this area.

People had access to their call bells at all times. Care plans and risk assessments identified the location of where equipment should be placed such as sensor mats.

Staff were clear as to why equipment was used and how it should be used in order to protect people. The recording of medicines had improved, however, there

were still areas for further improvement around ensuring recording was accurate and complete. New systems were being put into place for the organisation and ordering of medicines.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

People were treated with respect and dignity by staff. People told us that staff treated them well. People were cared for by staff who were aware of the risks to their safety and health and staff knew how to support them in a safe way. People told us "I feel safe at night" and 'carers are respectful and they are my friends' and 'I have no complaints'.

Staff we spoke with told us that they had attended safeguarding training and knew how to recognise and report abuse. They demonstrated their understanding of safeguarding issues and their responsibilities in reporting concerns.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The registered manager had submitted a recent application and had been trained to understand when an application should be made. This meant that people were kept safe from harm. There were effective systems in place where people did not have capacity and best interest decisions were made through a multiagency approach.

Is the service effective?

People we spoke with told us that they were generally happy with the care they received and their care needs were met. It was clear from observations and from speaking with staff that they had a good understanding of people's care and treatment.

A visitor told us that care staff were 'mostly' knowledgeable and understood their relative's needs. We were told 'all care staff are delightful, very nice and helpful, and do their best' and the nurses were 'good'. However they said that when care staff were new they did not always know how to support their relative in a consistent way.

The service had gone through a period when several staff had left, leaving agency workers to cover vacant shifts. Comments people made about the staffing included 'you never know who's going to be here today, that is the problem here' and 'wasn't like that six months ago, has gradually happened'. Some staff told us 'everyone is under pressure, staff leave and at times we have not been fully staffed.' Another member of staff told us staffing had improved recently with more cover organised. We found the lack of continuity of a regular staff team had resulted in a low staff morale. Recruitment processes had begun to fill vacancies.

The records of care that staff provided to people were not always accurate. There were gaps in records relating to people's fluid and nutrition intake and the support they received to reposition to prevent pressure damage. This increased the risk that people would receive inappropriate or unsafe care and treatment.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. They demonstrated their knowledge about the people they cared for and understood their preferences in consenting to how they liked things to be done.

We saw people were receiving care in a sensitive way. We observed people being supported in making choices about their daily routines and the activities they would like to do.

Is the service responsive?

We found evidence there had not always been good communication in the management of people's care between the provider and external professionals. Healthcare professionals had concerns about staff having a lack of knowledge and that local resources such as district nurses had been called in to support staff in setting up equipment to meet people's needs and support people with nursing. This showed us that when the home admitted some people they had not always made sure there were suitable arrangements in place to meet individual needs, prior to admission. We found that the provider had not always ensured that there were sufficient staff on duty who had been trained to meet people's needs.

Is the service well-led?

The registered manager has left and the service was being managed in the interim by the regional manager.

Quality assurance processes had not always helped to make improvements to the quality of the service where they were needed. Actions was recorded but had not always been followed up at regular intervals.

We found there the service had not always been well led. This was because there had been a lack of regular staff supervision taking place, staffing vacancies unfilled and communication that had not always been managed well leading to a lack of staff morale and cohesion among the staff teams.