Archived: Apsley House Care Home

Apsley House Care Home is a care home registered to provide nursing and residential care and accommodation for 35 people with various health conditions, including dementia and diabetes. There were 26 people living at the service on the day of our inspection. Apsley House Care Home is a large converted period property located in Bognor Regis, West Sussex.

People’s experience of using this service:

People were happy with the care they received, felt relaxed with staff and told us they were treated with kindness. They said they felt safe, were well supported and there were sufficient staff to care for them.

Our own observations supported this, and we saw friendly relationships had developed between people and staff. A relative told us, “Staff are very approachable, very attentive and are also very caring”.

People enjoyed an independent lifestyle and told us their needs were met. They enjoyed the food, drink and activities that took place daily. One person told us, “I get what I need in the way of care and I like the entertainment”. A visiting relative added, “The meals here are very good, [my relative] has a glass of wine usually”.

People felt the service was homely and welcoming to them and their visitors. One person told us, “Staff are very respectful towards me and others. My family visit occasionally and they all feel welcome coming here”.

People told us they thought the service was well managed and they enjoyed living there. A visiting relative told us, “I do feel we’ve got nothing to worry about and I’m quite happy. Everything here is okay, I feel positive about it all”.

Staff had received training considered essential by the provider. It was clear from observing the care delivered and the feedback people and staff gave us, that they knew the best way to care for people in line with their needs and preferences. A member of staff told us, “My induction and training was very useful”.

The provider had systems of quality assurance to measure and monitor the standard of the service and drive improvement. These systems also supported people to stay safe by assessing and mitigating risks, ensuring that people were cared for in a person centred way and that the provider learned from any mistakes. Our own observations and the feedback we received supported this. People received high quality care that met their needs and improved their wellbeing from dedicated and enthusiastic staff. A member of staff said, “The care we give is very person centred, it’s all about the residents and they rely on us”.

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

Rating at last inspection: Requires Improvement (report published 27 December 2018).

Why we inspected: The inspection was prompted in part due to concerns received that the provider was not submitting statutory notifications to the CQC. A notification is information about important events which the provider is required to tell us about by law. Services that provide health and social care to people are required to inform the Care Quality Commission, (the CQC), of important events that happen in the service. A decision was made for us to inspect and examine those risks.

Follow up: We will continue to monitor the intelligence we receive about this home and plan to inspect in line with our re-inspection schedule for those services rated Good.

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

Staffing levels did not routinely meet people’s needs, and we received negative feedback from people and staff in relation to their preferences being met.

Care plans were not routinely person centred and did not detail people’s likes dislikes and preferences.

The provider carried out quality assurance reviews to measure and monitor the standard of the service and drive improvement. However, systems of quality monitoring and governance had not ensured that staffing levels were suitable and that care plans remained up to date and person centred.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were encouraged to express their views. People said they felt listened to and any concerns or issues they raised were addressed. Staff were asked for their opinions on the service and whether they were happy in their work. They felt supported within their roles, describing an ‘open door’ management approach, where the management team was always available to discuss suggestions and address problems or concerns.

People felt well looked after and supported. We observed friendly relationships had developed between people and staff. People were treated with dignity and respect, and they were encouraged to be as independent as possible.

Risks associated with people’s care, the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

People chose how to spend their day and they took part in activities. They enjoyed the activities, which included, arts and crafts, exercise, quizzes and visits from external entertainers. There were representatives from local churches, so that people could observe their faith. People were also encouraged to stay in touch with their families and receive visitors.

People were cared for in a clean and hygienic environment and appropriate procedures for infection control were in place. Healthcare was accessible for people and appointments were made for regular check-ups as needed. People’s end of life care was discussed and planned and their wishes had been respected.

When staff were recruited, their employment history was checked and references obtained. Checks were carried out to ensure new staff were safe to work within the care sector. Staff had received essential training and there were opportunities for additional training specific to the needs of the service, such as the care of people living with dementia. Staff had received supervision with their manager and formal personal development plans.

Staff were knowledgeable and trained in safeguarding adults and knew what action they should take if they suspected abuse was taking place. Staff had a good understanding of equality, diversity and human rights. People’s care was supported by adaptations made to the service.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future.

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank.

We found one breach 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 back of the full version of the report.

Royal Bay Nursing Home provides care and accommodation, including nursing care, for up to 35 people. There were 18 people living at the home when we inspected. People living at the service were all aged over 65 years and had needs associated with old age and frailty as well as dementia. The service also provides care for people who are at the end of their lives.

At the last inspection of 29 and 30 November 2016 we rated the service as Inadequate and it was placed in Special Measures which meant we monitored and reinspected the service within six months. This was due to concerns we identified at the inspection regarding the following:

• The provider had not ensured the risks to service users were adequately assessed and action taken to mitigate the risks.

• The provider had not ensured staff always had the required qualifications to provide safe care.

• The provider had not ensured medicines were safely managed.

• The provider had not ensured equipment was safe for people to use.

• The provider had not ensured people’s nutritional needs were met.

• The provider had not ensured there were systems to assess, monitor and improve the quality and safety of the services provided.

• Care records were not always secure.

We took enforcement action in the form of warning notices regarding these failures to meet standards.

We also found the provider had not met the required standard for the following:

• The provider had not ensured that care and treatment met the needs and preferences of

people. This included failing to ensure needs were always assessed and that the design of

care and treatment met service user's needs and preferences.

• The provider had not ensured staff received appropriate training, support, and supervision.

We issued a requirement for these failures to meet standards to be addressed.

The provider sent us actions plans of how these matters were to be addressed. We carried out an inspection on 7 February 2017 to check if the provider had taken sufficient action regarding the warning notices we issued. We found the provider had taken sufficient action for us to judge the matters highlighted in the warning notices had been addressed. At this inspection we found the provider had continued to make improvements. The requirements made at the inspection of 29 and 30 November 2016 were now met. We judged sufficient improvements have been made that the service no longer needs to be in Special Measures.

At the inspection of 29 and 30 November 2016 we also found the service did not have a registered manager and that management arrangements were unclear. For example, there was a lack of clarity regarding who made decisions regarding nursing care. Since then the provider has appointed a manager who is now registered with the Commission. 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 now has a deputy manager who is a registered nurse and has responsibility for decision making regarding nursing care. There was a management team of: the registered manage and a deputy manager who a lead responsibility for coordinating nursing care as well as a head of care. The management team were committed to making improvements.

Whilst we noted considerable improvements have been made to the service we judged sufficient time has not elapsed for us to say these changes were fully sustained and embedded. We also took account of the fact the service only accommodated 18 people when it is registered for up to 35. We were therefore only able to assess the performance of the service at just 50 per cent occupancy.

Sufficient numbers of care and nursing staff were provided to meet people’s needs although some staff and a person at the home felt there were times when additional staff were needed.

Staff gave us mixed views on the support they received from the management team. These ranged from staff saying they felt valued and were supported to other staff saying they did not feel valued and that the registered manager and head of care were too isolated from the care staff team and the care of people. The management team acknowledged this and stated their commitment to address the staff concerns.

People and their relatives said the staff provided safe care. Staff had a good awareness of safeguarding procedures and what to do if they had any concerns of this nature.

Risks to people were assessed and there was corresponding guidance for staff to follow to mitigate these risks.

Checks were made on newly appointed staff to ensure they were suitable to work in a care setting.

Medicines procedures were safe, although we noted minor edits were needed to a care plan regarding ‘when required’ medicines for one person.

Staff were well trained and skilled in providing care. Regular supervision and appraisal of staff took place.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Staff were trained in the MCA and DoLS. People’s capacity to consent to their care and treatment was assessed and applications made to the local authority where people’s liberty needed to be restricted for their own safety.

People’s nutritional needs were assessed and there were clear care plans for supporting people who were at risk of malnutrition or dehydration. There was a choice of nutritious meals.

People’s health care needs were monitored and addressed. Referrals were made to health services when this was appropriate.

People were cared for by compassionate staff who promoted their dignity and privacy. Care was provided in a way which reflected people’s preferences and choices. People were consulted about their care. Staff promoted people’s privacy.

People’s care needs were comprehensively assessed and care plans gave staff guidance on how to provide care. People said their care needs were met. People’s social and recreational needs were assessed and there was a range of activities for people which they enjoyed.

People and their relatives said they knew what to do if they had a complaint. There was a complaints procedure and complaints were looked into and responded to.

The provider sought the views of people and their relatives about the service. People and their relatives said they had contact with the service’s management team. A number of audits were used to check the quality and safety of the service. Records showed audits of incidents and accident included measures to be taken to reduce the risk of a reoccurrence.

We undertook a focused inspection on 7 February 2017 to check that they had followed their plan and to confirm that they now met the requirements of the Warning Notices. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Royal Bay Nursing Home on our website at www.cqc.org.uk

Royal Bay Nursing Home provides care and accommodation, including nursing care, for up to 35 people. There were 17 people living at the home when we inspected. People living at the service were all aged over 65 years and had needs associated with old age and frailty as well as dementia. The service also provides care for people who are at the end of their lives.

At this inspection we found improvements had been made and that the shortfalls identified in each of the three Warning Notices had been rectified.

The service did not have a registered manager but a new manager was recently appointed and they intended to apply to the Commission for registration. 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 has been without a registered manager for over a year and at the previous two inspections we identified there was a lack of leadership at the service. The new manager was motivated and committed to improving the service. A new deputy manager had also recently started work at the service; this person was a Registered General Nurse (RGN) and her role involved taking a lead responsibility for nursing care in the service. We found the deputy manager was also motivated to improving the service and had a good knowledge of nursing procedures. The service also had another manager who worked alongside the manager and deputy manager, who referred to themselves as the interim manager.

The provider had taken action to address the shortfalls identified in a Warning notice regarding the safe care and treatment of people. This included the provision of first aid training for staff and taking measures to reduce the risks of injury to people by maintaining equipment correctly. Action had been taken to ensure risks of pressure injuries to people’s skin were consistently addressed. Action had also been taken to rectify the concerns we found regarding the safe management of medicines. People and their relatives told us they received safe care and treatment. We spoke to health and social care professionals who identified improvements in how risks were managed.

The provider had taken action to address the shortfalls identified in a Warning Notice regarding meeting people’s nutrition and hydration needs. We saw improvements had been made regarding the assessment of people who were at risk of possible malnutrition or dehydration and that referrals were made to relevant health care professionals for advice and support regarding food and fluids. We observed people were supported to eat and drink. People told us they liked the food.

The provider had taken action to ensure there was a system of assessing, monitoring and improving the quality of the services provided which was identified in a Waning Notice as in need of significant improvement. Audits and checks were carried out to identify where improvements were needed. People were able to express their views about the service.

Despite improvements made and compliance with Warning Notices issued, further time and work was required of the provider to ensure compliance with all legal requirements made at the last inspection and to ensure those improvements are sustained over time. We will assess the improvements made and how they will be maintained at our next comprehensive inspection of Royal Bay Nursing Home.

Royal Bay Nursing Home provides care and accommodation, including nursing care, for up to 35 people. There were 30 people living at the home when we inspected. People living at the service were all aged over 65 years and had needs associated with old age and frailty as well as dementia. The service also provides care for people who are at the end of their lives..

The service did not have a registered manager. At the last inspection in January 2016, the service did not have a registered manager and it was unclear then who was managing the service at that time. Since then the provider had not confirmed in writing who was managing the day-to-day operations of the service. Therefore the provider was in breach of the Registered Manager condition of their registration which requires them to have a registered manager in place. 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 lacked oversight of the service and there was poor quality monitoring. Some of the concerns found at the previous inspection continued to be areas of concern at this visit. At the last inspection we found the system to assess, monitor and improve the quality and safety of the service was not adequate and we made a requirement for this to be addressed. The provider submitted an action plan to say how they would meet this regulation. At this inspection we found this regulation was still not met. There were shortfalls in how care was coordinated and sufficient action was not taken to ensure people received safe care and treatment. We were concerned about the lack of consistency in the management of the service since the last inspection. Care records were not securely stored.

At the last inspection we found the provider had not ensured people’s nutritional and hydration needs were met and made a requirement for this regulation breach. The provider sent us an action plan of how this was to be addressed. At this inspection we found sufficient action was not always taken where people were at risk of malnutrition and dehydration. This is regulation was still not met.

Providers are required to notify the Commission of certain events or incidents affecting service users and the safe operation of services.

At the last inspection we found the provider had failed to notify us that the heating system was not working. At this inspection we found incidents were not always notified to us, namely, a safeguarding investigation being carried in conjunction with the local authority safeguarding team. This regulation was still not met.

At the last inspection, we found the provider had not ensured the home was adequately heated. The provider sent us an action plan of how this was to be addressed. At this inspection, we found the heating was generally working but that one person’s radiator did not work which was repaired at the time of the inspection visit. This regulation was now met.

Whilst some staff told us they were supported and could seek advice when they needed there was a lack of formal supervision of staff and registered nurses.

Sufficient action had not been taken to ensure the equipment in the service was safe. This included a hot water dispenser, supplementary heating in bedrooms and servicing of the portable electrical appliances. Sufficient numbers of staff were not trained in first aid. Medicines procedures were not always safe and people did not always receive the correct medicine.

Care plans and assessments did not always include sufficient detail of how care needs were to be met, including end of life care.

People told us they felt safe at the service. We saw people were clean and appeared well cared for. People, relatives and professionals said the standard of personal care was good. Staff were observed to treat people with kindness and respect. People told us the staff generally treated them well.

There were sufficient numbers of staff but we were concerned that only two registered nurses were employed as part of the staff team.

The CQC monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Staff and the manager were aware of the principles and guidance associated with the MCA. Where needed assessments of those who lacked mental capacity to consent were carried out and applications made for DoLS.

Records were maintained of complaints and how they were looked into.

Following the inspection we wrote a Letter of Intent to the provider explaining the Commission’s concerns about the safety and quality of the service. We asked for an immediate response as to how these matters were being addressed. The provider responded as requested explaining actions they were taking to address the most immediate concerns but action was still needed to improve the overall safety and quality of Royal Bay Nursing Home.

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.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 including continued breaches from our inspection in January 2016. You can see what action we told the provider to take at the back of the full version of this report.

We found that the home was clean and that staff were taking infection control seriously.

We also found that care was delivered that met with people's needs.

The daughter of one person told us they were upset that their parent was becoming more frail but that the staff had helped them cope and see that it was the best thing. They said their parent had been isolated and lonely living alone and had become depressed. Since moving into the home they had 'got their second wind' and enjoyed the activities and company of others.

Staff were described as very kind and helpful. We were told that the senior staff and management were approachable and sorted out any small issues before they became problem. One group of people that we spoke with said they really enjoyed chatting to the 'young girls' as it made them feel young again.

We spent time observing care and saw that, on the whole, people's needs were being met but that the records did not always reflect this. We did identify some areas where improvements were necessary to ensure compliance with the regulations and people were put at some degree of risk because of lack of oversight of care by the trained nurses.