Stowford House Care Home

Stowford House Care Home is a residential care home providing personal and nursing care to 44 people aged 65 and over at the time of the inspection.

Stowford House care Home accommodates up to 51 people in one purpose-built building which covers two floors. One floor specialises in providing care to people living with dementia.

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

People received safe care from sufficient staff who were skilled and knowledgeable about people’s needs. Staff understood how to report any concerns relating to harm and abuse. The provider had recruitment processes in place that supported safer recruitment decisions.

Risks to people were assessed and managed. Staff were knowledgeable about how to support people to manage risks. People received their medicines as prescribed from staff who were trained and competent to administer medicines.

The service was well-managed. Everyone was positive about the management of the service and the culture promoted by the registered manager and deputy. There was an open and honest culture that promoted good communication and involvement with people, relatives and staff.

The registered manager had introduced a range of effective systems that ensured the continuous monitoring and improvement of the service. The registered manager worked well with external professionals and promoted community involvement.

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 9 August 2019).

At this inspection we found improvements had been made.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 10 June 2019. Two breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and governance in the service.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Stowford House Care Home on our website at www.cqc.org.uk.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

Follow up

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

Stowford House is a care home that was providing personal and nursing care to 47 people aged 65 and over at the time of the inspection. The care home accommodates up to 51 people across two separate floors. One floor provides nursing care and the other floor provides care to people living with dementia.

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

There were not always enough staff deployed to ensure people’s needs were met. People were at risk of not receiving medicines as prescribed because medicines were not always administered safely. People and staff told us there were not always enough staff to support them in a timely way. The registered manager and provider did not ensure they were meeting all the requirements of their registration as they did not ensure there were enough staff deployed to meet people's needs.

The provider’s systems to ensure compliance with the regulations were not always robust. This included assessing, monitoring and mitigating all risks relating to the health, safety and welfare of people in the service. Staff told us they felt listened to, however they did not always feel action was taken to address issues. This included having enough staff to meet peoples’ assessed and changing needs.

The registered manager continually looked for ways to improve the service. There were links with the local community and there were plans in place to improve those links. There were systems in place to engage people, relatives and staff. The provider had effective recruitment processes in place which enabled them to make safer recruitment decisions. This included pre-employment checks to ensure potential staff were of good character.

People were supported by staff who understood how to report concerns relating to harm and abuse.

Rating at last inspection: The last rating for this service was Good (published 21 June 2018).

Why we inspected:

We received concerns in relation to the safe management of medicines and staffing levels. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only. As well as the concerns raised, CQC was also aware of an incident where concerns had been raised in relation to the conduct of agency staff. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident. However, we considered this information in assessing any ongoing regulatory risks to other people in the service.

We reviewed the information we held about the service. No areas of concern were identified in the other Key Questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those Key Questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvements. Please see the Safe and Well Led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were regulation 18 (Staffing) as systems were not robust in demonstrating staffing levels were adequate to meet people’s changing needs. Regulation 17 (Good governance) failing to effectively evaluate the safety and wellbeing of service users and use this information to improve practice.

Details of action we have asked the provider to take can be found at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up:

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

Stowford House 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. The service is registered to provide accommodation, nursing and personal care for up to 51 people. At the time of our inspection there were 37 people using the service. One of the units specialises in providing care to people living with dementia.

The service has a 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.

People had a range of activities provided by the service to participate in. However, we heard from people and relatives that these could be improved. We have made a recommendation about improving activities.

People received their care and support safely. There were systems and processes in place to safeguard people from abuse and harm. People's risks were assessed and reduced by staff who understood how to protect people from improper treatment. People's medicines were stored securely and administered in line with the prescriber's instructions. Staff followed appropriate personal care and food safety practices to prevent infection.

People's needs were assessed and they receive the support they required to eat and drink. Staff were supported in their roles by the registered manager who delivered supervisions and appraisals and coordinated staff training. People had access to healthcare services whenever required. People were supported to have maximum choice and control of their lives and staff delivered care in line with the principles of the Mental Capacity Act 2005.

Caring staff maintained people's privacy and dignity. People were supported to maintain relationships with their relatives and friends. Visitors were made to feel welcome.

People had personalised care plans which detailed how they wanted staff to meet their individual needs. Information was available for people to access the provider's complaints procedure. The registered manager understood the provider's procedure for handling complaints and those that we saw were clearly documented. People received responsive and positive care at the end of their lives.

The registered manager had improved quality assurance processes since the last inspection which evidenced learning and sustainability. There was an open culture at the service and the views of people, relatives and staff were gathered. The service worked in partnership with other agencies to secure positive outcomes for people.

Stowford House Nursing Home is registered to provide residential and nursing care for up to 51 older people some of whom are living with a dementia. At the time of this inspection, 38 people were living at the service.

At the last inspection on 5 and 8 December 2016 the overall rating was Inadequate and the service was placed into special measures by the Care Quality Commission (CQC). Seven breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. Following the inspection, we received regular action plans which set out what actions were been taken to bring the service up to standard.

We undertook this inspection on 11 May 2017 in line with our special measures guidance to see if improvements had been made. At this inspection we found considerable improvements in the service. We could see that action had been taken to improve people’s safety but further improvements were needed in some areas. We have made a recommendation about the management of some medicines. Improvements on recording were required so that accidents and incidents could be better monitored and managed.

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.

Staffing numbers had been increased to ensure there were sufficient numbers of suitable staff to meet people's needs. Staff had been recruited safely to ensure they were suitable to work with vulnerable people. Staff knew what action to take if they were concerned that someone was being abused or mistreated.

Risks to people's safety were appropriately assessed and managed. We found the premises were clean and tidy, with no unpleasant odours. There was a record of essential inspections and maintenance carried out. The service had an infection control policy and measures were in place for infection control.

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.

Records showed staff received the training they needed to keep people safe. The manager had taken action to ensure that training was kept up-to-date and future training was planned.

Staff told us they felt supported by the management and supervision and appraisals had been scheduled in to ensure these meetings were undertaken regularly. Training and development plans were in place for staff.

People were supported to ensure they had adequate nutrition and drinks and were supported to access a range of services to meet their health care needs.

People and their relatives told us staff were caring. Staff treated people with compassion and dignity and respect during delivery of care.

Each person had a personalised care plan containing information about their life histories and support needs. The care plans had been updated in line with people’s changing needs. People said they were involved in making decisions regarding their care.

People were provided with the opportunity to participate in the activities they found interesting. People and their relatives were aware of how to make a complaint. Complaints had reduced considerably.

The management had acted on people's and relatives’ opinions on the service, including complaints. This had been used to implement changes to improve the service. The service had engaged an external consultant to support with improvements in the quality of care. People and staff had confidence in the management of the home and were complimentary about the improved positive culture within the service.

This service has been 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 improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Stowford House Nursing Home is registered to provide residential and nursing care for up to 51 older people some of whom are living with a dementia. At the time of this inspection, 48 people were living at the service. There were three vacancies at the service.

The service was previously inspected in November 2015 and we identified the service was not meeting two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s medicines were not always administered as prescribed. We also identified that food was not served and maintained at the right temperature for the whole meal. People were not being supported to eat and drink where necessary. Following the inspection, the provider sent us an action plan, which detailed how improvements would be made. During this inspection, we did not see adequate improvements and also identified more concerns.

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. They were supported by a deputy manager and regular visits from the provider's regional manager and a compliance manager.

Before the inspection, we had received a number of concerns about the staffing levels and the impact this was having on people receiving safe and effective care. We found there were not enough staff on duty on the day of our inspection. People and their relatives reported that people had to wait for an unacceptably long time before their needs were met. The provider was using a dependency level tool to calculate how many staff were needed to care for people. This was not evidenced as meeting the needs of people and the low staffing impacted upon most areas of the inspection.

People's medicines were not safely managed and not always administered as prescribed. We found gaps on the Medicine Administration Record (MAR). Records did not demonstrate clear guidance for staff in relation to medicines or topical creams.

Risks to people's safety had not been ensured. Clear plans to minimise and manage risks were not in place. Not all information was up to date and clear in the risk assessments meaning staff would not be able to take all necessary steps to promote people’s safety.

Staff generally felt well supported but we found minimum records of any meetings such as one to one meetings and annual appraisals. Some staff felt there was low morale due to the workloads associated with low staffing levels. A range of training was arranged to increase staff's knowledge and help them to do their job more effectively.

People were not always supported to ensure they had adequate nutrition and drinks. The quality and quantity of food and assistance required were not adequate. People did not always get the food they had chosen.

People were supported to access a range of services to meet their health care needs.

People found staff to be caring but people’s dignity was not always protected. People were not assisted as often as they needed to be and this meant they often had to wait in undignified conditions until assistance was available. Staff were rushed and did not have time to spend with people.

Care plans were not always up to date which meant staff could not respond appropriately to people's needs or provide care in a person centred manner. Information stated care needed to manage falls and wounds but these people no longer had these needs. Records recording food and fluids was not completed consistently and was done both electronically and on paper. This meant there was not a clear system for monitoring people’s food and fluid intake.

There was a complaints system in place. However, people and relatives had little confidence that complaints would be resolved to their satisfaction. Where areas for improvement had been discussed with people and their relatives the resulting actions had not always been effective in maintaining an improvement.

There were a range of systems to assess and monitor the quality of the service. However, not all were effective in identifying and addressing shortfalls. Accidents and incidents were being analysed yet action to minimise reoccurrence was not always sufficient.

Relatives and staff did not feel confident that the registered manager took on board all actions necessary to improve the service. We had many concerns raised before, during and after the inspection about staffing levels impacting on all areas of people’s safety.

We found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014.

The overall rating for this service is ‘Inadequate’ and therefore the service in special measures. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel their 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 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 re-inspect and it is no longer rated as inadequate for any of the five key questions, it will no longer be in special measures.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

This inspection was carried out by an inspector and a pharmacist inspector. We looked at the management of medicines. During this visit we found that the required actions had been taken and we saw significant improvements.

We found the provider had appropriate arrangements in place to manage people's medicines safely. Medicines were stored safely and within their recommended temperature range. Detailed records were kept when creams and ointments were applied as part of personal care. Allergy information was consistently recorded.

Medicines were administered by appropriately skilled staff.

During our inspection we spoke with six people and seven people’s relatives. We also spoke with three care workers, a nursing assistant, two nurses and the manager. We reviewed six peoples care files and documents made available to us by the manager around staffing levels and quality assurance. We also carried out a short observational framework for inspection (SOFI). This is used to capture the experiences of people who use the service where they may not be able to express this for themselves.

We considered our inspection findings to answer 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. The summary describes what people using the service, their relatives and the 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?

The service wasn’t safe because appropriate arrangements were not always in place for obtaining and disposing of medicines safely. Medicines were stored safely in a locked cupboard and medicine trolleys which were secured to the wall when not in use. Suitable records were not always kept regarding medication administration. The home did not have appropriate systems in place to account for the amount of medicines given and for those left in stock. We saw that the amount of medication documented as being in stock for people’s medicines did not correspond with the actual amount of medication in stock. This meant that medicines were not always handled safely and securely.

Staff understood the needs of the people they supported. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

At our last inspection we found that there were not enough qualified, skilled and experienced staff to meet people’s needs. At this inspection we found that improvements in relation to staffing had been made. We concluded that there was an appropriate number of staff with the necessary skills and experience to meet people’s needs.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. While no applications have been submitted, proper policies and procedures are in place but none had been necessary. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people’s human rights were recognised, respected and promoted.

Is the service effective?

The service was effective because people told us they were happy with the care they received and felt their needs were understood and met. People’s relatives were also complimentary about the care their relatives received. Our SOFI observations identified a number of warm and meaningful interactions that visibly had a positive impact on people’s mood.

Is the service caring?

This service was caring because people we spoke with felt cared for. One person told us, “I like it here otherwise I wouldn’t stay.” Relatives we spoke with were also complimentary of the care their relatives received. One relative told us, “The staff are good. I have faith in them and I’m sure they do their best.” We observed a number of caring, warm and patient interactions between care workers and the people they supported.

Is the service Responsive?

The service was responsive because people’s needs were assessed when entering the home and were subject to on-going review of their needs. When people’s needs changed the service responded and took the appropriate action. For example, advice and guidance was sought from other professionals when required. People were offered a number of activities to participate in and also had access to music therapy.

Is the service well led?

The service was well led because staff we spoke with felt they had clear leadership from the registered manager who always had their door open and would listen to any concerns.

Robust systems were in place to monitor the quality and safety of the service. Systems in place ensured that care files were kept up to date and people’s care plans/needs were reviewed. We noted that audits were in place to protect people from the risk of malnutrition and ensure incidents and accidents were learnt from.

Where issues were identified appropriate action was taken. Relatives told us they attended relatives meetings and were able to speak to the manager if needed.

We spoke with eight people and four people's relatives. We also spoke with six care workers, two nurses and two activity co-ordinators.

People told us they were happy with their care and had no complaints. One person told us that they were "well cared for". Another person told us that “staff worked really hard”.

People's nutritional care was not always delivered in line with their care plan. For example, one person's nutritional care plan indicated they should be referred to a dietician or GP if they lost weight. This person had lost 7kg in the last six months but a referral had not been made.

People were provided with a choice of suitable and nutritious food and drink. Two choices of main meals and puddings were available to people on a daily basis. Where people wanted an additional option this was provided. For example, we saw that one person requested salmon for lunch and this was provided.

Medicines were not always secured safely. For example we noted that the downstairs clinical room was accessible throughout the afternoon.

There were not always enough qualified, skilled and experienced staff to meet people’s needs. Everyone we spoke with felt there weren’t always enough staff on duty. One relative told us, "as far as carer's go they're fantastic. There is not always enough of them".

People were asked for their consent before receiving care. One person we spoke with said "they ask permission before helping me”. We saw that staff consistently asked permission and sought involvement from people before administering their care.

We saw that people's needs were being met by a team of busy staff. A person told us “I like to get up at lunchtime. There are two people [staff] who help me with the hoist. They are quick to give me help. It’s very nice here”. Care plans were personalised and included peoples' likes and dislikes such as 'does not like cold drinks'.

All the people we spoke with told us they were safe, one said “Absolutely safe, no concerns”. We saw records confirming all staff received safeguarding training.

We reviewed staff files and found that the provider had undertaken appropriate checks before staff were allowed to begin work. We saw that induction training took place before staff started their first duty.

People were asked for their views on the service they received. We saw that people asked for activities and that activity organisers had been recruited. The provider held monthly quality audit meetings.

We were told there were not enough staff on duty during the day to meet people’s needs. We saw that staff were busy. However, we observed that people’s care needs were being met.

We spoke with five people who used the service, with three relatives of people and with four members of staff.

One person we spoke with who used the service told us "You can get up when you want. Always someone to help you".

We reviewed staff duty rosters covering a period of seventeen days, equating to 34 day time shifts. We saw that on seven occasions there had been eight staff on duty. However, on seven other occasions there had been ten staff on duty. The registered manager told us they aimed to have nine staff on duty for the forty three people who were using the service at the time.