The Old School House

About the service The Old School House is a residential care home providing accommodation in one adapted building for up to 36 older people who require personal care. The service specialises in supporting people living with dementia. At the time of the inspection 26 people were living at the home.

Since our last inspection improvements had been made in how risks to people were assessed, monitored and managed. There were sufficient staff deployed to meet people's needs and staff recruitment was on-going. Medicines were managed safely, and people received their medicines as prescribed.

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; although there were policies in place the systems in the service did not always support this practice because records relating to decision making were not always in place.

The provider, manager and staff were clear about their roles and responsibilities. Quality assurance checks were in place to monitor the quality of the service provided, however improvements were still being embedded.

People living at The Old School House told us they received safe care from staff who knew how to identify and report any concerns. People told us and we observed staff treated people with kindness, dignity and respect.

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 13 September 2022) and there were 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.

At our last inspection we recommended that the provider consider, The National Institute for Health and Care Excellence's (NICE): Giving medicines covertly: A quick guide for care home managers and home care managers providing medicines support and take action to update their practice accordingly. At this inspection we found the provider had acted on this recommendation and the provider was able to explain how people would receive their medicines covertly and in line with NICE guidelines.

Why we inspected.

The inspection was prompted in part by notification of an incident following which a person using the service died. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of falls. This inspection examined those risks.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe section of this full report.

Further to this we carried out an inspection of this service on 11 July 2022 and breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve risk management, medicines management and governance arrangements.

We also undertook this focused inspection to check they had followed their action plan and to confirm they met legal requirements. This report only covers our findings in relation to the Key Questions safe, caring and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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 meet with the provider following this report being published to discuss how they will fully embed and sustain changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Old School House is a residential care home providing accommodation in one adapted building for up to 36 older people who require personal care. The service specialises in supporting people living with dementia. At the time of the inspection 32 people were living at the home.

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

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People and staff told us there were insufficient staffing levels to meet peoples’ needs safely and effectively, we observed staffing levels to be insufficient. People did not always receive there medicines as prescribed.

We were not assured the service was following safe infection prevention and control procedures. Some people's care records were lacking in guidance for staff on reducing the risks associated with people's on-going health needs.

In some of our observations we witnessed staff being kind and compassionate towards the people they supported. However, we also noted that people were not always treated with dignity and respect at all times.

People were protected against the employment of unsuitable staff because the provider followed safe recruitment policies and procedures. People were protected from potential abuse by staff who had received training and were confident in raising concerns.

We have made a recommendation about The Mental Capacity Act (MCA).

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 good (published 16 July 2021)

Why we inspected

We received concerns in relation to staffing, risk management and the quality of care provided. As a result, we undertook a focused inspection to review the key questions of safe, caring and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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 Good to Requires Improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, caring and well-led sections of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to staffing, medicines, risk management and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

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

People lived in a service that was well-led and had a positive and inclusive culture. Infection prevention and control procedures were being followed to keep people safe from COVID-19, this included the implementation of government guidance.

People were now supported by staff who had received training in relation to people’s needs. However, there was an action plan in place to ensure staff completed all of the providers mandatory training courses.

People’s needs were assessed prior to moving into the service; however, we have recommended the provider reviews their assessment to ensure it captures people’s health and social care needs.

People had care plans in place, so staff knew how to support them in line with their wishes and preferences. Records relating to people’s support were now documented more accurately. People’s capacity to make decisions was known and legislative frameworks were followed to ensure their human rights were protected.

People had their needs individually met and had access to external health and care professionals. The environment had been designed to take account of people’s individual social needs.

Relatives felt confident to complain and were complimentary of the registered managers approach to concerns raised. The provider had an overarching system in place to continuously monitor the quality and safety of the service. Since the last inspection, the system was now embedded and sustained.

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 the service was Requires improvement published on (04/05/2019). 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

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Effective, Responsive 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.

The ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Requires improvement to Good. This is based on the findings at this inspection.

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

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.

People’s experience of using this service:

• There had been changes to the management structure of the home since the previous inspection. A new manager had been appointed and the senior management team had been strengthened with the appointment of a general manager supporting the provider. The provider had employed a management consultant and was working with the local authority and other organisations to improve the management of the home. People and staff told us the home had improved. We also received positive feedback from the local authority and the community nursing team.

• Comprehensive quality assurance audits had been put in place. A variety of audit tools ensured all aspects of service provision and health and safety were reviewed in detail by the management team each month.

• People told us they felt safe living at the home. Protocols and training provided staff with the information and guidance they required to identify and report suspected abuse.

• Some people told us they felt anxious about a person entering their rooms. The manager stated action was being taken to reduce the risk of this person entering people’s rooms. Following the inspection, the manager told us some people’s bedroom door locks had been changed to ones they found acceptable.

• Staff recruitment processes were safe and staff were employed in sufficient numbers to meet people’s care needs.

• People told us staff were kind, caring and respectful. Our observations showed staff were kind, caring, friendly and attentive. The increase in staffing levels allowed staff more time to spend with people, and not feel rushed. Staff enjoyed working at the home and confirmed improvements had been made since the previous inspection.

• The computerised care record system was being used to record people’s care needs and associated risk and provide staff with the guidance they required to meet people’s needs and reduce risks. However, where people were resistive to receiving support with their personal care, this needed to be better recorded, and flexible and responsive support detailed. Further attention was also needed to monitoring forms as we found these had not always been fully completed, or had inconsistencies.

• People’s healthcare needs were being met. We received positive feedback from the community nursing team about the care people received.

• The home was acting within the principles of the MCA. Staff sought people’s consent and where necessary with authorisation, restricted people’s liberty to maintain their safety.

• Medicines systems were organised and managed safely. Where the manager had identified supply and support issues with the pharmacist, action had been taken.

• Training in relation to people’s care needs required some further improvement and the manager had plans in place to address this.

• The provider and manager planned further improvements to the social and leisure activities provided for people and recognised the importance of meaningful engagement to people’s well-being.

• People told us they had no complaints and said they knew who to talk to if they had any concerns. Where complaints had been received, these were recorded and actions identified to resolve the issue.

• The home was clean, tidy and well maintained.

The home met the characteristics of a rating of “Good” for two key question and “Requires Improvement” for three key questions. Our overall rating for the home after this inspection was “Requires Improvement”.

We made four recommendations for improvement in relation to staffing levels, training, personal care and social engagement.

Rating at last inspection: At the last inspection in September 2018 the home was rated “Inadequate” and the home was placed into special measures (the report was published in October 2018). Services in special measures are kept under review. Following the inspection, CQC required the provider to send us monthly reports. These detailed the outcome of internal audits in relation to staffing levels and staff training, care records and people’s care needs, as well as those in relation to the management of the home.

Following this inspection, the home was removed from special measures.

Why we inspected: This was a planned inspection based on the rating of the service at the last inspection.

Follow up: We will continue to monitor the service and liaise with the provider and local authority. We will re-inspect the service in line with our inspection schedule, or sooner if we receive information of concern.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

There was a registered manager employed at the home. 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 and associated Regulations about how the service is run.

The last inspection in September 2017 rated the service as Good overall, and across all key questions. This inspection was brought forward because of a high number of safeguarding concerns being raised and being investigated by the local authority, which had resulted in the service becoming part of an organisational safeguarding process. This meant the local authority safeguarding team, commissioners, CQC inspectors, police and other professionals had met to discuss the safety and well-being of the people living at the service. The provider, their operations team and the registered manager had been part of these discussions. The findings of our inspection have also been shared with the local authority, so that it can form part of the safeguarding process.

At this inspection in September 2018 we found there were failings across all key questions. People were not safe at The Old School House. There were not enough staff to ensure people's needs were met in a timely way or by staff who had the information they needed to meet people's needs. Many people at The Old School House were living with some degree of dementia with complex needs, requiring support and supervision to keep them safe. The staffing levels did not ensure they received the care they needed.

The organisation and leadership of the service was poor. This meant the registered manager and provider had not recognised that the staffing levels did not reflect people's individual needs. The service was based on completing tasks for people with a routine focussing on staff rather than people's needs. The provider and managers had not listened to staff, who said they had raised the issue of inadequate staffing levels many times but had been told the numbers of people at the home was low so staffing levels had been reduced. This meant that although staff were caring and worked hard to meet people's basic needs, they were physically unable to ensure people received person centred care in a timely way. This had led to very low staff morale.

The lack of effective staff deployment meant three people were not able to get up and go to bed when they wanted or have their needs met in a person centred or timely way. Staff said personal care support continued into late morning on a regular basis as during our inspection on the first day, based on how much time staff had. Many people required one or two care staff for personal care and mobility support, and most people needed prompting or assistance with eating and drinking. All the people living at the home required their food and fluid intake to be monitored, to help ensure adequate nutrition and hydration. There was not enough time for staff to meet these needs effectively or keep people safe. Staff had recorded people's weights and food and fluid input was recorded but they had not recognised that in reality people may not be receiving adequate nutrition, including those people identified as being at high risk. This meant people remained at risk of losing weight and not receiving enough food and fluids throughout the day and night.

Falls risk assessments showed that most people at The Old School House were at high risk of falls which was increased due to lack of staff supervision, especially in the lounge and during the night. Continence management was also poor, there was a lack of regular assistance with maintaining continence which further put people at risk of skin damage and lack of dignity.

Although people were supported by kind, caring and compassionate staff who tried to promote people's independence and treat them with dignity and respect, they were unable to ensure that people's dignity was maintained at all times. The atmosphere was chaotic, rushed and task orientated. People had poor personal care and there were call bells ringing constantly.

People's health needs were not always managed well, such as short term health problems and skin care. The provider and registered manager did not ensure staff had the information they needed to meet people's needs. Staff relied on verbal communication or none at all. The agency care workers told us they had not received any handover on the first day. On the second day staff were using handover summary sheets which we had asked the registered manager to complete to help promote people’s safety.

Staff did not all know how to use the electronic care plans and told us they did not use the care plans to inform people’s delivery of care. This included senior staff managing a shift. Training and supervision was not up to date or comprehensive, ensuring staff had the knowledge they needed to meet people’s needs.

Records were not always comprehensive or completed meaning that health risks were not always identified, consistently recorded or managed to completion. This put people at risk of not having their health needs met effectively or identified. On the first day of our inspection, we contacted the provider and asked for reassurances that there would be enough staff to meet people’s needs going forward and they showed us a new rota with some additional staff.

Medicine management was poor and put people at risk.

On the second day of our inspection there were some improvements due to the additional staff. The service appeared calmer and cleaner, people were not so late in getting up or having to wait as long for assistance but the organisation of the shift pattern, staff deployment, lack of adequate communication, training and person centred care remained a concern.

Although there were some quality assurance systems in place to monitor all aspects of the home to identify areas or improvement, the provider had failed to identify the urgency of our concerns or identified the experience for people living at the home in reality.

We found that people's day to day life in the home was not always a positive experience. There was no activity co-ordinator or designated staff member to ensure people’s social and leisure needs were met. This was despite some instructions in the brief care plans showing how people’s needs should be met.

Arrangements were not effective or responsive and did not ensure each person had regular opportunity for stimulation and engagement. People were not facilitated to maintain regular social stimulation in a person centred way to maintain wellbeing. During our inspection many individuals were left for long periods alone, despite care plans identified specific need for engagement, such as depression, behaviours which could be challenging for staff and anxiety. Staff did not have time to spend with people, chat or to have input into activities and social stimulation. This meant that people had little contact with staff other than for tasks.

Some people with more complex needs such as living with dementia or other mental health needs were not consistently supported. Staff were unable to be pro-active in ensuring care was based on people's preferences and interests, join in and seek out activities in the wider community and consistently help people live a fulfilled life, individually and in groups.

People, relatives and staff did not have confidence in the registered manager and provider. Staff were visibly upset about the lack of time to provide a good service to people they cared about. They told us how they sometimes cared for people in their own time or visited them in hospital. They did not feel valued, listened to or part of a team with no regular team meetings or supervision sessions. Staff had not received an appropriate induction and suitable training, and did not have the knowledge to meet people’s needs.

The home was not always clean and free from offensive odours. Staff did not have time to do cleaning. Equipment such as commodes, hoists and wheelchairs were not clean and there was no system to check the ongoing cleanliness of the service. There was no cleaner employed on the first day of our inspection so we asked that this be addressed as a priority.

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 time frame. 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.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five

At the last inspection in August 2015, the service was rated Good.

At this inspection we found the service remained Good.

Why the service is rated good:

People and a relative commented, “I like it here. They are all nice” and “I can’t fault them. All the carers are lovely and approachable. I help them do the gardening with people. They are really good to mum.”

People remained safe at the service. There were sufficient staff available to meet people's needs. Risk assessments had been completed and actions taken to minimise harm. This was particularly

important for people who may challenge others due to living with dementia, for example. People received their medicines safely.

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

People continued to receive care from staff who had the skills and knowledge required to effectively support them. Staff were competent and well trained. People's healthcare needs were monitored by the staff and people had access to a variety of healthcare professionals according to their individual needs.

Staff were caring and people had built good relationships with the staff. We observed staff being patient and kind, understanding how people liked to be cared for. People's privacy was respected. People where possible, or their representatives, were involved in decisions about the care and support people received.

The service remained responsive to people's individual needs and provided personalised care and support. People were able to make choices as much as possible in their day to day lives. There had been no formal complaints since the last inspection and the complaint process ensured any complaints would be fully investigated and responded to. Complaints were also discussed in regular staff meetings to ensure all staff knew where care could improve.

People were supported to take part in a range of activities. However, there was no dedicated activity co-ordinator employed during our inspection but there was an advertisement publicised. Therefore, organised activities were mainly through external entertainers at present. The registered manager was pro-actively looking at ways to improve the opportunities for more meaningful stimulation, especially for people living with dementia. We saw staff engaging with people throughout the day including those people who spent more time in their rooms. The registered manager had introduced ‘dementia friendly’ sensory stimulation to further engage people. The registered manager was introducing more individualised activity records to ensure people received engagement and stimulation, especially whilst the home sought a new activity co-ordinator.

The service continued to be well led. People and staff told us the registered manager and current deputy manager were approachable and there was always a manager available for support. The provider lived close by and the managers also felt well supported. The registered manager/provider sought people's views to make sure people were at the heart of any changes within the home and regularly enabled them to have time to discuss any issues.

The registered manager/provider had monitoring systems which enabled them to identify good practices and areas of improvement.

Further information is in the detailed findings below.

We found there were sufficient staff on duty to meet people's care and treatment needs. Staff told us they felt supported and had regular access to supervision, training and development. This enabled them to provide high quality care to the people they supported. The staff we met and observed caring for people were kind and patient and often acted as their advocate when needed to ensure their best interests were considered.

We found the home was clean and there were good systems in place to help reduce and prevent infections.

The home had robust systems in place to monitor all aspects of quality within the home and acted on areas where there were concerns. People who lived in the home and staff were involved in improving aspects of care provision where possible.

The people we spoke with told us they were happy with the care and treatment they received. People told us they felt able to raise any complaints they might have with staff. Staff told us they felt supported by the management team and felt able to raise concerns.

On the night of our visit that people were well cared for and treated with respect and dignity. The staff on duty responded to meet people's needs. We saw staff engaging with people and meeting their needs. We observed staff respecting people's choice to be awake late, watch the television programme they chose to and choose where they wished to relax.

We saw people at the home were being well cared for. Many of the people at Lambspark Care Home had some degree of memory loss associated with older age. People told us they were happy there. People said: 'They look after us', 'Nice people, staff great, foods good' and 'I love it, everyone's friendly, it's my home. I have no regrets'. People we observed who could not communicate with us verbally about their experiences appeared contented and settled.

We found that care plans had been improved to better reflect people's individuality and past history.

We saw people's rights were being protected, including the right to make decisions. Where people lacked the capacity to make decisions themselves appropriate arrangements were in place to act in their best interests.

We found that people had opportunities to engage in activities that met their needs. Although there had been a high turnover of staff in the last year we we saw positive relationships in place.

We found that staff were not receiving appraisals or supervisions. The service had identified this and had an action plan in place.