The Laurels and The Limes Care Home

The Laurels and The Limes Care Home is a care home providing personal and nursing care to up to 88 people. The service provides support to older adults with a range of support needs, including people living with dementia. The service has 2 separate buildings within the same grounds; The Laurels and The Limes. The Laurels predominantly supports people living with dementia. The Limes is the larger building and supports people who require nursing or residential care. At the time of our inspection there were 60 people using the service.

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

Risks to people were assessed, however the records made by staff did not always evidence risks were managed effectively. People received safe support with their medicines and infection risks were mostly well-managed. Staff understood their responsibility to protect people from the risk of abuse.

There were enough staff deployed to keep people safe and staff were recruited safely. The provider used agency staff to ensure there were enough staff on each shift, but this had placed pressure on the regular staff team who had to spend time supporting agency staff to get to know people.

People were not always meaningfully occupied or stimulated. People told us they were often bored as there was not enough to do. Improvements were therefore needed to ensure people consistently experienced a good quality of life whilst using the service. We have made a recommendation about daily activity provision.

People’s care plans described people’s preferences for receiving care, however their care plans were not consistently updated when people’s needs changed. Staff worked alongside the GP and district nurses to manage people’s health needs. People received effective support with their nutrition and hydration needs.

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. The policies and systems in the service supported this practice.

The provider’s audit system had not identified all the issues we found during this inspection. However, some audits completed by the provider and managers had identified concerns and ensured issues were resolved.

We received mixed feedback about the culture of the service. Staff morale was not positive, and most staff told us there were not supported to do their jobs effectively. Staff had not received one to one supervision meetings recently and many staff were not up to date with the training the provider expected them to complete.

People and their relatives had opportunities to provide feedback about the service. Most people were happy with the care they received and felt they could approach the managers if they had any concerns.

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 25 February 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the key question ‘is the service safe?’. 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 undertook a focused inspection to review the key questions of ‘is the service safe?’, ‘is the service effective?’ and ‘is the service well-led?’ only. For those key questions not inspected at this inspection, we used the ratings awarded at the last comprehensive 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 read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Laurels and The Limes Care Home on our website at www.cqc.org.uk.

Enforcement and recommendations

We have identified a breach of regulation in relation to the provider’s governance system. Please see the action we have told the provider to take at the end of this report.

We have made a recommendation about the daily activity provision in the service.

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.

We found the following examples of good practice.

The home had systems in place to support relatives to visit their family members, minimising the risk of infection. Relatives and friends were encouraged to keep in contact with their loved ones via telephone and video calls. They were also able to visit in person, by appointment, inside the home or using the visitor pod in the garden.

The home had implemented cohorting effectively, with staff allocated to either The Laurels (building one) or The Limes (building two), and they did not mix between the two buildings.

We observed signage around the home to guide staff on the use of protective personal equipment (PPE) and appropriate handwashing technique. The premises were clean and hygienic. Frequent touch points, such as handrails and door knobs were regularly cleaned. Staff supported people to keep apart as much as possible to try and maintain safe social distancing. For example, by moving chairs in communal areas further apart.

All people living and working at The Laurels and The Limes Care Home had been offered a vaccine and were regularly tested for COVID-19 in line with government guidance.

Risk assessments were in place to consider and reduce any impact to people who used the service and staff who may be disproportionately at risk of COVID-19. These included Black, Asian and Minority Ethnic groups (BAME), people with learning disabilities and people with dementia.

The Laurels and The Limes Care Home is a nursing and residential home. The service comprises of two neighbouring buildings. The Laurels predominantly supports people living with dementia. The Limes supports people who require nursing or residential care. At the time of this inspection the service was providing personal and nursing care to 67 older adults, some of whom were living with dementia. The service can support up to 88 people.

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

People received a good standard of care and we saw examples where people had experienced a better quality of life after moving to the home, made possible due to the dedication and skill of the staff team. People received care from a knowledgeable staff team who had access to a wide variety of training and support.

The service was safe. Risks to people’s health and safety were assessed and mitigated. Medicines were managed in a safe and proper way. Staffing arrangements had improved so there was enough permanent staff available each day to provide people with stimulation, interaction and ensure they were safe. Incidents and accidents were logged and investigated and learnt from where appropriate.

The management team was supportive, responsive and promoted a culture of person-centred care at the service. The registered provider had an effective system of governance in place to monitor and improve the quality and safety of the service. The service used a number of methods to ensure people and relevant persons involved in their care had a voice, which was valued and listened to.

Throughout the inspection we saw very caring interactions between staff and people who used the service. Everyone involved in the service provided very positive feedback about the overall quality of the service. There was a person-centred culture with the management and staff team and all were highly involved in peoples’ care and support.

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; the policies and systems in the service supported this practice.

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 requires improvement (published 11 May 2017). There was also an inspection on 13 June 2018 however, the report following that inspection was withdrawn as there was an issue with some of the information that we gathered.

Why we inspected

This is a planned re-inspection because of the issue highlighted above.

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.

At the last inspection on 2 November 2016 we found breaches in three regulations: Regulation 9, Person-centred care, Regulation 12, Safe care and treatment and Regulation 17, Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Following that inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to these breaches. This inspection was undertaken to check that they had followed their plan and to confirm that they now met all of the legal requirements. We saw that sufficient improvements had been made to achieve compliance.

The Laurels and the Limes is a nursing home that provides care for up to 88 people. The service operates from two separate buildings on the same site in the south of Sheffield. The Limes building is purpose built. The majority of bedrooms are single and some have ensuite facilities. There are well maintained gardens and car parking is available. At the time of the inspection there were 43 people living at the service. The Laurels building is a residential unit primarily used for people living with dementia. At the time of the inspection there were 11 people living in the Laurels. The Limes building has three floors and a lower ground floor where the service’s kitchen, laundry and staff rooms are based. At the time of the inspection there were 32 people living in the Limes.

The service did not have a registered manager in post at the time of the inspection. The registered provider had recently appointed two managers, one to manage the Laurels and one to manage the Limes. 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.’

There had been some improvements with concerns identified at the last inspection in relation to the management of medicines, but there were some actions that we identified during the inspection that were attended to during the inspection. The senior managers assured us that measures would be put in place to ensure these shortfalls did not reoccur.

At this inspection we saw improvements had been made in managing individual risk, including behaviour that challenged, but staff would benefit from further training in completing behaviour analysis charts.

At the last inspection we found the recruitment of staff was not safe. At this inspection we found sufficient improvements had been made by the registered provider.

Improvements had been made to the meal time experience for people living at the Limes.

At this inspection we saw improvements had been made for people living with dementia, so that they did not become disengaged with their surroundings.

Regular resident and relative meetings had been held at the service since the last inspection. People and relatives we spoke with told us their views about the service were being actively sought.

People we spoke with told us they felt ‘safe’ and had no worries or concerns. Relatives we spoke with felt their family member was in a safe place. Since the last inspection the registered provider had improved the systems in place to ensure people were safeguarded from the risk of harm.

Our observations during the inspection told us people’s needs were being met in a timely manner by staff.

The service had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). Staff were aware of the need to and had submitted applications for people to assess and authorise that any restrictions in place were in the best interests of the person.

We saw that sufficient improvements had been made to ensure people with DoLS conditions received appropriate care and treatment. 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.

People’s preferences and dietary needs were being met. We received positive comments from people regarding the quality of the food.

People we spoke with made positive comments about the quality of care they had received. Relatives we spoke with were satisfied with the quality of care their family member had received.

There was evidence of involvement from other health care professionals where required and staff made referrals to ensure people’s health needs were met.

We saw that people responded well to staff and they looked at ease and were confident with staff. Staff were respectful and treated people in a caring and supportive way.

Staff had undertaken training to ensure they had the skills and knowledge to support people effectively.

There was a complaints procedure available to people and their relatives. People and relatives we spoke with felt confident senior staff would listen and take appropriate action to address their concerns.

During the inspection we found some shortfalls relating to records.

At the last inspection in November 2016 we found that there were not effective systems in place to monitor and improve the quality of the service provided. At this inspection we saw there had been some improvement, however we found that further improvement was required in some areas.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

The service was last inspected on 13 July 2015. At the last inspection we found the service was not meeting the requirements of the following regulations associated with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 Safe care and treatment, Regulation 17 Good Governance and Regulation 11 Need for consent. As a response to the last inspection the registered provider sent a report to the Care Quality Commission of the action they would take to become compliant with the regulations. The registered provider told us they would complete all the action to achieve compliance by the end of 2015.

The Laurels and the Limes is a nursing home that provides care for up to 88 people. The service operates from two separate buildings on the same site in the south of Sheffield. The Limes building is purpose built. The majority of bedrooms are single and some have ensuite facilities. There are well maintained gardens and car parking is available. At the time of the inspection there were 53 people living at the service. The Laurels building is a residential unit primarily used for people living with dementia. At the time of the inspection there were 14 people living in the Laurels. The Limes building has three floors and a lower ground floor where the service’s kitchen, laundry and staff rooms are based. At the time of the inspection there were 39 people living in the Limes.

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 to manage the service. Like registered providers, they are “registered persons”. Registered persons have a 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 inspection we saw the registered provider had not ensured DoLS authorisations had been obtained for some people living at the service. We saw that sufficient improvement had been made for to achieve compliance in Regulation 11, Need for consent.

We checked that improvements had been made in the safe handling of medicines. We saw that insufficient improvement had been taken to achieve compliance. We found the service continued not have appropriate arrangements in place to manage medicines to ensure people were protected from the risks associated with medicines.

The outcome of the inspection identified the service continued to be in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014, plus a further three breaches were identified. These findings showed the registered provider’s processes to monitor and improve the quality of the service were still ineffective in practice.

Although people told us they felt ‘safe’ and relatives spoken with felt their family member was in a safe place, we found that people were not safeguarded from the risk of harm. We saw the service had not always followed the local safeguarding protocols and made a safeguarding alert in line with the local multi agency agreement.

Staff recruitment records reviewed showed that information was not always obtained in accordance with Schedule 3. This meant we could not be confident that people were cared for by suitably qualified staff who had been assessed as safe to work with people.

At the last inspection we found that people’s daily charts were not maintained to ensure they were accurate, complete and contemporaneous. We saw that insufficient action had been taken so that we could be confident that people’s daily charts were completed accurately and were contemporaneous.

Most people and relatives spoken with told us the activities provided at the service could be improved to meet the needs for all the people living at the service.

At the last inspection we raised concerns regarding the lack of stimulation provided for people living in the Laurels. We found that insufficient action had been taken by the registered provider to ensure people living with dementia did not become disengaged with their surroundings.

People and relatives made positive comments about the staff and the manager at the service.

In the Limes building we observed a lot of laughter and friendly ‘banter’ between people and staff. We saw that people got on well with staff and that people’s relatives and visitors were greeted in a friendly way.

In the Laurels building we observed the interaction between staff and people was centred on tasks. This lack of engagement between staff and people created an unstimulating atmosphere.

People spoken with were satisfied with the care they had received.

Relatives told us they were involved in their family members care planning and were satisfied with the care their family member had received.

In people’s record we saw evidence of involvement from other professionals such as doctors, opticians, tissue viability nurses and speech and language practitioners.

We reviewed one person’s Deprivation of Liberty Safeguards authorisation which had been granted with conditions in May 2016. These conditions are legally binding and had not been met. This showed there was a risk that people would not receive appropriate care and treatment to meet their needs.

We found that there was a risk that people’s behaviour was not managed consistently and the risk to their health, welfare and safety was not managed effectively.

People’s preferences and dietary needs were being met. We received mixed views regarding the quality of the food provided.

We saw the environment in the Limes dining area was not a calm and conducive atmosphere for people to eat in.

Accidents and untoward occurrences were monitored by the registered provider to ensure any trends were identified.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still 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 this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We considered all the evidence against the outcomes we inspected to help answer our five key questions; is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of what we found-

Is the service safe?

Most of the people we spoke with felt 'safe' and had no worries or concerns. Relatives felt their family member was in a safe place although one person told us they didn't feel safe due to the number of changes of staff at the home.

We observed individual staff members treating people with respect. However, we observed some staff did not explain their actions when they were supporting people to be moved with a hoist.

The home had policies and procedures in relation to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The home was aware of the need to submit applications for people to assess and authorise that any restrictions in place were in the best interests of the person.

We found the arrangements in place to safeguard people using the service from financial abuse could be more robust.

People were not protected against the risk associated with medicines because the provider had not got appropriate arrangements in place to manage medicines.

We have asked the provider to tell us what they are going to do to meet the requirements of the legislation in relation to the management of medicines.

Is the service effective?

People's health and care needs were assessed and care plans formulated. However, people's needs were not always being met in accordance with those plans.

We have asked the provider to tell us what they are going to do to meet the requirements of the legislation in relation to people's care and welfare.

People were cared for by staff who were not supported deliver care and treatment safely and to an appropriate standard.

We have asked the provider to tell us what they are going to do to meet the requirements of the legislation in relation to supporting staff.

Is the service caring?

People spoken with told us they were satisfied with the quality of care they had received. Their comments included: 'the foods okay, there isn't a great deal of choice, but it's not bad', 'we are treated very well, I get up at eight o'clock, go to bed at 10 o'clock, I have got a decent room and a television', 'we get decent meals' and 'I'm happy here, I mostly stay in bed and when I call them [staff] they usually come quickly, but they are very busy'. People also made positive comments about the staff. Their comments included: 'the [staff] are alright', 'some of the staff are alright', 'they [staff] are very kind' and "I've got no complaints about the staff'.

We spoke with two relatives about the quality of care that had been provided to their family member. Their comments included: 'they don't cut [family member's] finger nails and clean them, I always have to ask for them to be done', 'mainly it is very good', 'I'm really happy with mum here, the activities co-ordinator did a life scrap book with her, but I don't know where it is'.

Is the service responsive?

The provider's complaints process was displayed in different parts of the home.

Our observations told us staff were not meeting people's needs in a timely and responsive way. For example, staff were not available to support someone to drink and staff were not available to support someone who became upset when their assistance was needed.

We have asked the provider to tell us what they are going to do to meet the requirements of the legislation in relation to people's care and welfare.

Is the service well led?

There was a range of quality monitoring checks in place to make sure the manager and staff learned from checks. However, our findings indicated the audits in place had not effectively identified the concerns we found during the inspection.

We have asked the provider to tell us what they are going to do to meet the requirements of the legislation in relation to identifying, assessing and managing risks to health, safety and welfare of people who use the service and others.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.

Food and drink met people's individual dietary needs. One person told us, 'I had toast and jam [for breakfast] it was nice.'

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The provider had an effective system to regularly assess and monitor the quality of service that people received.

People that we could communicate with told us that they were happy living at the home and that they were very satisfied with the care they received. People's comments included, "it's not home but it's good." Another person said, 'I'm very happy here, everybody is nice and the staff are wonderful."

We spoke with three relatives who were visiting the home and they confirmed that they were very happy with the care provided. One person told us, "I'm happy with the staff, they are caring, cooperative and friendly."