Archived: Southwater Residential Home

Southwater Residential Home is a care home providing care and accommodation for up to 12 people. The home provides support to older people. On the days of our inspection, there were four people living at the home.

The home is a large property situated in Paignton, Devon. There was a communal lounge, dining room and a front and rear conservatory. There was a garden.

People’s experience of using the service

People lived in a service that was continually improving but the governance systems in place had not yet been embedded into practice. The areas of concern we found during the inspection had not been identified by the provider’s own quality checking systems. We found aspects of the environment’s safety had not been identified as a potential risk to people. We found further improvement was required to people’s records and care plans. Prompt action was taken during the inspection period to address these areas.

People using the service benefitted from caring, dedicated staff. People we spoke with all confirmed they were happy and well looked after at Southwater Residential Home.

People and their families were placed at the heart of the service and involved in decisions as far as possible. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible.

People’s care was provided safely. The staff team were consistent, staff knew people well and supported them to move safely around the service if needed, and when they were out of the home.

People’s medicines were well managed.

People’s risks were known and managed well, promoting independence as far as possible. However, professionals were concerned changes in people’s risk and health were not always noted promptly and acted upon swiftly.

People were protected from discrimination because staff knew how to safeguard people. People told us they felt safe. Staff knowledge of people meant they were alert to signs of change which may indicate someone was not happy.

People lived in a service which had a welcoming atmosphere and was led by a committed provider and staff team.

The service were working closely with the local authority, commissioners and primary care to improve standards of care.

Rating at last inspection:

The last rating for this service was Requires Improvement (published 13 December 2018).

The provider completed an action plan after the last inspection to show what they would do and by when to improve. The provider had conditions on their registration which included monthly reports to the Commission.

At this inspection we found improvements had been made in many areas, however not enough improvement had been made in all areas and there was still a breach of regulations.

The last rating for this service was requires improvement. The service remains requires improvement. The service has been rated requires improvement for the last two inspections.

Why we inspected:

The inspection was prompted in part due to concerns received about people’s care, record keeping, medicine practices and people’s nutrition. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements in some areas. Please see Safe, Effective, Responsive and Well-Led sections of this full report.

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

The provider took action to mitigate the risks related to the environment and security following the inspection. They were working to address the other areas identified in inspection feedback. Monthly reporting to the Commission remains in place.

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

Enforcement:

We have identified breaches in relation to Good Governance in the Well Led report section at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up:

We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned based on the rating. If we receive any concerns, we may bring our inspection forward.

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

When we last inspected the service in March 2018 we found eight breaches of the Health and Social Care Act 2008 and associated regulations. The overall rating for the service was ‘Inadequate ‘. It was rated Inadequate in two domains; ‘Is it safe?’ and ‘Is it well led?’ It was rated ‘Requires Improvement’ for ‘Is it effective?’ and ‘Is it responsive?’ It was rated Good for ‘Is it caring?’ The Care Quality Commission (CQC) issued requirements for breaches of the regulations related to consent and the employment of fit and proper persons. We took enforcement action against Southwater regarding breaches of the regulations related to safe care and treatment, staffing and governance. We imposed a condition on the provider’s registration, requiring the provider to send a monthly progress report on the areas of greatest concern and risk. The provider also changed their registration to reduce the number of people living at the service from up to 18, to seven. The service was put 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, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

The provider sent an improvement plan outlining the immediate steps being taken to protect people and improve the service, and continued to send monthly progress reports to CQC which showed ongoing improvements. This comprehensive inspection in November 2018 was carried out to check whether the improvements made had been sustained and the service was now providing safe and effective care to people. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, the service is now out of special measures.

Prior to the inspection in March 2018 Southwater had developed a joint action plan with the local authority under their ‘Provider of Concern’ process. The majority of the actions in the plan had been completed when it was reviewed in October 2018, and the service continues to be monitored by the community nurse team and local care trust.

At this inspection in November 2018 we found action had been taken to address all areas of concern, but improvements were still needed. Some care plans contained inaccurate information, and were not person centred. People had not been consulted when their care plans were reviewed or their end of life wishes documented. In addition, the systems in place for assessing and monitoring the quality of the service, had not identified these issues, which meant they were not yet fully effective.

When we last inspected in March 2018, the registered manager had needed to take an unplanned leave of absence from the service and there was nobody with the knowledge and training to manage, monitor and carry out the day to day running of the service in their absence. At this inspection we found there was now a management team at Southwater who were able to carry out the day to day running of the service in the registered managers absence. The registered manager and management team acknowledged the areas in which the service needed to develop and improve, and were working with the local authority to make this happen. “One person living at Southwater told us, “I think it’s a well-oiled machine…They are a good team.”

When we last inspected in March 2018 we found people did not receive safe or effective care because staff did not always have the competence, skills and experience required, or receive the necessary support and training. People were at risk because there were not always trained staff available to administer their medicines. Staff did not understand the legislative frameworks designed to protect people’s rights. At this inspection we found staff had detailed knowledge of people's individual risks and the measures necessary to minimise them. Their practice was routinely monitored through supervision and observation. All staff had completed relevant training which meant people were now receiving safe and effective care and their legal rights were protected. People were receiving their medicines safely. Staff documented the support provided on the computerised care planning system, and referred people promptly to external health professionals if required. The community nursing team were available daily for advice and guidance. Risks were further mitigated because the service now only supported people with low level needs.

At the last inspection we found staff were not always available to meet people's needs and keep them safe. At this inspection we found the staff team had stabilised and the rotas were clear and easy to follow. Staff were visible and safely supporting people throughout our inspection. One person told us, “When I ring my bell they come pretty quick. There’s always somebody overnight if you need them.”

At the last inspection we found people were not always protected from risks posed by the environment. At this inspection we found people now lived in an environment which had been assessed to ensure it was safe.

People had previously been at risk because the service did not routinely ensure prospective staff were suitable to work with vulnerable people before employing them. We found staff were now recruited carefully and appropriate checks had been completed to ensure they were safe to work with vulnerable people. People were protected from abuse because staff understood and knew what action to take if they suspected someone was being abused, mistreated or neglected.

People did not face discrimination or harassment. People’s individual equality and diversity was promoted and staff were committed to this. Staff promoted people's independence and treated them with dignity and respect. People were supported to make choices about their day to day lives, for example how they wanted their care to be provided and how they wanted to spend their time. The service ensured people and their advocates where appropriate, were fully consulted and involved in all decisions about their lives and support. At the time of the inspection they had not been consulted about the content of their care plans however, although action was being taken to address this before the end of the inspection.

People had sufficient to eat and drink and received a balanced diet. Care plans guided staff to provide the support they needed. People spoke very positively about the food and choices available. They enjoyed the ambience of the dining room and socialising there with friends.

The service was proactive in identifying and meeting the information and communication needs of people living with dementia and/or experiencing sensory loss.

There was a regular afternoon activities programme at the service. People were supported to participate, but it was their choice to do so. People were also supported to pursue their own hobbies and interests, and maintain links with their families and local community.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The actions we have taken can be found at the back of the full version of the report.

Southwater is a family run ‘care home’ which offers accommodation with care and support to up to 18 older people. Nursing care is not provided by the service. This service is provided by community nurses. At the beginning of the inspection there were 12 people living at the home. However, during the inspection more appropriate accommodation was being sought for two people with complex needs. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The home was managed by a person who was registered with the Care Quality Commission as the provider and registered manager for the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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 had needed to take leave of absence for personal reasons. However no contingency plans were in place for this eventuality, and there was nobody with the knowledge and training to manage, monitor and carry out the day to day running of the service. In their absence wider concerns were raised about the leadership and management of the service. A family member stepped in to support the service in the role of ‘business manager’, although they had no previous experience of working in the care sector. An interim deputy manager was working at the service for three mornings a week. On the final day of the inspection the registered manager commenced a phased return to work.

During this inspection we identified a number of issues which impacted on the quality and safety of the support provided. This included issues around medicines administration, the assessment of risk, care planning, staffing levels and deployment, training, management and leadership and protecting people’s rights under the Mental Capacity Act 2005.

People were not always being protected from the risks associated with medicines. The registered manager had previously taken sole responsibility for this task. In their absence there were no other staff able to administer medicines because they did not have the skills or training. By the time of the inspection three members of staff had been trained and further training was planned. Despite this there were not always trained staff available to administer people’s medicines. On one occasion three people did not receive their medicines as prescribed and pain relief was not offered.

Risk assessments were not always completed or accurate, or had not been reviewed when people’s needs changed. This impacted on the monitoring and management of risks related to people’s food and fluid intake, tissue viability and moving and handling needs. Care plans did not consistently provide the guidance staff needed to understand and meet people’s needs in line with their preferences. They did not consistently document people’s end of life wishes. Formal reviews had not been completed or documented which meant some of the information on the care planning system was out of date, for example related to moving and handling needs.

Staff did not have the training required to enable them to meet people’s needs and keep them safe. There was no evidence that mandatory training had been updated. Staff had not been trained to administer medicines, which meant there had been no staff available to do this task in the absence of the registered manager. People were at risk because staff had not completed training in pressure area care. People were at risk of dehydration and malnutrition, because staff had not completed the training required to enable them to accurately identify and monitor risk.

There were not always enough staff on duty to meet people’s physical care needs. Rotas did not accurately reflect the number of staff on duty. Staff were themselves unclear about who was working and when, whether there would be a trained member of staff on duty to administer medicines or who was providing management cover. On one occasion there was just one member of care staff on duty for an afternoon shift.

People were not always referred promptly to external healthcare services, and health professionals told us that their advice was not always followed. This meant people were at risk of deterioration in their physical health.

The service did not routinely ensure prospective staff were suitable to work with vulnerable people before employing them. During the inspection a new member of staff completed shifts at the service before evidence of their suitability to work with vulnerable people had been obtained.

People’s rights under the Mental Capacity Act 2005 were not always being respected. Capacity assessments and best interest decisions had not been completed; however staff had a good understanding of consent issues in day to day practice.

The environment was not always safe for people. Regular health and safety checks were undertaken, and some maintenance checks carried out but there was no evidence that electrical equipment had been tested for safety, or legionella and temperature checks undertaken on the water outlets.

There was a lack of consistency in how well the service was managed and led. People and their relatives spoke highly of the registered manager and told us the service was well run. Staff told us they were well supported. However, during the inspection we found that management had not been effective at identifying quality and safety concerns or addressing them.

The service responded promptly to concerns raised during the inspection process and took immediate action to address them. They were open and transparent with the staff team about the concerns raised and the expectations of the CQC and local authority in improving the quality and safety at the home. They had also been open and transparent with the people living at Southwater who were aware of the difficulties facing the service.

People told us they were able to make decisions about how they wanted to be cared for, including where they spent their time. We observed that staff showed concern for people’s well-being in a meaningful way, and supported them with patience and kindness. People told us staff were caring and compassionate. Many staff had been working at Southwater for several years and had a good understanding of people and their needs and preferences.

People chose to eat in the dining room or in their room if they wished. They spoke very positively about the quality of the food and choices available and enjoyed the evening buffet supper which gave them an opportunity to socialise with other people living in the home.

There was an activities programme in place which was highly valued by people at Southwater. People were supported to participate and contribute to the development of the programme , including people with significant sensory loss. There were ‘one to one’ sessions for people who were cared for in their rooms.

Staff understood how to report concerns about people’s well-being and welfare. Systems were in place for the management of complaints.

We identified a number of breaches of regulation on this inspection. You can see what action we told the provider to take at the back of the full version of the report.

Southwater residential home offers accommodation with care and support to up to 18 older people. Nursing care is not provided by the service. This service is provided by community nurses. At the time of our inspection there were 10 people living at Southwater. The home is a large converted 1930’s house, with many original features and has an attractive, well maintained and secluded garden.

At the time of our inspection the provider was also the registered manager, and is referred to as the registered manager throughout the report. 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 service provided excellent and innovative person centred care. People were supported to maintain their interests by a staff and management team that not only respected the persons adult status, but treated them as individuals. Activities were varied and tailored to their preferences, interests and wishes. People were able to make suggestions and discuss improvements and changes at any time. They felt listened to and put at the centre of their care. The whole ethos of Southwater is centred around making sure that people feel at home and part of an extended family creating a home from home environment. Southwater constantly strives to listen to people and does everything possible to ensure that everyone living and visiting the home feels comfortable and at ease. Comments from visitors include "we've hit the jackpot! It's a wonderful place" and "delighted to have found such a lovely home".

People told us that they were supported by staff that were kind and caring. Relatives of the people who lived at the home felt welcomed and supported by all of the staff. Staff had time for people and treated them with respect. People received care in a dignified manner that protected their privacy. Staff encouraged people to be as independent as possible and offered them choices in their day to day living.

People told us they felt safe, and we found that the registered manager had a number of systems and processes in place to promote safety. Staff received training in and understood their responsibilities in relation to safeguarding of vulnerable adults. We found risks to individuals were well assessed and clear plans were in place to minimise these risks. People had been involved in planning the care and support they received from the service. Their needs had been identified, assessed and reviewed on a regular basis.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Care plans contained assessments of people's capacity to make decisions in line with the Mental Capacity Act 2005. We found that people’s consent had been obtained for care and treatment provided to them by the home. We found that none of the people living at the home lacked capacity to make a decision. While no applications to deprive people of their liberty had needed to be submitted, policies and procedures were in place. The registered manager and care staff had received training in the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and understood the principles of the MCA and when an application should be made.

People received personalised care and staff treated them as individuals and with respect. Staff knew peoples' likes and dislikes. We saw staff offering people choices. People who lived in the home told us how they made choices in relation to their care and support. For example when they wanted to get up, what they wanted to eat and where they wanted to spend their day.

People were protected from the risk of abuse as staff could demonstrate they understood what constituted potential abuse or poor care. Staff knew how to report any concerns and they felt confident the service would address these appropriately.

The home ensured that they had the correct staff recruitment process in place. Staff files sampled demonstrated that the home had carried out interviews to assess people's suitability for employment and had made the necessary Disclosure and Barring Service (DBS) check. We found that some staff files we sampled did not contain the required references and two files did not contain a full employment history or an explanation about any gaps in employment. This meant that insufficient information about their suitability to work with vulnerable adults was available in respect of some staff. This was brought to the attention of the registered manger who immediately updated the staff files, improving the interview checklist and applied for new references. These actions were all completed and presented to the lead inspector prior to the report being written.

Staff rotas showed that the staffing remained at the levels required to ensure all peoples needs were met and helped to keep people safe. Staff told us they worked as part of a team, that Southwater was a good place to work, that they felt supported, morale was good and people were happy in their work. Staff had received sufficient training to support them to carry out their jobs. They received regular supervision and appraisal. They told us they felt listened to and were comfortable making suggestions.

We found the provider had audits in place to check that the systems at the home were being followed and people were receiving appropriate care and support. People's comments and complaints were responded to appropriately and there were systems in place to seek feedback from people and their relatives about the service provided. We saw that any comments, suggestions or complaints were appropriately actioned.

Below is a summary of what we found. The summary describes what people using the service and the staff told us, what we observed and the records we looked at. If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

One person we spoke with described living at the home as 'I don't think anything here could be improved. Anything you ask for you get".

The service was safe because people had been protected against the risks associated with medicines because the provider had appropriate arrangements in place to safely manage medicines.

Care staff received regular training and supervision to ensure that they could meet people's health care needs.

Systems were in place to make sure that the Registered Manager and care staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The Care Quality Commission [CQC] monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had needed to be submitted, policies and procedures were in place. The Registered Manager and care staff had been trained to understand when an application should be made and how to submit one.

Is the service effective?

The service was effective because we found that people's consent had been obtained for care and treatment provided to them by the service.

People's health and care needs had been assessed with them or their representative and they had been involved in writing their plans of care

Is the service caring?

The service was caring. We spoke with five people who lived at the home. We asked them for their opinions about the staff that supported them. Feedback from people was positive, for example; 'Staff are never too busy to help you. I haven't got to ask for anything".

When speaking with and observing care staff during this inspection it was clear they genuinely cared for the people they supported. They told us about people's individual health and social care needs and how these needs had been met in an individual way.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The service was responsive. We spoke with five people who lived at the home. We saw from records that planned care and treatment had been provided in line with people's individual care plans. Aspects of people's needs or care had been linked to risk assessments. Specialist health needs had been identified where required and appropriate health care professionals had been consulted and involved in providing care.

Is the service well-led?

The service is well led. The service had a quality assurance system, and records showed that identified problems and opportunities to change things for the better had been addressed promptly. As a result the quality of the service was continuously improving.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and quality assurance processes were in place. This helped to ensure people received a good quality service at all times.

We saw there was an effective system in operation which had been designed to enable the provider to regularly assess and monitor the quality of the services provided. For example during 2014 the Registered Manager had sought feedback from health care professionals who had visited the home. The Registered Manager told us and people who lived at the home confirmed that their opinions about the running of the home are sought on a daily basis.

One person described the home as a "the best place I could be". Another person said "It is absolutely marvellous here, we are spoiled rotten.'

We saw that care workers interacted with people in a relaxed, friendly and respectful manner. Care workers worked with and supported each individual at their own pace.Their independence was respected and encouraged. People appeared well cared for and said they were happy.

We saw people had a choice of suitable and nutritious food and drink available in sufficient quantities. People said the food was good. One person said 'the food is always good.'

Care workers were skilled and experienced and most had worked at the home for many years. Care workers had received training in safeguarding vulnerable adults and recognising abuse and knew how to report any concerns.

We looked at the quality assurance methods used to monitor the quality of care delivered. We saw that there were numerous systems in place to assess the risks and ensure safe delivery of care.

We spoke with six of the eight people living at the home and three staff. We also spent time observing care and looked at three care plans. One person said 'My life has completely changed since moving here, I am really happy.' One member of staff described the home as a 'Real family'. All the staff we spoke with were positive about the support they received.

People told us that they were involved in discussions and decisions about care. One person said 'We are always being asked for our opinions'.

People enjoyed their social lives and could choose how to spend their days. Staff demonstrated a good understanding of how to protect people from abuse. People's health and welfare needs were well met. Risks to people's health and wellbeing were identified and plans were in place to manage these risks.

Staff at the home were positive about their work and the rewards it brought. They felt well supported by the management at the home and confident that they could get advice and support. People's needs were met by staff who were skilled, trained and who received supervision.