Archived: Celia Johnson Court

This inspection was carried out on 15 June 2017 and was unannounced. At their last inspection on 10 June 2015, they were found to be meeting the standards we inspected. At this inspection we found that they continued to meet all the required standards.

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Celia Johnson Court provides accommodation and personal care for up to 37 older people with age related frailty. It does not provide nursing care. At the time of our inspection there were 27 people residing at the home.

The service had a manager who was registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with the 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 and associated Regulations about how the service is run.

People were protected from potential harm and staff were able to demonstrate they were aware of the risks of abuse and how to report or raise concerns. We found that there was a robust recruitment process in place and sufficient staff deployed to meet people’s individual care and support needs at all times. There were suitable arrangements in place for the safe ordering, storage administration and disposal of medicines.

People were asked for their consent and staff were aware of MCA principles and where people lacked capacity to make decisions, consent had been obtained in accordance with the Mental Capacity Act (MCA) 2005.

People were supported to maintain their health and well-being and had access to a range of healthcare professionals such as GP’s, district nurses, and dentists. People were offered choices of what food and drinks they wanted and were supported to maintain a healthy balanced and varied diet.

People were treated kindly and in a way which respected and maintained people’s privacy and dignity. Staff demonstrated that they knew people well and met their needs in a personalised way.

People were supported to participate in a range of activities and meaningful engagement which took into account peoples individual abilities and interests. People and staff told us they were always consulted about all aspects of the service, as well as how the home was run. People told us they felt 'listened to' by the management team. The management team valued people and staff. There were systems and processes in place to monitor the overall quality of the service and to drive continual improvements.

The management team were open and transparent about all aspects of the service. The home is in the process of being sold to a new care home provider. We saw and people confirmed that people were fully consulted throughout the process.

Below is a summary of what we found. The summary is based on what we found at the inspection by looking at records and what people told us about their experiences of the service. We spoke with five people using the service, a relative of one person, four care workers, three ancillary staff and two management representatives.

At the time of our inspection Celia Johnson Court provided care and support to 25 older people. Our first Inspection was on 4 September 2014 and a further visit was required on 10 September 2014 to check that urgent action had been taken in response to our concerns about the safety of the premises.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found the service was not safe. There were no safe or usable fire exit routes out of the six available (secondary exits) throughout the building. Only the main entrance was accessible for entering or leaving the building. We found the service was in contravention of the organisational fire safety policy, particularly in regards to having safe fire exits, keeping escape routes clear, having fire doors closed correctly, having correct and adequate signage and an up to date evacuation plan.

People who used the service told us they felt safe. We found people's needs had been assessed, and care plans and risk assessments were in place to ensure that they were provided with appropriate and safe care.

We found people's care was managed in accordance with the requirements of the Mental Capacity Act 2005 (MCA) and the related Deprivation of Liberty Safeguards (DoLS), to ensure a balance between keeping people safe and not depriving them of their liberty.

Is the service effective?

Detailed care plans were in place to provide guidance to staff on how to deliver appropriate and effective care.

We found the service was effective in supporting people in a way that suited their individual needs, and maintained their quality of life. It was clear from our observations and from speaking with the care workers, that they had a good understanding of people's care and support needs and they knew them well.

Is the service caring?

We found people were supported by care workers who were understanding and sensitive to their needs. People who used the service told us that the care workers met their care needs, they were kind and treated them with respect. However, we found people's privacy and dignity were not always protected, as we observed a workman entering people's bedrooms without being accompanied by the care workers and without knocking.

Is the service responsive?

We found the service was not responsive because they had failed to identify and manage the risks to people's safety during the external and internal building work. However, the provider acted promptly to rectify the safety concerns we had raised on 4 September 2014.

We saw that the care plans had been updated when people's needs had changed. However for one person, the provider had failed to respond appropriately to the person's health needs. This is because the person had lost significant weight over a four month period, but had not been referred to appropriate health professionals. Additionally, the person's weight continued to be monitored monthly. We found this was not frequent enough to ensure that their condition was not worsening.

We saw that the provider took account of complaints and comments and acted promptly to resolve these. They also used the learning from these to improve the quality of the service.

Is the service well-led?

The service had quality monitoring processes in place. However, we had concerns that these were not effective, particularly in relation to the safety concerns we raised on 4 September 2014. We found the provider did not use the processes available to them to effectively identify, assess and manage the risks posed by the building work to people who used the service, the staff employed by the service and others accessing the premises. We saw that the health and safety checks completed during this period did not identify the fire risk issues we found during our inspection. This posed a high level of safety risks to people who used the service and others.

The home was in the process of a significant refurbishment programme on the day of the inspection. The home had made appropriate plans to minimise disruption to the people living in the home and had taken suitable steps to keep people safe during the building works being carried out.

We found that people's care plans and records were current and reflective of their assessed needs and that staff were following them to deliver safe, appropriate care.

The home did not have robust systems in place to manage the risks of cross infection, and were not keeping suitable records to evidence effective cleaning programmes.

The home was undergoing significant refurbishment at the time of inspection. People who lived at the home were being kept up to date about the progress of refurbishment work in the form of organised meetings and bulletins. The registered provider was taking suitable steps to provide care in a suitable environment that was appropriately maintained.

We saw that people's support plans and risk assessments were informative, easy to follow and up to date. Staff we spoke with were aware of their contents, which supported them to deliver appropriate and safe care. The provider had systems in place that ensured the safe receipt, storage, administration and recording of medicines. We found that staff recruitment systems were robust and there were enough suitably qualified staff on duty to meet the needs of the people who lived at the home.