Prestbury Care Home

We found the following examples of good practice.

¿ Relatives spoke positively about the home and their comments included; "Everyone has been wonderful at Prestbury", "We are delighted with the amount of effort staff have made for us to maintain contact with Mum" and "I never worry about [Name] as I know they are safe and well cared for."

¿ Relatives told us they had previously participated in conservatory visits with screens in place. They said these were pre booked and well managed.

¿ All visitors were asked to complete a health screening form, have their temperature checked and were provided with face masks to wear throughout their visit. Full personal protective equipment (PPE) was available for all visitors along with access to handwashing facilities and hand sanitiser.

¿ Relatives spoke positively about the admission process to the home during the pandemic. Comments included; "We were sent a video of the room that [Name] would be staying in during the isolation period on admission" and "The staff and management team have helped us tremendously during Mum's transition in to the home."

¿ The service had increased the cleaning schedules and routines to reduce the risks of cross infection. The environment was very clean and hygienic.

¿ We observed staff to be wearing the correct personal protective equipment (PPE) throughout the inspection.

¿ People and staff were taking part in regular COVID-19 testing.

¿ People had individual risk assessments in place that reflected their specific needs in relation to COVID-19.

¿ Staff had all received training to meet the requirements of their role and for the management of COVID-19.

Further information is in the detailed findings below.

Prestbury Care Home is a residential care home providing nursing and personal care to 57 people at the time of the inspection. The service is registered to support up to 75 people in one adapted building. The home has three floors known as Gawsworth on the first floor, dedicated to residential care and specialist dementia support, and Haddon (second floor) and Capesthorne (ground floor) for nursing care.

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

Improvements had been made with regard to staffing levels. There were enough staff to meet people’s needs safely and ensure people received person-centred care. However, during the inspection we observed a lack of staff presence in the main lounge at tea time on the first floor floor, due to ineffective deployment of staff. We made a recommendation about this.

The environment of the home was pleasant and clean throughout, although there were some furnishings in need of replacement. Some parts of the home had been adapted to support people living with dementia, however there was a lack of signage to ensure people could orientate around the home safely. We made a recommendation about this.

People were supported by kind and caring staff who treated people as individuals and with dignity and respect. The provider had robust recruitment systems to ensure staff were safely recruited. Staff spoke knowledgeably about the systems in place to safeguard people from abuse.

People told us they felt safe. Risks to them were identified and managed. Where required people were safely supported with their medicines needs. Infection control measures were in place to prevent cross infection. The support required by people with health and nutritional needs was identified and provided.

People received care and support which was personalised and responsive to their needs. People’s choices regarding their care and how they were supported were respected, and there were enough staff to support this. Care plans were kept up to date to reflect any changes in people’s needs and wishes. People and family members knew how to complain, and they were confident about complaining if they needed to. Complaints were used to improve the service.

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.

The management of the home promoted a person-centred service. There was an open and transparent culture and good partnership working with others. The quality and safety of the service was monitored through regular checks.

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 11 January 2019) and there were multiple 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 we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Prestbury 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.

Prestbury Care Home provides accommodation and nursing care for up to 75 people. At the time of our inspection there were 57 people living at the home.

At this inspection we found that improvements had been implemented. The provider was no longer in breach of several of the regulations. However, we identified a continued breach with regards to Regulation 18 (staffing) and identified a breach of Regulation 9 (person centred care). Although improvements had been made and the effective and caring domain had improved to “Good”, we found that the overall rating for the service remained “Requires improvement”.

There was a registered manager 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.

There were mixed views about staffing levels. Observations, feedback and records indicated that at times insufficient staff were deployed to meet people’s needs in a timely way. The regional manager told us that this would be addressed. Several new staff had been recruited and recruitment of nursing staff was a priority.

Aspects of care were not provided in a person-centred way. Within the Gawswoth Unit we found that a routine was in place around personal care, which did not always meet people’s individual needs.

A new electronic recording system had been introduced. We found that charts were not always completed to demonstrate that people had received appropriate care such as positional changes and safety checks. Care plans contained some person-centred information, however these had not always been updated or amended to reflect changes where there were changes to care needs.

Overall medicines were managed safely. However, we found some minor shortfalls in medicines management relating to covert administration and inaccurate recording.

Checks were carried out during the recruitment process to ensure only suitable staff were employed.

Risks associated with people's care and support needs were assessed and guidance was in place to support staff to keep people safe, however further work was needed to improve aspects of risk management further.

Improvements had been made to ensure that safeguarding procedures were robustly followed and continued to be embedded. Staff understood their duty to protect people from harm and abuse.

The home was clean and well maintained. The home was decorated and furnished to a high standard and suitable for the people living there.

People were supported by staff who were suitably trained and supervised. The registered manager and staff were aware of their responsibilities and acted in accordance with the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards. (DoLS).

People's nutritional and healthcare needs had been assessed and were met. People were positive about the food on offer and staff supported people to have sufficient to eat and drink. People had access to healthcare professionals as required

Overall, staff were caring and treated people with dignity and respect. Where possible staff supported people to be as independent as they wanted to be. People's diverse needs were considered. People spoken with were complimentary about the support they received.

People could take part in a range of activities. Two new leisure and wellbeing coordinators had been recruited. There was a varied activity and entertainment programme in place. People's end of life wishes were discussed and recorded.

People felt able to raise any concerns and records indicated that any complaints were addressed following the provider’s policy.

Staff told us that the registered manager was supportive. People and relatives were positive about the management of the home. People were able to provide feedback about the service.

There were quality assurance and audit systems in place. A number of areas for improvement had been identified by the provider and action plans were in place. However, these were not fully effective, as they had not identified the issues highlighted in this inspection relating to staffing and person-centred care.

On this inspection we found the provider had met the legal requirements of regulations 9, 11, 14 and 19. The provider remained in breach of regulations 10, 12, 13, 16, 17 and 18 of the Health and Social Care Act Regulations.

Following the last inspection, the provider sent us an action plan to show the Commission what they would do and by when to improve to at least good. The provider demonstrated they had met the positive conditions which were served by the Commission. We also met with the provider and discussed progress being made to meet the breaches found.

Prestbury Care Home is a 75 bedded care home. There were 53 people living in the home at the time of this inspection. 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. It has three units over three floors called Haddon, Gawsworth and Capesthorne which have separate adapted facilities. Gawsworth specialises in caring for people living with dementia. There was a registered manager in post at the time of our 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.

On the last inspection which commenced on 18 April 2017 we found the provider was in breach of regulation 9 Person Centred Care. This was due to care plans not providing enough detailed information about the person's preferences, likes of dislikes. Some risk assessments/care plans required to deliver person centred care were absent. On this inspection we found improvements had been made and the provider was no longer in breach of person centred care. Care plans were no longer absent and some person centred information such as a person’s place of birth, family member’s names, previous pets and places of interest were seen in the care plan.

On our last inspection which commenced on 18 April 2017 we found the provider had not mitigated risks when they became aware of them. We found some improvements on this inspection but continued to find risks which were not mitigated. For example, we found a trailing oxygen pipe on the floor and although there was a risk assessment for having oxygen in the home there were no risk assessments in place for the storage of oxygen in people's bedrooms. A new computerised system to manage recording of administration of prescribed medicines was being implemented in the care home at the time of our inspection. We found one person had not received their prescribed medicine on our inspection. The provider remained in breach of Regulation 12 Safe Care and Treatment.

Improvements were seen in safeguarding people as unexplained bruising was being recorded, reported and body mapped however, some complaints seen in the complaints file were safeguarding concerns which had not been dealt with appropriately. There was a repeated breach of Regulation 13 Safeguarding.

On the last inspection we found concerns in relation to people having appropriate foods to meet their needs and a breach of regulation 14 Nutrition and Hydration. We found improvements on this inspection and the provider was no longer in breach of this regulation.

Complaints and concerns had not been dealt with consistently on the last inspection with a breach of Regulation 16 Complaints. We received some concerns prior to the inspection that concerns raised were not being dealt with effectively. On this inspection there was no contemporaneous record to demonstrate how each complaint was dealt with. This is a continued breach of Regulation 16 of the Health and Social Care Act Regulations 2008 (Regulated Activities) 2014.

We found the provider was in breach of staffing on our last inspection due to the concerns about the deployment of staff and staffing numbers in the home to meet people's care needs. Prior to this inspection we received anonymous concerns about staffing and on inspection we observed staff taking six minutes to respond to a call bell. On further inspection of call bell response times we found the provider remained in breach of Regulation 18 Staffing numbers.

We received positive comments and some negative comments about staff who were delivering care. People's dignity was not always being upheld. The provider remained in breach of Regulation 10 Dignity and Respect.

The provider had recently brought in a new regional manager to supervise the registered manager and drive improvements. We found their leadership effective during our inspection. The registered manager had not acted in a timely manner, dealt with complaints robustly or provided the leadership necessary to drive improvements since the last inspection. There was a continued breach of Regulation 17 Good Governance.

Activities were being provided including trips out but this was limited due to the staffing ratios required according to staffing within the home. Leisure and Wellness staff were seen providing activities on the inspection.

The home were following a Mental Capacity Framework but further improvements were needed to ensure best interests decisions were in place for decisions people had difficulty making due to their impaired mental state.

Training had improved to include a dementia specialist trainer who had undertaken staff training and a seminar within the home. Staff were receiving supervisions and induction.

Staff had knowledge of safeguarding people from abuse and knew how to report any concerns.

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

Prestbury House Care Home is a modern purpose-built three story care home located in the centre of Macclesfield. Shops and amenities are within easy walking distance. The Home is registered to provide nursing care for up to 75 people divided into three separate units. Prestbury House Care Home is part of the Porthaven Care Homes Group. Sixty one people were living at the care home at the time of our inspection.

The service has a registered manager. 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. The registered manager was present during the inspection.

The service was not always safe with risks not always being identified to remove the risk or mitigate the risks for the person. There was no challenging behaviour care plan for 9 people with challenging behaviour and 3 behaviour care plans seen were not detailed enough.

Not all safeguarding concerns documented in the care records seen were being reported to the safeguarding authority and some staff were not competent to know when to report a safeguarding concern. Staff were aware of whistleblowing and were aware of what to do.

Staff recruitment systems were in place however, we raised concern staff were not always being assessed according to their probationary period. Staff who did not have a background in care were not always being supported to be competent in caring for people. Induction included staff reading the staff handbook and shadow shifts. We found the staff handbook did not include any information in safeguarding people.

Supervision sessions were inconsistent and appraisals were not always undertaken with staff. They were not being undertaken in line with the provider’s policy issued October 2015 which stated supervision should be undertaken at least once every two months and an annual appraisal. The provider was working towards an action plan to address this.

Staffing levels were not sufficient in meeting people’s care needs. People who required staff to be aware of their whereabouts at all times according to their care plan were not receiving this level of oversight from staff. Others were not receiving one to one assistance to ensure they had the optimum opportunity to eat and drink.

Medication management was not always safe with some people not receiving their prescribed creams and food supplements.

Recommendations by healthcare professionals were not always being followed by staff with weekly weights not always being recorded therefore, health monitoring was not always effective.

There was a structure in place for assessing people’s mental capacity and best interests meetings seen in the records. DoLS (Deprivation of liberty safeguard’s) authorisations were not always being renewed when expired. We found one person's DOLS authorisation had expired. Staff were unaware of what constituted restraint until we asked the provider to include training for staff.

People were not always being supported to have enough to eat and drink. We observed people being interrupted when being supported to eat, another person spilling their liquid down themselves due to not receiving the support they needed.

People told us if they needed to see a doctor this was arranged quickly. We found healthcare professionals were involved such as Dietician’s, Speech and Language Therapists and Chiropodists.

People told us staff were kind. We observed both positive and negative interactions. Staff did not always have the necessary training, skills and knowledge in dementia care. The care delivery was not always seen to be compassionate with inappropriate use of language used within care documentation.

Training being provided for staff was not effective. We found it was being delivered in a compressed way with staff watching up to 9 different training DVDs in the same day. There was no training in restraint being offered for staff. The provider took action and now includes a DVD for staff on restraint and additional training in dementia care since our inspection.

People who were able to mobilise around the care home moved freely and were able to access all floors of the care home including the coffee lounge on the ground floor. People were encouraged to be independent.

There were activities for people inside the care home and trips outside the care home. Guests such as the Mayor of the town were being invited to visit the people within the care home.

End of life care was being planned with the person and their family. The care plan we viewed was written in detail with clear guidance for staff.

Person centred care was not being provided with people’s backgrounds, likes/dislikes and preferences not well documented in the care plans. Staff were not always following the guidance in the care plans.

There was a system of receiving complaints however, we found one serious complaint/allegation written in the file dated April 2017 which had no investigatory records to confirm what actions had been completed as part of the investigation and also no response to the complainant. The safeguarding authority were not made aware of the serious allegation/complaint until 15 June 2017 during our inspection.

The service was not well led. The concerns we highlighted during our inspection had not been identified through the quality assurance systems in place. We viewed audits undertaken with actions to be taken forward, however the audits had not identified the specific concerns identified as part of the inspection.

There was no system in place of recording hospital admissions. This reduces the opportunity for the provider to identify any trends in hospital admissions from within the care home.

We found the provider had no policy in fluid management for staff to know how to manage people’s fluid intake.

There were residents and relatives meetings taking place. Pastoral meetings for staff were also being provided however the tone of the minutes distributed to staff were not always appropriate to promote a supportive approach/culture towards staff.

The Commission and Safeguarding Authority had not received all notifications or referrals as required which is a registered manager’s responsibility.

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

The overall rating for this service is ‘Inadequate’ and the service is therefore 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 service was last inspected in August 2014 and was found to be meeting the regulatory requirements which were inspected at that time.

Prestbury House Care Home opened in 2011 and is a modern purpose-built two story home located in the centre of Macclesfield. Shops and amenities are within easy walking distance. The Home is registered to provide residential accommodation for up to 75 people including those who need nursing care and is divided into three separate units each catering for different levels of need. Prestbury House Care Home is part of the Porthaven Care Homes Group. Sixty four people were being accommodated at the time of the inspection.

The service has a registered manager. 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.

The registered manager was present during the inspection and was able to provide all the necessary information and documentation we requested.

The people who lived at Prestbury House and their relatives told us that they were treated with respect and kindness by the staff. Comments included, “All the staff are kind and caring, even the agency staff are good with us” and “Wonderful place I have never looked back since I came here”. Everyone we spoke with told us they felt safe and secure within the building and with the care and support received. Risks to people’s safety and welfare had been assessed and information about how to support people to manage risks was recorded in their plan of care.

Medicines were administered safely to people by staff. We found in a small number of cases there was a lack of clarity around the recording of people’s medicines. This was brought to the manager’s attention during the inspection and appropriate actions taken.

Arrangements were in place to protect people from the risk of abuse. We spoke to staff about their understanding of safeguarding and they knew what to do if they suspected that someone was at risk of abuse or they saw signs of abuse. People who lived in the home and their relatives told us that they felt that staff provided safe and supportive care.

We looked at recruitment files for a selection of newly appointed and long term staff members to check that effective recruitment procedures had been completed. We found that appropriate checks had been made to ensure that they were suitable to work with vulnerable adults.

Staffing levels were structured to meet the needs of the people who used the service. Observations and records identified there were sufficient numbers of staff on duty to meet people’s assessed needs.

The registered manager ensured that staff had a full understanding of people’s support needs and had the skills and knowledge to meet them. Training records were up to date and staff supervisions and appraisals had been planned by the newly appointed registered manager to ensure staff were able to discuss training issues or any areas of concern. There was a robust management structure in place which ensured that staff at every level now received support when they needed it. Staff were clear about their roles and responsibilities and how to provide the best support for people.

People had a plan of care. We saw that care files were in the process of update. The care files that we looked at contained the relevant information that staff needed to care for the person. We could see from the detailed daily records and discussions with people receiving the service that the care provided was person centred and took account of the person’s wishes and preferences.

The activities programme was most innovative and varied and staff ensured that activities were arranged seven days a week to meet the interests, choices and capabilities of the people who lived in the home.

Discussions with staff members identified that they felt happy and supported in their roles. They told us that the registered manager and her deputy were supportive and they felt that they could contact them at any time. Comments included, “we are well supported”, and “we did not get regular supervision at one time but since Tracey (registered manager) has been here we have been able to meet with her and arrange regular supervisions. She has made a big difference to this home already and she has only been here since May 2016”.

The service had a quality assurance system in place which used various checks and audit tools such as questionnaires and random out of hours visits by the registered manager. Systems and processes were in place to monitor the service and drive continuous improvements. A number of other audits on how the service was operating were also undertaken. These included monthly visits from the regional manager and infection control and care plan reviews. The purpose of this was to monitor staff practice ensure the premises were hygienic and safe and also to check whether people were satisfied with the support they received.

The manager had a clear knowledge and understanding of the Mental Capacity Act (MCA) 2005 and their roles and responsibilities linked to this. People who had capacity told us they were able to make their own choices and were involved in decisions about their support.

The agency had a whistleblowing policy, which was available to staff. Staff told us they would feel confident using it and that the appropriate action would be taken.

A complaints procedure was in place and details of how to make a complaint had been provided to people who used the service and their representatives. People we spoke with knew how to raise a complaint but told us they had never needed to complain as ‘things were always very good’.

During our inspection we talked with five of the people who lived in the home and with three relatives of people who were visiting at the time of our inspection. We also spoke with seven members of care staff as well as catering and other staff. We met with the registered and assistant manager as well as a member of peripatetic staff who arranges training. We looked at staff rotas as well as training records.

We looked around the building. Prestbury Care Home is purpose built for 75 people arranged over three floors. There were 74 people living in the home at the time of our inspection. The middle floor specialised in the care of people who are living with advanced dementia. Movement between floors is by means of a central lift although there is a second service lift.

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

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

Below is a summary of what we found '

Is the service safe?

We found that the staffing levels at Prestbury House Care Home were as described by the manager and that these related to the level of need of the people who lived in the home.

This was a responsive inspection to concerning information and we did not look specifically at other areas.

We spoke to people who used the service but their feedback did not relate to this standard. We spent time in each of the three units within the home looking the arrangements for the storage and administration of medicines. We talked with staff and with the managers about how they made sure that people who used the service received the medicines that had been prescribed for them. We found that Prestbury Care Home now met the relevant standard relating to the storage and administration of medicines.

We spoke to five people who used the service and six members of staff as well as reviewing records relating to eleven people who use the service. We looked around the building and talked to people privately in their bedrooms. People told us 'It's all right living here' and 'The staff are excellent ' they are so kind ' over the top really. I can't fault it'.

We looked at the arrangements for the storage and administration of medicines but we could not always reconcile some of the records of medicines given out with the stocks which remained.

We found that staff at the home respected the rights of people when offering care and treatment and particularly when that treatment was refused. We found that the relationships between staff and people who use the service were positive and respectful. We talked to staff about the training arrangements at the home and saw that there were good arrangements for this. We looked at arrangements for complaints and found that there was a policy in place for these.

Staff told us that they enjoyed working at the Home and that 'the building is fantastic ' there is everything you need ' the rooms are a good size'. We were told that as a newly-opened Home, Prestbury House Care Home had built up the number of people living there gradually and that the levels of staffing had had to be phased around this.

We were told that the local Primary Care Trust (PCT) funded intermediate care at the Home and we met staff from the PCT who told us that they were satisfied with the care provided by this part of the Home. One of the people using this part of the service told us 'We could do with more places like this'.Other people using the service have a range of requirements including people living with dementia whose care is focused on the first floor of the building.

We talked with the Manager who has managed the Home since 1st November 2012. We also talked with the Operations Director representing Porthaven Care Homes.