Puttenham Hill House Care Home

Puttenham Hill House Care Home is a residential care home that provide personal and nursing care for up to 30 older people who may be living with dementia and or a physical disability. The home accommodated people across three separate units. At the time of our inspection the service was providing care to 23 people.

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

Staff were not deployed effectively at the service which left people at risk. Although staff were aware of the risks associated with people’s care this was not always being managed in a safe way. Quality assurance was not always effective. The provider had failed to maintain robust oversight of the service. As a result, the level of care had deteriorated from the last inspection.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests. People had access to health care professionals to support them with their care. People and relatives told us that staff were kind and caring and we saw examples of this.

Safety checks were undertaken at the service and there were plans in place to protect people in the event of a fire. People received their medicines when needed. Staff were aware of the procedures of reporting safeguarding concerns and people told us they felt safe with staff. People were given opportunities to feedback how they wanted their care to be delivered.

Rating at last inspection (and update)

The last rating for this service was Good (published 25 October 2018). At the latest inspection we found breaches of three regulations.

Why we inspected

The inspection was prompted in part due to concerns received about unsafe staff levels which was impacting on the care being provided to people. A decision was made for us to inspect and examine those risks.

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.

We have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well Led sections of this full report. You can see what action we have asked the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Puttenham Hill House 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 risks related to staffing levels, safe care being provided to people, people being at risk of social isolation, people being supported with adequate nutrition and hydration, and the lack of robust provider and management quality assurance at this inspection.

For requirement actions of enforcement which we are able to publish at the time of the report being published. 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

The provider supplied three mobile telephones to ensure people were able to stay in regular contact with friends and families whilst shielding. People also used handheld tablets to be able to video call their friends and families and staff supported people with this. There was a booking system in place for visitors. Staff had created an area in the garden with a clear screen and spaced out chairs for people to see their loved ones. Visitors were provided with hand gel, mask and gloves for outdoor visits to reduce the risk of transmission and surfaces were cleaned before and after visits.

Staff worked together with community district nursing teams and engaged with local Clinical Commissioning Groups (CCGs). This ensured the latest guidance was being followed in the use of Personal Protective Equipment (PPE) and COVID-19 testing.

This inspection site visit took place on 9 October 2018 and was unannounced.

There was a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

At the last comprehensive inspection in September 2017, we found that improvements were required in relation to the management of medicines and the information around how people needed to be supported in an emergency. We also identified that people’s records were not always kept up to date and there was insufficient oversight of clinical care. At the latest inspection we found that this had improved.

People told us that there were enough staff at the service. We found that there were sufficient levels of staff to provide support to people when needed. The management of medicines was being undertaken in a safe way. Updates had been made to the clinic rooms since the last inspection. People told us that they received medicines when they needed.

People told us that they felt safe at the service. Staff understood the risks associated with people’s care. Clinical risks were regularly monitored by the nursing staff. There were robust recruitment procedures in place to ensure that only suitable staff were employed. Accidents and incidents were responded to well by staff and actions were taken to reduce further occurrence. The registered manager reviewed all accidents and incidents to ensure that patterns were identified and actions taken.

In the event of an emergency such as a fire or flood there were plans in place to ensure that people were evacuation safely. There was a business continuity plan in the event the building needed to be evacuated. Staff understood how to protect people from the risk of infections spreading. The service was clean and well maintained. Staff understood safeguarding adults procedures and what to do if they suspected any type of abuse.

Staff were sufficiently training and supervised to ensure that they were undertaking their duties appropriately. People had access to health care professionals where needed. Where people were nutritionally at risk staff monitored and took action to address this. People liked the food at the service and had access to drinks regularly.

Staff understood the principles of the Mental Capacity Act 2005 (2005). People’s consent was sought before care was delivered. Appropriate applications were submitted to the Local Authority where people may have been deprived of their liberty. Staff worked well together within the service and followed guidance from health care professionals.

People were cared for by staff that were kind, attentive. Staff treated people in a dignified and respectful way and developed good relationships with people. People were encouraged to be independent and were involved in discussion around their care. Visitors were welcomed to the service. People were supported to practice their faith.

Detailed assessments were undertaken before people came to the service. Care plans contained detailed guidance for staff on how to deliver care. Staff read and understood the care plans. People had access to appropriate activities and regular outings were arranged. People in their room had regular contact with staff to prevent the risk of isolation. The environment was set to up meet the needs of people that lived at the service.

There was a comprehensive system of audits in place to review the care being delivered. Actions were taken to ensure any shortfalls were addressed. Complaints were recorded and responded to the satisfaction of people and relatives.

People, relatives and staff felt that the service was managed well. Staff felt supported and valued and enjoyed working at the service. People and staff were asked for feedback on care and their views were taken on board. Staff worked with organisations outside of the service to support the care being provided.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had informed the CQC of significant events including significant incidents and safeguarding concerns.

There was a registered manager in post and present on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 undertook this inspection to check that actions had been taken in relation breaches around the lack of staff. We found that this had been addressed.

Records at the service were not always kept up and date, accurate and there was a risk that staff may not provide the most appropriate care. Records were not always being completed when needed. Staff were not always being monitored to ensure they were undertaking the work they needed to do.

People told us that they felt safe with staff. Relatives felt their family members were safe at the service.

On the day of the inspection we found that medicines were not always stored appropriately. The medicine room was cluttered and untidy. After the inspection we were contacted by the registered to confirm that this had been addressed. We also found that people’s evacuation plans were not always accurate. We have made recommendations around these matters.

There were aspects to people’s medicines that were being managed in a safe way. People told us that they had access to medicine when they needed.

There appropriate numbers of staff to meet the needs of people. We did ask the registered manager to ensure that staff did not leave the top floor as this left people at risk; They assured us that this would be addressed. Staff underwent robust recruitment checks before they started work to ensure that they were safe to work with people.

When clinical risks and risks to people’s mobility were identified appropriate management plans were developed to reduce the likelihood of incidents occurring.

Staff understood what they needed to do to help keep people safe. There were systems in place to ensure that people were protected from the risk of abuse. Incidents and accidents were recorded and action taken to reduce the risks of incidents reoccurring.

People confirmed that staff asked their consent before care was delivered. Staff had received training around the Mental Capacity Act (MCA) 2005 and how they needed to put it into practice. DoLS applications had been completed and submitted in line with current legislation to the local authority for people living at the home. For example, in relation to bed rails.

Staff had the appropriate training and were sufficiently skilled to carry out their role. Staff had received appropriate support that promoted their professional development.

People told us that they liked the food at the service. People’s health and nutritional needs were monitored. People had access to health care professionals when they needed.

People and relatives told us that staff were caring and respectful towards them and these were our observations. People were involved in their care planning and made choices around their care delivery. Visitors were able to visit the service when they wanted. People were supported at the end of their lives with the appropriate care.

People care plans showed detailed guidance for staff. They were reviewed on a monthly basis or more frequently when required. Staff communicated people’s changing needs effectively.

There were sufficient activities for people to get involved in including those that were cared for in their rooms.

Complaints and concerns were reviewed and used as an opportunity to improve the service. Compliments were received at the service and these were shared with staff.

The registered manager and the senior management team responded well to any areas that we felt required improvement on the day of the inspection. Other quality assurance systems were in place to monitor the quality of care being delivered and the running of the service.

People, relatives and staff were complimentary about how the service was managed. Staff told us that they felt supported, valued and listened to.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. The registered manager had informed the CQC of significant events.

There was a registered manager in post however they were on annual leave on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. Instead on the day we were supported by the interim manager and the clinical lead.

There was insufficient numbers of care staff deployed at the service to meet people's needs. This was a continued breach from the previous inspection around staffing levels.

The provider did not always have systems in place to regularly assess and monitor the quality of the care provided. They had not acted on concerns we identified at our last inspection.

Qualified staff had not always received appropriate clinical supervision. However other staff were having one to one support with their manger that promoted their development. We found the staff team were knowledgeable about people's care needs. People told us they felt supported and staff knew what they were doing.

People told us they were safe at the service. Staff had a good understanding about the signs of abuse and were aware of what to do if they suspected abuse was taking place. There were systems and processes in place to protect people from harm. Recruitment practices were safe and relevant checks had been completed before staff started work.

Medicines were managed, stored and disposed of safely. Any changes to people's medicines were prescribed by the person's GP and administered appropriately.

Fire safety arrangements and risk assessments for the environment were in place to help keep people safe. The service had a business contingency plan that identified how the service would function in the event of an emergency such as fire, adverse weather conditions, flooding or power cuts.

Staff were up to date with current guidance to support people to make decisions. Where people had restrictions placed on them these were done in their best interests using appropriate safeguards. Staff had a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and the Mental Capacity Act (MCA) as well as their responsibilities in respect of this.

People had enough to eat and drink and there were arrangements in place to identify and support people who were nutritionally at risk. People were supported to have access to healthcare services and were involved in the regular monitoring of their health. The provider worked effectively with healthcare professionals and was pro-active in referring people for assessment or treatment.

Staff involved and treated people with compassion, kindness, dignity and respect. People's preferences, likes and dislikes had been taken into consideration and support was provided in accordance with people's wishes. People's privacy and dignity were respected and promoted when personal care was undertaken.

People's needs were assessed when they entered the service and on a continuous basis to reflect changes in their needs. People's care and welfare was monitored regularly to ensure their needs were met within a safe environment.

People were encouraged to voice their concerns or complaints about the service and there were different ways for their voice to be heard. Concerns and complaints were used as an opportunity to learn and improve the service. The provider actively sought, encouraged and supported people's involvement in the improvement of the home.

People had access to activities that were important and relevant to them. People were protected from social isolation through systems the service had in place. There were a range of activities available within the service and outside.

People told us the staff were friendly and management were always approachable. Staff were encouraged to contribute to the improvement of the service. Staff told us they would report any concerns to their manager. Staff felt that management were very supportive.

During the inspection we found breaches 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. We have also made recommendations around some regulations. Details of these are shown on the full report.

We were provided with further details of the three complaints that we had seen at the inspection. We were provided with evidence of the documents in place to record the details, actions and learning points from any future complaints received.

We found that people had been consulted about their care and their verbal consent had been sought. Where people lacked the capacity to make a decision for themselves the correct procedures had been followed.

People's care records showed that their care needs had been assessed and risks to them had been identified. We found that a specific risk to one person had been identified and managed by staff. However there was no care plan or risk assessment within the person's care record in relation to this.

We found that people had been offered a range of foods to meet their needs. People had received appropriate support to ensure that their nutritional needs were met.

We saw evidence that the home had liaised with a range of professionals and other agencies to ensure that people's needs had been met.

The complaints system had been brought to people's attention and any complaints had been responded to. However as we were unable to see any records of the complaints received we were unable to review how effectively they had been dealt with.

We found people who used the service were treated with dignity and respect. The home had sought people's opinions in relation to their preferences regarding their care.

We saw people's needs were assessed and care plans and risk assessments were in place to ensure their needs were met and their care was delivered safely.

Medicines were stored and administered safely in the home.

We found there were sufficient staff to meet people's needs. The home used some agency staff. Measures had however been put in place to maintain continuity of care for people who used the service.

There were systems in place to seek people's views and to monitor the quality of the service provided.