Alton Manor Care Home - Portsmouth

Alton Manor Care Home is a residential care home providing personal care to up to 34 people living with dementia and/or physical frailty in one adapted building. At the time of our inspection 25 people were living at the home with one person in hospital.

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

Infection control processes were not always managed safely and placed people at risk of harm.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We have made a recommendation about this.

Current guidance on isolation of people on admission was not always followed. We made a recommendation about this.

Care plans and risk assessments although improved still required further updating and improvement, we made a recommendation about this.

Staff felt well supported by the manager and told us overall they were happy working at Alton Manor Care Home. Staff in the service worked well with each other and external professionals to ensure good health outcomes for people.

Medicines were managed safely, and the provider recruited people safely.

We observed positive and kind interactions between staff and people. Relatives felt staff treated people with dignity and respect and we observed staff respecting people's right to privacy.

People’s rooms were personalised, and the layout of communal areas had significantly improved.

People knew how to raise concerns. They had confidence in the registered manager. Incidents and accidents were monitored by the registered manager. Where accidents and incidents occurred the registered manager ensured appropriate action was taken to reduce the likelihood of injury or reoccurrence.

The provider and the manager demonstrated a willingness to make further improvements and had identified areas for improvement prior to the inspection through their quality assurance systems and processes. They planned to ensure the service consistently provided good, safe, quality care and support. Further progress was still needed to fully embed and sustain these improvements.

Rating at last inspection and update

The last rating for this service was requires improvement (published 26 May 2021). There were three breaches of regulation in relation to regulation 12, Safe Care and Treatment, regulation 17, Good Governance and 11, Need for Consent. We imposed a condition on the providers registration which required them to submit a monthly report to the Care Quality Commission on the actions being taken to ensure improvements were being made to the quality and safety of the service.

The is the third consecutive rating of requires improvement for this service however, we have seen significant improvements at this inspection.

Why we inspected

The inspection was prompted in part due to concerns received about staffing, poor care, management and culture of the service, communication, medicines management, activities and confidentiality. A decision was made for us to inspect and examine those risks.

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

We have found evidence that the provider needs to make some improvement. Please see the safe, effective and well-led sections of this full report.

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

Alton Manor Care Home is a 'care home'. Alton Manor Care Home accommodates up to 34 people living with dementia and physical frailty in one building. At the time of our inspection 30 people were living at the home.

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

Quality assurance systems had not always been effective in identifying the concerns we found at this inspection.

The lack of robust infection control practices placed people at risk of being exposed to infections. This included known risks associated with the current Covid-19 pandemic.

Some risks to people’s safety had not been effectively assessed, monitored or mitigated. The management of medicines was not always safe. No harm had come to people, but we were concerned about the increased risk of harm to people. The provider promptly addressed some of these concerns and had plans in place to address the remaining concerns.

People and relatives provided us with a mixed view about whether there was enough staff to effectively support people. We observed that people were supported in a timely way apart from at lunchtime. The provider told us they would monitor the deployment of staff to ensure people’s needs were met at lunch time.

People were not 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 support this practice.

Staff felt well supported through training and supervision. Staff in the service worked well with each other and external professionals to ensure good health outcomes for people

We have recommended that the provider seeks reputable guidance to ensure the requirements of the Accessible Information Standard are consistently met. This was because staff did not always communicate with people in a way they could easily understand.

We mostly observed positive and kind interactions between staff and people, although on some occasions we saw that staff did not engage with people who lived with dementia in the most effective way. Relatives felt staff treated people with dignity and respect and we observed staff respecting people’s right to privacy.

People and relatives told us they were happy overall with the service. Staff enjoyed working at Alton Manor and felt well supported by the registered manager.

The nominated individual, registered manager and director demonstrated a willingness to make improvements and during the inspection began reviewing their systems and process to ensure the service consistently provided good, safe, quality care and support. Further progress was still needed to fully embed and sustain these improvements.

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

Rating at last inspection and update:

The last rating for this service was requires improvement (published 01 April 2019). There were four breaches of regulation in relation to regulation 17 Good Governance, regulation 12 Safe Care and Treatment, regulation 11 Consent and regulation 20 Duty of Candour. We met with the provider and they completed an action plan after the last inspection to show what they would do and by when to improve.

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

At this inspection enough improvement had not been made and the provider was still in breach of regulation 11, 12 and 17. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections. We will describe what we will do about the repeat requires improvement in the follow up section below.

Why we inspected

We undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Safe, Effective, Caring and Well-led Key Questions which contain those requirements. 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 coronavirus and other infection outbreaks effectively.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained as requires improvement. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvement. Please see the Safe, Effective, Caring and Well led sections of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to consent, safe care and treatment and governance.

Follow up

We have imposed a condition on the providers registration which requires them to submit a monthly report to the Care Quality Commission on the actions being taken to ensure improvements are being made to quality and safety of the service.

We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Alton Manor Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Alton Manor Care Home is situated in a residential area. The accommodation is arranged over three floors of a large, converted Victorian building with stair and lift access to all floors. At the time of our inspection there were 31 people living at the home.

There was 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.

We previously inspected Alton Manor Care Home on 10,11 and 26 May 2016 and rated the service as Good. At this inspection we found evidence that demonstrated risks or concerns. This was because risks to people were not assessed, monitored and mitigated effectively and medicines were not managed safely. We also had concerns that the principles of the Mental Capacity Act (MCA) 2005 were not followed and the requirements of the duty of candour had not been met. The provider did not have effective quality assurance processes in place to identify these concerns. The overall rating of the service has changed since our last inspection to ‘Requires Improvement’.

Risks to people were not always managed effectively. Clear plans and records were not in place for people at risk of choking, falls and risks associated with specific health conditions. This meant staff did not always know about risks to people and how to manage or mitigate them.

The administration of medicines was not managed safely. This had not been identified by the service because effective checks had not been undertaken.

There was not a robust quality assurance process in place. Systems to assess the quality of service provision were ineffective in identifying some of the improvements needed. The provider had not followed legislation that required them to act in an open and transparent way when people came to harm.

Staff sought verbal consent from people, before providing support, but did not always follow legislation designed to protect people’s rights when making decisions on their behalf. Care plans lacked mental capacity assessments and there was no record that people had consented to their care at Alton Manor Care Home. All people with the exception of one had a Deprivation of Liberty Safeguard (DoLS) applied for when necessary. Staff were not aware of who had a DoLS in place in the home.

Care plans contained information about how to support people but areas of these needed to be more personalised and detailed to ensure people received support in a person centred way. We have made a recommendation about this.

People’s communication needs were recorded in their care plans. However, we have made a recommendation that the service consults guidance to further develop their practice in accordance with the Accessible Information Standard (AIS).

People had access to external healthcare professionals such as GPs and nurses when needed but were not referred to the falls prevention team or speech and language therapists when risks were identified in these areas. This meant appropriate guidance was not always sought to safely support people.

Accidents and incidents were recorded and monitored to determine if any trends were occurring for individuals but accidents and incidents were not analysed at a service level which meant improvements could not be made across the service because trends and patterns were not identified.

Feedback about the food on offer was positive and people were given a choice. Where people needed support to eat, this was given in a dignified way.

The home was visibly clean and staff used protective equipment when needed. Staff were seen to follow infection control procedures during the inspection.

People and relatives were complimentary about the staff. All interactions we observed between staff and people were positive. Staff promoted people’s privacy and dignity and encouraged people to remain as independent as possible. However, people’s confidential information was not stored securely which compromised their privacy.

Staff displayed good knowledge on how to report any concerns and could describe what action they would take to protect people from harm.

Safe recruitment processes, including pre-employment checks had been followed and sufficient staff were deployed appropriately. Staff were supported by regular supervision, appraisals and training.

People, relatives and staff were positive about the leadership of the home and told us the registered manager was supportive and approachable.

Due to the concerns we found we made a referral to the Local Authority. We requested that the provider took action to address some of the concerns we found. Following the inspection, we received confirmation they had reduced risks to people because they had improved their practice.

During our inspection we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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.

At the time of our inspection, there were 32 people living at the home. There were 17 care workers, six domestic, maintenance and kitchen staff, one senior care worker, one deputy manager and 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.

Staff had a good understanding of how to keep people safe, identify signs of abuse and report concerns appropriately. Staffing levels were sufficient to meet the needs of people living at the home. Robust processes were in place to recruit staff, which ensured people were cared for by staff who had the appropriate checks and skills to meet their needs.

There were systems in place to ensure medication was administered safely.

There were procedures in place to identify, assess and mitigate any potential risk to people's health and wellbeing. However, actions following risk assessments in relation to skin integrity were not fully applied in every day practice. External health and social care professionals were involved in the care of people and care plans reflected this.

Where people were legally deprived of their liberty to ensure their safety, appropriate guidance had been followed and where people were unable to consent to their care the service had adhered to the Mental Capacity Act 2005.

Staff received an induction and ongoing training to ensure they had the knowledge and skills to carry out their role effectively. They were supported by the registered manager with supervision and appraisals.

People were encouraged to eat and drink enough to promote and maintain a balanced diet. People who had specific dietary requirements were supported to manage these.

People were supported to access healthcare professionals, but this was not always in a timely manner.

Staff involved people and their relatives in the planning of their care. People's privacy and dignity was respected and people spoke positively about their care experiences. Staff were caring and considerate when they were supporting people within the home.

People’s care plans were personalised and met the individuals’ needs. People were involved in their care planning, which was reviewed regularly and care was delivered according to the person’s preferences and wishes. People knew how to complain about their care, and complaints were logged and dealt with in a timely manner and according to policy.

People, staff and relatives spoke highly of the registered manager. There was an open and supportive culture promoted by the registered manager.

Staff told us that they felt able to go to the registered manager with any concerns or worries and they would be listened to. There were robust auditing and management systems in place to monitor and improve the quality of care provision within the home.

We made a recommendation that the service review the outcome risk assessments that come from Waterlow assessments with a high risk and take action to improve the clarity in such assessments as to what steps are taken on a case by case basis.

A single inspector carried out this inspection. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well led?

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

Is the service safe?

People told us they felt safe living at the home. One person told us 'There's nothing to worry about'.

Effective safeguarding and whistleblowing polices and systems were in place to ensure people were protected against the risk of abuse. People were protected against risks associated with their medicines and people's medicines were safely and appropriately managed by the home.

The home had a policy and procedure in place in relation to the Mental Capacity Act. CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. At the time of our inspection applications were not being submitted to review whether the arrangements for people's care and treatment in the home amount to a deprivation of their liberty because there was no one living at the home that was having their liberty deprived.

Is the service effective?

People told us they were happy with the care and support they received. People's needs were assessed and updated regularly and care plans were person centred and reflected their individual needs and preferences. It was clear from what we saw and from speaking with staff that they understood people's care, support and communication needs and they knew them well.

People's relatives told us they were involved in developing the care plan with their relatives. One relative told us, 'I was involved in the care plan'. 'They ring me up when medication changes or if [the person] is poorly and we will come in'.

Is the service caring?

People told us staff were friendly and kind but could sometimes be sharp with their responses and be uninterested. One person told us, 'Sometimes people make a fuss and they have to be spoken to sharply'. Another person told us, 'Staff look after me very, very well, they are brilliant and they make sure I eat to keep well'. 'The food is good and there are ample cups of tea', 'I go to bed happy and content'. A relative told us, '[The person] gets on famously, nothing is perfect but I can walk in and feel that it's her home although it is sometime tense.'

We saw on occasions some staff spoke to people in a direct and abrupt manner and when they interacted with people they did not give people the time to respond. However we observed staff talking to people who used the service and they seemed very comfortable and made good eye contact. We spoke to the registered manager who told us they would look into this and speak with staff.

Is the service responsive?

The service had quality assurance processes in place. However people's comments were not always acted upon. Relatives and people who used the service stated they would like more activities to take place in the home. During the inspection we did not see any activities being carried out and people who used the service remained asleep, watching the television or completing a wordsearch for most of the day. One person told us 'when I am sitting here I calculate what I'm going to do tomorrow'. Another person told us, 'There wasn't much entertainment, I can't remember the last time'

Those people who needed a 'mental capacity assessment' or best interest decision' had these made by the right people. Staff were trained on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

Is the service well led?

There was a registered manager in post and they were present at the time of our inspection. Management arrangements provided leadership and there was an open culture. Staff told us they felt supported and could raise any concerns with the registered manager.

All staff we spoke with told us they knew who the manager was and who would be responsible if the registered manager was not available. One relative told us 'the manager is very dependable'.

The service had effective processes in place to monitor and deal with complaints, accidents and incidents and learn from them.

We found that people's care was based on an individual needs assessment and planned and delivered to ensure their safety and welfare. A person told us "the staff are excellent, I need a lot of help and they are good at it". We found that staff demonstrated a good understanding of people's needs and preferences. A person's relative said "I have no qualms that my relative's needs are catered for".

We found that the home was well maintained and procedures were in place to ensure the home was safe, clean and comfortable. People we spoke with told us that they were satisfied with the standard of the premises.

We found that staffing levels were sufficient to meet people's needs and that training was provided to ensure staff were suitably knowledgeable and skilled to meet people's needs.

There was an effective system in place to assess, monitor and manage risks to people's safety and welfare. People and their relatives were asked for their views on the quality of care provided by the service and their comments were acted on.

We looked at six people's care records and found that care plans did not include all the information staff would need to support the person effectively. Care plans had not been updated and we saw that these were not always followed by staff. People told us that staff were nice and they liked living in the home.

We found that people were not protected against the risk of developing infections because of poorly managed cleaning procedures.

We saw potential hazards to people's health and safety. These included split and damaged flooring which had lifted in places, mould in the shower room and a lack of procedures to assess for hazards to the environment.

We found that staff were supported effectively and received appropriate professional development. We spoke to four staff who told us they were supported, they were comfortable to talk to the manager and were confident they would be listened to. Staff we spoke to confirmed the home conducts a robust recruitment process.

People were able to express their views about the service and their care, however the home did not have an effective system in place to assess, monitor and manage risks to people's health, safety and welfare.