Choice Care Home

Choice Care Home is a care home without nursing registered to provide accommodation and care for up to 32 people. People living at the service are mostly older people, some of whom may be living with dementia or physical disability. At the time of our inspection there were 32 people using the service.

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

The environment was safe and there was equipment available to support staff in providing safe care and support. Health and safety checks of the environment and equipment were in place. However, we found some areas of the service with clutter left around and some carpets heavily stained. The manager told us new flooring was being ordered for many areas in the service.

Medicines were ordered, stored and disposed of safely. However, one person who had a daily patch applied did not always have this placed in different areas on their body as required. The manager assured us they would discuss with staff and have a protocol put in place to ensure this happened.

We have made recommendations about the management of medicines. The report highlights the actions the provider had taken at the inspection.

People were supported by staff who completed an induction, received appropriate training and support to enable them to carry out their role safely, including fire safety and dementia care training. Staff were recruited safely in sufficient numbers to ensure people’s needs were met. There was time for people to have social interaction and staff carried out activities to assist people. Staff knew how to keep people safe from harm.

Records were accessible and up to date. The service used a computerised care planning system. The management and staff knew people well and worked together to help ensure people received a good service.

People told us they were happy with the care they received, and people said they felt safe living there. Comments from people included; “Yes I feel safe” while a relative said; “I’m happy he is safe and happy.” People looked relaxed, happy and comfortable with staff supporting them. Staff were caring and spent time chatting 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.

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. People’s communication needs were identified, and where they wanted, people had end of life wishes explored and recorded.

Staff told us the manager and deputy manager was available, assisted them daily and helped cover shifts when some staff had been off with COVID-19. They went onto say how they were approachable and listened when any concerns or ideas were raised. One relative said; “It is delightful here and I would recommend it and much has improved since (named manager) has been here.” While a staff member said; “(named manager) is not just a manager, she will do everything that we are doing.”

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 7 November 2018).

Why we inspected

We were prompted to carry out this inspection due to concerns we received about the service, staffing and management. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe, effective 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 not changed and remains good. We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the Safe, Effective and Well led sections of this full report.

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

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

Following the last inspection, we met with the provider and asked them to complete an action plan to show what they would do and by when to improve the key questions safe, effective, responsive and well-led to at least good. After the last inspection we added a positive condition to the providers registration asking for a monthly report to be sent to us so the service could share with us the improvements they were making and how they were managing risks. The service adhered to this positive condition and sent in reports as required.

Choice Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service accommodates up to 32 people in one adapted building. At the time of our inspection there were 24 people living in the home. Six of the rooms were allocated for people discharged from hospital who needed recuperation before moving home. The people in these rooms had specialist community health professionals from the integrated care team visiting them as well as care support from staff in the service.

Choice Care Home had a registered manager in post 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.

There had been a marked improvement in the way risks were managed for people since our last inspection in August 2017. There was better oversight in ensuring people were hydrated and how this was recorded. The service had implemented a new electronic recording and support planning system which flagged up to care staff when people needed support and recorded when it was given.

People told us they were happy living in the service and staff were kind and caring. Some people said care staff could spend more time with them but we saw that people were having their needs met.

People were kept safe through robust safeguarding processes and staff were aware of what abuse might look like and how to report it. The service had shown how it learned from incidents such as falls and reduced the risk as a result. Risks around health concerns were managed well and health professionals told us they were pleased with the communication in the service.

Care plans were person centred and regularly updated. Care staff knew people’s needs and how they liked their personal care to be provided. People said they enjoyed the food and were offered different meal choices.

Complaints were recorded and fully investigated. People and relatives said they were happy to and knew how to complain. The quality assurance systems were thorough and the registered manager and deputy managers monitored the day to day running of the home.

Medicines were managed safely and staff who administered medicines were trained and competency tested. The home was clean, tidy and pleasantly decorated. Infection control procedures were followed and care staff wore appropriate personal protective clothing such as aprons and gloves where appropriate.

Prior to this inspection we had received some information of concern about the service through recent safeguarding processes. The concerns related to people not receiving sufficient fluids, reports of people with unexplained bruising, concerns about staffing levels and people falling. Two safeguarding processes were ongoing at the time of the inspection.

At the last inspection on 3 July 2015 the service was rated as ‘Good’ with requires improvement in the key question of ‘Safe’. This had been because some information about one incident that occurred at the home had not been shared with the local authority safeguarding team at that time, which meant they had not been subject to external scrutiny and review. At this inspection in August 2017 we found the service had not sustained some areas of good practice. We also identified a number of concerns and breaches of legislation. The service has been rated as requires improvement overall.

The management of the service was reactive in that they had taken action to address concerns once identified by external agencies. However some of this action had not been sustained and had led to repeated poor outcomes for people. Management or governance systems were not always effective in making changes and improvements at the service, or identifying when systems were failing. This told us learning did not always take place and actions taken had not always been effective in reducing risks to people’s safety or poor health outcomes.

Risks to people’s health or well-being, particularly with regard to fluids or pressure ulcers were not always robustly addressed. We identified although risks to people had been identified, actions had not always been consistently taken or recorded. This meant it was not easy to see if actions had been successful in reducing risks or preventing additional risks. Poor recording meant records could not always be relied upon to highlight ongoing concerns. For example we found the systems for analysing risks did not assess the effectiveness of actions taken; fluid charts were not completed well or consistently and where poor fluid intakes were recorded concerns were not always immediately highlighted or actions taken.

There were not always sufficient staff on duty to meet people’s needs. We found there were times of the day when people did not receive sufficient supervision from staff which had left them at risk. We observed instances where people not being supported led to situations where their dignity was not respected. People using the service, visitors and staff told us there were not enough staff at times, particularly during the afternoon and evening.

Infection control practices for staff were effective but the laundry area and management systems needed attention to ensure infections could be managed safely. This was because this area was cluttered and there was limited effective separation between clean and dirty items. However a recent infection risk had been managed well. We have recommended the provider seeks and implements guidance on the provision and maintenance of a clean and low infection risk laundry management system.

Systems were in place for the management of complaints. When we looked at the systems we identified these did not cover all the concerns we were aware had been raised with the service. The registered manager told us they did not record minor concerns as complaints. Relatives told us there were some areas they had repeatedly raised such as issues about laundry, but these had not been resolved. The registered manager told us they had not previously considered these as complaints but would now include them in the system This means there would be a clearer audit trail of actions taken.

Records were not all well maintained. We found some people’s care records were inconsistent or had not been updated to reflect people’s care and treatment needs or risks associated with their care. We have made a recommendation about this. Charts such as for moving and positioning people at risk of pressure ulcers had not always been completed. This meant it was not always possible to check whether people were receiving appropriate care.

Systems for staff training and support were in place. However, learning was not always followed up to ensure practice had improved.

People received a well-balanced and nutritious diet. However we found some people would benefit from additional equipment to increase their independence with eating. For example we found some of the crockery was difficult for people to handle, and evening meals were served on small side tables in the lounge, which made it difficult for some people to eat from.

The environment was homely and comfortable, but would benefit from additional adaptation to meet the needs of people living with dementia. For example, we identified a lack of signage made it difficult for people to orientate themselves or make sense of their environment. We found one person who was living with dementia stuck in the lift and unable to understand how to get out as there was no clear information available to help them. Some adaptations had already been made and some other items had been ordered following two recent dementia audits at the service. The manager told us this had been ‘inspirational’ and they were going to continue with the recommendations they had identified. The environment was regularly assessed for risks and plans put in place to manage these. We found two rooms had a strong odour and action was taken to investigate and remedy this.

People received their medicines safely. Staff received appropriate training before they were able to administer medicines and appropriate records were being kept to ensure people received the correct medicines at the correct time as prescribed.

Staff understood how to raise concerns about people’s well-being, and staff recruitment systems were robust. Staff were recruited following a clear process which ensured risks were minimised. This included ensuring disclosure and barring service (police) checks were undertaken, and any risks identified were assessed.

People‘s rights regarding capacity and consent were understood and supported. We saw staff offering people’s choices and acting on them. Staff knew some information about people’s histories, and had built positive relationships with people. We saw staff delivering gentle and supportive care. Staff spoke about people respectfully.

The service had some activities available for people, and the registered manager described this as ‘work in progress’ to provide more person centred activity. Some people’s care plans did not contain information about what interests people had or their social and personal history. The registered manager was working on this with the implementation of documents about people’s history and social biography to help staff understand and support people with knowledge about their life prior to moving into the service.

Notifications had been made to the Care Quality Commission or other services as required by law. Policies and procedures were up to date.

People overall told us they were happy with the services they received. One person told us the service had exceeded their expectations and another they had been looked after “fantastically”.

Quality assurance systems had involved gathering the views of people living at the service and their relations, staff and other interested parties about what was working well and what could be improved. This had then been fed back to people at a meeting. This had meant people had been informed about the impact their response had made.

We took enforcement action against the registered provider as a result of this inspection, and proposed a condition be placed on their registration that they update us each month with a report on the actions they have taken to address the concerns. The registered provider exercised their right to make representations against the imposition of the condition. Their representations were unsuccessful, and a notice of decision was issued to the service accordingly.

The inspection was carried out by an adult social care inspector. During the inspection the inspector looked at the evidence to answer five key questions:

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Choice is a care home without nursing, providing care and support for up to 24 older people, most of whom had some degree of dementia. We spoke with six people who lived at the home about their experiences there. We also spoke with a relative, four members of staff and the Registered Manager. We also reviewed records relating to the management of the home which included six care plans and observed the care and support people received in periods throughout the day.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

Is the service caring?

We saw staff engaging with people in positive ways. For example we saw one person had been given a cup of tea but they had fallen asleep and it had gone cold. We saw a staff member approach the person and gently touch their arm to wake them. They said 'Your tea has gone cold ' I'll get you a hot one'.

One person we spoke with told us 'The best thing about here is that we matter to them as people. They really care about us. Look at all the work they have carried out to make us comfortable.' Another person said 'They've been as good as gold- when you don't feel well it is so lovely to have them look after me'.

We saw staff working with people in a caring manner. As an example, we saw staff supporting a person with hoisting equipment. We saw they were competent and confident with the transfer. We saw that the person was consulted and informed about every action they were taking. This helped reassure the person during the activity. When the task was finished the staff members checked the person was comfortable and got them a cup of tea and something to eat. We saw the person was left smiling and enjoying some toast. This showed us that staff cared about the wellbeing of the person they were caring for.

Is the service responsive?

We saw the home was responding to changes in people's needs. We saw staff identifying and addressing people's needs in a timely way. We saw people were given additional cold drinks for example as it was a hot day. People who went outside to sit had sunhats provided. This told us staff kept people's needs under review.

We saw that the home responded well to changes in people's needs. For example we saw evidence that the home responded quickly to seek medical or paramedic advice following falls or injuries to people. We saw that following two recent falls a person had been referred to the specialist falls team for a specialist assessment.

We saw that the provider had taken steps to gather the views of and consult with people about changes taking place at the home. We saw that concerns or complaints raised were investigated and addressed.

We saw that since our last inspection, under the previous provider, significant work had been undertaken both internally and externally. A shaft lift had been provided to help people access the first floor. We saw that an attractive and secure garden had been provided where people could spend time safely but independently of staff. A member of staff we spoke with about the changes said 'I really think that they have done us proud.'

Is the service safe?

We found the provider had undertaken work to improve safety for people at the home.

We saw that the home had clear information available to support people's healthcare needs. For example we saw staff at the home administered insulin to a person under the delegated authority of the district nurses. We saw the person's condition was monitored regularly by the nurses who had trained three named staff to carry out the administration. We saw staff had clear protocols in place to manage changes to the person's blood sugar levels. This told us safe practice was implemented.

However we also identified concerns about the records kept at the home. We saw that these were not always maintained in enough detail to enable staff to care for people consistently or safely.

We saw that there were enough staff on duty with the right level of skills needed. However we did not identify the staffing levels had been decided upon as the result of a formal assessment of skills or dependency level of the people who lived at the home.

We saw there were risk assessments undertaken of the environment, people's needs and safe working practices. For example we saw there were nutritional risk assessments for people who lived at the home and pregnancy risk assessments had been undertaken for staff who were pregnant. However, we found some audits had lapsed and new quality assurance systems had not yet been implemented. This could leave people at risk if potential areas of risk had not been identified, for example infection control risks.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS) and report on our findings. No-one at the home was subject to an authorisation by the Court of Protection at the time of the inspection. The provider was however discussing the people at the home with the local authority and community psychiatric team to assess and prioritise applications due to a recent clarification of the law in this area. This told us that the provider understood the actions they needed to take to ensure that people's rights were protected and that where people were being deprived of their liberty this was in accordance with legislation.

We identified that although the home was clean and substantially odour free, the laundry area was cluttered and therefore not easily cleanable. This could leave people at risk of potential cross infection.

Is the service effective?

Information was used and communicated effectively by staff. We saw staff taking part in a handover of information between shifts. Each person was discussed, along with any particular needs that had been identified and any changes to their care plans. For example staff discussed one person who was going to attend a family party and what they needed to pack to take with them that day. This showed us that staff were organised and tasks were delegated to meet people's needs in a timely way.

People we spoke with told us their needs were met. We saw that staff knew people well and that people received their care in a timely way. We saw that staff were observant of people's needs and intercepted requests. One person we spoke with told us 'Of course we could do with more staff as they are so very busy. But we don't go without and they always have a cheerful face for us even if they are busy'.

Is the service well led?

People who lived at the home told us the manager and staff were 'Wonderful'. Staff we spoke with were clear about their roles and lines of authority at the home. They told us 'I get a lot of support from the manager and deputy. I can go to them at any time for advice. There is a good atmosphere ' all the relatives remark on it ' and we all work really well together.'

We saw that the new provider had still to implement the major part of their quality assurance system and ensure effective governance of their policies and procedures since the change of ownership. This meant staff might not have access to policies that resulted from clearly understood or authorised management systems.