Appletree House Residential Care Home

Appletree House Residential Care Home is a care home providing personal care to up to 15 people in one adapted building. The service provides support to people with dementia and frailty associated with age. At the time of our inspection there were 12 people using the service.

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

People felt safe. People told us they were supported by staff who were kind. Risks to people had been assessed and mitigated. Staff followed safeguarding guidelines and knew how to identify and report potential signs of abuse. Medicines were managed safely.

People were complementary of the service they received. They told us the food was good and they were supported by attentive and compassionate staff. Visitors told us the care people received was very good and the staff were kind, caring and compassionate. We observed warm and positive engagement between people and staff. Staff were recruited safely and there were enough staff to meet people’s 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.

People told us they were involved in the planning and reviewing of their care. Care was personalised and care plans provided detailed information and guidance for staff. Staff provided support in line with people's preferences. People were treated with dignity and respect.

Since the last inspection significant improvements had been made to achieve the required level of compliance. Systems and process were in place to monitor the quality of the service being delivered. A new registered manager had been appointed and we received positive feedback about them from people and visitors to the service. The provider and registered manager worked with stakeholders to drive and sustain service improvements.

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 27 September 2021). There were breaches of regulation and conditions were placed upon the providers registration. 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 inspection was prompted by a review of the information we held about this service and to follow up on action we told the provider to take at the last 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.

Follow up

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

Appletree House is a residential ‘care home’ registered to provide personal care for up to 15 older people in one adapted building. At the time of the inspection there were 15 people living in the care home. Some people were living with dementia or frailty and other associated health conditions.

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

There was a failure to assess, monitor and mitigate risks relating to the health, safety and welfare of people. People's care plans and risk assessments lacked important detail to guide staff on how to make people safe. There were unsafe practices in the way medicines were stored and recorded.

Leadership and governance of the service were not effective in identifying some service shortfalls. There was not an adequate process for assessing and monitoring the quality of the services provided and that records were accurate and complete.

Some infection control practices did not mitigate the risk of contracting and spreading COVID-19 within the care home. Processes were not in place to support safe visiting inside and away from the care home. Infection control processes had failed to identify some risk of cross contamination and transmission of COVID-19.

Systems were in place to protect people from the risk of abuse and improper treatment and staff knew how to identify potential harm and report concerns. 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.

Staffing levels were enough to meet people’s individual needs. Positive and caring relationships had been developed between staff and people. People were treated with kindness and compassion and staff were friendly and respectful. People and their relatives told us they were happy with the service they received.

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 30 April 2019) and there were two breaches 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 enough improvement had not been made and the provider was still in breach of regulations.

The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We carried out an unannounced comprehensive inspection of this service on 4 March 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve. We identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to gaining people’s consent and good governance.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment , infection control and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

• Appletree House Residential Care Home is situated in Lancing, West Sussex. It is a residential ‘care home’ registered for up to 15 older people, some of whom are living with dementia or frailty and other associated health conditions. At the time of the inspection there were 12 people living in the home.

People’s experience of using this service:

• People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and procedures in the home did not support this practice. Staff continued to lack understanding about mental capacity so made decisions for people rather than with them.

• Although improvements had been made, for example, people now had the equipment they needed, there were continued concerns about the oversight of the systems and processes within the home to ensure people received high-quality care.

• Shortfalls found at the inspection had not always been identified by the registered manager.

• Potential risks to people had not always been considered or lessened.

• Staff recruitment practices did not always comply with guidance or the provider’s policy to help ensure staff were suitable to work with people.

• Staff did not always have access to learning and development that the provider considered essential for their roles.

• People told us they were happy living at the home and there was a relaxed, friendly and homely atmosphere.

• People were treated with dignity and respect. They told us staff were kind, caring and compassionate. One person told us, “They’re lovely, they normally give me cuddles.”

• People could plan for their end of life care.

• There were sufficient staff to meet people’s needs.

• People had access to healthcare services and had their medicines when they needed them.

• Infection prevention and control was maintained and the home was clean.

• People told us that they were happy with the food. One person told us, “We are lucky with the food, it is beautiful, such a treat. The food is lovely, very nicely prepared.”

• People had their own rooms and access to communal spaces so that they could spend time alone or with others.

• People received care that met their physical, social and emotional needs.

• People told us that they enjoyed the interaction with staff as well as the activities that took place.

Rating at last inspection:

• At the last inspection the home was rated as Requires Improvement. (Published on 11 December 2018). This home has now been rated as Requires Improvement in the last three consecutive inspections.

Why we inspected:

• This was an unannounced comprehensive inspection. At our last inspection, on 27 September 2018, the provider was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We took enforcement action against the provider and gave them a date to meet the Regulations by. This inspection took place to check that improvements had been made and that they were now meeting the Regulations.

Enforcement:

• The provider had met the Warning notices that had been issued following the previous inspection on 27 September 2018.

• Although improvements in some areas had been made since the last inspection, which included the provision of equipment and the oversight of the service, we continued to have concerns.

• Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up:

• We will continue to monitor the intelligence we receive about this home and plan to inspect in line with our re-inspection schedule for those services rated as Requires Improvement.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

The home provided care for older people, some of whom were living with dementia. The home had 14 rooms and was registered to care for up to 15 people. Two people shared a room. At the time of the inspection there were 15 people living within the home.

The home had a registered manager, who had been in post for 2 years, 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We inspected Appletree House Care Home on 27 September and 1 October 2018. We brought this comprehensive inspection forward, due to information of concern we had received. This information related to the safe care and treatment of people within the home. We had received concerns relating to the suitability of staff, staffing levels and a lack of activities, the availability of food, the facilities and the management of the home.

When we completed our last inspection, on 14 November 2017, we found breaches of the regulations relating to the mismanagement of risks, due to unsafe equipment. We also identified that the provider had failed to provide meaningful activities for people and there were insufficient staff. There was a lack of oversight of the home and quality assurance systems had not improved the care people received. The provider sent us an action plan, after this inspection, detailing the changes they were making to improve the service. However, at this inspection concerns continued about the care people received and the running of the home.

At this inspection there were not enough suitably trained and competent staff available to ensure people received safe care. On the first day of the inspection the staff on duty did not have the required experience. The provider had not ensured all staff had the required pre-employment checks to ensure they were suitable to work within the care industry. Training was not up to date and had not ensured good standards of care were maintained. However, staff did receive supervision and told us that they felt supported by senior staff.

Medicines were not always delivered in a safe and consistent way. Not all staff felt confident in the delivery of medicines and this meant that some people did not receive their medicines at appropriately spaced intervals. There was a medicine procedure and audit in place, but this had not ensured medicines were always stored appropriately.

Appropriate infection control measures were not always followed and the facilities within the home did not always provide for people’s needs. At this inspection the lift was still out of action, although it has since been mended. The risks relating to the use of the chair lift had been managed, as people who were less mobile had been moved to downstairs rooms. However, other environmental risks had not been addressed in a timely manner. Due to the size and age of the property the facilities were limited and if things broke, this impacted on the people within the home. The facilities also impacted on people’s privacy and dignity.

Personal risk assessments and care plans were not always updated, in a timely fashion and actions were not always completed. Staff did seek the advice of health-care professionals but the documentation around decisions was not always completed thoroughly. Staff did not always anticipate the needs of people who were approaching the end of their lives. People did not always have choice in relation to their food and strategies, to ensure people had appropriate support at mealtimes, were not always followed.

There was a range of activities for people within the home but these were limited and did not always happen, if the home was understaffed. We have made a recommendation, about reviewing the activities programme and sourcing information, about meaningful activities.

Staff had not always addressed people’s communication needs. We have made a recommendation about making information more accessible for people.

There was a list of audits but these did not always produce appropriate action plans or lead to positive change. Complaints and concerns were responded to but they were not recorded in a way which helped identify trends or themes. There were limited opportunities for people to feed back about the care they received. The registered manager and provider did not have a good oversight about the standards of care within the home.

There was a safe-guarding procedure in place and the manager cooperated with the local authority, as necessary. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive ways possible; the policies and systems in the home supported this practice. However, staff did not always have a working knowledge of the Mental Capacity Act (2005). We received some mixed comments about the caring nature of staff. However, during the inspection we observed some caring interactions. Some aspects of care were task orientated, rather than being based on the needs of the individual and there were limited attempts to promote or maintain independence.

At this inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities 2014). You can see what action we told the provider to take at the back of the full version of this report.

The overall rating for this service is ‘Requires Improvement’. This is the second consecutive time it has had this rating.

Appletree House Residential Care Home provides accommodation and residential care for up to 15 people living with dementia, mental health needs and frailty of old age. Communal facilities include a sitting room with dining area and access to outside space. All rooms are of single occupancy, except for one room, which is shared by two people. Appletree House Residential Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

A registered manager was 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.

Risks to people had not always been identified or assessed appropriately. Some care plans lacked detail or guidance for staff. One person had sustained a number of falls during the year, but no referral had been made to the local authority’s falls team for advice and support. Premises were not always managed to ensure people’s safety. The lift was out of commission and a stair lift had been installed for people to access the first floor. However, the stairs were steep and some people were too nervous or unable to use the stair lift which meant they could not come downstairs. A commode chair was used to transport one person, which was unsafe. Some topical creams and bath lotions had been left on the windowsill of a communal bathroom and not stored safely. The provider had failed to ensure that risks to people, the use of equipment and premises were managed appropriately.

Staffing levels were not sufficient to ensure people were supported safely. For 15 people who lived at the home, care was provided by two care staff, although the registered manager and cook occasionally helped out during the week if required. The provider had failed to ensure there were sufficient numbers of staff to meet people’s care and support needs safely.

People’s preferences were not always identified or taken account of in relation to the care they received. One person persistently told staff they did not like vegetables, but every day they were served with them. People and/or their relatives were not involved in reviewing their care. Activities in the home were limited and did not relate to people’s likes or interests. There was a lack of meaningful activities for people to engage with and no outings into the community.

There were no systems in place to measure and monitor the overall quality of the service and no means of identifying areas that required improvement. The culture of the home did not promote person-centred, open or inclusive care. Issues we identified at this inspection had not been picked up through the audits we looked at. Relatives were not asked for their feedback about the service. The provider had failed to establish systems or processes that operated effectively to assess, monitor and improve the quality of the service. The registered manager was unaware of the new Key Lines of Enquiry which the Care Quality Commission introduced from 1 November 2017.

People’s identified needs were not specifically catered for in relation to the adaptation and design of the home. There was only one bathroom, located on the first floor, for up to 14 people. The majority of people had a bath once a week. People who were unable to access the first floor via the stair lift were unable to have a bath. Some parts of the home were not well lit and could pose a risk to people as they navigated around the home. Opportunities had been missed in relation to the use of signage to assist people. We have made a recommendation to the provider in relation to this.

Generally, medicines were managed safely. However, two medicines for two people had not been administered over the last couple of days as stocks had run out. The registered manager immediately followed this up with the medical practice to ensure these medicines were delivered on the day of the inspection.

People were supported to have sufficient to eat and drink. Choices for meals were limited, although people generally were happy with the meals on offer. Drinks were freely available. People had access to a range of healthcare professionals and services. The registered manager understood the principles of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards legislation and put this into practice. People’s consent was gained lawfully.

People were looked after by kind and caring staff who knew them well. Staff were warm and friendly and genuine relationships had been developed. People were able to express their views in relation to their day-to-day care needs and they were treated with dignity and respect by staff.

Staff completed a range of on-line training to meet people’s care and support needs. Moving and handling training and dementia care training was delivered face to face.

Care plans were in the process of being reviewed and updated by the registered manager and this was work in progress. No complaints had been logged with the new registered manager since they commenced employment.

Systems were in place to ensure the safe recruitment and vetting of new staff. Staff understood how to protect people from potential abuse and knew what action to take. They had completed training in adults at risk.

Staff spoke positively about the registered manager and felt supported by her. Staff were asked for their feedback about the home and results overall were positive. People too were happy to live at the home and spoke of the caring attitude of staff.

We found Appletree House Residential Care Home in breach of four regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The registered manager was present for the inspection.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe? Is the service caring? Is the service effective? Is the service responsive? Is the service well led?

This is a summary of what we found

Is the service safe?

People who lived in the home said they felt safe because 'Staff are lovely'. Staff told us the service was safe because it was a 'Small home' which meant they had time to get to know people well and gain their trust. They said this meant people living in the home could talk to them about things that were worrying them.

The home did not have appropriate procedures in place to support people who could not make decisions about their care and treatment. CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw the home had not made applications for DoLS and staff had no understanding of this and how it impacted on people. Staff had not been trained in the Mental Capacity Act (2005) and no mental capacity assessments had been undertaken even though we were told there were people who lacked mental capacity to make some decisions.

We found that the home had suitable procedures in place to protect people against the risks associated with medicines.

Is the service caring?

People who lived in the home said the staff were caring and they felt well looked after. One said 'Nothing is too much trouble.' Relatives also told us it was a caring home, one said people were 'Very well cared for', another said they were 'Fine on caring.'

Staff spoke about people in a caring and respectful manner. They knew people well and treated them as individuals. One staff member told us the home was 'More relaxed, time to sit and chat to clients.' Another said it was a 'Homely home, we get to know people individually.' When asked if they would recommend the home to a loved one, the staff we spoke with told us they would.

Is the service effective?

The service is effective because people were involved in their care planning and their individual needs were recorded in their care plans. We saw examples of how people's needs were met and this was confirmed to us by the people we spoke with.

Is the service responsive?

We saw the home responded to people's individual needs and preferences. We saw that action was taken if people's needs changed or their health deteriorated.

Is the service well led?

The registered manager was very open and committed to improving the service. However, there were several areas which required improvement and these had not been picked up through the provider's quality monitoring systems. Staff spoke highly of the registered manager saying they were well supported and communication was good between staff and management.

People told us that they were happy in the home. They said staff were very kind and friendly. One person said 'I feel safe and secure here'.

People told us that staff understood their needs and provided appropriate care and support. One person told us staff were 'So friendly and could not be more helpful.' Another person said 'Staff go the extra mile for you.'

We saw there were systems in place to protect people from the risk of infection. Staff told us that they had recently completed their infection control training refresher course.

We found that the issue identified at our last inspection in March 2013 had not been fully attended to. The provider had not relocated the medicines cupboard to a suitable location. However, the provider had introduced a monthly audit of medicines and new medicine charts. Additionally, the provider had ensured staff used new ordering and disposal forms for medicines.

There were systems in place to get the views of people who used the service as well as their relatives. The provider took notice of people's comments and took action to make changes they were able to undertake.

The provider had systems in place to ensure good records were maintained to protect people from the risk of unsafe or inappropriate care and treatment. For example, we saw that the provided regularly update people's care plans.

We observed that people were happy and comfortable during the day and were treated respectfully by staff. Staff appeared dedicated and were knowledgeable about all the people in the home. We saw that people were cared for with sensitivity and at a pace appropriate to them.

We found that medication was not stored in a suitable environment. The system for recording medication administration was confusing and there were sometimes errors in recording.

Staffing levels were sufficient to carry out all the necessary care tasks. However, we found that staffing levels did not allow much flexibility. One staff member told us "I often leave late" and that "Staff take people out voluntarily". Staff were supported in their roles trough training and supervision.

There were systems in place to get the views of people who used the service as well as their relatives. We found that the provider took notice of people's comments and took action to make changes where needed.