Gorselands Residential Home

Gorselands is a residential care home registered to provide personal care for up to 21 older people, some of whom may be living with dementia. There were 16 people using the service when we inspected. The building is a large period property with communal areas and bedrooms on two floors. There is a lift to the second floor.

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

Following the last inspection, the provider and registered manager had undertaken a review of the systems and procedures which had contributed to the Inadequate rating and the service remaining in Special Measures. The actions taken following this review were clear to inspectors and there was evidence of improvement throughout the service. However, further work was still needed to address the concerns identified during this inspection and to ensure the improvements already made were fully embedded and sustainable.

People who were able to, had consented to their care. However, records relating to people who did not have capacity to do this, required further review to ensure they were fully in line with best practice. Following our inspection, the provider confirmed that they had carried out a comprehensive review of these records to make sure they accurately reflected how people's rights were being protected.

Risks had been reviewed since the last inspection, but some risks posed by the environment had not been fully assessed and mitigated. The environment was not always suitable for people living with dementia, especially if their condition was likely to deteriorate. We have made a recommendation about creating a suitable dementia friendly environment.

There were enough staff and they were safely recruited. Staff understood their safeguarding responsibilities and knew how to reduce the risk and spread of infection. Medicines continued to be very well managed.

Staff received training and support to carry out their roles and worked well with other healthcare professionals. People’s needs were assessed before they were admitted to the service and their healthcare, eating and drinking needs were well managed.

Staff demonstrated a kind and caring attitude and relationships between staff and those they were caring for were good. There was a warm and homely atmosphere within the service and people told us they felt well cared for. People’s privacy and dignity were maintained.

Care was person centred and care plans contained information about people’s needs and preferences. Activities were varied and people enjoyed them. People’s care needs and preferences for the end of their life had been discussed with them and recorded.

Rating at last inspection and update

The service was rated Inadequate at the last inspection (published 16 August 2019.) At that inspection we found three breaches of regulation. This was because the provider did not have systems set up to safely assess and manage risk and had not ensured people had consented to their care. The inspection before this had also identified the same concerns about safety and risk management. The service remained in Special Measures following that inspection, having been previously placed in Special Measures on 28 September 2018.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe.

The rating for this service has now improved to Requires Improvement. During this inspection the service demonstrated to us that sufficient improvements have now been made and the service is no longer rated as Inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor this service and will request an improvement plan to help us do this. We will inspect it again in line with our regulatory inspection schedule, or sooner should we have any concerns.

Gorselands Care Home is a care home which was providing personal care to 17 older people at the time of the inspection.

People’s experience of using this service:

People’s safety was compromised because some risks were not well managed and some had not been assessed. Procedures relating to choking, pressure care and the management of risk, especially those posed by the environment, required improvement to ensure people were always safe.

Although staff received training relating to consent their understanding of the Mental Capacity Act 2005 needed to be improved. Records demonstrated that the provider had not always assessed people’s capacity to consent to their care and treatment in line with legislation and some records needed review.

Systems designed to monitor the quality and safety of the service were not robust and did not always identify risks. There were repeated breaches of regulation and the provider had not made the progress we expected since the last inspection. This was of particular concern because the same regulations, relating to good governance and safety, had been breached at previous inspections in 2018, 2017 and 2016.

Medicines were well managed and there were enough staff to meet people’s needs. Staff understood their responsibility to keep people safe from the risk of abuse and knew how to raise concerns. The service was clean and infection control procedures were understood by staff.

Staff were skilled and received a variety of training. The registered manager and provider had focussed on improving this significantly since the last inspection. Regular supervision, spot checking and appraisal of staff was in place. People who used the service were very happy with the quality of the food. Better monitoring of some people’s drinking and eating was needed to ensure that people were not placed at any increased risk. People’s health needs were well monitored in most cases and the provider made prompt referrals to healthcare professionals. Management of people’s diabetes required improvement. Healthcare professional’s advice needed to be captured accurately in records so that staff were always clear about people’s current needs.

The environment had much improved since the last inspection and the service was warm and comfortable. Further improvements were needed to enhance the environment, and these were scheduled.

Staff were patient, kind and caring and relationships between staff and the people they were supporting and caring for, were good. People were very happy with the care they received and praised staff. Staff managed people’s distress, associated with their healthcare conditions, well.

The registered manager kept care records under review, but care plans did not always reflect people’s needs when there had been a change. There were limited activities to occupy people’s time, especially for those people who were cared for in bed.

However, we did identify significant improvements in many areas, notably the management of medicines, training, staffing and refurbishment of the environment. The provider and registered manager demonstrated to us a willingness to continue to improve. They were open and honest with us and assured us they would act robustly on our feedback.

There is more information is in the full report below.

Rating at last inspection: Inadequate with the key questions of Safe and Well-Led being individually rated Inadequate and the other three rated as Requires Improvement (report published 29 September 2018.)

Why we inspected: This was a scheduled inspection based on the previous rating. At our last inspection we rated this service Inadequate overall with breaches of regulation relating to safe care and treatment, staffing and good governance. We placed the service into special measures and asked them to provide us with an action plan documenting how they would make the required improvements. Conditions imposed on the service at the inspection prior to this, carried out on 21 June 2017, remained in force and the provider was required to send us monthly updates regarding the management of medicines and the management and monitoring of accidents, incidents and risk. At this inspection we found people’s experience had improved but there were still some significant areas of concern which needed to be fully addressed.

Follow up: The rating for this service is Inadequate and the service remains in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that, although some improvements have been made, people remained at risk from unsafe practice and a lack of oversight in some areas.

The conditions on the provider’s registration, regarding the requirement to send monthly updates to CQC, will remain. This is because the service has failed to make all of the required improvements outlined at the last inspection. We will request an action plan from the provider documenting how they intend to ensure the required improvements are made within a specific timeframe. We will continue to monitor this service closely and inspect it again in line with our regulatory inspection schedule.

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

Gorselands Residential Home provides accommodation, support and care for up to 21 older people, some of whom are living with dementia. People in care homes receive accommodation and 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. At the time of our inspection 18 people were using the service.

There was no registered manager in place but a new manager had been appointed who had previously been the registered manager and they had applied to be registered again. 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.

At our previous comprehensive inspection which was carried out on 22 and 23 February 2017 we rated the service as Requires Improvement. During that inspection we identified breaches of regulation relating to the unsafe management of medicines and poor monitoring of risk. The service was also in breach of the same regulations at the previous inspection in July 2016, alongside breaches relating to person centred care, consent and staffing.

Following our February 2017 inspection we placed additional conditions on the provider’s registration. We required the provider to send us monthly audits relating to medicines and the analysis of accidents and incidents to ensure a better overall management of risk. The provider has not always complied with this requirement and the quality of the information supplied has not always been acceptable. We had not received any monthly update in the four months leading up to this inspection.

During our current inspection we found some improvements with regard to the management of the service under the new manager but we also identified some significant concerns about people’s safety. We have identified continued breaches of regulation relating to the management of medicines and the management of risk. In addition we found that staffing levels constituted a breach of regulation.

We could not be assured that medicines were always managed safely as stocktaking measures were not effective. We also identified some recording errors relating to the administration of controlled drugs which audits had not picked up.

Risks were not always well managed. Hot water posed a potential risk as did the lack of effective security for people who were not safe to go out into the community without support. Staffing levels meant sometimes people were left without staff support which increased any potential risks.

Staff understood their responsibilities with regard to keeping people safe from the risk of abuse but some safeguarding matters had not been promptly notified to CQC.

Infection control procedures were in place and staff demonstrated an acceptable knowledge of how to reduce the risk and spread of infection.

Staff were well trained and supported in their roles. They were positive about the support of the new manager and supported the initiatives she had put in place to try and drive improvement at the service. Further relevant training, such as that for end of life care, was planned to increase staff skills and knowledge.

People had good and prompt access to healthcare and staff worked well with other healthcare professionals to meet people’s healthcare needs. Some improvements were needed with regard to the oversight of people’s eating and drinking to ensure people always had their needs met.

The service needed to improve their practice with regard to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. We found that staff understanding of MCA and DoLS was not clear and people were effectively denied their liberty in a way which was not in line with the Act.

The environment required some updating and refurbishment to bring it up to a fully acceptable standard. A programme of refurbishment was in place.

Staff were kind and caring and demonstrated that they had built up good relationships with the people they were supporting and caring for. People were supported to be as involved in decisions about their care as they could be. Although staff were respectful, staffing levels sometimes meant decisions were taken by staff which did not always reflect people’s preferences and expressed wishes.

Opportunities for people to follow their own hobbies and interests were limited and this was an issue for some people. The provider had recruited an additional member of staff to provide some activities but they were also to have caring responsibilities so it was not clear exactly how this would work, although it was a clear improvement.

Care plans were person centred and reflected people’s individual needs and preferences. Regular reviews of plans were taking place, although some current information had not been recorded. Care for people at the end of their life was good. There was a commitment to ensuring people had a dignified and pain free death and were not left alone, unless this was their wish. People’s wishes were clearly documented.

A clear complaints procedure was in place and complaints were appropriately managed. People who used the service and relatives were given the opportunity to provide feedback and raise informal complaints via the twice yearly survey which was sent out.

The new manager had begun to address some of the historical concerns at this service which were identified at previous inspections. Although a lot of work had been undertaken to improve the quality and frequency of staff training and support and to review the care plans, a great deal of work is still needed to bring about further improvement.

Concerns relating to medicines and risk management continued to be highlighted at this inspection, as they were at previous inspections. We also found that the provider had not complied with the additional conditions we placed on their registration. This was unacceptable practice. However, the new manager has begun to send us good quality current information in a timely manner since the inspection visit.

Both the manager and the provider understood that the service needs to make significant improvements and maintain them. Both told us they are prepared to do this work and to engage with any external support such as the local authority quality assurance team.

The overall rating for this service is 'Inadequate' and the service is 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 timeframe. 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. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

The last registered manager left the position in November 2014, although their registration with us was not cancelled until February 2016. 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. There was a manager in post during this visit who was in the process of applying for registration with us.

At the last inspection on 12 July 2016, we asked the provider to take action to make improvements to assessing risks to people, staffing levels, medicine management, mental capacity assessments, care planning and activities, and monitoring the quality of the service. Some of this action, such as completing individual risk assessments, mental capacity assessments, staffing levels, and the availability of activities and social stimulation for people had been improved. Other areas, such as care planning records had been reviewed and improvements were on-going. There had not been enough improvement in two areas.

People did not always receive their medicines when they needed them, and medicine administration records did not always show why medicines had not been given.

The quality of the service was not effectively monitored for the risks to people, to ensure that these were reduced as much as possible and to improve the quality of the care provided.

You can see what action we told the provider to take at the back of the full version of the report.

Staff were aware of safeguarding people from the risk of abuse and they knew how to report concerns to the relevant agencies. They assessed individual risks to people and took action to reduce or remove them.

There were not always enough servicing and maintenance checks to fire equipment and systems in the home to ensure people’s safety.

People felt safe living at the home and staff supported them in a way that they preferred. There were enough staff available to meet people’s needs and the manager took action to obtain additional staff when there were sudden shortages. Recruitment checks for new staff members had been made before new staff members started work to make sure they were safe to work within care.

Staff members had received training, to provide them with the skills and knowledge to carry out their roles, although this training was not always refreshed or up to date. Staff received adequate support from the manager and the provider’s representative, which they found helpful.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The manager had acted on the requirements of the safeguards to ensure that people were protected. Where someone lacked capacity to make their own decisions, the staff were making these for them in their best interests.

People enjoyed their meals and were able to choose what they ate and drank. They received enough food and drink to meet their needs. Staff members contacted health professionals to make sure people received advice and treatment quickly if needed.

Staff were caring, kind, respectful and courteous. Staff members knew people well, what they liked and how they wanted to be treated. They responded to people’s needs well and support was always available. Care plans contained enough information to support individual people with their needs. People were happy living at the home and staff supported them to be as independent as possible.

A complaints procedure was available and people knew how to and who to go to, to make a complaint. The registered manager was supportive and approachable, and people or other staff members could speak with them at any time.

The home is registered to provide accommodation with personal care for up to 21 older people. On the day of our visit there were 19 people living at the home.

The nominated individual was currently overseeing the running of the home. A nominated individual is a person named by the organisation as responsible for supervising the management of the running of the service. This person is referred to as the ‘provider’ hereafter.

At the time of our inspection there was no registered manager 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. There has not been a registered manager in post for three years. There have been care managers in post, but these have not registered with us.

People felt safe at the home and staff were knowledgeable about safeguarding adults and the different types of abuse to look out for. They knew what action to take if concerned about possible abuse.

The safety of people living at the home had been compromised on a number of occasions in terms of day to day care. There were not enough staff on duty to always meet people’s needs or preferences. Care was delivered in a task orientated way rather than based on the person’s individual need.

Some care records and risk assessments were not up to date and did not reflect changes in need for people living at the home. Risk had not always been assessed and appropriate steps were not always put in place to keep the person safe. Medicines were not always managed safely and staff did not have accurate notes to confirm if people had received their medicines.

The Care Quality Commission monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The service was not acting in accordance with the principles of the MCA. People’s capacity to make decisions had not always been assessed when there was a change to their mental health. Best interests decisions were not being made.

Staff sought consent from people regarding their immediate care needs. Staff had received training and said that most of the time they felt supported.

People living at the home received enough food and drink, and there was choice available at meal times. People health care needs were assessed, monitored and recorded, and referrals for assessment and treatment were made. Where people had appointments within healthcare services, staff supported them to attend these.

People’s rooms were decorated with their personal belongings so that they were comfortable and the area was made into their own space as much as possible. People’s feelings were not always taken into consideration by staff, and sometimes people’s dignity was affected because of this.

There were mixed feelings from people living at the home about raising concerns. Some people felt happy to do so whilst others were unsure if they would be listened too.

The provider did not have any effective systems in place to monitor the quality of the service or the running of the home. Health and safety audits were also out-of-date and evacuation plans for people were not easily accessible in the event of an emergency.

You can see what action we told the provider to take at the back of the full version of the report.

We looked at care plans that clearly explained how a person preferred to be supported. For example, records showed where a person had been asked what time and how often they wished to undertake certain activities, showing people were fully consulted at every stage.

At our inspection all areas of the service were clean and tidy. We found that the routines and systems in place supported the well being of people using the service and minimised the risk of infection.

Staff received training and supervision on a regular basis and staff told us they felt fully supported by the manager at all times. This ensured that staff had the relevant training to meet the needs of people and that the manager was aware of any areas that needed strengthening.

We saw there was information on display for people to use if they had any complaints. Staff told us that people usually spoke directly with the manager if they had any problems and this was also confirmed when we spoke with people living in the home.