The Old Parsonage

The Old Parsonage is a residential care home providing personal and nursing care to up to 22 people. The service provides support to people living with dementia. At the time of our inspection there were 19 people using the service.

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

Incidents and accidents were reported and reviewed. Staff understood their responsibilities to protect people from harm and abuse. Risk assessments had been carried out to assess the risks to people’s safety, and care plans informed staff how to keep people safe. Safe recruitment practices were in place and there was enough staff on duty to meet people’s needs. Systems were in place for people to receive their medicines safely. Staff had received training in infection prevention control and understood how to prevent the spread of infection. Staff wore PPE in line with published guidance.

There was a quality assurance system in place to assess the standards of care in the service. This was overseen by the management team. Staff spoke very positively about working at the home and the people they cared for. One member of staff said, “[Registered manager] is so supportive and friendly. She has an open-door policy. She really listens to you. She's more than just a manager. She's always there for us.” One person’s relative said, “[Registered manager] is brilliant, absolutely wonderful. She's always willing to chat. She runs a friendly but efficient ship. I can't speak highly enough of her. We're very impressed with all the staff.”

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 23 May 2021) and there was a breach of regulation. 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

We carried out an unannounced inspection of this service on 26 March 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve notification of incidents.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements. 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 Requires Improvement to Good. This is based on the findings at this inspection.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

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

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Old Parsonage is a care home providing personal and nursing care to 20 older people at the time of the inspection. The service can support up to 22 people and specialises in providing care to people living with dementia.

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

The provider had not notified CQC of significant events in the home when they were legally required to. These were incidents in which people had sustained injuries or where there had been physical altercations between people living in the home.

The failure to notify us of significant events had not been identified by the quality assurance systems. We have made a recommendation about improving these systems so any shortfalls can be identified quickly and rectified.

Despite not notifying us of significant incidents, the provider had taken action to keep people safe and manage the risks they faced. Staff had a good understanding of the action they needed to take to keep people safe.

People were supported to take any medicines safely and staff sought advice from health and social care services when needed. Relatives were happy with the care people received and were confident that people were safe at The Old Parsonage.

The provider had made changes in response to the COVID-19 pandemic and there were good infection prevention and control measures in place.

The registered manager worked well with relatives to meet people’s needs. They had developed good relationships with health and social care professionals.

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 27 June 2019)

Why we inspected

We received concerns in relation to staffing levels, support for people in the early morning and infection prevention and control measures. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to 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 well-led section of this full report. 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 The Old Parsonage on our website at www.cqc.org.uk.

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.

The Old Parsonage is a care home with nursing for up to 22 older people living with dementia and other needs in relation to their mental health in one adapted building. 18 people were living in the home at the time of the inspection.

What life is like for people using this service

The registered manager had made improvements to the way risks were managed for people. However, work was needed to ensure moving and handling techniques were implemented consistently by all staff.

People were supported make choices and have as much control and independence as possible.

People and their relatives had been supported to develop care plans that were specific to them. These plans were regularly reviewed with people to keep them up to date.

People received caring and compassionate support from kind and committed staff.

People and their relatives were positive about the care they received and about the skills of staff.

Staff respected people’s privacy and dignity.

People received support to take their medicines safely.

People were supported to maintain a good diet and access health services if needed.

The registered manager provided good support for staff to be able to do their job effectively.

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 30 May 2018). 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 rating at the last inspection.

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 this inspection, the majority of shortfalls had been addressed but further work was required in some areas. This meant the service had not been compliant with regulation since the registered manager gained their position in 2015. Other shortfalls were identified in 2014 and 2013. Whilst there was a quality auditing system in place, this had not identified all shortfalls noted at this inspection.

The Old Parsonage 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. The service is registered to provide personal care and accommodation and treatment of disease, disorder or injury for up to 22 older people with dementia or other associated mental health needs. At this inspection 18 people were living at the home. The service was run by Roseville Care Homes (Melksham) Limited.

The Old Parsonage accommodates people in one building. People's bedrooms were located on the ground and first floor with communal toilets and bathrooms. A small passenger lift was available to enable easier access. There were two communal lounges and separate dining room. The kitchen and laundry room were located on the ground floor.

There was a registered manager in post. 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 registered manager was available throughout the inspection. A regional manager was present on the first day.

Risks to people’s safety had not always been identified and addressed. For example, one person’s risk of choking had not been reassessed after a recommended action had not been successful. Other records gave conflicting information about the use of thickeners and the texture of people’s food.

All care plans were being transferred to a new electronic system. However, this process was not complete and some information was insufficient in detail. The electronic system had generated some formats but these were not accurate and did not clearly inform staff of the support the person required. The lack of person centred information was identified at the last inspection.

People were able to personalise their bedrooms but the environment was not reflective of recognised dementia care. This was because flooring and décor were similar in colour and there was limited texture or stimulation to gain people’s attention as they walked around.

Some areas of the home had marks on the walls and there were stains on the stairs carpet. The windows on the first floor were fitted with restrictors to reduce the risk of people falling from height. However, the restrictors were made of thin chains, which did not meet current health and safety guidance. Staff had opened the windows in some bedrooms and on the corridor on the first floor. These were still open at 17.00, which made some areas of the home cold.

Less visible areas of the home were not always clean. This included the beading on over-bed tables and the wheels on some specialised chairs. The registered manager said they had identified this and cleaning schedules were in the process of being reviewed. Other areas including bathrooms were clean.

There were many positive interactions but staff did not always consider the reasons why some people displayed certain behaviour. For example, one person attempted to take their jumper off. Staff assisted them to put it back on again without further discussion. They did not investigate if the person was hot or if they needed the bathroom.

Improvements had been made to the management of people’s medicines. A daily audit had been introduced. This ensured all medicines had been given as prescribed and staff had signed the medicine administration record appropriately. Information regarding medicines to be taken “as required” lacked detail but this had been addressed by the second day of the inspection.

There were sufficient staff to support people safely and appropriately. Staff answered call bells without delay and had time to spend with people. The home was relaxed and calm and staff went about their work without rushing. The registered manager had reviewed the admission criteria. This ensured the person’s needs could be met without significant impact to those already in the home.

People had enough to eat and drink. Those people at risk of malnutrition or dehydration were encouraged to have additional intake to ensure their wellbeing. Records were consistently maintained to monitor people’s intake. There was an emphasis on fresh produce and the majority of food was cooked “from scratch”.

People were supported in line with the Mental Capacity Act 2015. This included gaining consent for restrictive practices such as bed rails and sensor mats. There was evidence that relatives and health care professionals were involved in decision making, where people did not have capacity to do this. Staff consistently asked people for consent when undertaking tasks.

People had good support to meet their health care needs. This included a range of specialised services related to health care conditions.

Staff felt well supported and received a range of training to help them undertake their role effectively. This included courses deemed mandatory by the provider and other topics related to older age. Emphasis was being given to training in social activity for people living with dementia.

There were many positive comments about the staff and registered manager. This included their caring, compassionate and respectful manner. People’s privacy and dignity was maintained.

There was an open culture. People, relatives and staff were encouraged to give their views about the service. This was informally on an individual basis, within meetings or by completing questionnaires. Feedback had been evaluated and action plans developed to ensure all points were addressed.

We found two repeated breaches of regulation at this inspection and made one recommendation.

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

At this inspection we found four new breaches of regulations. The previous breaches from the last comprehensive inspection in August 2015 had not been repeated. The five new breaches were in relation to good governance, safe care and treatment, need for consent and person centred care.

The Old Parsonage provides accommodation and care, including nursing care, for up to 22 older people who have dementia and other associated needs in relation to their mental health. On the day of our inspection, there were 19 people living at the home.

There was a registered manager in place at the time of our 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Overall we found that quality and safety monitoring systems were not fully effective in identifying and directing the service, to act upon risks to people and ensuring the quality of service provision.

The administration of people's medicines was not in line with best practice.

Care plans were not all person centred. Peoples' risk assessments and the associated parts of the care plan did not provide adequate detail to enable safe and effective care.

Monitoring of peoples’ fluid intake was not completed effectively.

Staff we spoke with had a variable understanding of the Mental Capacity Act 2005 and DoLS. There were no examples of best interest decision making on behalf of people who lacked capacity to agree to the delivery of their care.

The registered manager had made applications for Deprivation of Liberty Safeguards (DoLS ) where they had been assessed as being required. These safeguards aim to protect people living in care homes from being inappropriately deprived of their liberty. These safeguards can only be used when a person lacks the mental capacity to make certain decisions and there is no other way of supporting the person safely.

Staff had received regular supervision and training.

The staff had received training regarding how to keep people safe and they were aware of the services’ safeguarding procedures.

People had access to healthcare professionals and records demonstrated that the service had made appropriate referrals when there were concerns.

There were enough staff to meet peoples' needs. We received positive feedback about the care staff and their approach with people using the service.

Recruitment procedures were followed appropriately. The provider had a complaints procedure and people told us they could approach staff if they had concerns.

The registered manager had made appropriate statutory notifications. Notifications tell us about significant events that happen in the service. We use this information to monitor the service and to check how events have been handled.

We found four breaches of regulations at this inspection and will be asking the provider to send us a report of the improvements they will make.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

People were usually treated with respect and dignity by the staff; however, we observed some conversations and interactions that did not demonstrate respect.

People were cared for by staff who were aware of the risks to people's safety and health and staff knew how to support them in a safe way.

Systems were in place to make sure that staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continue with implementing improvements.

Is the service effective?

Relatives told us they were happy with the care people received and that their care needs were met. It was clear from observations and from speaking with staff that they had a good understanding of people's care and support needs. Staff had received training to meet the needs of the people living in the home.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Suitable policies and procedures were in place and applications to authorise deprivations had been submitted to the supervisory body. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service caring?

People were supported by kind staff, and most interactions were respectful. We saw that staff showed patience and compassion when supporting people. One person told us; 'They really are excellent, I couldn't ask for better'. Staff told us they were able to provide the care that people needed.

The provider was taking action to address the way staff were previously working with people, ensuring they had the time and skills to provide a caring service.

Is the service responsive?

The provider had taken action to review all of the care people required. We saw that people and their relatives were involved with this process. This work was still on-going, and there were some areas where the care people needed and the way decisions about that care had been made was not clear. This increased the risk that people may receive care and treatment that was not responsive to their needs.

The service worked well with health and social care professionals and services to make sure people received their care in a joined up way.

Is the service well led?

The service did not have a registered manager. The provider was aware that this was a breach of the conditions of their registration and was in the process of recruiting to the post.

As a result of previous concerns, the provider had developed their quality assurance system. Records we saw showed that people's care needs and the care provided was being monitored and action taken to address shortfalls. As a result the quality of the service was starting to improve.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the concerns about the service and the action that was being taken to address them. This helped to ensure that people's experience of care was improving.

At the previous inspection, we had warned the provider they needed to take action to become complaint with the law by 30/05/14, across a range of areas. These related to ensuring people were provided with appropriate care to ensure their welfare, to ensure there were sufficient staff on duty with the appropriate skills to meet people's needs. Additionally we warned the provider they needed to appropriately assess and monitor the quality of service offered to people and ensure accurate records were maintained. We additionally asked the provider to take action to appropriately safeguard people from abuse and that staff were supported in their roles by training and supervision. The provider sent us an action plan in which they confirmed they would take action and would be compliant by 30/05/14. At this inspection we found the provider had not taken appropriate action to become compliant with the law. We additionally found they had become non-complaint with the law in relation to two other areas.

We considered our inspection findings to answer questions we always ask;

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. If you would like to see the evidence supporting our summary please read the full report.

Is the service caring?

Relatives reported staff cared about the people living in the home and knew their needs. One relative described the 'compassion and the care and the thoughtfulness shown' by staff. We observed staff supporting people a kindly, friendly way at times. We saw a registered nurse taking time to support a person who was confused and distressed.

We also saw staff were variable in their responses to people. For example we saw a member of staff take cups away from two people with no interaction to find out if they had finished or would like anything more to drink. We observed a person who stood up and tried to leave a sitting room. The member of staff in the area asked the person to sit down again, as they might be unsafe. This member of staff did not ask the person if they wanted anything. All, apart from one of the care workers, supported people who needed help to eat by standing up above them. This made the meal a functional occasion and did not support the person in social engagement.

We are going to take action to ensure the provider meets the requirements of the law in relation to ensuring people's dignity, privacy and independence are respected.

Is the service responsive?

We saw the home manager had sent out questionnaires to people about service provision. A person's relative had raised an issue. This had not been responded to by the home.

The provider had taken some action to ensure staff had been trained to meet the general needs of people, including moving and handling and first aid. They had not ensured staff were trained in conditions which may be associated with older age, including prevention of pressure ulceration and stroke care. Two people had sustained pressure ulceration while in the home. Staff told us although training had been provided in dementia care, the training did not relate to the complex needs of the people cared for in the home. We saw staff did not consistently respond to people who were living with dementia in an effective way, in accordance with national guidelines.

We are going to take action to ensure the provider meets the requirements of the law in relation to ensuring staff are appropriately supported in their roles to deliver care and treatment to people in a safe way and to an appropriate standard.

Is the service safe?

We found people were not safe as the home was not following guidelines on infection control and hygiene. This involved not following precautions for the prevention of spread of infection, including in the management of laundry. We also observed a wide range of areas which were not clean, such as dirty commodes and stained arm rests to chairs in lounge areas.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. No applications had been submitted from this home. Information from some staff indicated they may not be following these guidelines when delivering care to certain people. Alerts had not been made to the local authority on all relevant occasions to ensure people were protected from risk of abuse.

We found the provider had not taken action to ensure there were sufficient numbers of staff on duty to meet the high dependency needs of people. The home also did not have sufficient registered nurses in post who had the skills or experience to meet the needs of people with complex dementia needs.

We are going to take action to ensure the provider meets the requirements of the law in relation safeguarding people from abuse, ensuring effective standards for hygiene and prevention of spread of infection and ensuring there are sufficient numbers of suitably qualified staff on duty.

Is the service effective?

Relatives said they felt the service was effective in meeting people's needs. One relative told us their relative had 'improved enormously since they've been here.'

The home specialised in caring for people who were living with dementia who had nursing needs. We found people's dementia care plans were not clear and did not include all relevant information relating to each person. When we spoke with staff they gave us information about management of these people's behaviour which differed from care plans.

The home were not following guidelines on prevention of pressure ulceration. One of the people we met with had sustained pressure ulceration in the home. They did not have a care plan about how this was to be managed. The person was not always having their position changed on a regular basis to reduce their risk.

Two of the people we met with had specific advice from external healthcare professionals about their care and treatment in their records. This advice was not reflected in these people's care plans. Staff we spoke with reported they did not know about this advice. We did not observe the advice was being followed in practice when people's care was being provided.

We are going to take action to ensure the provider meets the requirements of the law in relation to meeting people's care and welfare needs.

Is the service well led?

The Old Parsonage did not have a registered manager in post. A person was appointed into this role but they left their employment before 02/06/14.

The provider performed monthly visits to the home and made a report. These visits had not identified the home's continued non-compliance with the law or other areas which needed action. The audits had also not identified staff were not completing records contemporaneously, that some records were incomplete and others were not in place.

We are going to take action to ensure the provider meets the requirements of the law in relation to ensuring they have effective systems for assessing and monitoring the quality of service provision and maintenance of accurate and appropriate records.

We found the home did not ensure people consistently experienced care, treatment and support which met their needs. This related to areas such as prevention of pressure ulceration and assessment and management of people with complex needs associated with dementia. Appropriate records relating to assessment and care continued not to be made.

Staff were not aware of safeguarding people in certain areas, including verbal abuse. Policies and procedures did not fully outline all relevant areas in relation to safeguarding vulnerable people.

The home did not have effective systems for ensuring there were sufficient and suitable staff available to support people. This included meeting people's dependency and dementia needs. Relevant records relating to staff qualifications and induction were not in place. The new manager was developing staff training systems. The systems for induction and training in specific needs of people who lived in the home needed further development.

The home did not have effective systems to regularly assess and monitor the quality of services provided to people. The systems which were available had not identified areas for action, including hygiene and infection control, maintenance and effective monitoring of accidents and incidents.

The home had made many improvements in hygiene. This included installing a sluice room and refurbishment of both cleaners' cupboards. The home now smelt fresh and looked clean. All of the equipment used in the delivery of care we looked at was clean, with intact wipeable surfaces.

The provider had taken full action to ensure fire safety in the premises. This was following reports and visits from the local fire and rescue service.

Some records used in care were not dated and signed to show they were current. Some matters relating to people's nursing and care were known to the staff. However people's care plans had not been up-dated to show this information so all staff could be made aware of relevant matters about people's nursing and care.

People had care plans about their dementia and other needs. One person commented on how staff 'notice if you look tired.' There was a lack of consistency in care planning, particularly relating to people's physical and nursing care needs. This included systems for prevention of pressure ulcers.

People told us they liked their meals, describing them as 'very good'. A meal we observed was calm and organised. The provider had made improvements in the home's staffing levels. This included there being enough staff to support people when they heeded help at mealtimes.

The home did not have appropriate systems to ensure cleanliness of the environment and equipment. We saw a range of issues which we had also identified at the last inspection such as the cleaning of commodes. Cleaning schedules had been put in place but they did not include all relevant areas. Some areas such as the suction machine had a record to show it had been cleaned when it had not been left clean and dry.

The new manager had begun to put processes in place to improve the system for reviewing the quality of the service provided. These included a review of the home's procedures and development of audits for such areas as incidence of falls.

Records of people's care needs were clear and completed at the time care was given. Staff worked with people and their relatives to gain consent to care. This was not documented, so full assessments of capacity were not in place.

The home did not have adequate systems for cleansing of items used in care, such as commode inserts. Staff did not have access to current guidelines on prevention of spread of infection.

The provider is making many improvements to the home environment. However certain areas, particularly checks on fire safety precautions had not been addressed.

The provider did not have systems to take the dependency of people into account when setting staffing levels. This meant some people did not receive the support they needed including at mealtimes, the provision of recreational activities and supporting frail people in the sitting rooms.

The provider did not have written systems to review quality of care and treatment in the home. This meant some risk factors were not identified and relevant action taken. This included having relevant and up-to-date policies and procedures to support people's care and treatment.