Fourways Residential Home

Fourways Residential Home is a care home without nursing that provides personal care for up to 20 older people, some of whom may be living with dementia. At the time of our inspection there were 14 people living at the service, two of whom had been admitted to receive respite care. The care home, which is set in a residential area, accommodates people in one adapted building, arranged over two floors. There was a communal lounge and a communal dining area on the ground floor. There was a substantial garden at the rear of the building.

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

People experienced safe care from staff who had been trained to protect them from abuse and avoidable harm. Risks to people were assessed, monitored and managed safely, whilst promoting their freedom and independence. The manager deployed enough suitable staff with the right mix of skills, competence and experience to meet people’s needs safely. We observed some discrepancies regarding medicines management, which the manager immediately addressed. Staff consistently applied good infection control and food hygiene practices. Staff were encouraged and supported to raise concerns and report incidents and near misses, The manager or deputy manager reviewed these incidents daily and took action to reduce the risk of future recurrence.

Assessments of people’s needs were comprehensive, identified expected outcomes and were reviewed and updated regularly to ensure they reflected people’s changing needs. The management team supported staff to maintain their professional skills and worked well with partners to make sure staff were trained to follow best practice. People were encouraged to eat a healthy balanced diet and staff effectively monitored the risks associated with poor hydration and nutrition. The management team made timely referrals to relevant professionals and services and staff acted swiftly on their recommendations to achieve good outcomes for people. The manager had sought and implemented guidance from a recognised source to adapt the environment to improve people’s quality of life and promote their wellbeing.

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.

The manager and deputy manager inspired staff to be committed to delivering care and support that treated people with compassion, kindness dignity and respect. Staff anticipated people’s needs and quickly recognised when people were in pain, distress and discomfort and provided sensitive and respectful care. Staff supported people to be fully involved in decisions about their care.

People were empowered to make choices and have as much control and independence as possible. Staff enabled people to carry out person-centred activities, hobbies and interests, and supported them to maintain relationships that matter to them. Staff actively promoted companionship within the home. Complaints were dealt with in an open and transparent way and used identified learning to improve the quality of the service. People were sensitively supported to make decisions about their preferences for end of life care. Staff had received additional training to support people who required end of life care.

The management team promoted a strong caring, person-centred culture where people and staff felt valued. Staff were passionate about their role and consistently placed people at the heart of the service. The service involved people, their family, friends and other supporters in a meaningful way. The manager understood their responsibilities to inform people when things went wrong and the importance of conducting thorough investigations to identify lessons learnt to prevent further occurrences. The manager and deputy manager operated robust measures to monitor quality, safety and the experience of people within 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 (report published 21/04/2022).

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 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.

We carried out an unannounced inspection of this service on 24 March 2022. Six breaches of legal requirements were found in relation to person-centred care, safe care and treatment, nutritional and hydration needs, premises and equipment, good governance and staffing. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this comprehensive follow up inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report covers our findings in relation to the Key Questions Safe, Effective, Caring, Responsive and Well-Led which contain those requirements.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Fourways Residential Home is a care home without nursing that provides personal care for up to 20 older people, some of whom may be living with dementia. At the time of our inspection there were 18 people living at the service, although one person had recently been admitted to hospital. The care home is in a residential area with accommodation arranged over two floors. There was a communal lounge and a communal dining area on the ground floor. There was a substantial garden at the rear of the building.

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

People were not protected against the risk of harm because staff did not always proactively respond when people were identified to be at risk. People were at risk of harm because the service had not effectively managed risks in relation to fire safety, legionella and infection control. The provider did not deploy enough staff to ensure people’s needs were met in a timely way to keep them safe. People did not always receive their prescribed medicines at the right time and in the right way to protect them from the risks associate with diabetes. Staff understood their responsibilities to raise concerns about incidents and accidents.

Improvement was required in the decoration of the home to ensure it was suitable for people who experienced living with dementia. People were not always supported to drink enough to protect them from the risks associated with dehydration. People were identified to have needs that exceeded the level of care staff could safely provide. People and relatives had been actively involved developing their care plans and told us the standard of care they received was good. Staff underwent robust selection procedures to ensure they were suitable to work with older people, some who may be living with dementia. The management effectively operated a system which enable staff to develop and maintain the required skills and knowledge to meet people’s needs. The manager had arranged for staff to complete enhanced training in March 2022 in relation to pressure area management, moving and positioning people, fire safety and diabetes. People’s health was monitored by staff and effectively promoted by a variety of community healthcare professionals.

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.

Some people were observed in communal areas looking unkempt wearing soiled clothing until mid-morning, as they had not received their personal care. People told us staff treated them with dignity, respect and felt staff took a genuine interest in their well-being and quality of their life. People and relatives told us they were fully involved in decisions about all aspects of people’s care and support.

People were not supported to take part in activities and there was a lack of stimulation for them. People’s care was task based and not always person-centred. Staff ensured people received information in formats they could understand. People were supported to maintain relationships that mattered to them. People and relatives had confidence that the deputy manager would take appropriate action if they raised concerns. People’s end of life wishes had been sensitively explored.

Quality assurance processes had not always effectively identified emerging risks to people and ensured they were managed safely. The deputy manager was frequently used to cover staff absence delivering care, which significantly reduced the time available to focus on quality assurance and management of the service. Staff were concerned that the provider did not always listen to their concerns. Staff were to held account about their performance when required, but managers did so in a manner which encouraged them to learn and improve. The managers were committed to implementing reflective practice and learning to drive service improvement.

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, with no breaches of regulation (report published 30 November 2022).

Why we inspected

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 inspection was prompted in part due to concerns received about unsafe staffing levels, poor moving and positioning practice, including people being roughly handled, and people not being treated with dignity and respect. A decision was made for us to inspect and examine those risks. We found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive and well-led sections of this 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 six breaches of regulations in relation to safe care and treatment, staffing deployed, safe management of medicines, infection prevention and control, premises not being adapted and decorated to meet people’s needs, failure to mitigate the risk of dehydration, the needs of people exceeding the level of care the service could safely deliver, failure to support people to take part in stimulating activities and failure ensure compliance with regulations.

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.

Fourways Residential Home is a care home providing personal care to 13 people aged 65 and over at the time of the inspection. The service can support up to 20 people in one adapted building split over two floors.

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

People experienced safe care and treatment, delivered in accordance with their care plans, which met their individual needs. People were involved in developing and reviewing their care plans, which ensured their preferences were always being taken into consideration.

People experienced care from staff who were aware of people’s individual risks, which had been carefully assessed and managed safely. Staff had completed the required training and understood their role and responsibilities to safeguard people from abuse, including how to report concerns internally and to external bodies. The provider completed robust staffing needs analyses, to ensure enough suitable staff were consistently deployed with the required skills and knowledge to meet people’s needs safely. Staff followed the provider’s policy, current guidance and regulations to ensure people’s medicines were managed safely. Staff maintained high standards of cleanliness and hygiene within the home, which reduced the risk of infection. Staff followed the required standards of food safety and hygiene when preparing, serving and handling food.

People experienced effective care and support which consistently achieved successful outcomes. Staff were enabled to deliver care in line with people’s support plans and best practice, through a framework of effective training, competency assessment, supervision and appraisal. People were supported to eat and drink enough to maintain good health. The service worked well with other organisations to ensure prompt referrals to healthcare services when people’s needs changed. The provider had completed a comprehensive programme of improvements and refurbishment, focused on making the environment safer and more suitable for people living with dementia.

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’s human rights were protected by staff who had a clear understanding of consent, mental capacity and DoLS legislation and guidance.

The registered manager and deputy manager provided clear and direct leadership, which had cultivated a positive and open culture within the home.

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 inadequate (published 7 May 2020) with multiple breaches. At this inspection we found improvements had been made and the provider was no longer in breach of

regulations 9 (person centred care), 11 (need for consent), 12 (safe care and treatment), 13 (safeguarding service users from abuse and improper treatment), 15 (premises and equipment), 17 (good governance), 18 (suitably qualified staffing) 20 (duty of candour) and 16 (registration regulations)

We did not focus on the domains of caring and responsive, however we found there to be sufficient improvement within regulation 9 (person centred care) for the service to no longer remain in breach. We found the service had adopted our recommendation and had sought guidance from a reputable source and implemented best practice on ensuring that the privacy, dignity and respect of people was always maintained (regulation 10). As the key lines of enquiries related to these domains were not inspected against, we are unable to comment on the entire domains.

This service has been in Special Measures since publication of our last inspection report (published 7 May, 2020). During this inspection the provider demonstrated that improvements had been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check the provider 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 Safe, Effective and Well-led, which contain those requirements. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Inadequate to Requires Improvement. 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 Fourways Residential Home on our website at www.cqc.org.uk.

Fourways Residential Home is a care home providing personal care to 16 people aged 65 and over at the time of the inspection. The service can support up to 20 people in one adapted building split over two floors.

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

People did not always receive their medicines as prescribed. Staff were not assessed as competent to administer medicines. Risks were not always assessed, monitored or managed safely and effectively. Accidents and incidents were not sufficiently recorded or investigated. People and health professionals did not always feel there was enough staff on duty. Records and observations confirmed this. There was not always evidence to show how lessons learned were shared and used to make improvements. Staff wore appropriate personal protective equipment. The home was free of malodour with a designated staff member cleaning the home. Staff recruitment checks were undertaken to ensure that they were suitable and safe to work with people made vulnerable by their circumstances. People told us they felt safe in the company of staff.

Staff were not in receipt of adequate training and support to meet people's needs. People's needs were not always identified through a robust assessment of needs and care plans lacked detail, which meant staff did not have access to clear information about how to support people safely and meet their needs. The decoration and some of the fabric of the building was in poor condition and some elements of the premises required action to be taken such as no hot water from the shower room tap and damp stained carpets. People were not always supported to have maximum choice and control of their lives and staff did not always support them in a way which met the Mental Capacity Act (MCA). Consent to care and treatment and best interest decisions had not always been obtained in line with legislation and guidance, such as the MCA.. The registered person was depriving people of their liberty without legal authority to do so. People were very positive about the food. People’s individual nutrition and hydration needs were being met.

People were not always supported to make decisions about their care. Some aspects of care delivery did not ensure people’s privacy was maintained and dignity upheld. People and relatives told us they felt staff were kind and caring. Staff were respectful and warm when they spoke about people. We observed kind and caring interactions. We have made a recommendation about privacy, dignity and respect.

People did not always receive individualised care which met their needs and preferences. For example, people had specific 'bath days' each week. People’s individual preferences on how they wished to spend their time had not always been explored and people felt they were not always met. People's care plans did not always contain sufficient information about the care and support they required. There were not always completed plans in place to support people at the end of their lives. Complaints had been dealt with appropriately. People and relatives knew how to complain and felt action would be taken by the management team.

There was no registered manager in post at the time of inspection. The provider failed to identify and manage risks appropriately and did not ensure a person-centred approach was in place. Audits were not sufficiently robust and the registered person failed to have effective oversight of the service. The provider did not always ensure Duty of candour. The provider conducted surveys to get feedback about the service. Residents meetings had recently been introduced for people to provide feedback. We saw evidence that staff worked in partnership with other professionals.

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 5 April 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 enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about infection control, staffing, allegations of abuse, poor management and risks to people not being mitigated or managed. A decision was made for us to inspect and examine those risks. We have found evidence that the provider needs to make improvements. Please see the detailed sections of the full report.

Enforcement

We have identified breaches in relation to person-centred care, medicines management, staffing, assessing, mitigating and managing risk, consent to care and treatment, deprivation of liberty safeguards, premises, governance, duty of candour, notifiable incidents and the registration condition to have a manager registered with CQC.

We are mindful of the impact of 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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Follow up

We have requested an action plan from the provider and we will have regular meetings with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as soon as CQC reverts to undertaking routine inspections. However, if absolutely necessary CQC will give consideration to the use of inspection and enforcement powers where we have concerns of harm.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of registration.

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 re-inspect it, and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

This inspection was completed on 10 January 2019, by one inspector. The inspection was unannounced, which meant the provider did not have any advanced knowledge of the date of the visit.

Fourways Residential 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. However, the home does not provide nursing care support.

Fourways Residential Home can accommodate a maximum of 20 people. This is a home based across two floors, with considerable alterations having been made to the building to accommodate some of the bedrooms.

The service had a registered manager. 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.

The service was previously inspected in 2016, and was rated Good in all domains. At this inspection we found that the service had not ensured compliance with all regulations, and was therefore now rated Requires Improvement.

People were not always kept safe. Medicines were not always managed safely. Whilst we found that medicines were stored securely in a locked trolley, when these were administered, the registered manager did not ensure staff followed safe practice and guidelines.

Adequate risk assessments and comprehensive documentation were in place to ensure people were offered responsive, safe care and treatment. Care plans contained sufficient information. However, this was not always followed. By not adhering to the care plan, people were placed at risk.

People were not being kept safe due to a failure in appropriate monitoring and recording of the environmental risks and what these potentially pose to people using the service.

The service did have robust recruitment processes in place to ensure staff employed were safe to work with people. However, there were significant gaps in training that meant that staff did not have the necessary skills and competency to carry out their role effectively.

Effective systems were not in place to audit the service. Such systems would monitor the care provided in relation to the care plans, therefore highlighting any errors as and when these were occurring. This was specifically important given the number of discrepancies noted between practice and care documents.

People's care was delivered in a dignified way. Privacy was protected, although bedroom doors were noted as having been left open for most of the day and night. It was unclear if all people residing at the service were happy for this to continue.

The management completed audits inconsistently. This meant that they did not have a comprehensive overview of the service. Whilst a management structure existed, this was not effective in ensuring governance of the provision. Information was not always analysed or passed to the correct people, leading to errors in care delivery and poor management. The service, although did not specialise in delivering care to people living with dementia, had a number of people residing at the service with the onset of this condition. The service did not environmentally meet the needs of the people. In addition the provider failed to ensure that a strong management structure was in place and working effectively to monitor the service.

During the inspection we identified several breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the end of this report.

Fourways Residential Home is a care home that offers accommodation for people who require personal care. The service is registered for up to 20 people, with bedrooms located across the ground and first floor. People who live at the service require assistance related to changing health needs due to increase in age.

The home is required to have a registered manager. The new registered manager was appointed in October 2015. 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.

Good caring practice was observed during the two days of the inspection. People and their families reported they were happy with the support and care provided by the staff. People, and where appropriate, their relatives, were involved in the development and reviewing of care plans. These were documented appropriately, detailing individual preferences well and reflected the person’s needs. Risk assessments specific to the person were contained in files, with guidance on how to manage these risks.

Responsive practice was observed during the inspection. The service responded to the needs of people, offering them both verbal and emotional support. This helped to lower anxiety. People were supported by a team of staff who were competency checked prior to being given responsibility for care. Medicines were kept and managed securely. Comprehensive records were kept of guidelines for as required medicines. Audits were completed regularly and showed no medicine errors. Observations during the inspection process, illustrated that staff correctly followed procedures when administering medicines, therefore kept people safe.

Staff knew how to keep people safe. They were able to describe how to report concerns promptly and confidentially. They were familiar with the internal and local authority procedures that were clearly outlined in training. Comprehensive recruitment processes were in place to ensure suitable staff were employed to safeguard people against the risk of abuse. Sufficient numbers of trained and experienced staff were provided by the service to ensure people’s needs were met. A training programme was in place, which focused on providing the company’s mandatory training as a minimum standard, with additional supporting training offered in line with best practice, meeting the Skills for Care guidelines.

Staff had training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). They understood the importance of informed choice being situation and time specific. Where applicable DoLS applications had been made to the appropriate authority.. Records included evidence of best interest meetings taking place, and staff were able to talk through the decisions that had been made in relation to these.

The quality of the service was monitored by the registered manager and deputy manager. Feedback was obtained from people, visitors, families and stakeholders and used to improve and make relevant changes to the service. Comprehensive audits were completed that produced reflective action plans that identified timescales for the registered manager to make improvements. Evidence illustrated action plans were addressed in a timely way.

The service offered people activities. These were predominantly group focused. We recommended that activities be developed specifically to reflect people’s individual needs and choice.

The home was clean and tidy, although the carpet looked worn and the furnishings had aged. The premises did not lend themselves to provide care to people with dementia. As structural changes to the premises could not easily be made, we recommended that the service refer to best practice guidelines on how to make the environment more dementia friendly.

As part of this inspection we spoke with the deputy manager and reviewed records relating to the recruitment of staff. Below is a summary of what we found. The summary describes what we were told, what we observed and the records we looked at.

Is the service safe?

There were effective recruitment and selection processes in place.

Appropriate checks were undertaken before staff began work. We reviewed the recruitment files of eight members of staff and the records we looked at were accurate and fit for purpose.

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

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

Is the service safe?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Staff personnel records did not contain all the information required by the Health and Social Care Act. This meant the provider could not demonstrate that the staff employed to work at the home were suitable. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

People's personal records including medical records, staff records and other records relevant to the management of the service were accurate and fit for purpose.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). A recent Supreme Court judgement had widened and clarified the definition of deprivation of liberty. The manager was not aware of this judgement relating to 'deprivation of liberty' but undertook to make contact with the local authority DoLS team, regarding the implications, when notified of this during the inspection.

Procedures for dealing with emergencies were in place and staff were able to describe the action they would take to ensure the safety of the people who use the service.

Is the service effective?

Care plans provided staff with the detailed information needed to enable them to provide care that met people's needs.

Staff were consistent in how they said they would support particular people's needs.

The service liaised effectively with other professionals such as GP's, District Nurses and other health care professionals.

Is the service caring?

Staff showed a positive and understanding approach towards the care needs of people who use the service.

People were supported by kind and caring staff who spoke politely to them. We saw that care workers showed patience and gave encouragement when supporting people.

Is the service responsive?

Care plans and risk assessments were reviewed regularly. If any changes to people's care needs were identified, they were recorded and acted upon.

Records confirmed people's preferences and interests. People's diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service well-led?

The provider had appropriate systems in place to effectively assess and monitor the quality of care they provided to people who use the service.

Incidents and accidents were monitored and analysed appropriately.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We looked in the records of five people and found they did not contain appropriate risk assessments and plans of care that provided staff with the information they needed to provide safe and appropriate care and support. We spoke with the new manager who told us they had identified issues with the records that needed to be resolved.

The provider did not have a system to regularly assess and monitor the quality of care at Fourways. This meant it was not always possible for the provider to identify incidents that may have resulted in unsafe or inappropriate care.