Cromwell House Care Home

Cromwell House Care Home is a residential care home providing regulated activities of personal and nursing care to up to 66 people. The service provides support to older people, some of whom may live with dementia. At the time of our inspection there were 49 people using the service.

Cromwell House Care Home accommodates people across three separate floors, each of which has separate adapted facilities.

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

We found extensive improvements had been made since the last inspection, however, enough time had not passed to ensure these were fully embedded. The registered manager and nominated individual were aware ongoing reviews to monitor and further improve the service were required, and they were committed to undertaking this.

Oversight and processes within the care home should be reviewed and further monitored by the provider. Specifically, the provider should ensure appropriate oversight and guidance is available to staff in the absence of the registered manager.

We have made a recommendation for the provider to ensure continued review of processes and systems takes place. Furthermore, staff support, oversight and guidance should be effective and robust in the absence of the registered manager.

People and their relatives told us they were not routinely involved in the care planning process on an ongoing basis.

We have made a recommendation for the provider to review how people and their relatives, where appropriate, are involved in the care planning process on an ongoing basis.

Staff had undertaken the required safeguarding training, and people told us they felt safe. Lessons learnt were appropriately shared with staff, and learning from incidents took place. Risks to people had been assessed, and staff were confident of the risk reducing measures in place. The care home was clean and tidy, and good infection prevention control practice was observed. Medicines were managed safely by suitably trained staff.

There were enough staff to meet people’s assessed needs. The provider had followed safe recruitment procedures. Staff had the right level of training and support to deliver effective care and meet the needs of people living at the care home.

People were supported to access health professional services, as required, and had access to a variety of food and drinks which met their dietary needs and wishes. Effective monitoring and support were provided by staff to those who required assistance with eating and drinking.

The care home environment had received extensive refurbishment since the last inspection. People told us they were happy with the décor and facilities available. 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.

Staff were kind and caring in their duties and showed people respect and dignity. People were supported in a person-centred way, and their likes and dislikes were adhered to. People were satisfied with the activities available at the care home, however, these could be improved upon with additional staff recruitment. People, and their relatives, knew how to raise a complaint or concern and felt confident to do so. Care plans were in place to support people nearing the end of their life.

A positive, open, and inclusive culture was now evident at the location. This had been firmly led, embedded, and sustained by the experienced registered manager who began working at the care home following our last inspection. Governance systems were appropriately used and managed, and effective oversight was in place.

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 inadequate (inspection completed August 2022, summary report published 22 April 2023).

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.

This service has been in Special Measures since August 2022. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

The inspection was prompted in part due to information received that the provider had made and sustained the necessary improvements we told them to take. This meant their CQC rating from August 2022 may not have been reflective of the service provided to people. A decision was made for us to inspect to follow up on action we told the provider to take at the last inspection.

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

Recommendations

We have made 2 recommendations during this inspection. One recommendation is for the provider to continue to monitor, review and embed their systems and processes. Furthermore, staff support and guidance should be effective and robust in the absence of the registered manager. Another recommendation is for the provider to review the involvement of people, and their relatives, in the ongoing care planning processes.

Follow up

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

Cromwell House Care Home is a residential care home providing regulated activities of personal and nursing care to up to 66 people. The service provides support to older people some of whom may live with dementia. At the time of our inspection there were 53 people using the service.

Cromwell House Care Home accommodates people across three separate floors, each of which has separate adapted facilities.

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

People gave us mixed feedback about the care and support they received. Some people said they could always ask staff for support and received this, but others told us they were not happy how their needs were met. Some relatives told us they felt the need to visit daily to ensure their family member’s needs were met.

Staff told us they had online safeguarding training and had reported concerns but lacked confidence in the registered manager taking action. Not all incidents and accidents were investigated or reported to external safeguarding authorities when the cause of these were not known.

People at risk of developing pressure ulcers, and those with existing pressure ulcers, were not protected from the risk of harm. The equipment in place had not been set correctly to mitigate the risk of people’s skin breaking down. There was insufficient equipment available to support people with their mobility. Good infection prevention and control measures were not always followed by staff. This put people at risk of infection and harm.

There were not enough staff to provide people with care that met their needs safely or personalised to their liking. The majority of people were cared for in bed without any clear reason. Relatives told us they needed to visit daily or several times a week to help people with their needs. They said this was because there were not enough staff to provide safe care to people and this worried them. People experienced delays in having their needs met and this had an impact on their health and well-being.

People’s needs were assessed prior to them moving into the home. Care plans were developed, however we found numerous examples where records referred to the name of a different person to whom they belonged. Care records did not always reflect people’s needs. In some instances, there were delays in referring people to health professionals.

Training was in place for staff, however some training was out of date or not given and the registered manager failed to ensure they checked staff’s understanding of the training following completion. Staff told us they had little support from the registered manager. Staff had lost confidence to approach the registered manager with any concerns they may have had due to lack of meaningful action taken in response to previous concerns raised.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. There were insufficient measures taken by the registered manager, the provider or staff to minimise the impact on people who were solely being cared for in bed. Some people had not been outside of the building since they moved into the home and had not been provided with opportunities to socialise with other people.

A high number of people required assistance from staff to eat and drink. They had not always received this support promptly.

People and relatives told us staff were kind and respectful towards them, however they were always in a rush and at times their actions had not demonstrated a caring approach. Some people were washed and then dressed in their day clothes in the middle of the night. They were then left in bed to continue sleeping whilst fully dressed. Some people told us staff had not always listened to what they wanted.

The registered manager and provider failed to ensure people received care and support in a personalised way. Staff worked in a task led manner which led to institutionalised practice of providing support for people when it was their “turn”. There were some activities and opportunities for engagement, but these were limited at the time of the inspection.

Systems were not effectively operated to provide safe care to people. The provider’s quality and assurance processes were not used effectively. Audits carried out by the registered manager failed to identify areas in need of improvement. Where the provider identified areas in need of improvement through their own audits, they had failed to ensure the improvement actions needed were completed and ensure people’s experiences improved.

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 15 November 2018).

Why we inspected

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.

The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. This incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances of the incident. However, the information CQC received about the incident indicated concerns about the management of skin integrity and risk assessments. This inspection examined those risks.

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

The provider took some immediate actions to ensure people were safe and they received care and support effectively. Actions included increase in staffing, ordering new equipment and involving health and social care professionals in re-assessing people’s needs.

Enforcement

We have identified breaches in relation to safeguarding people from abuse safe care and treatment, staffing, personalised care, dignity and management of the service at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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 found the following examples of good practice.

There was a purpose-built visiting pod in place with a clear screen to separate visitors from people. Visitors, one or two people only, could visit their family member/friend for 20 minutes by appointment. Entrance and exits for visitors to this pod was different to the main entrance. Gaps in-between each visit were 10 minutes so that staff can clean in between the visits. These visits are currently suspended due to the local area being in Tier 4. Phone calls and video calls were in place so people could stay in contact with friends and family. There was a designated staff member employed to support people with this. These calls were also by appointment to make sure everyone had their fair share of contact with relatives and friends.

On arrival into the building, an external health or social care professional visitor waited to enter, then signed in (track and trace), sanitised their hands and had their temperature checked. They also answered a health declaration around COVID-19. There was also a request to take COVID-19 lateral flow test. The registered manager told us that in an emergency such as for paramedics this would not be expected of them.

Posters were on display to prompt people and staff to social distance. Information was also provided to people in large print to aid with their understanding.

Relatives were communicated to about COVID-19 restrictions when booking their visit, or via email and letters. A relative meeting via a video call had also taken place where the registered manager answered any questions, they may have about COVID-19 and restrictions.

Post to the home and parcels were wiped clean wherever possible or set aside for 72 hours to prevent cross contamination.

Chairs in communal areas such as dining rooms and lounges had been spread out to promote social distancing.

Staff changed into their uniform and don and doff their PPE before starting work. Lockers were in place for staff to store their non-work clothes and belongings. The registered manager conducted a daily walkaround to check staff were wearing their PPE correctly. Spot checks on staff competencies were in place re handwashing and hand hygiene (using ultraviolet lights), and PPE assessments.

Staff wore uniforms with their name and picture badge on it to reduce the risk of people becoming alarmed due to face masks being worn. The nurses at the service had taken on designated health tasks such as wound management and dressing to help free up and support the local district nurses team.

Cromwell House Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

There was a registered manager at the home, although they were no longer in the position and a new manager was in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

Staff knew how to keep people safe, how to respond to possible harm and how to reduce risks to people. There were enough staff who had been recruited properly to make sure they were suitable to work with people. Medicines were stored and administered safely. Regular cleaning made sure that infection control was maintained. Lessons were learnt about accidents and incidents and these were shared with staff members to ensure changes were made to staff practise or the environment, to reduce further occurrences.

People were cared for by staff who had received the appropriate training and had the skills and support to carry out their roles. People received a choice of meals, which they liked, and staff supported them to eat and drink. They were referred to health care professionals as needed and staff followed the advice professionals gave them. Adaptations were made to ensure people were safe and able to move around their home as independently as possible. Staff understood and complied with the principles of the Mental Capacity Act 2005 (MCA). People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible; the policies and systems in the home supported this practice.

Staff were caring, kind and treated people with respect. People were listened to and were involved in their care and what they did on a day to day basis. People’s right to privacy was maintained by the actions and care given by staff members.

People’s personal and health care needs were met and care records provided staff with clear, detailed guidance in how to do this. People were able to take part in social events and spend time with their peers. A complaints system was in place and there was information in alternative formats so people knew who to speak with if they had concerns. Staff had guidance about caring for people at the end of their lives and information was available to show how each person wanted this.

Staff were supported by the new manager, who had identified areas of concern and developed a plan to address these. The provider’s monitoring process looked at systems throughout the service, identified issues and staff took the appropriate action to resolve these. People’s views were sought, although further systems were being developed to ensure everyone was able to give these.

Further information is in the detailed findings below.

We carried out a focused unannounced comprehensive inspection of this service on 5 November 2015. A breach of two legal requirements was found. These were in relation to the management of medicines.

After the focused inspection on 5 November 2015, the provider wrote to us to say what they would do to meet the legal requirements in relation to the safe management of medicines.

We undertook this unannounced comprehensive inspection on 30 March 2016 to check that the provider had followed their plan and also to confirm that they met legal requirements. We found that the provider had followed their plan which they had told us would be completed by the 15 January 2016 and legal requirements had been met.

The service did not have a registered manager. The previous registered manager left in August 2015. 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.

Staff had a good understanding of the identification, prevention and reporting of any incident of harm. People’s assessed needs were not always met by a sufficient number of staff who were qualified and competent in their role. Satisfactory pre-employment checks were completed on staff before they were offered employment.

Action had been taken, and sustained, in the administration and management of people’s medicines. Staff had been regularly trained and assessed as being competent to safely administer people’s prescribed medicines. An effective staff training and induction process was in place to support staff in their role.

Risk assessments to help safely support people with risks to their health were in place and these were kept under review according to each person’s needs. This included risk assessments to support people in an emergency such as a fire should this ever occur.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The regional manager, home manager and staff were knowledgeable about when an assessment of people’s mental capacity was required. Appropriate applications had been made by the provider to lawfully deprive people of their liberty as well as people being cared for in the least restrictive manner. This meant that, where appropriate, people were being lawfully deprived of their liberty.

People were supported to eat and have sufficient quantities of their preferred food and drink choices. This included the provision and choice of appropriate diets for those people at an increased risk of malnutrition, dehydration or weight loss.

People were supported to access a range of health care services and their individual health needs were met.

People were cared for with dignity in a compassionate way. People were given the opportunity to be as independent as possible. People were involved in the planning and provision of their care

Information was made available for people or their relatives who may need access to independent advocacy services. People were given various opportunities to help identify and make key changes or suggestions about any aspects of their care. Some opportunities were missed to support people with their care needs in an individualised manner.

A range of effective audit and quality assurance procedures were in place. This was to help identify what worked well and any area that required improvement.

As part of this inspection we spoke with eight people who used the service, six family members of people who use the service, the registered manager, an operational manager, eight members of care staff and a visiting healthcare specialist. We also spoke with a member of staff from the Continuing Health Care team in Huntingdon, and a representative from the Local Authority Contracts team both of whom had regular contact with the home. We reviewed records relating to the management of the service which included five care plans, daily records, infection control procedures, staff rotas, staff records and quality assurance monitoring records.

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

Is the service safe?

Risk assessments regarding people’s individual care and support needs had been improved to ensure there were measures in place to minimise any potential harm to people who used the service. Carers understood their roles and responsibilities in making sure people were protected from harm. The provider had taken appropriate action to ensure that there were appropriate levels of staff to meet people’s needs .There were safe infection control procedures in place. Staff we met confirmed that they had received training regarding Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.

Is the service effective?

We found that nurses and care staff were knowledgeable about people’s individual care and support needs. People that we spoke with confirmed that staff provided consistent and kind support. Care planning documentation was well recorded and reviewed to ensure that individual care and support needs were being met. The manager confirmed that support documentation was regularly audited to ensure it met people’s assessed needs.

Is the service caring?

People told us that they received consistent and respectful support from care and nursing staff and felt able to make choices and changes when required. One person we met told us that “The care staff are very kind and always help me with what I need”. Staff told us that they felt supported so that they could provide safe care and support to people.

Is the service responsive?

We saw that people’s personal care and social support needs were assessed and met. This also included people’s individual choices and preferences as to how they liked to be supported. People we spoke with told us that they felt well cared for and this was confirmed when we observed care delivery during our inspection.

Is the service well led?

The home has a registered manager in place. Staff we spoke with told us that they felt supported by the manager and were regularly trained to provide safe care and support to people who lived at the home. People we spoke with told us that they felt they were listened to and support was consistent and provided in a safe way. Quality assurance systems were in place to regular audit the care and services provided. Surveys were carried out to gather opinions from people who lived at the home, their relatives and care staff.

Care records gave staff clear guidance on meeting each person's individual needs. Potential risks to people had been assessed and plans put in place to minimise the risks.

The home was very clean and there were systems in place to ensure that people were protected from the risks of infection.

People were adequately safeguarded from harm although not all staff were familiar with the Local Authority reporting procedures.

Medication was managed safely and the associated records had been accurately recorded.

The premises were well maintained and there was a large well kept garden that people and relatives told us they enjoyed.

The provider had suitable supervision arrangements in place to ensure staff were well trained and received regular management support.

Relatives told us they knew how to complain, but had never had to.