Archived: Malmesbury House

Updated 23 May 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 15 February 2017. The inspection was unannounced and was carried out by four inspectors.

Before the inspection we reviewed the evidence we had about the service. This included any notifications of significant events, such as serious injuries or safeguarding referrals. Notifications are information about important events which the provider is required to send us by law. We also reviewed feedback from the local authority, which had been carrying our regular monitoring visits since our last inspection. We had not asked the provider to complete a Provider Information Return (PIR) as we were following up concerns identified at the previous inspection. The PIR is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection we spoke with five people who lived at the service. If people were unable to express themselves verbally, we observed the care they received and the interactions they had with staff. We spoke with the provider’s representative and training consultant and six staff, including the acting manager, care, catering and domestic staff. We looked at the care records of four people, including their assessments, care plans and risk assessments. We looked at how medicines were managed and the records relating to this. We looked at the recruitment files of four staff and other records relating to staff support and training. We also looked at records used to monitor the quality of the service, such as the provider’s own audits of different aspects of the service.

Updated 23 May 2017

The inspection took place on 15 February 2017.

Malmesbury House provides accommodation and personal care for up to 20 older people, some of whom are living with dementia. There were 12 people living at the service at the time of our inspection.

The registered manager had been granted an extended period of absence at the time of our inspection. The provider had appointed an acting manager to cover the registered manager’s absence. 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.

At our last inspection on 20 September 2016, we found the provider was breaching legal requirements. People were not adequately protected from the risk of fire or from avoidable risks. There was no evidence of learning from accidents and incidents. People were not adequately protected against the risk of infection because standards of infection prevention and control were poor. People were not protected by the provider’s recruitment procedures. People were not protected against the risk of abuse because staff had not been made aware of their responsibilities to report concerns. Medicines were not managed safely. Staff had not received the training required for their role and this had an effect on the care people received. People’s care was not always provided in line with the Mental Capacity Act 2005. People were not cared for in a clean and properly maintained environment and were not always supported to maintain their dignity. People’s needs were not always accurately assessed before they moved in to the service. People did not have access to meaningful activities. The service was not well led. None of the registered providers were involved in monitoring the service. People were not given opportunities to have their say about the service. The overall rating for the service was 'Inadequate' and the service was therefore placed in 'Special measures'.

Following the inspection, the provider submitted an action plan telling us how they would make improvements in order to meet the relevant legal requirements.

At this inspection we found some improvements had been made but these were not sufficient to ensure that people received consistently safe and effective care. Staff were not following relevant guidance on the safe handling of dirty laundry, which meant people were not adequately protected from the risk of infection. The en suite bathrooms in people’s bedrooms and a communal bathroom on the ground floor did not contain soap or disposable paper towels, which meant staff were unable to maintain appropriate hand hygiene after providing people’s care and support. Staff were not following relevant guidance on the Control of Substances Hazardous to Health (COSHH) or the provider’s policy on the use of COSHH products.

Staff had attended medicines training but there was no evidence that their competency had been assessed following this training and records showed that medicines errors occurred regularly. We found medicines errors on the day of our inspection that had not been identified by staff. A pharmacist had made recommendations to improve medicines practice following a medicines audit but these recommendations had not been implemented.

Adaptations and equipment had not been serviced regularly, which resulted in poor care for one person and unsafe practice being used by staff. The service had a hoist to enable staff to transfer people safely and an adapted bath but the safety certificates for these items had expired in December 2016. Staff were unable to use the hoist to transfer people, which meant they had to use a manual lifting technique when supporting one person during our inspection. There was evidence that people had been supported to use the bath since the expiry of the safety certificate.

Some people were not receiving the care they needed to keep them free of pain and discomfort. Staff told us five people needed their feet elevated when sitting because they suffered from swollen feet and ankles. We saw that, in two cases, this measure had been recommended by a healthcare professional. Staff told us they did not encourage people to elevate their feet when seated, for example with footstools, as people had refused this care in the past. Staff said it would not be possible to implement this measure for all five people who needed it as there was only one footstool available in the service.

The care planning system used in the service required staff to record people’s preferences regarding end of life care but this information had not been recorded in the care plans we checked, which meant the provider could not be sure staff were providing end of life care in accordance with people’s wishes.

The activities available to people had increased since our last inspection but we observed that people remained without interaction or engagement for long periods outside the time of the planned activity. Staff were occupied with the provision of care to people who needed it, which meant people sitting in the lounge did not have opportunities to engage in conversation with them. As a result, people spent the majority of their time unoccupied and without stimulation.

Quality monitoring procedures remained ineffective in identifying risks to people and shortfalls in the care people received. Infection control audits had not identified that the practice used by staff was not effective in protecting people from the risk of infection. Quality monitoring procedures had also failed to identify that staff were not following guidance on the Control of Substances Hazardous to Health (COSHH) or the provider’s policy on the use of COSHH products. Quality checks had not identified that the servicing of equipment used for the delivery of care was overdue, which resulted in poor care for one person and unsafe practice being used by staff. Medicines audits had not been effective in addressing shortfalls in medicines management and ensuring that people received their medicines safely.

Some aspects of the service had improved since our last inspection. The provider had taken action to protect people from the risk of fire and avoidable risks in the service. The recording of accidents and incidents had improved and people were protected by the provider’s recruitment procedures. People were better protected against the risk of abuse because staff had attended safeguarding training and were aware of their responsibilities if they suspected abuse was taking place. There were sufficient staff deployed to meet people’s care needs in a timely way.

Supervision had been introduced for staff and training had been provided in key areas such as safeguarding, dementia and falls prevention. Staff had also attended training in the Mental Capacity Act 2005 and understood how the principles of the Act applied in their work. Applications for DoLS authorisations had been submitted to the local authority where people were subject to restrictions to keep them safe.

People enjoyed the food provided and were supported to maintain adequate nutrition and hydration. People’s healthcare needs were monitored and they were supported to access advice and treatment when they needed it. The environment in which people lived had greatly improved. New carpets and flooring had been installed and the property had been redecorated throughout. New beds, bedding, mattresses and furniture had been purchased and the smell of urine had been eradicated. The environment in which people lived was lighter, brighter and more welcoming as a result.

People were supported by kind and caring staff. Staff were friendly towards people and spoke to them in a respectful way. Staff spoke with enthusiasm about the people they cared for and knew their preferences about their care. Staff encouraged people to do things for themselves where possible and provided their care in a manner that maintained their privacy and dignity. There were appropriate procedures for managing complaints.

The provider had engaged a care consultant to provide advice on improvement and a trainer to ensure staff had access to appropriate training. A deputy manager had been appointed, who was due to begin work shortly after our inspection. Staff said the registered manager was approachable and spent more time outside the office than they had previously. Team meetings had been introduced, which provided an opportunity for staff to discuss the needs of the people they cared for.

Residents meetings had been introduced, which gave people opportunities to have their say about how the was the service was run and there was evidence that people’s suggestions had been acted upon. Surveys had been distributed to relatives since our last inspection and the feedback received from the relatives who had returned surveys was positive.

The overall rating for this service is ‘Requires improvement’. However, the service remains in special measures. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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.

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