Archived: Devonshire House and Lodge

Bickleigh Down Care Home (known as Bickleigh Down) is a purpose built nursing and residential home caring for a maximum of 77 people. At the time of the inspection 53 people were living at the service. Bickleigh Down is part of the corporate group Four Seasons (DFK) Ltd. The service is divided into five units, three nursing units and two residential units. Bickleigh Down provides care for older people who may have dementia and physical health needs.

Bickleigh Down Care Home was owned by Four Seasons (DFK) Ltd at the time of the inspection. The service had been sold to Harbour Healthcare Ltd. The new owners were in the process of registering as the new providers during the inspection process. This was due for completion at the end of May 2016.

A registered manager was employed to manage the service locally. 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.

We last inspected Bickleigh Down Care Home on 4, 5 and 6 March 2015. We asked the provider to take action to ensure the safe management of medicines and accurate records were kept. The provider sent us an action plan detailing the improvements they would make by the end July 2016. At this inspection we found improvements were still required.

Aspects of people’s medicine management were not always safe. We found documentation and care plans did not always reflect what action was taken if people did not wish to take their medicines. We had concerns the procedures in line with the Mental Capacity Act (2005) were not always followed when people required their medicine covertly. Agency nurses did not always know the systems in place for medicine audits, ordering and emergency medicine which some people might require. This had meant some people had been without their medicine for a short period and there might have been a delay in receiving emergency medicine.

There were sufficient staff on duty to meet people’s needs safely however, there was a high level of agency staff which particularly affected the dementia nursing units. This affected the leadership and continuity of care in these units. Agency staff were unfamiliar with the systems and processes on these units and did not know people well.

Essential work was reported promptly to the provider, but not completed in a timely way. This impacted on people’s safety. For example there were problems with the call bell system and with one of the fire doors.

People’s environment was clean and staff followed safe infection control procedures. However, there was a strong smell of urine in the two dementia nursing units. This affected the carpets in the communal areas and some bedrooms. This had been reported to the provider and action had not been taken.

People had risk assessments in place to mitigate risks associated with living at the service however we found particularly on the nursing dementia units some of these had not been reviewed to reflect people’s current care needs.

People’s mental capacity had not always been assessed in line with the Mental Capacity Act (2005) as required. Applications to deprive people of their liberty had been submitted where required. However, some staff did not have a good understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS). Further training was being arranged for staff following the inspection.

People were asked for their consent prior to being assisted; however some staff were unsure how to manage people who might decline personal care. This had led to the distress of one person. Staff told us they were keen to learn alternative ways to manage this and be creative in how personal care could be provided to meet people’s individual needs.

People’s nutritional and hydration needs were met, but the systems in place did not ensure people always had their preferences met. For example the current system used to deliver food to people from the kitchen to the dementia nursing units meant some people’s choices were not always met as the food was plated up in the kitchen. Staff also told us evening tea was often before 5pm which meant there was a long gap between tea and breakfast. Although night snacks were available for those who were able to ask for these, many people on the dementia nursing units were unable to communicate if they might be hungry.

Staff were recruited safely. People were looked after by staff trained in many areas. Additional training needs identified during the inspection were promptly booked. People were protected by staff who could identify abuse and who would act to protect people. People told us they felt safe living at the service.

People told us staff were kind, caring and compassionate. Permanent staff and regular agency staff knew the people they care for. People knew how to raise a complaint if they had one and there were systems in place to investigate complaints.

There were activity coordinators and a range of social events to support people to remain active and stimulated. Arts and crafts, dressing up days and musical events were held at the service. People's faith needs were met.

People had their health needs met and saw their doctors, opticians and attended hospital appointments when required.

People were supported to maintain their independence for as long as possible. People told us personal care was provided in a way that maintained their dignity; staff knocked on doors before entering people’s rooms, closed curtains and spoke to them and addressed them in the way they preferred.

We found breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

As part of this inspection we spoke with five people who lived in the home, one relative, the Acting Regional Manager, the Deputy Manager, seven staff and one visiting healthcare professional. We reviewed records relating to the management of the service which included eight care plans, daily care records, medication records, and quality assurance records.

Below is a summary of what we found. The summary describes what people who used the service, their relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The environment was not clean and hygienic. The service did not have systems in place to ensure that people who lived in the home, staff and visitors were protected from the risk of infection. Medicines were administered safely. We watched some medicines being given to people at lunchtime, and we saw that they were given in a safe way. There were enough staff on duty to meet people's needs. During our inspection we observed staff spending time talking with people. This meant the service had ensured staff were able to spend time caring for and engaging with people. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deputy Manager told us the service had recently submitted nine applications. One had been declined, one had been granted and the others were waiting for a decision. Proper policies and procedures were in place. The Deputy Manager knew when an application should be made, and how to submit one.

Is the service effective?

Five people who used the service told us they were happy with the care they received. Comments included 'They look after me very well' and 'I'm very happy with the care provided'. People's needs were not always assessed and care and treatment was not always planned and delivered in line with their individual care plan. We looked at eight care plans. We found that five care plans were detailed and had been reviewed regularly. However, the other three care plans did not contain all of the information needed. This meant that people were not protected against the risks of inappropriate care or treatment.

Is the service caring?

People we spoke with were positive about the home and the staff. Comments included 'They're all brilliant here' and 'The staff are very good.' We spoke with a visiting healthcare professional who told us 'staff seem very caring'. We observed that staff were patient when assisting people with their mobility, food, and medication. On one occasion we observed a staff member chatting with a person about dolls. The person clearly enjoyed the conversation and both of them were laughing. This showed that staff were professional and respectful to people living in the home.

Is the service responsive?

People's needs had been assessed before they started to receive care. The service carried out an assessment to ensure it was able to meet people's needs. During the inspection we saw that one staff member was taking a person to hospital as they had concerns about the person's condition. However, we also found evidence that the service had not promptly sought professional advice for another person.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities. Staff we spoke with told us they felt well supported and had regular meetings with the Registered Manager. They told us they were able to approach the Registered Manager at any time. The provider had an audit programme in place to ensure that a number of areas were looked at during a 12 month period. We identified shortfalls relating to infection control. No action had been taken to rectify these. The service's quality assurance systems had not identified the shortfalls relating to care plans and treatment.

We found people had their needs assessed and their risks identified. The people we met appeared content. We found staff understood people's needs well and were looking at ways to improve the experiences of people with dementia related conditions.

Staff told us they felt supported in their roles and had good training. We found that progress had been made since our last inspection and staff were receiving one to one supervision from their manager and a process had been started to ensure staff received an annual appraisal. These methods of review supported staff to develop their practice and maintain good standards of care at the home.

People told us "The girls are brilliant" and "...they're doing a good job." The staff we met told us how much they enjoyed their jobs and we observed staff that were respectful in their interactions with people and knowledgable about the people they cared for. We found people had an assessment of their needs prior to coming to live at Bickleigh Down Care home and their needs were incorporated in to a care plan.

We found there were systems in place to monitor infection control and the home was clean and tidy. The provider was recruiting for additional cleaning staff. We met a committed housekeeper who was keen to establish a robust schedule to maintain a clean, hygienic home.

We spoke with staff who felt supported in their roles, able to talk to the unit managers if they had questions and had undertaken training to support their development needs and enable them to provide high quality care with confidence. We found a system for supervisions and appraisals needed to be developed.

People told us, "If I had a complaint I'd talk to the boss!" We found there was a policy and process in place for people and staff to make a complaint and this was evident at the entrance to the home. Complaints were dealt with promptly and feedback given to the complainant and to staff.

People we spoke with who lived at the home said that their care and welfare needs were being met.

Care files demonstrated that relevant assessments had been completed from pre-admission through to ongoing reviews of care and showed the involvement of other health and social care professionals and the contacting of relatives when a person had a fall.

Everyone said that they felt safe and that their possessions were in a safe place. People knew who to speak with if they had a concern and cited the manager or a close relative.

We looked at a random selection of medication charts on the various units. We found that the main medication charts were signed and the corresponding cream charts had been completed in people's bedrooms.

Staff we spoke with informed us that staff morale had improved over recent months and that the management structure was more robust, which meant that people's needs were being met in a timely and organised manner.

We spent time with the unregistered manager, who had been in post for four weeks. They explained that since their appointment, they had observed issues within the home relating to the running of the home and low staffing levels. They were in the process of dealing with these issues by means of meetings with unit managers and registered nurses and through additional recruitment of staff.

Comments from people living at the home and relatives included: 'there's not enough staff, all it takes is for two staff being needed to assist someone and then everyone else is left unattended' and 'the staff are really caring and work hard, there's just not enough staff.' A person who had recently moved to Bickleigh Down told us, 'one night the staff were pushed, someone was always calling for the nurse.'