Two inspectors and an expert by experience visited the home and answered our five questions, Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. The summary is based on our observations during the inspection. We spoke with 18 people using the service, eight relatives or friends, 12 of the staff supporting them, the manager and the regional operations manager. We looked at eleven care plans in detail or partially. Additionally we used the Short Observational Framework for Inspection (SOFI) for a forty minute period.
Is the service safe?
Care plans instructed staff how to meet people's needs in a way which minimised risk for the individual. However there was no evidence to show that these were followed. We found that daily records had not been completed consistently and care plans were not always up-dated to reflect people's current needs. This put people at risk of not being cared for in the best and safest way.
Mental Capacity Act (2005) assessments were included in plans of care. Assessments had been completed by care staff who had not completed Mental Capacity Act training. We saw that a best interest decision, which could involve restraint, had been made by an individual carer. This meant that the decision made may not be appropriate.
CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We found that the home liaised effectively with the local authority DoLS team and had, generally, made applications as appropriate. The home had made two DoLS referrals in 2014.
The home did not have any behavioural guidelines to support people with behaviours which could cause themselves or others distress. This put people at risk of not being supported safely during periods of difficult behaviour. We found that unexplained injuries or bruising were not investigated and it was not clear what action if any had been taken to minimise the risk of recurrence. People told us they felt they were: 'very safe' living in the home. One person said: 'there is no poor treatment, no abuse, it's not a bad place to live'.
The home did not administer people's medication safely. We found that medication trolleys were left unlocked where people could access them. Medication was not always given at the prescribed times to allow safe timeframes between doses. This meant that people in the home may not be safe from harm caused by medication.
We found that there were not enough staff (or they were not effectively deployed) to meet people's needs. Call bells were not answered in a timely way which put people at risk of harm. The majority of people told us that there were not enough staff around but others told us: 'There are always enough staff'.
Health and safety was taken seriously by the home and all the appropriate safety checks had been completed. This reduced the risks to people and helped the service to continually improve.
Is the service effective?
Plans of care were not reviewed regularly and it was not clear if any necessary changes had been made to them. This meant that the care being given may have been out of date or inappropriate for the individual's current needs. It was unclear how people were identified as requiring 'nursing' or 'residential care'. People who were 'residential' care had their health care needs met by district nurses or community health professionals. This meant that people sometimes had to wait for paramedics to arrive for simple procedures such as the application of dressings.
People's individual well-being records were not completed accurately. They did not include 'targets' such as how much an individual should drink for staff to know if the individual was at risk of dehydration and of the action to take. The pressure setting of specialist mattresses used to promote individuals pressure care was not detailed for staff to monitor effectively. This meant that people may be at risk of harm because staff were not aware of how to ensure their well-being.
People told us they were happy with the care they received and felt their needs were met. One person told us they were going to an outpatient appointment they said: 'the home has arranged a taxi and one of the nurses is going with me. It's lovely; I don't have to worry at all'. However, some relatives told us they were concerned that their relatives care needs were not met in a timely manner.
Is the service caring?
People were supported by some staff who were mostly patient, kind and responsive. People who lived in the home told us staff were 'very nice, anything you want they do, they are not bad at all'. Another told us how: 'excellent' staff were when they helped them after a fall. However we observed that people were not always responded to in a timely manner when calling for assistance. Our observations found that some staff had not responded in a professional and caring manner. Examples included negative responses we overheard from staff when people had repeatedly asked for a drink, such as: 'Oh dear everyone would think you were never fed and watered'. Some people's requests during the lunch time meal had been ignored.
We found that care and support had not always been provided in line with people's preferences and wishes. An example included a person who wanted to get up in the morning still being in bed at 2.30 pm. One person said, 'you get fed up being in bed'. They told us that they weren't sure if it was their choice to stay in bed but didn't think so because they hadn't been up much.
Is the service responsive?
Staff did not always respond to people's needs and requests in a timely way. We observed people calling out for help with little to no response. Care plans were not always amended as people's needs changed.
It was not always clear that the home had acted on the learning gained from accidents, incidents and complaints. They did not respond to advice from other professionals such as the pharmacist. We saw that pharmacist had visited in October 2014. They had made two recommendations which had not been actioned.
The home had various ways of listening to the ideas and opinions of the people who lived in the home and their relatives and friends. They had made some changes and improvements as a result of ideas and discussions with people who live in the home and their relatives.
Is the service well-led?
The regional manager told us that the registered manager had left her post in May 2014. We had not received a registration cancellation application from them. An interim manager was in post until the permanent manager was appointed on 2 July 2014. Staff told us it: 'feels like months since a manager was in place'. Some told us: 'Things have gone down-hill since the manager left' (referring to the last registered manager).
Staff told us they were clear about their roles and responsibilities. Most of the staff we spoke with told us there were not enough staff to meet the needs of the people who lived in the home. They told us they felt unsupported, staff morale was low and that they did not always work well as a team. Some staff told us that they had no confidence in the management of the home. There were high levels of staff sickness in the home.
The service had a comprehensive quality assurance system. However, the system had not identified shortfalls in important areas of the quality of the care being given. As a result the quality of the service was not being maintained or improved.