Archived: Malmesbury House

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

Malmesbury House provides accommodation and personal care for up to 19 older people. There were 13 people living at the service at the time of our inspection, all of whom were living with dementia.

There was a registered manager in post at the time of our inspection who had been registered since 9 December 2014. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.

People were not adequately protected from the risk of fire. The provider had not implemented the actions required in the fire risk assessment they had commissioned to maintain appropriate standards of fire safety. Fire drills had not been carried out as often as they should and some staff had not attended fire training to enable them to adequately evacuate people from the home.

People were not protected from avoidable risks and 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 adequately protected by the provider’s recruitment procedures. The provider had not made all necessary checks on staff to ensure they were suitable and eligible to work at the service. People were not adequately protected against the risk of abuse because staff had not been made aware of their responsibilities to report concerns.

People’s medicines were not managed safely. There were no protocols in place to guide staff about the administration of ‘as required’ medicines.

The provider did not support staff to gain the skills they needed to provide people’s care effectively. Staff had not received all the training required for their role and this had an effect on the care people received. Staff did not receive feedback about their performance or have opportunities to discuss their training and development needs.

People’s care was not always provided in line with the Mental Capacity Act 2005. There was a lack of understanding of the Act and its principles at all levels and we found that decisions had been made on behalf of people without their mental capacity being established.

People were not cared for in a clean and properly maintained environment. There was a pervasive smell of urine and mattresses and bedding were old and stained. Pest control treatment to eradicate bed bugs was ongoing. The carpets in many areas were threadbare, the curtains stained and items of furniture were missing handles.

People were not always supported to maintain their dignity. Some people were dressed in stained and dirty clothes. Other people were visibly unkempt and had not been supported to maintain their personal hygiene. There was no guidance for staff about how to support people who refused personal care to maintain their appearance and personal hygiene. Staff had positive interactions with people but spent periods of time together when they could have been engaging with people.

People’s needs were not always accurately assessed before they moved in to the service. This had resulted in some people being unnecessarily restricted due to a lack of appropriate equipment and staff training. Care plans did not always record people’s individual needs, which put them at risk of receiving inappropriate care and treatment.

People did not have access to meaningful activities. There was a lack of appropriate activities to keep people occupied and engaged and there were no opportunities to go out.

The service was not well led. None of the registered providers were involved in monitoring the service. Concerns identified that had been identified by the registered manager’s audits had not been addressed. People were not given opportunities to have their say about the service. Concerns that had been raised were not addressed by the registered manager or the provider. People’s care records contained inconsistent information and were not stored securely.

The provider had developed plans to ensure that people’s care would not be interrupted in the event of an emergency. People’s healthcare needs were monitored and they had access to treatment when they needed it. Care records demonstrated that people saw healthcare professionals when they needed to.

People told us they liked the staff at the service. They said staff were kind and friendly. Relatives told us staff knew their family members well and had positive relationships with them. They said they could visit at any time and that their family members could have privacy when they wanted it.

People told us the registered manager was approachable and available if they wished to speak with them.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

At our last comprehensive inspection under previous legislation on 3 January 2014, we found the provider was compliant with all the regulations assessed. We carried out a responsive inspection on 26 February 2014 due to information of concern and found that some areas of the service were not adequately maintained. We made a requirement action about this.

We carried out a follow up inspection on 26 September 2014 and found the provider had taken action to become compliant with the regulations. Safety measures had been implemented and issues relating to electrical safety addressed.

This was the first comprehensive inspection of the service under the Health and Social Care Act 2008.

At this inspection we found that the provider had addressed the concerns related to health and safety. New carpets had been installed where necessary and fixtures and fittings repaired. Safety measures had been implemented and issues relating to electrical safety addressed.

During the inspection we spoke with eight residents, two visitors and the senior member of staff on duty. We checked the condition of communal areas and a sample of bedrooms.

We observed that people had been supported to maintain their appearance and relatives told us that their family member was always well-presented when they visited. Staff told us that there were always enough staff on duty to meet people's care needs but that they were not always able to spend time speaking with people due to the demands of their role.

The home did not employ an activities co-ordinator and we found that there were limited opportunities for people to take part in activities or to go out.

We found that some areas of the home were not adequately maintained. Some of these issues were cosmetic but others posed a potential health and safety risk to people. We had no concerns about the cleanliness of the home and we found that there were appropriate measures in place to monitor people entering the premises.

One relative said of the home, 'It could do with a facelift' and another described the d'cor as 'Very tired.' There was no evidence that the provider had a planned programme of redecoration in place for the home.

People had up to date care plans and risk assessments that were regularly reviewed and that met their support needs.

We found that staff received annual safeguarding training and had a good understanding of their responsibilities regarding this.

We saw that the premise were safe, suitable and adequately maintained.

We found that the provider had an adequate number of skilled staff in order to provide individualised care. All staff received regular training and were well supported. We saw that staff had appropriate qualifications and experience in order to meet the care needs of the people.

The provider had systems in place to assess and monitor the quality of the service people received.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by a practising professional.

People using the service said that staff were polite and treated them with respect. They told us that staff were available when they needed them and that they provided good care. One person said, 'I'm fortunate to be here' and another told us, 'I like it here - everything's very nice.' One person said, 'They're very kind. They help me get up and ready every morning' and another told us, 'They're all good ones ' they're all lovely.'

Most people told us that they enjoyed the food provided by the home and that could have alternatives to the advertised menu if they did not like the dishes prepared that day. One person told us, 'There's always something on the menu I like.' A visiting relative told us, 'My mum enjoys the food here ' she eats well.'