Austen House

Austen House is a residential care home providing personal and nursing care for to up to 79 people. The service provides support to older people and younger adults who may also have dementia. At the time of our inspection, there were 73 people using the service. Austen House accommodates people across four units in one building. Each unit has separate adapted facilities. Two of the units specialise in providing care to people living with dementia.

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

Medicines were not always managed safely. People and staff felt there were not always enough staff deployed and the provider had not ensured sufficient staffing levels in order to safely meet the needs of people. The provider had not ensured risks and actions identified in relation to fire had been undertaken. We recommended the provider reviews their recording and documentation regarding incidents and accidents. People told us they felt safe. Staff understood their responsibilities to raise concerns and report incidents or allegations of abuse.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. We recommended the provider improves the decor of the premises in order to make it more dementia friendly. We also recommended the provider review their staff training provision in line with current best practice guidance.

The provider did not ensure systems were embedded to ensure compliance with the fundamental standards. The duty of candour was not always followed when required.

Staff worked well with people, families and health and social care agencies to support people’s wellbeing. People reported that they were supported with their nutritional requirements. Staff knew people they supported well and cared about their wellbeing.

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 good (published 14 November 2019).

Why we inspected

We received concerns in relation to people’s nursing care needs, staffing levels and documentation. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

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 breaches in relation to good governance, medicines management, staffing, fire safety, duty of candour and the Mental Capacity Act. 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.

Austen House is a care home with nursing providing personal and nursing care to 57 people aged 65 and over at the time of the inspection. The service can support up to 79 people. Accommodation is provided in four units. One of the four units was closed for refurbishment when we visited.

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

The previous registered manager left the service in August 2018. There followed a 10-month period where there were a number of different interim managers with one manager who registered in April 2019 and then left four months later. During that time the staff team worked very hard to minimise the impact the management changes and uncertainty had on the people who live at the service. The registered manager at the time of this inspection started working at the service in June 2019 and became registered on 25 September 2019. The staff team, together with the provider management team, succeeded in making the required improvements and had met the six breaches of regulations found at the last inspection. The registered manager was clear on improvements that were still needed at the service and had well thought out plans in place to address them.

People benefitted from receiving support from staff who were happy in their work and felt well managed and supported. They benefitted from a service which had an open and inclusive culture and encouraged suggestions and ideas for improvement from people who use the service, their relatives and staff.

People received effective care and support from staff who knew them well and were well trained. They were protected from the risks of abuse and felt safe living at the service. Risks to people’s personal safety had been assessed and plans were in place to minimise those risks. Medicines were handled correctly and safely. Staff recruitment and staffing levels supported people to stay safe while going about their daily lives as independently as possible.

People's rights to make their own decisions were protected. They were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were treated with care and kindness. They were consulted about their care and support and could change how things were done if they wanted to. People were treated with respect and their dignity was upheld. This was confirmed by a relative who provided feedback. People's diverse needs were identified and met and their right to confidentiality was protected.

People received care and support that was personalised to meet their individual needs. Staff worked well together for the benefit of people and were focused on the needs of people living at the service.

Rating at last inspection and update

The last rating for this service was Requires Improvement (published 15 October 2018) and there were six breaches of regulations. 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

This was a planned inspection based on the previous rating.

Follow up

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

Austen House 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.

Austen House provides personal care and nursing to up to 79 people in four units. The people supported have nursing needs and may be living with various types of dementia. At the time of this inspection 71 people were receiving support.

The service is required to have 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 has had seven registered managers since its registration in 2011. The most recent registered manager left in early August before this inspection. An experienced acting manager was in place from another of the provider’s local services.

This inspection was brought forward in response to a series of safeguarding incidents, complaints from relatives and a service user, concerns raised by a recent whistle-blower and by the local authority. Concerns mainly centred around safeguarding, the provision of adequate fluids, pressure area care, staff conduct/approach and staffing levels/deployment.

People told us they now felt safe in the service. However, we found people may not always have been kept safe because the provider or manager had not always responded in a timely or effective way to address issues to reduce the risk of recurrence. We had not been able to fully evaluate the provider’s investigative response to recent concerns, particularly about specific staff, because information we requested about these was not provided in a timely way.

People had further been put at risk of potential harm because of ongoing errors and omissions we found in medicines records. This was despite these issues having been highlighted previously within pharmacists reports and internal management monitoring.

People’s safety was also potentially compromised because we found gaps in the recruitment records. This meant we could not be assured the required checks on the health, skills and previous conduct of staff recruited, had been verified to ensure they were suitable to provide safe care to people.

Staffing levels had recently been increased to address identified shortfalls which had led to gaps in care provision and some delays in receipt of care. Recruitment was ongoing to address the significant staff shortfalls which were being covered by agency staff in the interim.

It was not clear whether people had always received sufficient fluids to maintain wellbeing. Fluid intake records were poorly completed despite the issue having been identified previously by the local authority.

People’s rights and freedom had not always been protected. Records of mental capacity assessments were not always present where Deprivation of Liberty Safeguards (DoLS) had been applied for. Records of best interest decisions and people’s consent were sometimes incomplete or conflicted with their stated capacity. Some consent given by families was not backed up by evidence of power of attorney.

It was not clear that people’s complaints had always been investigated thoroughly or resolved satisfactorily. Complaints records were incomplete and poorly maintained.

The activities provided by the service did not effectively meet people’s individual and collective needs sufficiently. The acting manager was taking steps to address this.

Care records were not always sufficiently detailed. Daily records lacked detail about the meeting of people’s social and emotional needs.

The service was non-compliant with the Accessible Information Standard. Suitable alternative versions of key documents were not yet available to meet the needs of individuals with sensory loss or other impairments.

Significant improvements had been noted since the recent arrival of the current acting manager. People felt the acting manager was approachable and was already addressing issues.

However, the service had not been sufficiently well led in the 12 months leading up to this inspection. Neither the previous registered manager nor the provider had exercised effective governance of the service over the previous 12 months, which had led to issues and shortfalls not being addressed effectively or in a timely way. The previous registered manager had failed to report to the CQC the outcome of all DoLS applications and had not understood her responsibilities under Duty of Candour.

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The recently appointed acting manager had begun to establish in-house monitoring and audit systems to help identify the areas for improvement with input from the provider’s clinical support and dementia specialist teams.

People and relatives' views about the service had been sought in the previous 12 months by means of a survey, with mostly positive results.

Staff received support through one-to-one or group supervision, regular meetings and periodic performance appraisal.

People were treated with respect and dignity by the staff. Staff interacted regularly with people and knew them and their needs well. People’s gender preferences were met wherever possible.

People told us the current staff were caring and treated them kindly although some concerns were raised about some previous agency staff. People and relatives felt involved indecision making about care. People felt the current staff and management were responsive to their needs.

Effective general healthcare support was provided and external healthcare practitioners were consulted when required.

People felt the effectiveness of the service had improved since the acting manager started.

We identified five breaches of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (as amended) and one breach of the Care Quality Commission (Registration) Regulations 2009. Details of the action we have taken are at the end of the full report.

We also made a recommendation that the provider should refer to the guidance available regarding the ‘Accessible Information Standard’ and address their current non-compliance as appropriate.

At the last inspection, the service was rated Good overall with a rating of Requires improvement in the Effective domain. This was because improvements were needed to the provision of ongoing support and development to staff through supervision and appraisal. We also found some omissions within daily monitoring records which could potentially have placed people at risk from less effective care being provided.

At this inspection we found the service had made significant improvements in these areas under the new manager, Staff were now receiving regular supervision and a programme of developmental appraisals had been carried out. Omissions in records had been addressed and improved monitoring systems put in place to help ensure people’s needs were effectively monitored.

However, there was a need for additional improvements to the physical environment, which was scheduled to take place as part of a planned refurbishment. Also, further developments were required to enhance the dementia-friendliness of the environment.

People were safe and well cared for. Their needs were assessed and identified risks monitored, with action taken to minimise these. The safety of the environment and equipment was maximised through regular checks and servicing. People’s medicines were managed safely on their behalf.

A robust staff recruitment system was used to try to ensure staff had the necessary skills and approach to provide appropriate care. Staff now received ongoing support as well as training, to perform their role effectively.

People received care based on detailed assessment and plans of care which reflected their needs and wishes. People and their representatives were involved in decision making about them and their rights and freedom were protected. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

Staff respected people’s dignity, privacy, cultural and spiritual needs. People were treated with patience and kindness by staff.

The views of people and their representatives were sought through surveys, meetings and reviews and action was taken to address identified issues. People found the manager approachable and accessible and said she responded when issues were raised with her.

The service had a new manager who was in the process of applying to become a registered manager. She had already improved the consistency of care, record keeping, management governance and staff support. The manager had a clear vision of her expectations and communicated these to staff through regular meetings. Where issues had been raised they had been addressed, including the requirements of an action plan provided by the monitoring local authority.

The inspection team consisted of one adult social care CQC inspector. On the day of our inspection 76 people used the service. Many of the people were unable to tell us their experiences. We used a number of different methods, including observation to help us understand the experiences of the people. We spoke with three people, three people's relatives, four care workers, four nurses, and two visiting health care professionals, the deputy manager, and regional manager. We reviewed records relating to the management of the home which included 19 people's care plans.

We considered all the evidence we had gathered under the outcomes we inspected, which related to consent to care, people's care and welfare, suitability and safety of premises, staffing, assessing and monitoring the quality of service provision and records. We used the information to answer five key questions; is the service safe, effective, caring, responsive and well-led.

This is a summary of what we found.

Is the service safe?

People and relatives of people who use the service were complimentary of how the provider maintained people's safety. One person told us 'I feel safe here.' Personal evacuation plans were in place for each person to ensure their safety in the event of a fire at the service.

There were enough staff on duty to meet the needs of the people and a member of the management team was available on call in case of emergencies.

The provider carried out appropriate risk assessments, checks and servicing to maintain the service to a safe standard. For example, we saw servicing records for the lifts and gas boiler.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to this type of service. The service was safe because requirements in relation to the DoLs had been met. The deputy manager had received training in relation to DoLs and was aware of the recent case law. They told us most of the people they provided care for did not have the capacity to determine where they wanted to live and all received a high level of support and supervision within the service. The deputy manager informed us that they had started the process of submitting DOLs applications for these people following consultation with the local authority. This was confirmed by our observations during the inspection.

We saw people's records were stored securely and could be located promptly when requested. However People's records were not always accurate and fit for purpose. People were not protected against the risk of unsafe or inappropriate care because of a lack of complete information about them. We have asked the provider to tell us what they are going to do to ensure they have effective processes in place to ensure that people's records are accurate and fit for purpose.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others in relation to incidents. There was a system for monitoring and learning from incidents relating to the welfare and safety of people who use the service. The provider could identify possible trends that may require additional actions, such as risk assessments and the implementation of appropriate actions, to minimise the risk of occurrences to people and others who use the service.

Is the service effective?

The service demonstrated effective practices through the assessment of people's health and care needs. People's views about the type of care they wanted had been sought. Relatives of people who use the service confirmed their involvement in the development of their family member's care plan. We found staff had a good understanding of people's care and specific support needs, for example, in relation to pressure sore prevention and medical conditions such as epilepsy and diabetes.

We spoke with two people who use the service and three relatives of other people. They were complimentary about the care received. One person we spoke with said 'The staff are very helpful and have a can do approach.' A relative said " Staff are very good. They work like Trojans, they get the work done'

During our visit we saw people were asked for their consent before they received any care, and staff acted in accordance with their wishes. However, the provider did not have suitable arrangements in place for formally obtaining the consent of people regarding their care and treatment. This meant staff asked relatives to sign for or verbally agree to consent on the person's behalf, without ensuring the relatives were lawfully able to do so. We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to gaining lawful consent to care and treatment on other people's behalf.

Is the service caring?

People were supported by kind and supportive staff. One person told us 'Staff are lovely.' A relative said 'Staff are very caring and patient.' All interactions we observed between the staff and people were respectful and courteous. We saw that care workers gave encouragement when supporting people. People were able to do things at their own pace and were not rushed.

A customer survey was conducted in October 2013 by the provider. This recorded 14 responses from people and their relatives. We saw feedback was positive. People rated staff support and care highly.

Is the service responsive?

People's needs were assessed before they were admitted to the service. Records confirmed people's preferences and diverse needs had been recorded with the exception of waking up times in the morning. Staff provided examples of care and support being provided in accordance with people's wishes, for example, in relation to where they received their meals and personal hygiene.

We found care was not planned and delivered to meet all of the identified needs for one person who used the service to ensure their safety and welfare. People's preferences in relation to waking up times had not always been recorded. Because of this care and support was not always being provided in accordance with people's wishes. We asked the provider to tell us what they are going to do to meet the requirements of the law in relation to ensuring care is planned and delivered to meet the needs of all people who use the service.

People knew how to make a complaint if they were unhappy. We looked at how four complaints had been dealt with, and found that the responses had been thorough, and timely. People could therefore be assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

We saw people's feedback was sought through meetings and surveys. The provider was responsive to comments from people, such as the implementation of a planned refurbishment to meet people's wishes and suggestions.

Audits and checks ensured people's safety and wellbeing was promoted. Where issues were identified, an action plan for progress and completion of this was monitored. We saw issues were identified and actions completed appropriately.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. One person living at the home told us the staff "always let me know" about their care. Care records were easily accessible by all staff and were reviewed and updated regularly to reflect any changes in people's care.

We saw there were effective systems in place to ensure cleanliness and for infection control. One relative told us they felt the home was "an excellent place, nice, clean and tidy".

There were effective systems in place for the recruitment of staff and appropriate checks were carried out before people began work at the home.

The provider had effective systems in place to monitor the quality of the service. There were regular resident and relatives meetings and an annual survey was carried out of the people who used the service. Regular quality audits were carried out by the provider and action was taken to address any issues arising.

At the time of our inspection the provider did not have a registered manager in post. The manager on duty during our visit was in the process of registering with the Commission.