Appletree Court Care Home

We found the following examples of good practice.

• The provider had developed new ways of recording observations about people’s health which were shared with healthcare professionals in advance of appointments. This had reduced the need for external visitors to the home, and had facilitated smooth virtual consultations with healthcare professionals.

• The provider was following best practice guidance in terms of ensuring visitors to the home did not introduce and spread Covid-19. They had a visitors’ code and visitors’ policy that family members and other visitors had to sign and adhere to. The home were not currently accepting family visitors due to a recent outbreak. Visiting was due to start again at the end of March 2021. A system of allocated time slots was developed for family visiting which would ensure visitors to the home were minimised.

• The provider had installed a thermo-imaging camera at the entrance to the home. This took the temperature of all who entered the home and emailed the results to the staff team. The camera also alerted staff when a person entering the home was not wearing a face covering.

• Information and instructions for visitors were clearly displayed and explained by the receptionist upon arrival. Our observations during the inspection confirmed staff were adhering to Personal Protective Equipment (PPE) and social distancing guidance. Infection prevention posters were clearly displayed within each unit of the home.

• The provider had a detailed admission process which included a Covid-19 assessment. The provider liaised with the local hospital for all admissions and requested that a Covid-19 swab test be carried out before discharge from hospital. A room was allocated before arrival and new residents were required to isolate for 14 days. The provider communicated with family members throughout this period.

• The provider had set up donning and doffing PPE stations across the care home.

• Staff had been appropriately trained in the use of PPE and infection control processes.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Appletree Court Care Home is a care home that was registered to provide nursing and personal care for up to 77 people. At the time of the inspection 41 people were using the service.

People’s experience of using this service:

People told us they felt safe and staff knew how to report concerns. Risks to people's health and care needs were assessed and effectively managed.

There were sufficient numbers of staff to support people. However, we received mixed views from people and relatives about this and agency usage.

People were supported to take their medicines as prescribed. Medicines were stored in a safe way.

Lessons were learnt following incidents. The service was clean and infection control was managed well and in line with the providers policy and procedures.

The design and décor of the service was not always developed and adapted around people's needs. We have made a recommendation about this.

Staff completed an induction and training relevant to their post. Staff received opportunities to review their work and development.

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's needs were assessed, and care was reviewed to ensure people's needs were met.

Nationally-recognised best practice assessments were used to help monitor people's health. People had access to healthcare professionals.

People were supported to have food appropriate to their needs.

People were treated with dignity and respect. People were involved in decisions about their care and supported to be as independent as possible.

Relatives and staff all felt the service had improved since the last inspection. They felt positively about the registered manager and felt they could contribute to the running of the service.

Monitoring systems were in place and the provider was proactive in supporting the service and worked in partnership with other organisations and professionals.

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:

At the last inspection the service was rated Requires Improvement (report published June 2018). 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 rating at the last inspection.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

At the last inspection on the 26 September 2017 we found six breaches of the regulations. We issued three Warning Notices for breaches of regulations in relation to meeting nutritional and hydration needs, governance of the service and staffing levels. The other three breaches related to lack of risk assessments and not always involving health professionals as required, safeguarding people from abuse and treating people with dignity and respect.

At the last inspection the service was rated Inadequate and the service was therefore in ‘special measures’. Services in special measures are kept under review. We undertook this comprehensive inspection to check on the progress made by the provider, and to consider whether the service could be removed from special measures, our framework to ensure a timely and coordinated response, where we judge the standard of care to be inadequate.

At this inspection we found progress had been made in meeting nutrition and hydration needs, and dignity and respect. In other areas such as staffing, risk assessments and governance of the service, limited progress had been made. We found additional breaches of the regulations in relation to person centred care and medicines.

At this 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 had been several changes in management personnel at the service since the last inspection. A permanently employed manager had taken up post from the end of November 2017. Whilst the service had worked to make improvements, the impact of numerous changes in personnel meant that outstanding management actions remained and this meant there were still issues with the quality of the care. At the time of the inspection actions were not always taking place following quality audits, and not all quality audits were taking place in keeping with the provider’s policy.

Staffing levels had improved since the last inspection, but there remained a period in the early evening when people’s needs were not safely met. People and their families told us staff worked hard and were busy.

Whilst the service had undertaken a significant number of risk assessments since the last inspection, there remained areas in which there were gaps in risk assessments. This meant staff were not always provided with guidance in how to meet people’s needs safely.

People told us that staff were kind and caring, but the lack of care plans in place meant that the service could not evidence they provided person centred care.

At this inspection we witnessed an unsafe practice in relation to medicines management, and the provider had yet to establish a system for reviewing people who were administered medicines covertly. Medicine administration records were completed in line with best practice, stocks corresponded with records and medicines were stored safely.

The provider had made progress in ensuring people’s hydration needs were met and recorded and we found fluid charts were in place and monitored appropriately. Where remedial action was required it was taken. The provider was aware some people found the menu limited.

Recruitment at the service was safe and sufficient checks took place before people were employed to work with vulnerable adults. Staff meetings and group supervision took place to share information and best practice with staff. Individual supervisions and appraisals were not taking place.

People told us they felt safe living at the service and since the last inspection the service were proactive in monitoring how safeguarding incidents occurred and in sharing that learning with staff.

Nursing and clinical tasks were undertaken as required, and recording of this was up to date.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

At this inspection we found that enough progress had been made to address our concerns about people's safety and welfare, and so the service was removed from special measures. However, there were four breaches of regulations, which are listed at the back of the full version of the report.

We have also made recommendations in relation to emergency fire safety procedures, staff training and nutrition arrangements for people on special diets.

This is the first inspection since the service was registered to the new provider in November 2016.

At the time of the inspection there was a manager who had only recently joined the provider and had been working at the service for less than a month. Consequently they had not applied to be a registered manager at the service 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.

Following the inspection the manager left the service and a peripatetic manager took over the day to day management of the service. This person had previous experience working for the provider in a ‘troubleshooting’ role, and is referred to throughout the report as the peripatetic manager.

People’s hydration needs were not always met, as records did not always accurately reflect what people ate and drank. People said they were content with the food provided and we saw people receiving food intravenously safely.

The provider was not always ensuring people were kept safe from harm or abuse as we found instances of people with unexplained bruising. The provider had not investigated the causes in a timely way to ensure people were not at further risk of abuse. People who were able to communicate verbally told us they felt safe living at the service.

There were risk assessments in place for some risks identified but there remained some areas including managing people’s behaviours where staff were not always given guidance on how to mitigate risks. We were concerned that people with behaviours that challenged the service were not always receiving appropriate attention as their behaviour charts were not always analysed and the provider had not always sought the advice or intervention of mental health professionals.

We found there were insufficient staff to meet people’s needs and this impacted on the quality of care provided to people.

The provider undertook quality audits but did not always follow through in a timely way on actions identified. This meant people were left at risk of receiving poor care.

The majority of people were positive about the staff. Whilst we found the majority of care staff did support people’s dignity and respect, we saw one person left in an undignified state for a period which was of concern.

People received health care for physical health issues and we saw where people had pressure areas remedial action was taken to improve this, with appropriate health support requested by the service.

There was an activities co-ordinator working at the service who arranged some activities but as the service was split over three floors this meant there were limited activities taking place. There was a well maintained garden at the service which people enjoyed sitting in.

Medicines including controlled drugs were stored and administered safely. The service was clean throughout.

Staff were safely recruited so were considered safe to work with vulnerable people.

The service was working with the local authority to ensure all the necessary documentation was in place where people’s liberty was being restricted.

We found the provider was in breach of six fundamental standards. These related to the safe care and treatment of people using the service, safeguarding people from abuse and staffing. The provider was also in breach of standards relating to meeting people’s nutritional and hydration needs, dignity and respect and the governance of the service.

We have made recommendations in relation to Do Not Attempt Cardiopulmonary Resuscitation documentation and staff supervision.

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.

We took enforcement action against the provider by serving three enforcement warning notices.

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