All inspections: The Maples Residential Care Home

This inspection took place over three days on 11, 14 and 20 August 2015 and was a short notice inspection, because the service were without a registered manager and we wanted a representative from the partnership to be present to answer any questions we had. A partnership is a legal relationship formed by the agreement between two or more individuals to carry on a business as co-owners.

Since 28 October 2013 Care Quality Commission inspectors have carried out six inspections and have found multiple areas of non-compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Whilst some improvements have been made the registered provider remains in breach of seven regulations.

The Maples Residential Care Home is a care home registered to provide personal care and accommodation for up to 15 older people. At the time of our inspection seven people were living at the home.

The service had been without a registered manager since June 2014. Since that time there had been four managers. The service were currently without a 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.

The registered provider had introduced some auditing systems and processes, but the audit process in place was not fully understood by the registered provider and was insufficient to assess, monitor and improve the service or manage risks to people.

The home had improved their systems and processes to manage medicines, which meant most people were protected from the risks associated with medicines, but we found one person who had not been administered one of their prescribed medicines for an infection they had.

Systems and processes had been improved to manage fire safety, but regular checks had not been maintained in terms of maintenance checks associated with fire extinguishers and emergency lighting.

Robust recruitment procedures continued not to be in place and staff were working without appropriate information and documents being obtained about them. Appropriate information was not available for agency staff who had worked at the home. This meant people may be cared for by staff who had not been appropriately assessed as safe to work with people.

Staff had still not received all the appropriate training relevant to their role and responsibilities. Staff had received supervisions, although this could be improved to cover a broader range of areas for staff to reflect and learn from practice.

In the main, people’s assessments, care plans and risk assessments contained up to date and accurate information about people, however, people had not always had an assessment of their needs carried out before admission to the service to ensure those needs could be met. Referrals were made to health professionals in relation to people’s health care needs, which included involvement from doctors and the community mental health team. One health professional confirmed a very caring staff team, but that the service lacked leadership and management for the staff and that this was reliant on support offered by them.

There was a lack of stimulating activities available for people to participate in or opportunities to maintain hobbies and interests.

When we spoke with people who used the service they all told us they felt ‘safe’. Relatives spoken with did not raise any concerns about mistreatment or inappropriate care provision of their relative. Staff had received safeguarding training, but were not confident the registered provider, without support, had the necessary knowledge to act on any concerns that were raised in an appropriate manner. We found an incident of potential theft that had not been reported to the appropriate authorities at the time the potential theft had been identified. This meant the registered provider continued not to inform the Commission about notifiable incidents in line with the Health and Social Care Act 2008.

The current staffing arrangements may not be safe and meet people’s needs as no dependency assessment had been undertaken to establish those staffing levels were sufficient to meet people’s needs, because five of the seven people who used the service needed two members of staff to assist them with moving and their personal care needs and at those times people in the lounge and dining areas were left unsupervised..

The MCA (Mental Capacity Act 2005) is legislation designed to protect people who are unable to make decisions for themselves and to ensure that any decisions are made in people’s best interests. Deprivation of Liberty Safeguards (DoLS) are part of this legislation and in place so that where someone is deprived of their liberty they are not subject to excessive restrictions. Some care staff we spoke with had not received training in MCA and DoLS and could not describe how these applied to their role and the registered provider had admitted a person to the service without the registered provider undertaking an appropriate assessment, which meant the person may have been admitted without lawful authority.

People were broadly positive about the food that they were served at mealtimes, but their responses indicated how choices were made could be improved.

The system and processes for identifying complaints had been improved. A complaints record was in place and the registered provider had taken action to resolve the complaint to the person’s satisfaction.

The registered provider had registered with the Information Commissioner’s Office, the office responsible for enforcing the Data Protection Act 1998 and where providers who hold personal data about people need to register.

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, the service will be inspected again in 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 up 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.

This inspection took place over two days on 12 January 2015 and 14 January 2015. The inspection was a short notice inspection. We provided notice because the service had recently appointed a new manager and we wanted a representative from the partnership to be present to answer any questions we had. A partnership is a legal relationship formed by the agreement between two or more individuals to carry on a business as co-owners.

Since 28 October 2013 Care Quality Commission inspectors have carried out five inspections and have found multiple breaches with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. At the inspection on 28 October 2013 a breach was identified in records. At the inspection on 10 February 2014 sufficient improvements had not been made and the registered provider remained in breach of the regulation associated with records. At the inspection on 19 and 26 August 2014 breaches of regulations were also identified in care and welfare and the management of medicines. Warning notices were issued for breaches of regulations associated with assessing and monitoring the quality of service provision and records. At an inspection on 24 November 2014 we found warning notices had not been met.

At this inspection we found sufficient improvements had not been made in the areas where previous breaches had been identified and we identified further breaches of regulations in safety and suitability of premises, recruitment of workers and supporting workers.

The Maples Residential Care Home is a care home registered to provide personal care and accommodation for up to fifteen older people, including some people living with dementia. At the time of our inspection ten people were living at the home.

The service had been without a registered manager since June 2014. Since that time there had been four managers. The current manager had commenced employment on 29 December 2014 and was in the process of applying to be the 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.

We found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of the report.

The home did not have effective systems in place to manage medicines, which meant people were not always protected from the risks associated with medicines.

Safe systems were not in place to manage risks to individuals and the service, for example, fire safety and hot water.

Robust recruitment procedures were not in place and staff were working without appropriate information and documents being obtained about them. This meant people were cared for by staff who had not been appropriately assessed as safe to work with people.

Staff had not received an appropriate induction and not all staff had received appropriate training relevant to their role and responsibilities. Staff had not received regular supervisions which meant their performance was not formally monitored and areas for improvement may not have been identified. This meant the service did not ensure staff received appropriate training, professional development, supervision and appraisal.

Assessments, care plans and risk assessments did not always contain up to date or accurate information about people. This meant that some people did not always receive the care and support they needed to meet their identified needs.

Effective quality assurance systems were not in place to monitor and improve the quality of service provided.

When we spoke with people who used the service they all told us they felt safe. Relatives spoken with did not raise any concerns about mistreatment or inappropriate care provision of their relative. Staff had received safeguarding training and were confident the manager would act on any concerns. However, we found that staff had failed to recognise that an incident that had occurred at the home should have been reported to the appropriate authorities.

People responded to questions about the numbers and availability of staff with positive comments and staff did not express any concerns about staffing levels at the home. However, we found people did not have access to call alarms in the lounge when staff were not present and needed to call for assistance. This meant people were unable to summon staff when they needed support in a dignified way.

The requirements of the Mental Capacity Act 2005 were not understood by staff, which meant there was a risk that people may be deprived of their liberty without due process being followed.

People were broadly positive about the food that they were served at mealtimes, but the meal time experience could be improved, for example, asking people their choice of menu on the day, a more varied choice of food and people not kept waiting at the dining table before lunch was served.

We saw information in people’s care files that health professionals were contacted in relation to people’s health care needs, which included involvement from doctors and the community mental health team. This was confirmed by the people who used the service and staff.

This service was a small service and this impacted on people’s experiences at the home, although they themselves did not say this. For example, there was one seat for each person in the lounge, which if everyone was sat in was cramped.

We observed very little interaction between people and staff, with most conversations being prompted by and based around tasks. At those times staff interactions were patient and caring in tone and language. About staff people said, “they are helpful in a way. The girls are very nice here – she’s lovely, that lady (indicating a carer worker). Always a smile.” and “they don’t sit and talk”.

People did not raise concerns about staff not respecting their privacy and dignity, but we saw occasions when this was not respected by staff, for example, we overheard staff saying “we need to start toileting”.

We asked people how they passed their time and whether there were was a stimulating programme of activities. No-one we spoke with was able to tell us of about any activity that they had taken part in, or how they were encouraged or supported to maintain hobbies and interests. One person said, “we just sit and wait.” Our observations during the inspection showed that the activities and stimulation for people to participate in could be improved.

We found the complaints procedure was not robust, staff were unable to locate a complaints log and the registered provider was not aware of one complaint.

The registered provider had not always informed the Commission about notifiable incidents in line with the Health and Social Care Act 2008, for example, serious injury notifications and outcomes of DoLS applications.

The registered provider was not aware of the requirement to register with the Information Commissioner’s Office, the office responsible for enforcing the Data Protection Act 1998 and where providers who hold personal data about people need to register. This meant their legal responsibilities had not been met and there was a risk people’s personal information was not held securely in accordance with the Data Protection Act 1998.

Two adult social care inspectors carried out this inspection. This was a follow up inspection to check that warning notices issued after our inspection on 19 and 26 August 2014 had been complied with. The inspection was a short notice inspection. We provided notice because the service had recently appointed a new manager and we wanted a representative from the partnership to be present to answer any questions we had.

At the time of the inspection, 11 people were living at The Maples Residential Care Home. We observed the care people received. We spoke with two people who used the service, one of their advocates, two family members and three members of staff. We also spoke with one of the registered providers and the manager. The manager was not registered with the Care Quality Commission. 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. The manager had previously worked at the home both as a member of care staff and deputy manager, but commenced working as manager on 17 November 2014. We also reviewed relevant documentation, including four care files and other records relevant to the management of the regulated activity.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask: is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found.

Is the service safe?

We asked people if they felt safe at the service. People said they had 'no concerns'.

An advocate of one person we spoke with and two family members of another person who used the service told us they were confident that the people they represented were safe at the service and if they had any concerns they would report them to either the manager or social services.

The warning notice identified there was no record of the financial transactions for 'resident funds', which is an appropriate record in relation to the management of the regulated activity. There continued to be no record of 'resident funds'.

We looked at the individual financial records for people who used the service. We found errors in the financial accounting and there was no effective governance of the system in place. We made a referral about this to the safeguarding authority and police.

The warning notice we issued following our inspection in August 2014 identified some people's care records did not contain up to date, accurate and appropriate information in relation to their care. This meant there was a risk that people who used the service may receive inconsistent/out of date levels of care and support. Whilst there had been some improvements in the standard of record keeping noted during this inspection, there remained instances where people's care records did not contain up to date, or accurate information. This had been identified to the registered provider on three previous occasions. The provider had given assurances in writing that they would improve the standard of record keeping to reduce the risk of inconsistent /out of date care, however, we found this not to be the case during this inspection. We decided a new approach inspection was needed to provide a rating for the service under the Care Act 2014.

Is the service effective?

This question was not covered during this responsive, follow up inspection.

Is the service caring?

People and advocates of people we spoke with made positive comments about the staff and told us staff treated people with dignity and respect. The staff were described as being friendly and approachable.

During the inspection we observed staff giving care and assistance to people. They were respectful and treated people in a caring and supportive way.

Is the service responsive?

This question was not covered during this responsive, follow up inspection.

Is the service well-led?

The manager told us she had not been a manager previously and discussions with her identified a lack of knowledge about her responsibilities as manager. The manager had received a 'handover' of one day from one of the registered providers. She had not been informed about the warning notices that had been issued at the previous inspection by the registered providers and had been told that the priority was 'getting the environment up to standard'. She had not been provided with any action plans to work to from the registered provider.

The manager was not aware of any action that had been taken by the previous manager in meeting the warning notice and putting in place systems and processes for assessing and monitoring the quality of service provision. She was not aware of a quality assurance policy/procedure that she could follow to guide her in how she should assess and monitor the quality of service provision. However, she had put in place a suggestions box for people and others to make suggestions at how the service could improve. She was also in the process of arranging a manager's surgery to establish another way of making contact with families to seek their views about the running of the service.

The manager had also implemented a complaints policy/procedure and displayed this for people and others to see, should they need to raise concerns about the service.

When we spoke with people who used the service they told us there had been a lot of changes at the service. We also spoke with an advocate of one person and two family members. They confirmed there had been a lot of changes at the service, which in their view were 'for the better'. They described how environmental upgrades had brightened up the service. They said they had never had any concerns about the care provided and if they had staff had resolved these before it became necessary to make any complaints. One set of family members commented, 'we've been happy. They seem to be putting money in now. They're on the up. It's nice and friendly and we like the fact that it's small'.

We asked the manager what systems were in place to identify, assess and manage risks relating to the health, welfare and safety of people and others who may be at risk. The manager was unable to describe the systems in place and was not aware of a policy/procedure file that could guide her. Through our discussions with her and asking for particular documents throughout our inspection we established some audits had taken place to identify, assess and manage risks, but not all of these had been effective in practice. For example, the manager had completed a record keeping audit. The questions on the audit were insufficient to identify if there were improvements needed with the content of the records and whether they were up to date and accurate and reflected the care provided to people. In addition, the records were not kept in a structured way, which meant documents could not be located promptly when required.

Our findings identified the registered provider had not paid sufficient regard to our previous reports of 28 October 2013, 10 February 2014 and, 19 and 26 August 2014 relating to their compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 as they had not taken sufficient action in that time to achieve compliance. We decided a new approach inspection was needed to provide a rating for the service under the Care Act 2014.

Two adult social care inspectors carried out this inspection. The inspection included checking that improvements had been made to records following concerns on our two previous inspections.

At the time of this inspection, 14 people were living at The Maples Residential Home. We observed the care those people received. We spoke with four people who used the service, four of their advocates or relatives, a visitor and four members of staff. We also spoke with the manager, as well as reviewing relevant documentation.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask: is the service safe, effective, caring, responsive and well led?

Below is a summary of what we found.

Is the service safe?

Manual handling risk assessments were insufficiently completed for five people moved in wheelchairs without the use of footplates to verify that was a safe and an effective way to meet those people's needs.

There was no record of the financial transactions for 'resident's funds', which is appropriate in relation to the management of the regulated activity.

We observed that the safe keeping and safe administration of medicines was insufficient to protect people against the unsafe use and management of medicines.

Is the service effective?

In July 2014 we received information about a person living at the service alleging neglect with the delivery of care she had received. That neglect was substantiated, which meant the service had not been effective in ensuring the person had received appropriate care to meet their individual needs to ensure their welfare and safety. Another allegation of neglect is currently being investigated.

Is the service caring?

Two people who used the service told us about the care they received at the service. One of their comments included, 'they're looking after me pretty well. I've nothing to grumble about. The food's good. I'm happy. I think they've brought people in who aren't trained and that's upsetting. We didn't get a Sunday lunch, they put a spread on instead. We told them we weren't happy about that. I like my own company. I have regular baths and showers. My daughter chose the place and she chose well'. Another two people were reticent to tell us about the care they received.

We spoke with three people's relatives. Two were satisfied with the care provided. They said, said, 'up to two months ago there were problems, but since the new manager has taken over we're finding things much better. Staff here at present are fine. It's now a lot more relaxed for mum. Things happen if I ask' and 'I've always been very satisfied with the care. The carers are very patient and caring and I've never known people to be neglected. I'd ring the last manager to find out how [family member] was and they'd always ring me if they weren't very well, or the doctor had been. They've never hesitated in getting a doctor. The food's always very good. They always have a good cooked dinner and the tables are laid out very nicely and daintily served. When we visit it's always very welcoming and [family member] and their room is clean. I've no regrets about her being there, particularly as it's small.

Our observations of staff were that people were not always provided with care that met their individual needs. For example, one member of staff told one person 'you've had your breakfast' when she said she was hungry. Another person said they were cold and a member of staff said, 'well you've got a blanket and slippers on'. We observed the kitchen door was open and was blowing a cold draught through the dining room where the person was sat.

One relative felt the care provided could be improved. They said, 'we're generally happier with The Maples, than previous homes, but every time we visit there's something not right. I don't think it's been a very good handover between the old and new manager. There are things with my mum's care that hasn't been passed on and we're having to explain things again. Also, communication is not always good between the staff as things haven't been passed on. Although mum and her clothes are always clean I'm not sure that mum gets all the care she needs. Until the new manager started she hadn't had a bath' and 'I'm happy with the care provided and [person's] happy here. I'm confident she's safe and well looked after'.

Is the service responsive?

One relative who had made positive comments about the care provided felt activities could be better. They said, 'the one thing I think is they are never provided with an opportunity to go out, but I think that's due to them being short staffed. They're always short staffed. To me they're treated worse than prisoners in that respect. We'd pay for [family member] to go out'.

The manager told us a planned programme of activity took place. When we spoke with people none recalled those activities. We observed little activity with people and throughout the days of the inspection found people spent a lot of time asleep. The lack of activity and engagement by staff with people did not have a negative impact on people's moods, but involving people in what they might like to do may engage them more and improve their wellbeing.

We found that the service had not always been responsive to meet people's needs in terms of falls, specific care needs, when people felt unwell and behaviour that challenged, because their care plans and risk assessments had not always been reviewed after any concerns had been identified and other professional's advice sought in a timely manner where necessary.

The manager made us aware of one complaint that had been made since her appointment. She had been responsive to the initial complaint, but there was no record of the outcome of the complaint and the action taken to improve the future service if needed.

Is the service well-led?

The manager of the service was not registered with the CQC which is a requirement of the home's registration. She commenced work at the service on 14 July 2014. She told us she had not been a manager previously. Discussions with her identified a lack of knowledge about her responsibilities as manager, but she was willing to learn and asked about actions she needed to take to make sure the service was compliant.

The registered person had not paid sufficient regard to our previous reports of 28 October 2013 and 10 February 2014 relating to their compliance with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 as they had not taken sufficient action to achieve compliance.

Policies and procedures provided relevant to the operation of the service had not been recently reviewed and did not contain current information or good practice guidance. This meant the manager and staff did not have information to refer to should they need to or know who was responsible for decisions to be made in relation to the provision of care and treatment for people.

The manager could not explain the quality assurance systems or the systems in place to identify, assess and manage risks relating to the health, welfare and safety of people and others who may be at risk. She was unable to provide a policy/procedure, which meant there was no guidance for her about how she might achieve this. We established resident and relative meetings, monthly surveys and audits within the service had not taken place on a regular basis. This meant there was no system in place to identify, assess and manage risks relating to the health, welfare and safety of people and others who may be at risk and to maintain compliance.

We have asked the provider to tell us what they are going to do to meet the requirements of the law in relation to the care and welfare of people who use services, assessing and monitoring the quality of service provision and records.

This was a follow up inspection to check that improvements had been made to records at the service since our inspection on 28 October 2013.

People were not protected against the risks of unsafe or inappropriate care and treatment, because full and accurate records or detailed information about them were not in place.

We observed that the care that people received met their needs. One person said, 'I like being here, it's open. I can talk if I want to, go to sleep if I want. The atmosphere's nice and friendly. The carers do anything for you. I love them very much. I'm not saying we've not had a cross word, but it's forgotten. They make me feel like number one, but they don't give in to me. They take me to the doctors if anything's a matter or they're worried. They make sure I'm happy and I've what I need.'

The service involved external health and social care professionals, to ensure people's health and social care needs were met.

People had equipment in place to support them in meeting their needs, for example, hoists and wheelchairs.

Food and drink met people's individual dietary needs. One person said, 'If I want anything, I've only to mention it. I can't always see what I'm eating, but they [staff] tell me and the flavour.'

People using the service and family members told us sufficient numbers of staff were on duty to meet people's care and health needs. One person said, 'They do a wonderful job for the staff they've got.'

People were not protected against the risks of unsafe or inappropriate care and treatment, because accurate records or detailed information about them were not in place.

We talked to three people who used the service. People told us they were happy at the home, liked the staff that looked after them, thought the home was kept clean and they enjoyed their food. People told us the general practitioner visited when needed and they were able to access a dentist.

Some comments captured from people who used the service included, 'I'm comfortable here', 'food very nice', 'I get on very well with them (staff)', 'lovely staff', 'I'm well looked after', 'the manager [X] is very nice, they are the right person for the job' and '[the staff] are very good to us'I've got them well trained!'

We used periods of informal observation to see how members of staff interacted with people who use services. Generally, we saw staff treated people with dignity and respect and people looked clean, tidy and had their personal care and welfare needs met.

We talked to six people who used the service and they told us they were happy at the home, liked the staff that looked after them, thought the home was kept clean and they enjoyed their food. Some general comments made by people who use the service included, 'Staff very good', 'Very nice ' make you feel very comfortable' and 'All [staff] very good to me'.

During our inspection visit in June 2011 we talked to people who use the service and relatives at this location. Comments were positive about aspects of their care. Please see the June 2011 report.

In September 2011 our focus was to review a compliance action previously identified in June. We were able to talk to two people who use the service who explained they thought it was 'nice and wonderful' at the Maples and said staff were 'friendly'. Another person thought the 'carers were nice' and they were 'well looked after'.

On the site visit conducted 20 June 2011 some comments from residents included:

'[relative] food fine, smells lovely whenever I visit'.

'[The manager] sorts out doctor '.when I need to see one gets onto phone to make appointment'.

'I like it here' and [the staff] 'are very good at everything'. They felt they 'had been alright ever since they had come here'been good';

'Staff are very good'they come straight away [when call system used]'.

'Meals are very good'plenty of variety';

'it's my home now'very settled';

The Maples submitted a collated report dated 4 April 2011, which had captured the views of residents. Some comments included:

'The staff care for me very well there all very pleasant. It's a lovely place to live'.

'I like living here the staff are all very nice'.

'I have lived here a few months, I feel I have settled well the staff are very nice to me. The food is always nice.'

'I feel really well cared for the staff are very good to me'.

'I feel very happy living here, the food is very nice'.

'The overall care is very good but I still miss my own home at times'.

Relative X 'Very friendly home, staff do there best and are very welcoming; always someone on hand'.

Relative X 'Very friendly good and efficient manager, deals with things professionally and quickly, always available'.

Archived: The Maples Residential Care Home

All Inspections

11, 14 and 20 August 2015

During a routine inspection

12 and 14 January 2015

During a routine inspection

24 November 2014

During an inspection looking at part of the service

19, 26 August 2014

During an inspection looking at part of the service

10 February 2014

During an inspection looking at part of the service

28 October 2013

During a routine inspection

13 September 2012

During an inspection looking at part of the service

15 May 2012

During a routine inspection

27 September 2011

During an inspection looking at part of the service

20 June 2011

During a routine inspection