Archived: Lifestyle (Abbey Care) Limited Elizabeth - Swale

During an inspection in February 2015, we rated the home, ‘Requires improvement’ because we identified multiple breaches of the regulation. Within this rating, we found the ‘Safe’ domain was ‘Inadequate. These breaches of the regulation related to the delivery of safe care and treatment, safeguarding people from abuse; premises and equipment; consent to care or treatment; and maintaining people’s dignity.

We completed a focused inspection in August 2015 to look at what changes the registered provider had made since inspection in February 2015. We found that improvements had been made and the breaches of regulation had been addressed. The domain of ‘Safe’ was now rated as ‘Requires improvement,’ and the domain of ‘Caring’ had improved and was therefore rated as ‘Good.’ However, we needed to see that the improvements were sustained.

We completed this inspection to review the action the registered provider had taken since the last inspection and to see if the improvements identified during inspection in August 2015 had been sustained.

Lifestyle (Abbey Care) Limited - Elizabeth Swale is a residential care home, located on the Abbey Care Village site in Scorton. The service provides residential care for up to 54 people living with a dementia and does not provide nursing care. The home is divided into Elizabeth House, which is a two storey unit that can accommodate up to 30 people. The other unit is Swale House, which is located on the third floor of another home on the site and can accommodate 24 people. Swale House is currently being refurbished and is empty. At the time of inspection there were 27 people living at the service.

There has been a registered manager in place since March 2015. 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 this inspection, we found that people’s prescribed medicines were not safely managed. People did not receive their prescribed medicines when they needed them and medicine administration records were not accurately completed. We found people were at risk of harm because of the way medicines were managed.

There was a lack of information in people’s risk assessments and care plans. This meant they did not accurately reflect people’s risks and the care and support they needed from staff to keep people safe. We found that these risk assessments and care plans contained conflicting information, were not updated when people’s needs changed which meant that the information in them was not always accurate.

From our observations, we found that some people who used the service required two to one support. We looked at staffing levels to determine whether there was sufficient staff on duty to care for people safely. We requested information from the registered manager/provider about how they determined staffing levels; however we did not receive this information.

During inspection, we noted there was one senior carer and three care staff on duty throughout the day and two care staff during the night. When we arrived for inspection at 06:00, we could see that one person had experienced a fall, but had been left unattended whilst staff contacted 111 emergency services for assistance and checked the other people using the service to ensure they did not need assistance. This meant there were not enough staff on duty to provide safe care and support to people.

The dependency level record produced by the registered manager on 12 November 2016 showed 13 people were rated as having a high dependency; 15 people rated at a medium dependency and one person was rated as low dependency. Although the level of need had been assessed this did not translate into a change in staffing numbers, as the rotas showed no variation in staff on duty. On the day of the visit the number of people who lived at the home was 27 but this impact of this change was minimal. The registered manager worked in a supernumerary capacity and the deputy manager during the week who told us they would assist if needed but this was dependent upon their workload. We found from the review the dependency levels, discussions we staff and people and our observations there were insufficient staff on duty to meet the care and support needs of people. There were insufficient staff on duty overnight to ensure people could be safely evacuated from the home in the event of a fire.The registered provider accepted our concerns that there were insufficient staff to meet people’s needs and since the inspection they have being in the process of recruiting more staff. However the updated dependency tool they have provided still indicates that only two staff are needed overnight.

We found that although refurbishment work had been completed, this had not involved ensuring the lighting and heating were adequate. The registered provider was asked to ensure the lighting levels complied with health and safety guidance.

We found that regular checks of the hot water temperatures were completed. These checks revealed water was routinely between 38°c to 39°c, which is below the recommended temperature of 43 degrees Celsius (°c). The registered provider failed to notice that water temperatures were below recommended levels and failed to take action to increase water temperatures to safe levels. This meant people experience unsafe bathing temperatures and put them at risk of harm.

We observed staff washing plates and cutlery in the sink in the dining room. Although a thermostatic valve was in place, we found the hot water was below safe water temperatures. A domestic dish washer was in place, however could not accommodate all of the dishes. When we spoke with staff, they failed to recognise the risks posed to infection prevention and control because of unsafe water temperatures. Following inspection, the registered manager took action to obtain an industrial dishwasher.

A third of the people chose to sit in the lounge in their overcoats; staff told us this was because the people believed they were going to work, but individuals told us it was because they were cold. No ambient room thermometers were in place so staff could not check the temperature of the home so could not be assured the recommended temperature of 21°c was met. We found during the morning that the ambient room temperature in the communal areas was 19°c.

There was evidence to show that the registered provider was working within the principles of the Mental Capacity Act 2005 (MCA). However we found that staff could not always effectively demonstrate how best interest decisions were made and followed. This meant we could not be sure if staff fully understood the requirements of MCA.

Deprivation of Liberty Safeguards (DoLS) authorisations had started to be obtained; of the 12 authorisations sent, only five had been completed. We found that the conditions imposed were not always met and there was no system in place to monitor how staff were meeting conditions and that renewals were requested in a timely manner. Staff were unaware that people had the right to contest the DoLS authorisation and they were entitled to legal aid should they wish to make representations to the Court of Protection about their detention.

Staff were unaware that some of the people who used the service had been detained under a section of the Mental Health Act 1983 (amended 2007) and were now residing at the home under a community treatment order (CTO). This meant, staff had failed to obtain information about the conditions these people had to abide by or that the person had a right to appeal to the Mental Health Tribunal about their detention and were entitled to legal aid.

We asked the registered manager if anyone needed the support of an advocate. They told us that no-one currently required this type of support.

People were protected from the risks of harm or abuse because there were effective systems in place to manage any safeguarding concerns. Staff understood their responsibilities in respect of protecting people from the risk of harm. No safeguarding alerts had been raised in the last two years, which is considered unusual for this type of service, as people living with dementia can become agitated, which can lead to them coming into conflict with staff and other people. Recent accident and incident records showed people could become agitated and confrontational, which would suggest alerts may have been needed.

New staff had been employed following the home’s recruitment and selection policies and this ensured that only people considered suitable to work with vulnerable people worked at the service.

We found that one staff member had transferred from a sister home but the registered manager had not checked their recruitment file. This file showed the person had previously been a registered nurse but was suspended from practice; the previous home had not followed this matter up. In failing to check this recruitment file, the registered manager had failed to notice that the sister home had not completed robust recruitment procedures and had failed to investigate this matter to determine whether this staff member had been fit and safe to work at the service.

Staff were receiving support through supervision and received relevant training but the registered manager needed to ensure discussions focused on relevant practice such as staffing levels and training was effectively implemented.

An activities coordinator was in post three days per week. We found that a limited range of activities were provided at the service. During our inspection, we

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

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

Is the service safe

When people were identified as being at risk, their care plans showed the actions that would be required to manage these risks. These included appropriate referrals to other health and social care professionals such as dentists, opticians, occupational therapy and dieticians.

Changes in management arrangements and a lack of continuity in completing audits placed increase risk on the quality of the service people received. This included ensuring staff had up to date current health and safety training.

Is the service effective?

People had an individual care plan. We saw that the care plans contained information about people's needs and in some cases people themselves had been involved in the development of these. The risk assessments in the records were sufficient to identify and minimise risks. The service was appropriately assessing risk and providing guidance for staff about to how to manage and minimise these risks.

Some people using the service were unable to tell us what they thought about the care they received. One person told us, 'I like it here. The staff are nice.' When we spoke with staff they told us that they felt they provided good and effective care. One relative told us the staff were very good.

Is the service caring?

All the staff we spoke with were enthusiastic to provide a caring and effective service. We observed during our visit that staff were patient and caring with people when supporting them.

The interactions we observed throughout our visit were mainly good. Staff spoke with people in a friendly and clear manner. When people were assisted to move, or complete an activity, instructions and support were straightforward and appropriate in nature. However, we saw one person being wheeled into the dining room at lunchtime in a potentially unsafe way. We spoke with the deputy manager about this potentially unsafe practice. Staff knew people well and offered care that was calm and friendly.

Is the service responsive?

A monthly audit system had been implemented following our last inspection. This included the environment, delivery of care, medication and infection control. This allowed management to monitor the quality of service. There were also systems in place for highlighting issues and learning from accidents and incidents. The audits had only been carried out in July and August and were due to be repeated in September. However, these need to be sustained to measure the quality of the service and ensure improvements are made where necessary.

Not everyone could tell us about their experiences at the service. However, the home had proactively sought the view of relatives. Out of thirteen surveys sent out recently two had been returned. Comments had been positive.

Is the service well-led?

We spent some time with the deputy manager discussing the areas of priority. All the staff that we spoke with felt that the staff team were focussed on providing the best service they could. One staff member told us, 'The deputy manager works with us. We work as a team and feel supported to do our work.' Another member of staff told us, 'The deputy is very approachable. I can ask her anything and I don't feel foolish. No question is seen as stupid.'

Staff told us a new manager was due to start work in the near future.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

People's nutritional needs were being met by the service. Comments made by people's relatives included 'My relative always seems to have plenty to drink, tea throughout the day and water. I have noticed that they have cakes in the afternoon and there is plenty to eat in between meals' and 'I have seen staff support my relative and they always take their time with them as they are a slow eater. I have no concerns regarding their weight, it is stable, in fact they have put weight on.'

The home was now clean and staff were aware of their roles and responsibilities in maintaining cleanliness and infection control. Suitable arrangements for supplying equipment, such as paper towels, soap and gloves, were in place.

We found that medication was being managed in a safe and effective way. This meant that people received their medication in the way that it had been prescribed.

At the time of our visit staffing levels were safe and suitable for the needs of the people living at the home. Although we observed that some staff needed more direction to ensure that they used their time more effectively.

We found that further improvements were needed to the way the provider monitored and assessed the quality of the service provided. Some improvements had been made, but these were in the early stages of development. We also found through discussions with staff and relatives that there was still a lack of confidence in the provider's ability to proactively make and sustain improvements. For example, one of the comments we received was 'The owners are an uphill battle, they don't buy or improve anything unless they are constantly pushed to do so.'

We found that the home's care and medication records needed to improve. Some of the records we looked at were not up to date and did not provide a full and accurate picture of the individual care and support people needed. We also found that some records were recorded in a way that did not adequately protect people's confidentiality.

We found that people were still not being protected from the risk of infection because appropriate guidance had not been followed. People were still not being cared for in a clean and hygienic environment.

We found that people had their basic health, care and welfare needs met. The relatives and local health care professionals we spoke with were happy with the service, with comments including 'very sympathetic and very accommodating' and 'very diligent, very caring.' We also found that people were now supported to have an adequate nutritional intake, with people's weight being monitored and specialist support provided when needed. However, improvements could still be made, to ensure that people receive responsive and individualised care and support.

We were assisted at this follow up visit by a Community Infection Prevention and Control Nurse. During our visit we undertook a tour of the service and observed that there were still poor standards of cleanliness and infection control. This placed people at risk.

Arrangements were in place to ensure that safety critical equipment was serviced and inspected regularly. However, the home still needed on-going maintenance to ensure that people had a pleasant place to live.

We found that the service was now notifying CQC of appropriate events.

Overall, we found that the standard of care records had improved. However, there was still some inconsistency in the standard of record keeping at the service.

People who use the service and two relatives told us that they were happy with the care being provided. We also found that improvements had been made to the way issues around consent to care and treatment and deprivation of liberty were handled by the service. However, during our visit we saw that people did not look well cared for and found examples where people's care needs had not been appropriately assessed and provided for. We found evidence of continuing non compliance as some people were still not being provided with the nutritional support that they needed.

We found that equipment and furnishings at the service were were not always kept clean and well maintained. For example, unpleasant smells were evident in parts of the home, the lounge carpet was badly worn and some maintenance issues had not been resolved promptly.

During this visit we found that there was evidence of continuing non compliance in standards of record keeping. People's care records did not give an accurate picture of their needs or the care and support that was provided. This meant that recording systems didn't always support staff to identify and provide the care people needed.

Arrangements were in place to assess and plan people's care and to make sure that people received the medication they needed. We also found that staff received support and training to help them do their jobs.

However, we found practices that need to be improved at the service. We found that staff were not sufficiently aware of their responsibilities regarding the Deprivation of Liberty Safeguards. This meant that in one case someone's legal rights had not been properly upheld. Improvements needed to be made to the way the service assessed, monitored and responded to people's nutritional needs. We also found that people were not always being protected from the risks of unsafe or inappropriate care and treatment because of poor record keeping.