Archived: Laurel Bank

On 17 March 2017 we received information of concern following visits made to the service by the Clinical Commissioning Group (CCG). The concerns related to risk management in terms of monitoring people’s weights, ensuring adequate nutrition and hydration and people being nursed continually in bed when there was no clinical reason why they could not get up. As a result we undertook a focused inspection to look into these concerns. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Laurel Bank on our website at www.cqc.org.uk.

We inspected the service on 20 March 2017. The inspection was unannounced.

Laurel Bank provides accommodation and nursing care for up to 37 older people. The property is a converted house which has been extended. Accommodation is spread over two floors and includes single and shared rooms. There are a variety of communal areas including lounges, a dining room and an enclosed garden. There were 24 people using the service when we visited.

The home has a registered manager who has been in post for many years. 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.

Many of the issues we identified at the inspection as detailed below, were raised at our inspection in February 2017 and have not been resolved by the provider.

We found people’s nutritional needs were not being met. Records showed people had lost significant amounts of weight or had been of very low weight for several months, yet no action had been taken by nursing staff to explore this and steps had not been taken to boost people’s calorie intake to help them gain weight. There was no evidence to show weighing equipment had been calibrated to make sure it was recording accurately. The last calibration date for one set of scales was 2013. Although the CCG had identified issues with the weighing scales and had asked for people to be re-weighed, we saw only 16 out of 24 people had been re-weighed.

Food and fluid charts were poorly completed, there was no evidence to show people were receiving regular snacks. Where people were having their fluid intake monitored there was no record to show the daily target intake and when we asked staff how much fluid people should be having they said they didn’t know. There was no evidence to show nurses were reviewing the food and fluid charts and the deputy manager acknowledged this wasn’t done. We saw charts which showed people had received very little to eat and drink, yet this had not been picked up or acted upon by the nursing staff. We saw some people were being nursed in bed and were not getting up on a regular basis.

Some people were having thickening agents added to their drinks. For two people the thickeners were not prescribed on the MARs. There was not always information recorded to show how much thickener people should be having in their drinks and when we asked staff they were not clear with some telling us everybody had one scoop per 200mls and others said they gave two scoops per 200mls.

We saw Personal Emergency Evacuation Plans (PEEPs) had not been updated and some people had changed rooms and this was not reflected in the PEEP. This meant in an emergency the fire brigade would not have the correct information if they needed to evacuate people. We found weekly fire alarm tests had not been completed since 1 March 2017.

There were ongoing problems with the hot water supply and many bedrooms had no hot water. Staff told us they had to fetch hot water from the kitchen to take to people’s bedrooms so people could have a wash. Although plumbers were on site trying to fix this issue staff we spoke with said there had been problems with the hot water for a long time. In one occupied bedroom we found there was a leak from the ceiling into the room.

Following the inspection a safeguarding meeting took place with the provider and an immediate protection plan was agreed and enacted which ensured people in the home were safe and received the care they required.

The Care Quality Commission is considering the appropriate regulatory response to resolve the problems we found. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded

The overall rating for this service is ‘Inadequate’ and the service remains 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.

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 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.

We inspected this service on 6 July 2016 and rated it ‘Inadequate’ and in ‘Special Measures’. We found five regulatory breaches which related to staffing, consent, dignity and respect, safe care and treatment and good governance. We took enforcement action and issued warning notices for the breaches related to safe care and treatment and good governance. The warning notices stated the provider had to address these breaches by 31 August and 1 September 2016 respectively. Following the inspection the provider sent us an action plan which showed how the breaches would be addressed. This inspection was to check improvements had been made and to review the ratings.

Laurel Bank provides accommodation and nursing care for up to 37 older people. The property is a converted house which has been extended. Accommodation is spread over two floors and includes single and shared rooms. There are a variety of communal areas including lounges, a dining room and an enclosed garden. There were 25 people using the service when we visited.

The home has a registered manager who has been in post for many years. 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.

Overall although we found new systems and processes had been put in place since our last inspection to improve the service we found these were not effective and people were not receiving the care and support they needed. Feedback from people and relatives was mixed with some expressing satisfaction with the care whereas others raised a number of concerns.

Some improvements had been made to the way medicines were managed. For example, better storage arrangements were in place and all the nurses had been trained in medicines and had their competency assessed. However, we found concerns still remained in relation to medicines given on an ‘as required’ basis and nutritional supplements.

Risks to people were not well managed particularly those relating to people falling and their nutritional needs. For example, we found one person had sustained several falls yet assessments had not been reviewed or updated to look at how these risks could be reduced and managed. Similarly the risks to people who had lost weight or who were low weight had not been assessed and managed to ensure people were getting enough to eat and drink.

Some people told us they didn’t feel safe and they felt there were not always enough staff. We found there were times when there were no staff in communal areas. The registered manager was not able to explain or show us how staffing levels had been calculated. We found safeguarding incidents were not always recognised or reported to the appropriate authorities.

We found some parts of the building were clean and comfortably furnished. In contrast others areas were not. We found two rooms were cold and the water from some of the hot taps was only lukewarm.

We found safe recruitment processes were in place and staff received an induction when they started working at the home. Many of the staff had qualifications in health and social care. Some staff training had been delivered since the last inspection, however there remained significant gaps in areas such as safeguarding, fire safety and dementia care. Systems were in place to ensure staff received supervision and appraisal.

People had mixed views about the food as some said they enjoyed it whereas others did not. Similarly some people and relatives praised the staff, yet others felt there were inconsistencies and described some staff as good but said others were not. People told us they were treated with respect.

People’s social care needs were not always met. Although activities were provided which some people enjoyed, other people told us they felt lonely.

A complaints procedure was in place however we found this was not always followed when complaints had been raised.

People’s care records were not always accurate, up to date or person-centred. People told us they had not been involved in planning their care. People had access to healthcare professionals however we found this support was not always accessed in a timely way.

People and relatives’ views about the registered manager were varied. We saw the registered manager and deputy manager worked with the staff team, however we concluded there was a lack of effective and strong leadership. Quality assurance systems had been put in place however these were not fully embedded or robust which is evident from the continued breaches we found at this inspection.

We found continued shortfalls in the care and service provided to people. We identified nine breaches in regulations. These related to staffing, safeguarding, person-centred care, dignity and respect, consent, complaints, the premises, safe care and treatment and good governance. The Care Quality Commission is considering the appropriate regulatory response to resolve the problems we found. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded

The overall rating for this service is ‘Inadequate’ and the service remains 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.

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 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.

At the last inspection in September 2014 the home was compliant with the standards we looked at.

We inspected the service on 6 July 2016. On the date of the inspection 29 people were living in the home.

A registered manager was in place. 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.

People and relatives provided positive feedback about the service and told us people were well cared for, treated well and that individual needs were met. We found the management team were very ’hands on’ and regularly got involved in care and support. This created a friendly and pleasant atmosphere within the home and we saw some examples of good care and support being delivered. However we identified a number of unacceptable risks which were not adequately controlled. As many of these had not been identified by the service, we concluded there was a lack of proper oversight of the service and systems to assess, monitor and improve the service were not fit for purpose.

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People told us they felt safe living in the home and said they had never witnessed anything of concern. In most cases, risk assessments were in place which considered risks to people and provided staff with guidance on how to provide appropriate care. However we identified where bed rails were in situ, the risks associated with these had not always been assessed.

Medicines were not safely managed. Medicines were not always stored securely and some of the practices we witnessed during the medicines administration round were unsafe.

There were sufficient quantities of staff deployed to ensure people were responded to in a prompt manner. Safe recruitment procedures were in place to ensure staff were of suitable character to work with vulnerable people. However staff were not all up-to-date with key safety related training.

The premises had a homely feel and people were encouraged to personalise their bedrooms. Key safety checks were undertaken on the gas, electrical and lifting equipment. However water temperatures were not monitored to ensure they were safe and we found a number of outlets where water was not warm enough.

People said staff had the right skills and personal attributes to care for them. However training had been provided in an inconsistent manner with a number of staff not receiving training in key subjects. Some staff had not received timely supervision or appraisal.

Most people praised the food and said it was tasty and there was sufficient variety. Where people were assessed as being nutritionally at risk, appropriate action was taken to address.

The service needed to take action to ensure it was working within the legal framework of the MCA and evidence that decisions made for people without capacity were done as part of a best interest process. Staff we spoke with did not have a good understanding of Deprivation of Liberty Safeguards (DoLS) and who had one in place.

People’s healthcare needs were assessed by the service and plans of care put in place. Care was co-ordinated with a team of external health professionals where required.

People told us staff were friendly and treated them well. We observed that staff knew people well and understood people’s likes, dislikes and personal preferences. However we identified a number of working practices which demonstrated people were not consistently treated with dignity and respect or in a fair manner.

People’s needs were assessed and plans of care put in place. These were well understood by staff. However some care plans needed more detail to demonstrate the exact nature of the care required.

An activities co-ordinator was employed and provided people with a range of activities. A new activity plan being recently been agreed to increase the variety of activities available to people.

People and relatives expressed a high level of satisfaction with the service. A complaints policy was in place and we saw evidence it had been followed.

Audits were undertaken to help assess monitor and improve the service. However many of these were not sufficiently robust as a number of risks we found had not been identified by the service.

Incidents and accidents were recorded and we identified no concerning trends. However there was a lack of evidence of preventative measures put in place following incidents.

We found breaches of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Registration Regulations 2009. You can see what action we asked the provider to take at the back of this report.

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, 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.

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 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.”

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

Below is a summary of what we found. The summary is based on our observations during

the inspection, discussions with people using the service, the staff supporting them and

looking at records. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

We saw the service had assessed risk of people living at Laurel Bank and had put plans in place to reduce risk where possible. We found sufficient levels of staff working to keep people safe. Medication was stored and administered in a safe way.

Is the service effective?

Care plans showed peoples' assessed needs, taking into account peoples' own preferences. People told us they were involved in developing their own care plans. The premises had been adapted to suit those people living in the service. Visitors confirmed they could visit whenever they wanted.

Is the service caring?

We saw staff talking to people using their preferred names and treating them with respect while maintaining their dignity. People told us the staff were very good and treated them well. Family members told us they were very happy with the service provided and would recommend the service to others.

Is the service responsive?

People completed a range of activities inside and outside the home on a regular basis and care was given in line with peoples' care plans. People told us they were aware how to complain if they needed to. One family member told us any concerns they had raised had been actioned. People can therefore be assured that complaints are investigated and action taken as necessary.

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. The service had a quality assurance system in place and records seen by us showed us that identified shortfalls were addressed promptly. As a result the quality of the service was continually moving forward.

One person we spoke with said their relative had lived at the home for 'a few years' and they felt the care was very good. They told us 'If there are any problems they always put it right; they are very good.' Another relative we spoke with was also very pleased with the care provided. They said 'The staff help my relative to do what they like. Sometimes they like to stay in bed a bit later, sometimes they don't ' it doesn't matter to the staff.'

The people who used the service all told us they felt safe living there. They told us the food was good and if they didn't like the menu option, they could ask for something else. Everyone said they got plenty of choices about their daily living. One person told us, 'It's lovely. They are always cleaning here. The rooms are kept clean and tidy and my sheets are changed regularly ' they meet all my needs.'

We observed people who used the service doing gentle exercise whilst enjoying a game of giant snakes and ladders by using a large sponge die, which people threw onto the floor to roll. This activity was facilitated by the activities co-ordinator. We saw that care staff were interacting well with people who used the service and actively encouraged others to get involved.

We found some records, including people's medical records, were not accurate and fit for purpose. We also found records for people who used to live at the home were not stored securely.

We found that there were enough and they had been deployed in a way that provided care and support for people sitting in the communal areas.

We spoke with three people who lived at the home and they told us:

'It's excellent here, I have no complaints at all.'

'The staff are very good and I get on well with all of them.'

'They do a good job arranging entertainment for us, there is all sorts of things happening before Christmas.'

'The staff will do anything for us, nothing is too much trouble.'