Archived: The Dell

The Dell 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. The home can accommodate up to 40 older people, some of whom were living with dementia. At the time of this inspection there were 32 people using the service.

People's experience of using this service:

• The registered manager understood their roles and responsibilities as a registered person. They worked in partnership with other agencies to ensure people received care and support that was consistent with their assessed needs.

• People felt safe and well cared for by staff who knew their needs and preferences. People told us they were given choices about their day to day life.

• There were sufficient staff available to meet people's needs and to ensure they could go out when they wanted to. Recruitment procedures were robust and ensured prospective employees had values in line with the service's aims and objectives.

• Care plans were up to date and detailed the care and support people wanted and needed. Risk assessments were in place and showed what action had been taken to mitigate any risks which had been identified.

• Appropriate referrals were being made to the safeguarding team when this had been necessary.

• There was a complaints procedure available which enabled people to raise any concerns or complaints about the care or support they received.

• Staff were competent, knowledgeable and skilled. They received regular training, supervisions and appraisals which supported them to conduct their roles effectively.

• People told us staff were kind and caring. We observed that staff knew people well. People's likes, dislikes and social histories were recorded in their care records. This helped staff get to know people well and care for them in a personalised way.

• People were supported to manage their prescribed medicines. Staff had received training to ensure this was carried out safely.

• Staff were competent, knowledgeable and skilled. They received regular training, supervisions and appraisals which supported them to conduct their roles effectively.

Rating at last inspection:

At the last inspection the service was rated requires improvement (published 23 February 2018). The overall rating has improved at this inspection.

Why we inspected:

This was a planned inspection based on the rating at the last inspection. At this inspection we found that improvements had been made to the environment and people's health care needs.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

The Dell 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.

The Dell provides accommodation and support with personal care for up to 40 older adults. The home does not provide nursing care. Accommodation and communal areas are located on two floors, which are accessible via a passenger lift. The home is situated in Gorton, Manchester and is located close to local amenities and shops. At the time of our inspection there were 34 people living at the home.

Our last inspection took place on 17 and 19 July 2017 when we rated the service as inadequate overall and for safe, effective and well led. We rated the caring and responsive domains as requires improvement. As the previous inspection in July 2017 had rated the service as inadequate overall, the service remained in 'Special Measures' because it was inadequate in three of the five domains. We identified breaches in relation to provision of safe care and treatment, the safety of the premises, care planning and assessment, safeguarding procedures, monitoring the quality and safety of the service and handling complaints.

Following our inspection, we took enforcement action against the registered provider. This included serving a notice of proposal (NoP) to cancel the registration of the service. The provider put forward representations to the Commission (CQC) in respect of the NoP to cancel the registration of the service.

At this inspection we checked to see if improvements had been made in all the areas we identified. We found there had been improvements which were sufficient for the service to be rated as requires improvement overall and good in safe, caring and responsive, with no inadequate domains. This means the service can come out of special measures. With the necessary improvements made we have withdrawn our NoP to cancel the registration of this service.

We were aware there was an on-going police investigation in relation to the conduct of one staff member who has now resigned. We found the provider took the appropriate action at the time of this matter by suspending the staff member and reporting their concerns to the police and safeguarding team. As a result this inspection did not examine the specific circumstances of this incident.

There was a registered manager at the service. 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 registered manager explained that since coming into post they had identified a number of areas for further improvement and had made some necessary changes. The registered manager understood their responsibilities and had worked hard to ensure that the service met the appropriate regulations. All of the breaches identified at the last inspection had been met at this inspection.

People could be assured the home environment was safe and secure. Safety checks of the premises were regularly carried out. People's electrical equipment had been checked and was safe to use. Fire safety checks were completed to ensure the service was safe. Fire exit routes were clear, which meant in the event of a fire people could be safely evacuated. Equipment to assist people with safe moving and handling such as hoists were serviced and maintained to ensure they were fit for purpose. All actions detailed in the fire risk assessment had now been fully completed.

During this inspection we found there were enough staff available to meet the needs of people living at the home. We saw that there were processes in place to ensure the home regularly assessed and monitored staffing levels to ensure sufficient staff were available to provide the support people required. However, a small number of people felt the staffing levels needed to be improved further.

Medicines were managed safely and people had their medicines when they needed them. Regular checks on the management of medicines were carried out and action taken where shortfalls were identified. Staff administering medicines had been trained to do this safely.

We examined training records which demonstrated that regular training was provided and staff underwent an induction. Care workers had supervision with senior staff. The registered manager had reviewed the supervision and appraisal system to ensure care workers received an annual appraisal and regular supervisions.

Care plans were personalised to the individual, and provided clear instructions to staff about what care should be provided and how. They were based on assessments of need undertaken before people came to stay at the service. They were reviewed regularly and were kept up to date. Staff kept clear records of the care provided.

The provider had submitted deprivation of liberty safeguards (DoLS) applications for all people living at the home. However, we found the use of consent forms for care and treatment were not completed consistently. For example, one person had full capacity and they were not asked to sign their consent form for care and treatment.

Food was provided via an external catering company who provided frozen meals to the home. We received mixed reports about the food on offer. The registered manager acknowledged further work was needed in this area.

The home employed two full time activity co-ordinators. People spoke positively about the activities on offer, and told us they were looking forward to forthcoming trips out that the activity co-ordinators had arranged.

People told us that they were well cared for and in a kind manner. Staff knew the people they were supporting well and understood their requirements for care. We found that people were treated with dignity and respect. People were supported and involved in planning and making decisions about their care. We saw that where they were able to, people had been involved in the development of their care plans and had signed them to say that they had been consulted with.

The service was responsive to people's needs and staff listened to what they said. Staff were prompt to raise issues about people's health and people were referred to health professionals when needed. People could be confident that any concerns or complaints they raised would be dealt with.

We noted there were a number of quality audits in the service; these included medicines, care records and health and safety. Actions were identified following the audits. We saw plans were in place to improve the care records, training, recruitment of permanent staff, and to complete the re-decoration and maintenance work at the home. Although we found a number of audits in place and action plans devised, we found the provider had not ensured these audits improved the food on offer and no audits had been completed on the meal time experience. Furthermore, the audits in respect of care planning had failed to pick up on the inconsistent approach to completing consent forms.

We last inspected The Dell on 09 January 2017 when we rated the service as inadequate overall. At that inspection we found breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to training and staff supervision, provision of safe care, maintenance of safe premises and having adequate systems in place to monitor the safety and quality of the service. At this inspection we found few improvements had been made at the service and found ongoing breaches of the regulations, as well as finding evidence of further breaches of the regulations. We identified breaches in relation to provision of safe care and treatment, the safety of the premises, care planning and assessment, safeguarding procedures, monitoring the quality and safety of the service and handling complaints. We are currently considering our options in relation to enforcement and will update the section at the back of the full version of this report once any enforcement has concluded.

The Dell provides accommodation and support with personal care for up to 40 older adults. The home does not provide nursing care. Accommodation and communal areas are located on two floors, which are accessible via a passenger lift. The home is situated in Gorton, Manchester and is located close to local amenities and shops. At the time of our inspection there were 36 people living at the home.

The home did not have a registered manager at the time of our inspection. The former registered manager had left the service in May 2017. The provider had appointed a new manager who was in the process of applying to register. 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 provider had not taken reasonable actions to ensure the premises were safe for people living there. We found the provider had not taken action to address all concerns raised in a fire risk assessment carried out in July 2016. This included concerns that the risk assessor had classed as being high risk and requiring immediate action. We requested an urgent action plan from the provider shortly after the inspection, and they provided evidence that action had been taken to address the key safety issues. We also alerted the local authority and fire service about these concerns.

Staff risk assessed potential hazards that could affect people’s health and wellbeing. This included risk assessments in relation to falls, malnutrition and pressure sores. However, we found staff did not always follow measures that had been identified to help keep people safe. For example, we found the falls team had advised for one person to be given a double bed to help reduce the risk of them fallen. This advice had not been acted upon several months later.

Staff did not always follow safe practice when providing care and support to people. We observed two members of staff support a person to transfer from their wheelchair to a lounge chair using an under arm lift. This person should have been supported using a hoist, and this practice had placed them at risk of harm.

Staffing levels had remained the same since our last inspection when we highlighted potential concerns about staffing and recommended the provider reviewed how many staff were required on each shift. The provider had carried out an assessment to help them decide how many staff were needed. However, staff told us they could feel rushed at certain times of the day, and this had an impact on the time they were able to spend with people, and how quickly they were able to respond to people’s needs.

Most staff were able to explain how they would recognise and act on potential signs of abuse or neglect. However, one staff member told us they would have to witness any abuse before they reported their concerns, which could prevent prompt and appropriate action being taken. The provider was not able to locate records of safeguarding incidents, which would prevent the effective monitoring and learning from safeguarding investigations.

Staff training had improved since our last inspection. However, there were still gaps in training that would be important to enable staff to care for people safely and effectively. For example, no staff had current training in food hygiene, falls management, nutrition or pressure care.

Although staff had received training in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), they did not fully understand their responsibilities in relation to this legislation. One person told us they were not able to go out without staff supervision. Staff told us they had not asked to go out without staff supervision, but confirmed this would not be allowed. The person had capacity and did not have an authorised DoLS. Therefore it would not have been lawful for staff to prevent this person from leaving the home if they wished to do so.

There was no secure outside area for people to access. This had an impact on people’s independence and meant staff were not able to support people in the least restrictive way possible. The manager told us they had recently obtained quotes for fencing to create a secure outdoor area that people could access.

Food was provided via an external catering company who provided frozen meals to the home. We received mixed reports about the food on offer. Some people told us they had raised complaints about the food and had been promised changes would be made. They told us they had not seen any changes as a result. The manager told us no complaints had been received since our last inspection, and we saw these concerns raised about the food had not been recognised or recorded as formal complaints.

People told us staff were respectful, and said that staff knew them well. The majority of interactions we observed were kind and caring. However, at times we saw staff were busy and therefore didn’t respond promptly to people who were upset or anxious.

Care plans contained details of people’s preferences in relation to their care. Information was also recorded out their social history. However, we found care plans were not kept up to date and did not always reflect advice given by other health professionals. Where people had been identified as having behaviours that could challenge the service, we found there were no care plans in place to help ensure staff responded effectively to such behaviours. This would increase the risk that people would not receive care that met their needs.

The home employed two full time activity co-ordinators. People spoke positively about the activities on offer, and told us they were looking forward to forthcoming trips out that the activity co-ordinators had arranged. During the inspection we observed craft activities taking place in preparation for a forthcoming summer fete. People were supported to access the local community.

The new manager told us they had been in post full-time for three weeks at the time of the inspection. Staff and relatives spoke positively about the changes the new manager had started to introduce, despite staff reporting that they had found some of the changes stressful. Relatives told us the new manager had made a good effort to get to know people, friends and relatives.

The manager undertook audits of medicines, recruitment records, care plans and catering. However, recorded daily checks and health and safety checks of the premises had lapsed. No system was being used to monitor and act on potential trends in accidents and incidents. This would prevent effective learning and action being taken to help improve the safety of the service.

We saw the provider had recently started carrying out monthly quality checks at the service. The manager told us they were well supported, and said there had been recent changes at the level of the provider that had strengthened the provider’s oversight and monitoring of the service. However, timely action had not been taken by the provider to secure improvements in the service, and the quality assurance processes had not been effective at ensuring the shortfalls we found at this inspection, and our previous inspection had been addressed.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. 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. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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

Accommodation on the ground floor comprises of a large dining room and two other smaller lounge / dining areas as well as communal seating areas along the corridors in different parts of the home. Upstairs there is another small lounge area and a lounge which is a designated smoking lounge.

This was an unannounced inspection carried out on the 9 January 2017 and at the time of inspection there were 30 people using the service but one of those was in hospital.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made

significant improvements within this timeframe.

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. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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 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

The service was last inspected in December 2015 and was found to require improvement. At the time we made recommendations that the home ensured all staff had access ot the care notes of people they were supporting in order to respond to their needs appropriately. The home was to ensure peoples personal emergency evacuation plans (PEEPS) were person centred and easily accessible and that people weren’t expose to risk of harm as at the previous inspection we raised concern that rooms which contained chemicals and electrical equipment were not being kept locked.

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.

During this inspection we found seven breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulations 2014. You can see what action we have told the provider to take at the back of the full version of the report.

People living at The Dell told us they felt safe. However we found the service had not always identified risks and where risks had been identified actions to minimise these risks were not always documented.

Medicines were not always stored safely and we found that not all staff were aware of protocols in place for staff to follow for people requiring ‘as required’ medicine as they were not kept with the medication administration records.

Staff working at The Dell had not received appropriate training to support them in their roles. Supervision wasn’t regular which meant the staff were not provided the opportunity to discuss concerns or identify any training needs. We found staff did not have sufficient training in the Mental Capacity Act or the Deprivation of Liberty Safeguards (DoLS) which showed when we questioned their understanding. We found that applications had been made to the supervisory authority for DoLS as required.

The service carried out quality assurance checks, however these had not identified the concerns we found. We found that not all the policies and procedures were up to date which meant staff did not have access to the most recent guidance and legislation.

People had mixed views on the meals provided. The majority of these were frozen meals delivered to the home as per the wider company policy. The home had discussed the concerns raised by people and was addressing them by introducing home cooked meals again. We saw that when necessary the service had referred people to the appropriate healthcare professionals.

People’s preferences and choices were respected. Staff knew people well and were responsive to people’s needs. People told us that staff were caring and kind and we observed caring interactions between staff and people living at The Dell.

People were supported to be involved in the planning of their care. They felt there were sufficient staff to meet their needs although we observed that people’s dependencies on staff had increased. We observed staff showing people respect and ensured people’s dignity was maintained when providing care. The service supported people with their end of life care and ensured their wishes were upheld whenever possible.

We found the recruitment process to be robust and appropriate checks were made prior to staff commencing work, staff received an induction to the service prior to commencing work.

There was a formal complaints procedure in place. Any complaints received were acted on appropriately. The registered manager understood their responsibilities and notified the Care Quality Commission (CQC) of significant events in line with the requirements of the provider’s registration.

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.

Is the service caring?

Is theservice responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Is the service safe?

We spoke with four people who used the service who told us they felt safe and were treated with respect and dignity by the staff. We found safeguarding procedures were in place and staff were able to tell us how they would safeguard the people they supported.

The home had policies in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). No applications had been submitted at the time of our inspection as none were needed. We spoke with the manager about their knowledge of the Mental Capacity Act and DoLS and what they told us meant they understood the correct protocol to follow in order to make an application.

We found the service to be clean and hygienic, although in need of re-decoration in some areas.

Is the service effective?

Health and care needs were assessed with people who used the services or their relatives and health care professionals before they moved in and were regularly updated and reviewed. People we spoke with said their care needs were being met. People using the service appeared content and settled and families told us they were able to visit at any time.

Staff told us they had no concerns about staffing levels and the manager ensured the correct number of staff were on duty at all times. This helped to ensure people's needs were always met.

Is the service caring?

People were supported by friendly and attentive staff. Staff showed patience and gave encouragement when supporting people. People commented, "I think staff are very nice", "You can have a laugh with them" and "I'm quite happy here."

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

Is the service responsive?

People participated in a range of activities inside the service regularly. The home had a dedicated activities coordinator who organised daily activities and events.

We saw there were parts of the home which were decorated with items and memorabilia to help assist people living with dementia and new care plans were being introduced specifically for people living with dementia. This meant the home recognised the complex needs of people living with dementia and was adapting the environment and updating care plans accordingly in order to meet the needs of people living with dementia more effectively.

Is the service well-led?

The service worked well with other agencies and healthcare professionals to make sure people received their care in a joined up way. The service had quality assurance systems in place which were regularly reviewed and action was taken when necessary to respond to complaints and to improve the service.

Records we saw showed us identified shortfalls were addressed promptly. As a result the quality of the service was continuingly improving. Staff told us they were clear about their roles and responsibilities. They felt supported by the manager. One member of staff told us; "I feel supported, the manager gave me chance to work in social care, I love my job, we are a good team."

The manager told us they spent lots of time with people who used the service and recognised this was an important part of their role. We saw positive interactions between people using the service and the manager and comments included "she is lovely," and "a real diamond."