Archived: Old Gates Care Home

Old Gates Care Home is a nursing and residential care home which provides nursing and personal care to up to 90 people, including older people, people with a physical disability and people living with dementia. Accommodation is provided over three units, with one unit specifically for people living with dementia. At the time of the inspection, 63 people were living at the home.

People’s experience of using this service:

Some improvements were needed to how people’s medicines were managed to ensure they were safe. Shortly after the inspection, the manager provided evidence that these had been addressed. People felt safe at the home and were happy with staffing levels. Staff understood how to protect people from the risk of abuse or avoidable harm. The provider followed safe processes when recruiting staff to ensure they were suitable to support people living at the home. Staff followed appropriate infection control procedures and we found the home clean. The provider ensured safety checks of the home environment were completed regularly.

Staff supported people in a way which met their needs. People felt staff were skilled and knowledgeable. Staff were happy with the induction they received when they joined the service and received regular supervision. Some staff training updates were overdue and the manager addressed this shortly after the inspection. We have made a recommendation about this. 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. Staff completed capacity assessments in line with the Mental Capacity Act 2005 and applied to the local authority for authorisation when people needed to be deprived of their liberty to keep them safe. Staff supported people with their dietary and healthcare needs and contacted community professionals when they needed extra support. The environment was suitable for people’s needs.

People liked the staff who supported them and told us staff were kind and respectful. Staff considered people’s diversity and respected their right to privacy and dignity. They encouraged people to be as independent as they could be and involved them in decisions about their care. The service provided people with information about local advocacy services, to ensure they could access support to express their views if they needed to.

Staff provided people with care that reflected their needs and preferences. They reviewed people’s care needs regularly and updated documentation when people’s needs changed. People told us staff knew how they liked to be supported and offered them choices. The provider managed people's concerns and complaints appropriately. Most people were happy with the activities and entertainment provided at the home.

The manager and senior staff completed a variety of audits to check appropriate levels of safety and quality were maintained at the home. The manager told us medicines practices would be monitored more closely in the future to ensure they remained safe. The provider had effective oversight of the service. Staff worked in partnership with a variety of community agencies to ensure people received the support they needed. People and relatives were happy with the management of the service. Staff felt well supported and told us care standards and the management of the home had improved since the last inspection.

Rating at last inspection:

At the last inspection the service was rated requires improvement (published 25 April 2019) and there were three breaches of regulations. 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. However, the service remains requires improvement, as further improvements were needed to medicines processes and practices at the home.

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

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

We will request an action plan from the provider to understand what they will do to ensure medicines processes and practices remain safe. We will monitor the progress of improvements, working alongside the provider and local authority. We will return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

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

People’s experience of using this service: People’s experience of Old Gates varied depending on the unit on which they lived.

We were unable to visit Rowan unit due to an outbreak of diarrhoea and vomiting. However, staff who had recently worked on this unit told us improvements had been made since the last inspection and the quality of care people received was good. One staff member commented, “It’s fun on Rowan. You go home smiling.”

People on Cherry unit, which provided care for people who did not require nursing care, was generally good. However, people on this unit told us there were not always enough staff to respond to their needs in a timely manner. During the inspection, we observed a lively atmosphere on Cherry unit with people engaged in conversation and activities.

Our observations, discussions with staff and review of records on Holly unit showed people’s quality of life was adversely affected by staffing levels. People on this unit had complex nursing needs and required two staff to meet their needs. Many people who lived in this unit remained in bed during both days of the inspection and we saw limited positive interactions between staff and people they were caring for. Staff told us they did not have the time to provide people with the care they needed. People’s medicines on this unit were not always safely managed.

Rating at last inspection: This was the first inspection since a new provider had taken over the running of the service on 15 December 2017.

Why we inspected: This comprehensive inspection was prompted by information of concern we had received from the local authority quality team and local clinical commission group following their visits to the service in January 2019.

Enforcement: We identified three breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014; these related to staffing levels and the support and training staff received, the unsafe handling of medicines and the lack of robust systems to monitor the quality and safety of the service. Information relating to the action the provider needs to take can be found at the end of this report. Full information about the Care Quality Commission's regulatory response to the more serious concerns found at inspections and appeals is added to reports after any representations or appeals have been concluded.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates. We will follow up on the breach of regulations at our next inspection.

Old Gates Care Home provides accommodation in three units, for up to 90 people who need either nursing or personal care and support. These units are Cherry, Holly and Rowan. Care and support for people living with a dementia is provided in Rowan. There were a total of 61 people using the service on the days of our inspection.

We had previously inspected this service in February 2017 when we identified five breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. These related to staffing arrangements on the unit for people living with a dementia, recruitment processes which were not sufficiently robust, a lack of effective systems to ensure people received safe and appropriate care, limited evidence of person centred activities particularly for people living with a dementia and a lack of effective leadership in the service.

Following the inspection in February 2017, the provider wrote to us to tell us the action they intended to take to ensure they met all the relevant regulations by the end of May 2017. This inspection was undertaken to check whether the required improvements had been made.

Since the last inspection the manager had registered with the Care Quality Commission (CQC). A registered manager is a person who has registered with 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. The registered manager was supported in the running of the service by a clinical services manager and three unit managers.

Staff had been safely recruited and there were sufficient numbers of staff on duty to meet the needs of people in a timely manner. People who used the service told us staff were kind, caring and respectful; this was confirmed by our observations during the inspection. Our discussions with staff showed they had a good understanding of people’s needs and were committed to providing high quality care. We saw that people were supported to maintain their independence as much as possible.

People told us they felt safe in Old Gates. Policies and procedures were in place to guide staff about the correct action to take should they witness or suspect abuse. All the staff we spoke with told us they had completed training in safeguarding adults. They told us they would have no hesitation in reporting any concerns and were confident they would be listened to.

We noted that 10 of the 12 care records we reviewed contained risk assessments to help staff mitigate against all identified risks. However, we found staff had failed to report and record an incident of aggressive behaviour exhibited by one person. This meant appropriate risk assessments had not been put in place to protect both the individual concerned and staff; this situation was rectified by the clinical services manager by the second day of the inspection. In addition, another person’s care records documented four recent incidents of aggressive behaviour. However, there were no risk management plans in place to guide staff on the appropriate action to take in the event of future incidents occurring. This meant people might not receive safe and appropriate care.

Systems were in place to help ensure the safe handling of medicines. Staff responsible for the administration of medicines had received training for this role. The competence of staff to administer medicines safely was regularly assessed.

People were cared for in a safe and clean environment. Procedures were in place to prevent and control the spread of infection. We observed these in practice during the inspection as staff effectively controlled an outbreak of diarrhoea and vomiting which had occurred on one of the units.

Regular checks were made to help ensure the safety of the premises and the equipment used. Systems were in place to deal with any emergency that could affect the provision of care.

Staff received the essential induction and training necessary to enable them to carry out their roles effectively and care for people safely. Systems were in place to ensure staff received regular supervision.

We saw that appropriate arrangements were in place to assess whether people were able to consent to their care and treatment. The registered manager was aware of their responsibility under the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) to ensure that people's rights were considered and protected.

Systems were in place to help ensure people’s health and nutritional needs were met. Although people gave us mixed feedback regarding the quality of food, they told us they were always offered alternatives if they did not like what was on the menu.

Improvements had been made to the range of activities available to people, particularly on the unit for people living with dementia. During the inspection we observed staff took the time to engage both individuals and groups in meaningful conversations and activities.

People had a number of opportunities to comment on the care they received in Old Gates, including resident/relative meetings and the completion of an annual satisfaction survey. We saw that systems were in place to investigate and respond to any complaints received.

Staff told us they enjoyed working in the home. They told us the registered manager and senior staff were approachable and supportive. Regular staff meetings meant that staff were able to make suggestions about how the service could be improved. Staff told us they were able to contribute to staff meetings and that their views were always listened to.

There were a number of quality assurance processes in place. We saw that information generated from audits, complaints and incidents was used to drive forward improvements in the service.

Old Gates Care Home provides accommodation in three units, for up to 90 people who need either nursing or personal care and support. These units are Cherry, Holly and Rowan. Care and support for people living with a dementia is provided in Rowan. There were a total of 72 people using the service on the days of our inspection.

The service did not have a registered manager in place. A new manager had been in post at the service since January 2017. They told us they intended to apply to register with CQC as the manager of the service. 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. The manager was supported in the running of the service by a newly appointed clinical services manager and three unit managers.

During this inspection we identified five breaches of the Health and Social Care Act (HSCA) 2008 (Regulated Activities) Regulation 2014. These related to staffing arrangements on the unit for people living with a dementia, recruitment processes which were not sufficiently robust, a lack of effective systems to ensure people received safe and appropriate care, limited evidence of person centred activities particularly for people living with a dementia and a lack of effective leadership in the service. You can see what action we have told the provider to take at the back of the full version of the report.

We identified a lack of leadership in the service particularly on Rowan and Cherry units. Staff were not appropriately deployed on Rowan unit to ensure people visiting or living and working in the unit were properly protected; this resulted in a number of serious incidents being witnessed by the inspection team on the second day of the inspection. Risk assessments and risk management plans did not contain sufficient information to guide staff on how best to support people whose behaviour might challenge others. Risk assessments were not in place for a person who was identified as being at risk of falling and choking; this meant staff might not be aware of the care the person required to minimise these risks. We also found that changes in people’s behaviour had not always triggered a review of relevant risk assessments and risk management plans; this meant staff did not always have up to date information about the best way to respond to people’s needs.

We found evidence that people who used the service, particularly those on Rowan unit, had not always received their medicines as prescribed.

The recruitment process in the service needed to be improved in order to properly protect people from the risk of unsuitable staff. Additional checks had not always been undertaken when staff had worked previously with vulnerable adults or children to ascertain why their employment in that service had ended. Records did not show that gaps in one applicant’s employment history had been explored.

People on Holly and Cherry units were generally satisfied with the range of activities available to them. We saw that, although objects were available for staff to use on Rowan unit to interact with people who used the service, none of these were utilised when people became distressed or exhibited behaviour which might challenge others. There was a lack of individualised and person centred activities on this unit which meant the well-being of people who used the service was not always promoted.

People who were able to express a view told us they felt safe in Old Gates and that staff were always kind and caring. Staff had received training in safeguarding adults. They were able to tell us of the correct action to take should they witness or suspect abuse.

People were cared for in an environment which was generally clean. Procedures were in place to prevent and control the spread of infection. Regular checks were made to help ensure the safety of the premises and the equipment used. Systems were in place to deal with any emergency that could affect the provision of care.

Staff received the induction and training they required to be able to deliver effective care. We saw that appropriate arrangements were in place to assess whether people were able to consent to their care and treatment. Where necessary applications had been made to the local authority to authorise any restrictions necessary to ensure people received the care they required.

Systems were in place to help ensure people’s health and nutritional needs were met. Records we reviewed showed referrals had been made to specialist services such as dieticians when any concerns were identified. People who used the service told us the quality of the food was generally good.

Staff told us they would always promote people’s independence as much as possible. We observed a member of housekeeping staff encourage a person on Rowan unit help them in their routine; this had a positive impact on the behaviour of the person concerned.

Although care records had been regularly reviewed and updated, there was limited evidence that people who used the service or, where appropriate their relatives, had been involved in formal review meetings. However, none of the relatives we spoke with had any major concerns about the care and treatment their family member received. .

Systems were in place for receiving, investigating and responding to complaints. The provider kept a central record of all complaints in order that any themes and trends could be identified. All the people we spoke with during the inspection told us they would be confident that any concerns they reported would be listened to and action taken by senior staff to resolve the matter.

Although staff told us they considered the overall management of the service had recently improved, we identified a lack of leadership on both Cherry and Rowan units. This resulted in staff not being appropriately directed to ensure people’s needs were safely met.

Quality assurance systems in the service were in the process of being improved. The clinical services manager had begun to work with staff on the units to improve the quality of records and auditing processes. Plans were in place to hold both staff and resident/relative meetings following the appointment of the new home manager.