Archived: Allison House

Allison House is a residential nursing home providing personal and nursing care to 34 people living with dementia at the time of the inspection. The service can support up to 38 people in a building that was built specifically for this purpose.

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

People’s medicines were ordered, stored and disposed of safely. Medicine records were not always fully completed. This had been identified by the provider and steps were being taken to improve this. Guidance around the administration of medicines that were given covertly (hidden in food or drinks) was not always followed correctly. We have made a recommendation about the management of covert medicines.

People were supported by well trained staff. Mealtimes were relaxed and people were supported to eat and drink enough to keep them healthy. When people required access to health care this was arranged to ensure the best outcome for the person’s wellbeing. The service had been thoughtfully decorated and adapted to encourage both independence and interaction.

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.

Care was delivered with dignity and respect. Relatives were happy with their family member’s care and felt well informed and included in decisions.

People’s care plans contained detailed information to ensure their individual needs and preferences had been considered. They were reviewed regularly to reflect any changes. Staff did their best to ensure people were not socially isolated and provide activities they enjoyed.

There was a calm, friendly atmosphere and relatives felt welcomed. There was a procedure in place for addressing complaints and a new system had been introduced to record and monitor low level concerns.

An effective system of checks and audits was in place. People and staff were regularly consulted about the quality of the service.

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 June 2018) and there was one breach 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.

Why we inspected

This was a planned inspection based on the previous rating.

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.

We last inspected the service on 16, 21 August, 18, 19 September and 2 October 2017 and at that time identified breaches in nine of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were related to safe care and treatment; person centred care; dignity and respect; safeguarding people from abuse and improper treatment; premises and equipment; good governance; fit and proper persons: directors; requirements where the service provider is a body other than a partnership and requirements relating to registered managers.

During this inspection we found improvements had been made and most of the matters we identified at the previous inspection had been addressed. As a consequence of these improvements the service remained in breach of only one regulation relating to good governance.

Allison House 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.

Allison House accommodates 38 people in one purpose built building. At the time of our inspection there were 29 people using the service.

There was a registered manager in place. 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.

Risks to people were assessed and plans put in place to reduce the chances of them occurring. Regular checks were made of the premises and equipment to ensure they were safe to use. Accidents and incidents were monitored to see if improvements to people’s safety could be made. Plans were in place to support people in emergency situations. Infection control practice had improved.

Policies and procedures were in place to safeguard people from abuse and any safeguarding referrals were now being made appropriately.

The registered manager monitored staffing levels to ensure enough staff were deployed to support people safely. The provider’s recruitment process minimised the risk of unsuitable staff being employed.

Systems were in place for the management of medicines so that people received their medicines safely. Arrangements were in place for recording the administration of oral medicines however, some further improvements were needed in the guidance for covert administration and the records and guidance for medicines prescribed ‘when required’.

A programme of redecoration and refurbishment had begun around the service. Improvements had been made to make the environment more suitable for people living with dementia.

People’s nutrition and hydration needs were met and special dietary requirements were appropriately catered for. People were given more support to make choices at mealtimes. Staff plated up meal choices and showed these to people so they could make their choice.

The majority of staff were up to date with all mandatory training and staff were supported with regular supervisions and appraisals.

People were supported to maintain their health and wellbeing. People's care records contained evidence of visits and advice from a variety of health professionals.

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.

Relatives were very happy with the care their loved ones received. Staff treated people with dignity and respect.

Care plans were based on people’s assessed support needs and preferences. This included information on their background, families, hobbies and interests. Staff provided support in a way that reflected the information in people’s care plans and people were supported to access activities based on their interests and preferences.

Policies and procedures were in place to investigate and respond to complaints and relatives were happy that their concerns were dealt with appropriately.

At the time of our inspection nobody at the service was receiving end of life care. The provider had a policy in place to provide this should it be needed.

There were still inconsistencies and gaps in some records. Work had been undertaken to improve the system of audits in place however they were still not identifying all of the issues we found during the inspection.

The provider and registered manager had worked together to make significant improvements at the service. Staff had been involved in the improvement process and feedback indicated that staff morale was high despite the challenges they had faced. Relatives had also been included and encouraged to become involved in monitoring of the service.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The service was previously inspected in June 2016 and was not meeting two of the regulations we inspected. These related to staff training and good governance. We took action by requiring the provider to send us action plans telling us how they would achieve compliance. When we returned for this inspection we found some of the issues identified had been addressed but others had not.

Following the first two days of this inspection we had a number of concerns which were shared with the provider. We invited them to submit an interim action plan but this was not received. During our visits we were also alerted by the local authority and Clinical Commissioning Group (CCG) to concerns they had following a joint visit. In response to these concerns we carried out a third day of inspection on 18 September which was unannounced. The registered manager was not available on 18 September and some information was inaccessible therefore we returned on 19 September 2017. Following our visit on 19 September 2017 we wrote to the provider outlining our findings and the concerns they raised. We again requested an action plan and following receipt of this, two inspectors visited the service on 2 October 2017 to review progress and complete the inspection.

Allison House provides accommodation, nursing care and support for up to 38 people living with dementia. The service is single storey and purpose built around a secure central garden and seating area. There are a number of communal areas around the building including four lounges and three dining rooms.

The service had a registered manager in place. 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.

Staff training had improved since our last inspection. Staff were up to date with most training, however, 20 out of 54 staff were in need of refresher training in dementia awareness.

The system of audits in place was still not effective. The issues we found during the inspection had not been picked up by the checks being undertaken by the manager and senior staff.

We looked at the arrangements in place for the management, storage, recording and administration of medicines. There were discrepancies and unexplained gaps on people’s medicine administration records and prescribed creams were not being marked with a date of opening. Records relating to covert administration of medicines were not clear.

The service had safeguarding and whistleblowing procedures in place. Staff knew how to identify signs of abuse and told us they would report anything they were concerned about. However, incidents of a safeguarding nature were not always reported to the local authority or the Care Quality Commission.

Checks of the building and maintenance systems were undertaken however when repairs were needed these were not always undertaken in a timely manner. Fire doors and emergency lighting that were identified as faulty were not replaced or repaired as a matter of urgency with some remedial work taking up to five months. We observed a window in one of the bathrooms had no restrictor in place. This was a large window which was very easy to access and opened wide enough to climb through. The manager told us they would ensure restrictors were fitted to all windows and when we returned to the service we found this had been done.

Individual risk assessments were not in place for all recognised areas of risk and some records were out of date. This meant that staff were not made aware of how to mitigate risks to people’s safety. A person had moved to the service who was at risk of self- harm. No risk assessment had been put in place to advise staff how to mitigate this risk. We highlighted this on the first day of our inspection and this had been addressed when we returned for the second day.

Information on how people should be supported in an emergency evacuation was not tailored to the needs of the individual and these documents were not in place for every person. Files containing information on how to deal with an emergency situation were locked in the manager’s office on one of the days we visited. Recommendations made by the fire service at a fire safety audit conducted in January had not been acted upon and fire drills were not scenario based or adequately recorded.

There were concerns regarding the infection control processes in place. Some improvements were made to the cleanliness of the service over the course of the inspection but areas of malodour were still present. Furniture was worn and stained and carpets were frayed and in need of deep cleaning. Some flooring and furniture was replaced after our first visit but further action was needed to bring the environment up to an acceptable standard.

People’s weights were not being accurately monitored and malnutrition risk was not being correctly calculated. We saw that the MUST scores were incorrectly recorded and appropriate action had not been taken when weight loss had occurred. The provider stated in their action plan that a new MUST tool would be introduced and people would be weighted weekly where necessary. When we returned to the service on 2 October 2017 we found that MUST scores were still not being calculated correctly and weights records were not always complete. This meant people were placed at risk of malnutrition.

The environment was not suitable for people living with dementia to navigate their way around independently. There was inadequate signage and poor use of colour as an aid to orientate people.

The dining experience was in need of improvement. People were not given appropriate support to make choices at mealtimes and there was nothing in place to support staff to do this, for example pictorial menus. People were seated at dining tables for up to half an hour before receiving their meal. We were told that mealtimes were to be staggered after the first day of our inspection but when we returned we saw that this was not effectively being put into practice.

Records relating to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) were poorly organised. Best interest decisions were not adequately recorded and staff knowledge was limited in this area.

People’s care plans did not always contain detailed information about how they would prefer their care to be delivered. Information was not comprehensive, accurate or up to date.

There appeared to be sufficient staff to meet people’s needs however the manager was not able to evidence that staffing levels were safe or how they were calculated as no dependency tool was in use.

We saw evidence of safe recruitment and selection procedures. Appropriate checks were undertaken before staff started work at the service. Existing staff felt supported. They received regular supervision and annual appraisal.

People had access to healthcare professionals to ensure health and wellbeing was maintained.

People and relatives were happy with the care delivered by staff. There was a calm atmosphere during our visits and staff engaged well with people throughout the day.

An activities co-ordinator was employed two days a week. On the days when they were not working there appeared to be very little to occupy or entertain people.

During the inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Allison House provides care and accommodation for up to 38 people and / or older people living with a dementia. The home is purpose built and offers all ground floor accommodation. The service is built around a quadrangle with a large garden and seating area in the centre, which people who used the service can access safely and securely. At the time of our inspection visit there were 38 people who used the service.

The home had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We looked at the arrangements in place for quality assurance and governance. Quality assurance and governance processes are systems that help providers to assess the safety and quality of their services, ensuring they provide people with a good service and meet appropriate quality standards and legal obligations. We were shown numerous checks which were carried out. However from looking at the health and safety inspection we could not determine the actual checks that were taking place. Staff had identified areas for improvement, however we could not determine if action had been taken. The care plan audit did not include looking at the care plans of all people who used the service. The medication audit was insufficiently detailed as it didn’t include a check on systems and although the service did an annual assessment of infection control there was no other auditing in-between.

Records looked at during the inspection indicated that not all of the staff were up to date with their training and that some staff had not received training in areas such as behaviour that challenged since 2012.

Staff had not always consistently received supervisions and appraisals were out of date. However, the registered manager had developed a plan to address this.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. People subject to DoLS had this clearly recorded in their care records and the service maintained a good audit of people subject to a DoLS so they knew when they were to expire. However, mental capacity assessments were not decision specific. Best interest decisions were recorded in some care plans but not all.

Systems were in place for the management of medicines so that people received their medicines safely. However, the room in which medicines were stored on occasions was too warm. If medicines are not stored at the correct temperature they can lose effectiveness.

Care plans were varied and some contained more information than others. The registered manager told us they were in the process of reviewing the care plans of all people who used the service.

We saw that people were provided with a choice of healthy food and drinks which helped to ensure that their nutritional needs were met. People were weighed and nutritionally screened. The service used the Malnutrition Universal Screening Tool (MUST) to assess people. This is an objective screening tool to identify adults who are at risk of being malnourished.

There were systems and processes in place to protect people from the risk of harm. Staff told us about different types of abuse and action they should take if abuse was suspected. Staff were able to describe how they ensured the welfare of vulnerable people was protected through the organisation’s whistle blowing and safeguarding procedures.

Appropriate checks of the building and maintenance systems were completed to ensure health and safety. Risks to people’s safety had been assessed by staff and records of these assessments had been reviewed.

We found that safe recruitment and selection procedures were in place and appropriate checks had been completed before staff began work. This included obtaining references from previous employers to show staff employed were safe to work with vulnerable people. There was enough staff on duty to meet the needs of people who used the service.

There were positive interactions between people and staff. We saw that staff treated people with dignity and respect. Staff were attentive, respectful and interacted well with people. Observation of the staff showed that they knew the people very well, encouraged independence and could anticipate their needs. Relatives complimented the kind and caring staff.

People were supported to maintain good health and had access to healthcare professionals and services. People were supported and encouraged to have regular health checks and were accompanied by staff or relatives to hospital appointments.

People were supported to access activities by a part time activities co-ordinator and staff. We saw that people engaged in meaningful activities.

The registered provider had a system in place for responding to people’s concerns and complaints. Relatives were asked for their views. Relatives said that they would talk to the registered manager or staff if they were unhappy or had any concerns. Staff and relatives spoke extremely highly of the registered manager describing them as open and transparent.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we took at the back of the full version of this report.

Are services safe?

The service had systems in place to assess risk and monitor health and safety. This included risk assessments related to the care of individuals and health and safety checks related to equipment and premises. People were also protected by incident and accident analysis and monitoring, which helped to identify trends and any actions needed to maintain people's safety.

Systems were in place to ensure that medication was stored safely and that people received the medication they needed. However, we identified some areas for improvement relating to the recording of some medications.

Staffing levels were safe and maintained at levels appropriate to the needs of the people living at the service.

Are services effective?

People told us that they were happy with the care delivered. Comments made to us included 'Generally very good, my (relative) is always clean and tidy' and 'They try to make (relative) look nice, do their hair and nails.' We observed that people looked cared for. Where needs had been identified in people's care records we were able to see that these were being met by staff. For example, the use of pressure relieving equipment to help maintain skin integrity.

Are services caring?

We saw that people looked cared for and observed staff treating people kindly. One relative told us 'They always have time for you.' Another said 'They all know my relative, you can tell they are paying attention.' Staff we spoke with demonstrated a good awareness of dementia care and were able to tell us how they tried to meet people's individual needs.

Are services responsive to people's needs?

People's needs had been assessed and care plans put in place which detailed people's needs and preferences. These records provided guidance to staff on what care and support was needed. The records we looked at also showed that people's needs were regularly reviewed, to help identify any changes to their care needs.

We observed staff responding kindly to people's requests for assistance during our visit. This included responding promptly to the call bell or sensor alarms, when people were spending time in their bedrooms.

Are services well-led?

The home had a registered manager, who was supported by the Trustees and the provider's administrative systems. Audits and checks were completed regularly to monitor the quality of service provision. There was also regular input from the Trustees, including visits to the service.

Relatives and staff told us that they were able to talk to the staff and management and felt they were listened to. One relative commented 'The staff are so nice and they always have time to talk to you.' Another relative commented 'If you have any problems they listen to you and sort it out.'

At this inspection we found that people were encouraged to make choices for themselves and encouraged to remain as independent as possible. People were also treated with respect and their dignity maintained.

Staff who worked at Allison House had been provided with a number of different training opportunities to enable them to complete their mandatory training. All staff had undergone supervision recently and further regular and frequent supervision sessions were scheduled.

There was sufficient well maintained equipment in the service to ensure that people's independence and safety were maintained.

The service carried out audits and had a quality assurance process in place, which involved people and their relatives to ensure that quality standards were maintained.

Staff who worked at Allison House were not up to date with all of their mandatory and specialised training. Additionally, they were not receiving regular supervision every two months as specified in the organisation policy.

Staff who worked at Allison House did not always ensure that they maintained the dignity of people. People were not always given choices about aspects of their daily lives and staff sometimes made assumptions about what people wanted without first asking. Additionally, some staff did not communicate with people, empathise with them or explain to them what they were doing when delivering care. This meant that sometimes people became distressed unnecessarily and staff did not react appropriately to manage the distress.

Records relating to people had improved and on the whole, were accurate and had been reviewed regularly. There were still some improvements needed in the recording in daily records but other records contained enough detail to ensure that people were cared for appropriately.

Most of the equipment used within the service was checked, maintained and serviced regularly to ensure its safety however there were a number of pieces of electrical equipment used within the service which had not had annual electrical testing carried out.