Archived: Greenhill Residential Home

Updated 6 December 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.There had also been a safeguarding concern raised relating to possible poor care for one individual and multiple medication errors. During our inspection further concerns were raised by visiting health professionals and registered nurses working over that weekend.

This inspection took place on 4, 6 and 9 October 2017 and was unannounced on the first day. The inspection team consisted of one adult social care inspector and a pharmacy inspector.

We reviewed information that we held about the service. Providers are required to notify the Care Quality Commission about events and incidents that occur including unexpected deaths, injuries to people receiving care and safeguarding matters. We reviewed the notifications the provider had sent us. We also looked at the safeguarding concerns information as part of the on-going safeguarding process.

During the inspection, we spent time with all 31 people living at Greenhill Residential Home. We spoke individually with 11 people and as some people could not tell us about their experiences directly due to medical conditions, we spent time with people observing their care in the communal areas. We also took lunch with people in the dining room on the first day.

We spoke with three visiting relatives, two visiting health professionals, the registered manager, team leader, the provider Nominated Individual who was also the Director of Independent Living and the Service Manager for Older People. We spoke with the administrator, two domestics, the cook, activity co-ordinator and kitchen porter. We also spoke with three senior care workers, eight care workers and two agency care workers and a bank care worker.

The records we looked at included six people's care records and daily records, 17 people's medicine records, health care records and other records relating to people's care. We looked at three staff recruitment files and staff training and supervision records. We also observed a medicine round. We also looked at records relating to how the provider monitored the quality of the service such as complaints, audits and quality assurance surveys.

Updated 6 December 2017

This inspection took place on 4, 6 and 9 October 2017. The provider, Guinness Care and Support Limited also runs two other care homes in Devon with a head office in Exeter. Greenhill Residential Home is purpose built and registered to provide accommodation for up to 36 people who require personal care. Some people require nursing support and this is provided by the local district nurses. At the time we visited, 31 people were living at the home.

There was a registered manager employed at the home. 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 and associated Regulations about how the service is run. The registered manager had given notice and a new manager was due to commence employment shortly. The team leader had also given notice and there would soon be a vacancy.

In May 2015 our inspection found that the service was rated as ‘Inadequate’ overall. The domains of effective, caring and responsive ‘required improvement’. There were concerns relating to people not being treated with dignity and respect, people not being protected from unsafe care and treatment, nutrition and hydration needs not being met and lack of action to ensure the quality and safety of the service improved. The service was put into special measures, meaning that we kept the service under review and inspected again in January 2016. At that inspection we found actions had been taken to address all the shortcomings identified at the May 2015 inspection. However, we were unable to judge well led domain as good because the actions taken to ensure people received well-led care had not been in place long enough to ensure they were applied consistently and over time.

At this inspection in October 2017 we found there were failings across all domains.

People were not safe at Greenhill Residential Home. There were not enough staff to ensure people’s needs were met in a timely way or by staff who had the information they needed to meet people’s needs. Many people at Greenhill had complex needs and high dependency levels requiring support and supervision to keep them safe. The staffing levels did not ensure they received the care they needed.

The organisation and leadership of each shift was poor. This meant that the registered manager and provider had not recognised that the staffing levels did not reflect people’s dependency levels. The service was based on completing tasks for people with a routine focussing on staff rather than people’s needs. Management had not listened to staff, who had raised the issue of inadequate staffing levels in supervisions and meetings. This meant that although staff were caring and worked hard to meet people's basic needs, they were physically unable to ensure people received person centred care in a timely way. This had led to very low staff morale and increasing sickness levels.

The lack of shift and effective staff deployment meant that people were not able to get up and go to bed when they wanted. Personal care support continued into late morning on a regular basis, based on how much time staff had. Many people required two care staff for personal care and mobility support and a large number of people needed assistance with eating and drinking. There was not enough time for staff to meet these needs effectively. For example, 29 people at Greenhill were at high risk of falls which was increased due to lack of staff supervision. Continence management was also poor and people could not always get to the bathroom in time which further put people at risk.

Although people were supported by kind, caring and compassionate staff who tried to promote people's independence and treat them with dignity and respect, they were unable to ensure that people's dignity was maintained at all times. The atmosphere was chaotic, rushed and task orientated. There were call bells ringing constantly, door alarms beeping and noisy ‘walkie talkie’ radio communications between staff.

The provider and registered manager had audited people’s weights and food and fluid records but had not recognised that in reality people were not receiving adequate nutrition, including those people identified as being at high risk. This meant people remained at risk of losing weight and not receiving enough food and fluids throughout the day and night.

People’s health needs were not always managed well. The provider and registered manager did not ensure staff had the information they needed to meet people’s needs. Staff relied on brief handover sheets and verbal handover rather than care plans or health care documents kept in the office. Records were not always completed meaning that health risks were not always identified, consistently recorded or managed to completion. This put people at risk of not having their health needs met effectively or identified. Particular areas of concern were catheter care and bowel management.

Following our findings on the second day of inspection, we were concerned about the safety of people living at the home. We contacted the provider and asked for reassurances that people would be safe over the weekend. The Service Manager for Older People and the Director of Independent Living who is also the Nominated Individual immediately assured us on the second day of our inspection they would be monitoring the service over the weekend and in the future. They confirmed that the service had already decided not to allow any further admissions. Extra care staff and a registered nurse on shifts over the weekend were put in place and the management team were considering people’s dependency levels as a whole for the future. The visiting district nurse also contacted the local bowel and bladder nurse on the second day of our inspection to ensure one person received the treatment they needed.

Medication security was not safe. We also asked to be assured that the medication keys were stored in a safe place and not left unattended. There were not enough continence aids; staff were concerned that none had been ordered in time for the weekend. We asked to be assured more continence aids would be purchased for the weekend. We also asked that people at risk of losing weight were weighed and receiving adequate food and fluids and that people’s bowel and bladder management improved as a priority. We also fed back our findings to the safeguarding team as part of the on-going safeguarding process.

On the third day of our inspection there were some improvements due to the additional staff. The service appeared calmer, people were not so late in getting up or having to wait as long for assistance but the organisation of the shift pattern, staff deployment, lack of adequate communication and person centred care remained a concern.

Although there were quality assurance systems in place to monitor all aspects of the home to identify areas for improvement, the provider had failed to identify the urgency of our concerns or identified the experience for people living at the home in reality.

We found that people’s day to day life in the home was not always a positive experience. Despite an activity co-ordinator being employed, their input, although caring, was not effective and did not ensure each person had regular opportunity for stimulation and engagement. People were not facilitated to maintain regular social stimulation in a person centred way to maintain wellbeing. During our inspection many individuals were left for long periods alone, despite care plans identified specific need for engagement, such as depression, loneliness and anxiety. Staff did not have time to spend with people, chat or to have input into activities and social stimulation. This meant that people had little contact with staff other than for tasks. Some people with more complex needs such as living with dementia or other mental health needs were not consistently supported. Staff were unable to be pro-active in ensuring care was based on people's preferences and interests, join in and seek out activities in the wider community and consistently help people live a fulfilled life, individually and in groups.

People, relatives, staff and external professionals did not have confidence in the registered manager and provider. Staff were visibly upset about the lack of time to provide a good service to people they cared about. They did not feel valued, listened to or part of a team, despite regular supervision session with more senior staff or management. All staff had received appropriate induction and training but felt they could not put this into practice.

The home was not always clean and free from offensive odours. There was no attention to detail and domestic shift patterns meant at times care staff had to provide cleaning which they did not have time to do.

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 time frame. 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.

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