Archived: The Limes Care Home

There was not a registered manager in post. An application for the current manager to become the registered manager had been made to CQC. 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.

At this inspection we found that the provider had failed to ensure that previous improvements had been sustained. We found that there were five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'. You can see what action we have taken at the back of the full version of this report.

On the day of our inspection people were not cared for safely. Staff knew how to safeguard people against abuse however staff did not have the appropriate competencies and skills to provide safe care. Staff did not respond appropriately and in good time to people's changing needs.

Medicines were not managed appropriately and safely. People did not always get their medicines as prescribed. The management of infection prevention and control did not mitigate the risk of cross infection.

Staff did not follow care plans when delivering care. Staff did not respond in an appropriate manner to people and did not always provide emotional support to people. Staff were not consistently kind to people when they were providing support. People did not have their privacy and dignity considered. Staff were able to tell us about people’s needs but we did not see care being provided in a way that met their needs.

We found that people’s health care needs were assessed however care was not planned and delivered to meet those needs. People had access to healthcare professionals such as the district nurse and GP and also specialist professionals. However we observed medical assistance was not always provided in a timely manner.

Staff did not always provide care according to their training. Staff were provided with training on core areas but had not received training in areas specific to the needs of people who lived at the home such as care of people with dementia. The provider had a training plan in place and staff had received supervision.

The provider did not always act in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA provides the legal framework to assess people’s capacity to make certain decisions, at a certain time. If the location is a care home the Care Quality Commission is required by law to monitor the operation of the DoLS, and to report on what we find.

People did not have their nutritional needs met. People had their nutritional needs assessed but were not always supported with their meals to keep them healthy. Where people had special dietary requirements we saw that these were not consistently provided for. People had choices at mealtimes.

People had access to limited activities. Signage in the home was poor and not provided in a manner which assisted people with dementia to orientate themselves.

Records were not accurate and did not include a record of the care and treatment provided to the service user and of decisions taken in relation to that care. Care plans were not updated consistently and did not reflect the care people required.

Systems were not in place to adequately assess, monitor and improve the quality and safety of the services. Audits were in place for areas such as medicines and infection control however they had not consistently improved the quality of care. Accidents and incidents were recorded and analysed.

Staff felt able to raise concerns and issues with management. Relatives were aware of the process for raising concerns.

The provider had informed us of notifications as required by law. Notifications are events which have happened in the service that the provider is required to tell us about. The current rating was not displayed on the provider‘s website as required by law by CQC.

Is the service safe?

During our inspection on 20 May 2014, where people did not have the capacity to consent, the provider had not acted inaccordance with legal requirements. It was not clear in the records whether people had capacity to consent to care.

The Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) are laws which protect people who are unable to make decisions for themselves.

The provider sent us an action plan which told us how they planned to address the concerns.

During our review on 31 July 2014, we found that the provider now had a process in place where people's capacity to consent had been reviewed. The provider had also taken action and amended a care plan audit which included when people's capacity to consent to care had been undertaken and if and when they were due for review.

We considered the findings of our inspection to answer questions we always ask: Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? This is a summary of what we found-

Is the service caring?

We observed care and saw how members of staff treated people. We saw care was delivered well and in a respectful way. We saw that staff were kind and attentive and encouraged people to participate in their care. Staff also showed patience and

gave encouragement when they supported people.

During our inspection we observed staff spoke with people on an individual basis and understood their particular needs. For example, we observed when staff provided care to people they chatted with them about things which were important to them such as their family.

We observed when staff supported people they did so at people's own pace and encouraged people to participate in their care. For example, when they supported people to move they asked them if they were okay and explained what they were doing whilst supporting them.

Is the service responsive?

We saw that people's individual physical, mental and social care and support needs were assessed and met. We saw evidence that care plans had been recently reviewed.

During our inspection we saw staff gave people choices and asked them what they would like to do before assisting them. For example, when offering drinks people were given choices about what drink they would like and if they would like a biscuit with their drink.

We observed staff obtained people's consent before they carried out any care. For example, staff asked people if they wanted support with a task and where they would like to eat their meal at lunchtime.

Is the service safe?

Risk assessments regarding people's individual care needs, for example falls and mobility were carried out and measures were in place to minimise these risks. The service had risk assessments in place for areas such as falls and skin care.

The home had policies and procedures in relation to the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) in place. Mental Capacity Act (2005) and Deprivation of Liberty Safeguards are laws protecting people who are unable to make decisions for themselves.

However, where people did not have the capacity to consent, the provider had not acted in accordance with legal requirements. It was not clear in the records whether people had capacity to consent to care.

At the time of our inspection there was no one who was considered to be deprived of their liberty.

The service was safe, clean and hygienic. We saw that regular checks were made on the cleanliness of the building. We observed some refurbishment had taken place since our previous inspection.

Is the service effective?

Our observations found that members of staff knew people's individual health and wellbeing needs. We saw that people responded well to the support they received from staff members. One relative told us that their relation had improved since coming to the home.

We observed care plans had been updated to reflect people's changing needs and where people had short term needs due to illness care plans were in place to ensure these were met.

We observed staff responded to people's needs and requests in a timely manner.

Is the service well led?

Staff said that they felt supported and trained to safely do their job. They told us they felt able to raise issues with the managers and had opportunity to do so at staff meetings and supervision sessions.

Quality assurance arrangements and checks were in place and people were listened to. Surveys had been carried out with relatives and people who lived at the home.

We saw evidence learning took place following incidents. Processes were in place to monitor incidents and accidents in order to prevent them occurring again. Audits had been carried out and action plans put in place to ensure the continual improvement of the service were undertaken.

We observed care and saw staff were responsive to people and interacted with them positively. We saw staff supported people to move at their own pace and safely.

We spoke with a relative. They told us the staff were, "Very,very good."

People told us the staff were caring and looked after them well. One person said, "It's not home but people (staff) are very caring.'

We looked at how people's nutritional needs were met and found people received effective nutritional support, to meet their assessed needs. People told us the food was good and we saw people were able to choose their meals.

When we spoke with staff they told us they had received training to enable them to provide appropriate care to people.

We found gaps in the records we looked at which meant people were at risk of receiving inappropriate care.

At our last inspection on 4 October 2012 we issued a compliance action, as we were concerned there were not sufficient numbers of suitably qualified, skilled and experienced persons available in order to safeguard the health, safety and welfare of people.

During this visit we spoke with the registered manager and a member of care staff. We also looked at a range of documentation.

We found additional staff had been recruited to to support care staff during the busy periods,for example mornings and evenings. These were new roles and the staff were called 'hostesses'. The provider had also employed staff to carry out cleaning and laundry services. When we spoke with a staff member they told us, "The staffing is better." They said they thought the new roles worked well and they were working as a team to support people.

When we looked at the staffing rotas we saw they were as the manager had told us and incuded the additional staff.

At our last inspection of The Limes on 4 July 2012 we issued a compliance action, as we were concerned staff were not receiving appropriate support to enable them to carry out their role. We were concerned that at this time no member of staff had received an appraisal.

Following this visit we received an action plan from the provider to address the issues. In the action plan the provider said they would provide all current staff with an appraisal by September 2012.

During this visit we spoke with the registered manager by telephone, relatives and three care workers. We checked a range of documentation and checked on the progress the manager had outlined at the meeting. We requested additional information which we have received.

We found all staff had received an appraisal by 30th September 2012. .

We spoke with staff and they told us they had found the appraisal process useful.

We did not intend to follow up on outcome 13 but during our visit we spoke to staff and relatives who raised concerns about staffing numbers. We also observed incidents where people did not receive their care in a timely manner.