Archived: Levanto Residential Care Home

Levanto Residential Care Home (hereafter referred to as Levanto) is a residential care home providing accommodation and personal care to up to 20 people. The service provides support to older people who are living with dementia. At the time of our inspection there were 16 people using the service.

Accommodation is provided over the first and second floors, with the registered manager and deputy manager's office being on the third floor. The second floor is serviced by chair lifts. Some bedrooms have ensuite facilities. There are two communal lounges and a dining room. There is a small veranda at the front of the property with comfortable seating.

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

We completed our last inspection at Levanto on 16 June 2022. During that inspection we identified breaches in relation to safeguarding, safe care and treatment, premises and equipment, person-centred care, dignity and respect, consent, staff training and recruitment, complaints, notifications and governance and leadership. We raised safeguarding alerts in relation to eleven people and the local authority responded by initiating a large-scale safeguarding adults enquiry.

Following our last inspection, a member of staff had contacted us to raise concerns about a medicines error. They had reported this to the registered manager but were concerned that no action had been taken. During this inspection we found three people had new and unexplained bruising, and staff raised further concerns about one person’s safety at night, and the impact of their behaviour on others. The registered manager had not recognised or reported any of these concerns as safeguarding concerns and had failed to investigate the medicines error. We notified the local authority of our concerns relating to five people.

Medicines were not being managed safely and stock was not being controlled. Some people had more medicines than they should have, one person had medicines missing and there was a large amount of paracetamol in the home that had not been recorded on people's medicines records. Care plans did not contain sufficient information to enable staff to meet people's needs safely and staff did not take action in response to people's declining health. Infection control continued to be poorly managed and no action was taken to prevent the spread of infection when four people displayed symptoms of infectious disease.

Staff told us managers were more present in the home since the last inspection, however, the culture of the service still meant staff were still reluctant to raise concerns. One said they felt it had been difficult to raise concerns because some staff members “hold a grudge, and never forget it”. Managers had not identified the additional concerns we identified during this inspection. Changes in the senior staff team had led to confusion over what staff were responsible for and this had impacted on people.

Following the concerns raised after our last inspection, at this inspection we saw the local authority had begun to take action to mitigate some of the risks identified. For example, they had begun to assess people's needs, had provided equipment to support people to mobilise safely and had provided agency staff both day and night.

Changing the culture of a service takes time. Due to the short time span between our last inspection and this inspection, it would not have been reasonable to expect the provider to have made any significant progress in regard to this. The provider had begun to make some changes, for example introducing a choice at mealtimes. The registered manager had reflected on the last inspection report, and now acknowledged that they had failed to keep their own skills and knowledge up to date and this had impacted on their ability to identify shortfalls within the service.

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 inadequate (15 July 2022).

At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received immediately after our last inspection about medicines, people's wellbeing and the management of Levanto. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service remains inadequate based on the findings of this inspection.

Following our last inspection, the local authority took action to reduce the risks to people. This included providing equipment to help people mobilise safely and providing agency staff who were trained to use the equipment. The agency staff were in place 24 hours per day at the time of this inspection. The provider was working with the local authority to make improvements, and at the time of this inspection that work was ongoing, with assessments beginning to be completed for people living at the service.

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

Enforcement

We have identified continued breaches in relation to safe care and treatment and good governance.

We cancelled the providers registration.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Levanto Residential Care Home (hearafter referred to as Levanto) is a residential care home providing accommodation and personal care to up to 20 people. The service provides support to older people who are living with dementia. At the time of our inspection there were 16 people using the service.

Accommodation is provided over the first and second floors, with the registered manager and deputy manager’s office being on the third floor. The second floor is serviced by chair lifts. Some bedrooms have ensuite facilities. There are two communal lounges and a dining room. There is a small veranda at the front of the property with comfortable seating.

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

Several staff members had raised concerns about abusive and neglectful practice with the registered manager, who is also the provider. They had done this verbally, in writing, and by whistleblowing to the Care Quality Commission (CQC). The registered manager did not take these concerns seriously and failed to effectively investigate them, despite some of the concerns alleging physical and emotional abuse. During the course of this inspection, several staff members disclosed they had witnessed staff inflict physical and verbal abuse upon people.

We raised safeguarding concerns with the local authority in relation to eleven people, and about the service as a whole. We also shared our concerns with the police and other agencies. The local authority responded by initiating a large-scale safeguarding adults enquiry.

There was a closed culture at the service. CQC guidance on closed cultures and the impact they have on peoples’ human rights identifies 33 warning signs of a closed culture. 21 of these warning signs were evident at Levanto. For example, staff not understanding or speaking warmly about the people they were caring for, care plans not reflecting peoples’ voice, people being restricted from moving around freely and staff not receiving training that enables them to meet the needs of and effectively safeguard people. One person’s family member told us, “Once the person is in Levanto (registered manager) has the overriding thing of looking after the person, instead of their family doing so.”

Staff did not always treat people with respect. They talked loudly to each other about people, within their hearing, and were not respectful when people expressed their needs. One person’s family member told us their loved one had said the staff “were not very nice to them.” We observed people to be bored, disinterested and to have little interaction with staff. We asked one person if they liked living at the service, they said, “Not really, I’m left on my own most of the time.”

Known risks were not well assessed, monitored or managed which put people at risk of harm. Care plans did not contain enough information to enable staff to mitigate risks to people or give important guidance, such as how to help people move safely. Risks relating to pressure damage, falls and choking were not well managed. There was no evidence any action had been taken in relation to peoples’ weight loss, which put them at risk of malnutrition. Medicines were not always stored securely or administered in line with best practice. Staff recruitment systems were not operated effectively or in line with legal requirements. This meant people were at risk of being supported by unsuitable staff.

The risk of the spread of infection was not well managed because good infection control practice was not being followed. Staff had not completed any training in relation to Covid-19. People were being supported to have visitors and we saw people visiting on both days of our inspection. This had not, however, been communicated to all family members and one person’s relative told us they were frustrated they could not visit.

Staff did not receive appropriate support, training or professional development. It was evident from our observations of staff practice they did not have the training and skills to support people safely and meet their needs. Equipment was not well maintained, and the environment did not support peoples’ independence. Two people had heavily stained and dirty, poor condition, sprung mattresses on their beds. The environment had not been adapted for people living with dementia. There were no signs to help people orientate themselves within the building and nothing to identify peoples’ bedrooms. One person told us, “I don’t know where anything is.”

Peoples’ needs were not always assessed prior to them arriving at the service. Ongoing assessments were not always accurately completed, and care was not delivered in line with current evidence-based practice and standards. Staff did not follow healthcare professionals’ advice and did not recognise when it was appropriate to seek further support. Staff made decisions about the type of equipment people should use without the knowledge or qualification to do so, which put people at risk of harm.

People were not given a choice of food at mealtimes and staff made decisions for them. We observed two people in their bedrooms for long periods of time with no drinks within reach. Staff told us people were sometimes rushed at mealtimes and told to hurry up. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Peoples’ care plans were task focussed and contained limited information about peoples’ personal preferences. People and their families were not supported to be involved in their care planning or express their views. One family member told us, “One carer told me off for giving my relative chocolate marzipan. I thought that it was rude and that she was treating me like a child.” There were routines in place which did not reflect peoples’ individual needs. People were not supported to have regular baths or showers and there were no systems in place to monitor oral healthcare.

There were no systems in place to identify, record or respond to complaints. Complaints were not investigated. The registered manager told us they did not accept verbal complaints and did not take notice of anonymous complaints. One family member told us, “You have to pick your battles with [registered manager].”

Staff told us that managers were not responsive, did not listen to their concerns, feedback or suggestions for change. One staff member told us, “(Registered manager) is very much the boss, it’s got to be ‘their way’, it’s very difficult to try and change things when someone is so set in their ways.” Concerns raised by staff were not investigated thoroughly and confidentiality was not maintained. This led to a culture of bullying. Peoples’ families did not feel the culture of the service was open. One relative said, “It is difficult to ask for information – you are made to feel like you are a difficult relative.” When we challenged the registered manager and other managers in the service about poor practice, they, at times, became defensive and hostile. We observed managers did not role model positive or professional behaviour to staff throughout the inspection.

The service was not open and transparent. They did not identify or recognise where people were subject to abusive or degrading treatment or where incidents between people constituted a safeguarding concern. The service did not work in partnership with others. In some cases, staff worked in direct opposition to the advice given by healthcare professionals. They did not communicate well with families about peoples’ health needs.

The registered manager was not aware of any of the concerns identified on this inspection. They considered they provided a “specialist dementia home” and told us, “We feel we do everything we can.” They told us they felt let down by their staff but failed to recognise their own failings in identifying the shortfalls.

Notifications were not sent to CQC in line with legal requirements. This included notifications of allegations of abuse and serious injury.

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

Rating at last inspection

The last rating for this service was good (February 2019).

Why we inspected

The inspection was prompted in part due to concerns received about the safety and quality of care people received, safeguarding, complaints, staffing, infection control, nutrition, record keeping and the leadership of the service. A decision was made for us to inspect and examine those risks.

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 COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make significant improvements, some of which were urgent. We shared our concerns with the local authority safeguarding team and other agencies. Please see the safe, effective, caring, responsive and well led sections of this full report.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

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

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

Enforcement and Recommendations

We have identified breaches in relation to safeguarding; safe care and treatment; premises and equipment; person-centred care; dignity and respect; consent; staff training and recruitment; complaints; notifications and governance and leadership at this inspection.

We cancelled the providers registr

Levanto Residential Care Home is a care home for older people. The care home accommodates 20 people in one adapted building. The service was providing personal care to 17 people aged 65 and over at the time of the inspection. Most people were living with dementia.

People’s experience of using this service:

People told us they felt safe living at Levanto Residential Care Home. There was a relaxed atmosphere between people and staff. Staff knew people well and were kind, caring and attentive.

Care and support was personalised to each person to ensure this was carried out to meet their needs and preferences.

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.

People were protected from the risk of harm. Risks were managed safely and safe processes were in place.

Staff had enough time to meet people’s needs and spend time with them in conversation. Staff had completed training to ensure they had the knowledge they needed to meet people’s needs effectively.

The environment was well maintained and equipment was regularly serviced. Signage helped people living with dementia to identify rooms. Some carpets had been replaced and were matt and even coloured. However, there were still some highly patterned carpets in communal areas. These are not suited to the needs of people living with dementia. The assistant manager told us there were plans to replace these.

Quality assurance processes ensured people received high quality care.

More information is in the full report.

Rating at last inspection:

Good (The comprehensive report was published on 17 August 2016); Good (The focused report was published on 15 March 2017).

Why we inspected:

This was a planned inspection based on the previous rating.

Follow up:

We will continue to monitor intelligence we receive about this service until we return to visit as part of our re-inspection programme. If we have any concerns, we may inspect sooner.

At our last comprehensive inspection on 27 May 2016 we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the registered provider had not ensured staff had acted in accordance with the requirements of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards for people living at the home.

After the comprehensive inspection, the registered provider sent us an action plan telling us how they would meet legal requirements. We undertook this focused inspection on 30 January 2017 to check they had followed their plan and to confirm they now met legal requirements.

This report only covers our findings in relation to the specific breach of regulation from the last inspection, and one question we normally asked of services; 'Is the service effective?'. The other four questions; whether the service is 'safe', 'caring', 'responsive' and 'well led' were not looked at on this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Levanto Residential Care Home on our website at www.cqc.org.uk'.

There was 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.

At the last inspection in May 2016 we found although staff sought people's consent for their day to day care, where people appeared to lack capacity, people's rights were not protected. This was because staff did not complete mental capacity assessments for all of the people that required them. There were no records to demonstrate staff involved relatives and other professionals in 'best interest' decisions about people's care and treatment. Some people were subject to restrictions on their liberty for their safety and well-being. We saw that only some applications had been made to deprive people of their liberty. this was not in line with the requirements of the Mental Capacity Act 2005.

At this inspection, we found that the provider had taken action to comply with the requirements of the Mental Capacity Act 2005. Improvements had been made in all of these areas and the breach of regulation had been met.

The provider sought authorisation if restrictions were in place to keep people from coming to harm. Staff understood which decisions people were not able to make for themselves and how to appropriately support them in their best interests.

People had their health needs met and had access to a range of health care professionals and records were kept of any visits or appointments along with any action required. People were supported to eat a healthy balanced diet and appropriate action was taken when concerns with people's dietary intake were identified.

Staff received effective levels of support and one to one supervision. Staff told us they felt supported by the management team. People were supported by staff who had completed relevant training to enable them to meet the assessed needs of the people who lived at the home. Staff were encouraged to develop their knowledge and skills by undertaking nationally recognised qualifications.

People’s rooms had room numbers and photographs displayed to help people recognise their rooms. There were picture signs on toilets and bathrooms.People's preferences and personalities were reflected in the décor and personal items present in their rooms.

Levanto Residential Care Home is a care home for older people some of whom may be physically frail or living with dementia. Nursing care is not provided by the service. This service is provided by community nurses. At the time of our inspection there were 19 people living at Levanto. The home had two lounges, one of which was a smaller “quiet” lounge. The dining room leads off from the main hallway. All bedrooms were pleasantly decorated and all were fitted with a call system and had access to bathroom and toileting facilities.

The home had 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 and associated Regulations about how the service is run.

Although staff sought people's consent for their day to day care. Where people appeared to lack capacity, people's rights were not protected. This was because staff did not complete mental capacity assessments for all of the people that required them. There were no records to demonstrate staff involved relatives and other professionals in 'best interest' decisions about people's care and treatment. Some people were subject to restrictions on their liberty for their safety and well-being. We saw that only some applications had been made to deprive people of their liberty. This was not in accordance with the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty safeguards (DoLS) and was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. .

We found risks to individuals were assessed and staff applied measures to minimise risk to people. We saw that some risk assessments did not contain detailed information about how the risk of harm could be reduced. We discussed this with the registered manager who immediately took action to update and amend risk assessments to show what action they were taking to respond to individual risks.

People were protected from harm and abuse because staff had suitable training and understood how to protect people. Staff knew of their responsibility to safeguard people in their care and knew of the whistleblowing procedure. Staff told us they were confident the management team would take action if any concerns of abuse were brought to their attention.

During the inspection people were calm and there was a relaxed atmosphere at the service. We observed kind and caring staff who supported people in a respectful and dignified way. People were encouraged to be as independent as possible. People received care and treatment that met their needs, and care was regularly reviewed to ensure it remained suitable and effective. When people required the attention of external healthcare professionals this was sought quickly, and care plans showed that the guidance of external healthcare professionals was followed by staff. People received their medicines as required and action was being taken in relation to infection control issues to reduce the risk of harm to people.

There were sufficient staff on duty to ensure the day to day welfare of people and staff were appropriately allocated throughout the home. Staff enjoyed working at the service and felt well supported and there was evidence of supervision taking place. They had access to training which equipped them to deliver their roles effectively. Recruitment processes had been followed to ensure staff were suitable for their jobs.

People's preferences and personalities were reflected in the décor and personal items present in their rooms. Important items and photographs were prominently displayed. All the bedrooms we saw were personalised.

We saw people were enjoying their meals. People said that the food was good and they always had enough to eat and drink. The menu's were varied and contained food that was healthy and nutritious. Staff supported people according to their needs and where concerns were raised about people's weight or eating, action was taken. People chose the meals they wished to eat and decided where to eat them. Special diets were available for people with particular dietary needs.

There were clear systems of governance and leadership in place. The provider and registered manager ensured there were systems in place to measure the quality of the service. People, relatives and staff were involved in giving feedback on the service. Everyone felt they were listened to and any contribution they made was taken seriously. Regular audits made sure the service was running well. Where issues were noted, action was taken to put this right.

People's safety had been protected through cleanliness and robust maintenance of the premises. Fire safety checks had been routinely undertaken and equipment had been serviced regularly.

We identified a breach of regulation during the inspection and made 2 recommendations. You can see what action we told the provider to take at the back of the full version of the report

We observed that staff treated people with dignity and respect. Staff were polite and interacted well with people. Staff understood the needs of the people who lived in the home and supported them in line with guidance in their care plans.

Due to people's conditions we were not able to talk to them in detail about their experience. However, all the people we spoke with made positive comments. One person said "Everybody's nice and it's just like being at home." Another person said "We have someone in charge of us, we can go to them if we have a problem and I'm happy to tell them anything."

Staff understood the importance about asking people for their consent before any care was given.

People were provided with appropriate care and support that met their needs and promoted their wellbeing.

Due to people's conditions we were not able to discuss their experience in detail. However all the people we spoke with made positive comments. One person said 'I think they're very good here. They're approachable.' A relative said 'Staff are polite. They'd do anything for you.' All the people we spoke with described staff as kind.

We noted in the care plan of a person who had recently moved in to the home that a healthcare professional had commented that the person 'already looked considerably better and more relaxed'.

We saw records that showed that care plans were being developed to improve people's involvement in their care. More detail was also being added to guide staff on managing challenging behaviour.

The system for managing staff training in 2012 had not been effective. However training had taken place in 2013. The manager agreed to add the monitoring of staff induction, training, appraisal and supervision to the quality assurance system.

People were asked for their views on the service. People had been supported to complete a quality survey and many of the areas had been rated as very satisfactory.

The manager agreed to add the monitoring of accidents and incidents to the quality assurance system.