Archived: Cairn House

Cairn House is a care home providing personal care and accommodation for up to five adults with a mental health need. The home is a large semi-detached house situated on the main bus routes close to a busy slip road leading off Eccles Old Road onto the A6. The driveway and back garden are shared with the house next door, Lancaster House, which is also a care home owned by the same provider. At the time of inspection five people were using the service.

The home was last inspected on 25 and 27 January 2017, when we rated the service as ‘requires improvement’ overall. We identified nine breaches in six of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including continuing breaches relating to premises and equipment, staffing and good governance along with additional breaches relating to safe care and treatment, management of medicines, person-centred care and receiving and acting on complaints.

We took enforcement action and issued the provider and registered manager with a warning notice in regards to good governance, to formally request action be taken to ensure quality assurance and auditing systems were in place and being utilised. We also asked the provider to take action to ensure people were actively involved in their care, ensure staff received the necessary support and professional development to enable them to carry out their roles effectively, assess the risk of and control the spread of infections, ensure the proper and safe management of medicines and ensure they had an system for the identifying, receiving, recording and handling of complaints.

At this inspection we identified five continuing breaches in four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including breaches relating to, staffing, safe care and treatment, management of medicines, person-centred care and good governance, two additional breaches in relation to safe care and treatment and record keeping along with one breach of the Care Quality Commission (Registration) Regulations 2009, due to a failure to inform the Commission of a notifiable incident. We also made two recommendations in regards to following best practice in relation to the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) and investigating systems to evidence sufficient staff are employed to meet people’s needs. We are considering our enforcement options in relation to the regulatory breaches found.

At the time of the inspection the home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found remedial action had been taken to address previously identified issues with the overall décor and maintenance of the property. A schedule of works had been produced, which the provider and registered manager had overseen. Bedrooms and bathrooms had been re-decorated, damaged or broken fixtures and fittings had been replaced and attempts to de-clutter communal areas had taken place. We noted work was ongoing and the replacement of carpets had purposefully been left until last, to ensure all building and painting tasks had been completed.

We saw staff continued to be responsible for cleaning tasks, with checklists in place detailing what tasks were required in each room. Cleaning equipment was stored safely and securely and Control of Substances Hazardous to Health (COSHH) forms were in place for the cleaning products in use. We noted the provider had installed paper towel dispensers in bathrooms, to replace cotton hand towels. However hand hygiene guidance was not in place and liquid soap bottles were still being used rather than wall mounted soap dispensers.

We identified some issues during our review of medicines management. We saw the service continued to not use ‘as required’ medicine protocols or topical medicine charts. Daily audits of the Medicine Administration Record (MAR) charts had also not been completed consistently. We identified some aspects of good practice especially around the receipt and booking in of medication.

Each person we spoke with told us they felt safe. The home had safeguarding policies and procedures in place, although did not have a dedicated safeguarding file and log of referrals, with referrals stored electronically in email folders. Staff had been trained in safeguarding vulnerable adults and had knowledge of how to identify and report any safeguarding or whistleblowing concerns.

People who used the service and staff we spoke with felt there was enough staff on shift, this was due to people reportedly being very independent and requiring minimal assistance. However the home did not have a system or tool in place to show staffing levels met the dependency levels and needs of people using the service.

We looked at three care files in detail, which were stored electronically on a laptop. We found limited improvements and additions had been made since the previous inspection, with gaps in information and an overall lack of detailed guidance for staff to follow, to ensure people’s needs were being met. We saw mental health care plans and risk assessments had been created to sit alongside people’s existing care plans; however at time of inspection these had not been implemented.

We found the service was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Training in both areas had been facilitated and staff had a reasonable understanding of both sets of legislation. However we did not see any evidence of a MCA / DoLS policy in place.

Staff told us training had improved with a number of sessions being held over the last six months. These included training in mental health awareness, which is imperative to the nature of the service and had been a noticeable omission at the previous inspection. Although the training matrix had not been fully updated at time of this inspection, we were still able to confirm sessions had been held. Following the inspection the registered manager updated and forwarded evidence of this to the us.

The provider’s action plan following the inspection in January 2017 stated staff would receive supervision on a bi-monthly basis, however our review of staff records demonstrated this was not being done. Whilst there had been an increase in the frequency of meetings, staff had only completed two meetings since January.

People told us they enjoyed the food provided by the service and received enough to eat and drink. People could choose when and where to eat, with meals being prepared for people to eat later, if they did not wish to eat at the allocated meal time.

Throughout the inspection we noted a relaxed, yet positive atmosphere within the home. People we spoke with were complimentary about the staff and the standard of care received. Resident meetings had been held and people were offered the opportunity to suggest agenda items, as well as being informed about things relating to the home.

We saw a new auditing and quality monitoring system had been introduced, which had been designed by the provider. However this had not been used fully or effectively and none of the issues noted during inspection had been identified by the registered manager or the auditing process.

We noted some issues in fire safety processes when reviewing safety procedures and checks. Not all checks had been carried out in agreed timescales and personal emergency evacuation plan (PEEPS) were still not in place.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services 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.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after an

Cairn House is a care home providing personal care and accommodation for up to five adults with a mental health need. The home is a large semi-detached house and is situated on the main bus routes close to a busy slip road leading off Eccles Old Road onto the A6. The driveway and back garden are shared with the house next door, Lancaster House, which is also a care home owned by the same provider. At the time of inspection five people were using the service.

The home was last inspected on 03 May 2016, when we rated the service as ‘requires improvement’ overall. We also identified three breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to ensuring premises and equipment was properly maintained, ensuring staff received appropriate support and professional development and good governance.

At this inspection we identified nine breaches in six of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including continuing breaches relating to premises and equipment, staffing and good governance along with additional breaches relating to safe care and treatment, management of medicines, person-centred care and receiving and acting on complaints. We are currently considering our enforcement options.

At the time of the inspection the home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The service was not being cleaned effectively, with areas of dust, cobwebs and stains observed during a walk round of the premises. Infection control procedures, specifically in relation to hand hygiene practices, were not in place with no guidance available and cotton hand towels, rather than paper towels being provided in all bathrooms and toilets. However cleaning equipment was stored safely and securely and Control of Substances Hazardous to Health (COSHH) forms were in place for the cleaning products in use.

We identified on-going issues with the overall décor and maintenance of the property. We saw broken or damaged fixtures and fittings with no record that these had been noted by the service. Paintwork in a number or areas was worn, cracked or flaking away, many of the carpets throughout the property were old and stained, and in some places had started to wear through. Some of the communal areas were also cluttered, with boxes and other items left lying around, which was reported to be due to a lack of storage.

During a review of medicine management we saw the service did not use ‘as required’ medicine protocols or topical medicine charts and the system in place for documenting medicines received and in use, made it difficult to ensure stock levels were correct. We did see that the Medicine Administration Record (MAR) chart was being filled in correctly and robust systems were in place to ensure staff knew what medicines people took and at what time.

People we spoke with told us they felt safe. The home had safeguarding policies and procedures in place, with all referrals being stored electronically. Staff had been trained in safeguarding vulnerable adults and had knowledge of how to identify and report any safeguarding or whistleblowing concerns.

Although the service advertised as providing 24 hour support we saw they ran with just one staff member who worked 9.30am to 5.30pm, people we spoke with told us this was a sufficient number to meet needs during the day, however would like someone there all of the time. This had previously been in place as the service used to have a live in housekeeper; however they were no longer employed. The registered manager told us people living in Cairn were very independent and could contact staff at the adjacent service, Lancaster House, should they require any support after 5.30pm.

We looked at two care files in detail, each contained detailed, personalised information about the people who used the service, their background and life history. Care files were stored electronically and covered a range of areas including care plans and risk assessments. However one person’s risk management plan was blank and did not cover behaviours or situations which were elsewhere documented as being a potential hazard. People could not remember being involved in planning or reviewing their care and whilst the service said that care plans were reviewed monthly, the dates of completion documented did not show this.

We found the service was working within the principles of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Training in both areas had yet to be facilitated, despite being identified as an issue at the previous inspection in May 2016; however we saw that this had been sourced and was being scheduled. We found no restrictive practices in place.

Staff told us training at the service could be improved. The training matrix showed since the last inspection in May 2016, only one training session had been completed, this being in first aid. We saw that aside from this session and training in safeguarding completed in April last year, most people had not completed any additional training since their induction, in some cases this was over five years ago. Despite the service providing support to people with a mental health diagnosis, only two people had completed any training in this area.

The services supervision policy stated staff would receive supervision on a bi-monthly basis, however our review of staff records demonstrated this was not being done. One person had completed two meetings within the last 12 months, whilst another had only completed one.

People told us they enjoyed the food provided by the service and received enough to eat and drink. People could choose when and where to eat, with provision being made in the way of a packed lunch or monies being given to people who would be out during meal time.

Throughout the inspection we observed positive and appropriate interactions between the staff and people who used the service. Staff were seen to be patient, caring and treated people with dignity and respect. People who used the service were complimentary about the staff and the standard of care received.

Complaints were documented in people’s electronic care files, however a centralised log of complaints received was not in place, nor did the service have specific complaints forms which were accessible to people using the service. We also noted the complaints procedure displayed in the service was out of date and provided incorrect information.

The service advertised in its literature that people would be consulted about the service through regular resident meetings; however we saw that none had taken place for some time. We also saw that staff meetings were not being held. Staff told us the need for these meetings had been discussed, but not been arranged.

The service did complete annual quality assurance questionnaires with people using the service, relatives and professionals. People we spoke with told us they liked having their say and found the forms easy to complete.

The service did not currently use any systems or procedures to monitor the safety, quality and effectiveness of the service. The registered manager told us the only audit currently being carried out was in regards to medication, and we saw this just involved a stock count, rather than an audit of the entire process. Documentation was in place, including a comprehensive audit document, however this was reported as being too complicated to use and a revised version had yet to be drawn up. Neither fire nor environmental risk assessments were in place, although regular checks of fire equipment and fire drills had been completed.

Cairn House is a care home providing personal care and accommodation for up to five adults suffering from a mental health needs. The home is a large semi-detached house and is situated on the main bus routes close to a busy slip road leading off Eccles Old Road onto the A6. The driveway and back garden are shared with the Lancaster House, which is also a care home owned by the same provider, from which the manager for both homes is located.

There was no registered manager in post at the time of our inspection, however the current manager for the service was in the process of registering with the Care Quality Commission (CQC) at the time of the inspection. ‘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.’

During this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

During the inspection, we looked around the premises to ensure it was clean, safe and properly maintained. We found that though the premises was generally clean, it was in need of redecoration and general upgrading of facilities. In one bedroom we looked at, the carpet was very stained and worn and the curtain was hanging off the curtain rail. In another room we looked at there were damp patches visible on the wall, which needed attention and decoration. The general appearance of the home was poor and neglected in places.

Both the manager and staff acknowledged that the premises was in need of upgrading and decoration.

This was in breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, in relation to premises and equipment. This was because the service had failed to ensure the premises and equipment was properly maintained.

We found the service could not demonstrate that staff had received the appropriate support and professional development to undertake their roles. Following initial induction training, there was limited evidence of further training having been provided in relation to specific areas such as medication and safeguarding. Of the four members of staff trained in first aid, we found their qualification in had since expired. This meant there were no members of staff currently certified to administer first aid in the home in the event of an accident or emergency.

We saw that two members of staff received medication training in 2006, another two member of staff received their training in 2009 with another member of staff receiving their training in 2010. No refresher training had been sourced since then to ensure staff were following up to date guidance and good practice when administering medication.

All staff we spoke with confirmed they received supervision with the manager. However when we reviewed personnel records, supervision records were inconsistent with some staff not having had any recent supervision.

This is a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to staffing, because the provider could not demonstrate that staff received the appropriate support and professional development.

We found the service undertook a limited number of audits and checks to monitor the quality of services provided. We were told that daily monitoring of medication was undertaken, which had not been recorded. The last medication audit we looked at was dated December 2015. We found no evidence of any audits relating to the maintenance of the home or evidence that training needs were regularly monitored to ensure staff were suitably trained to undertake their roles. We found the service lacked effective auditing systems to monitor the quality of service provision.

This was a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance, because the service failed to assess and monitor the quality of service provision effectively.

People who used the service told us they were safe.

We found people were protected against the risks associated with medicines, because the provider had appropriate arrangements in place to manage medicines safely.

We found there were sufficient numbers of staff on duty during our inspection to support people who used the service.

During our inspection we checked to see how people’s nutritional needs were met. Staff prepared meals for people with choices available. We found that people’s individual nutritional needs were assessed and planned for by the home.

People told us that staff treated them respectfully, were friendly and helpful.

During the inspection we saw people were offered choices around how they wished to spend their day, or what they wanted to eat for lunch.

Staff we spoke with demonstrated a good knowledge of person-centred care principles and the importance of respecting peoples’ rights and preferences.

The structure of the care plans was clear and easy to access information. All care plans were reviewed annually with other professionals.

The home arranged ‘Keyworker Sessions’ with people to meet people’s specific needs. A member of staff would be assigned to a person to provide one-to-one support for certain areas of need or development.

We found the service routinely and actively listened to people to address any concerns or complaints.

Staff told us they believed there was an open and transparent atmosphere in the home, they felt supported in their role and that the manager was very approachable.

The home had policies and procedures in place, which covered all aspects of the service, however these were in need of review and updating to ensure the covered the most recent best practice guidance.

Our inspection was co-ordinated and carried out by one inspector, who addressed our five questions; 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, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We spoke to three people who used the service, they said they were treated with respect and dignity by the staff. People told us they felt safe.

Safeguarding procedures were in place and staff were able to demonstrate how they would safeguard the people they supported. This meant that people were safeguarded from abuse.

There were systems in place to make sure that the manager and staff learned from events such as accidents and incidents, complaints and concerns. This meant people benefited from a service that responded to feedback on how to improve the service.

The service had policies in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications have been submitted. All staff we spoke to were able to demonstrate a good understanding of the relevant legislation and had received appropriate training. From reviewing staff records, it was apparent no recent refresher training had been undertaken. The manager confirmed that refresher training in the Mental Capacity Act would be scheduled following our inspection.

The service was safe, clean and hygienic, however some areas required redecoration and some carpets needed replacing. We were reassured by the manager the service would be addressing these issues.

People who used the service and staff told us there were sufficient numbers of suitably qualified staff on duty. This helped to ensure that people's needs were always met.

Recruitment practice was safe and thorough. No staff had been subject to disciplinary action.

Policies and procedures were in place to make sure that unsafe practices were identified and people were protected.

Is the service effective?

People's health and care needs were assessed with the people who used the service or their representatives. Individual needs had been clearly identified in care plans.

Without exception, people and their relatives said that their care needs were being met.

Relatives confirmed that they were able to visit their loved ones at any time and speak in private. They felt welcomed by friendly and caring staff. One relative told us; 'I can turn up at anytime, I'm always made to feel welcome.'

Is the service caring?

We observed people were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. People commented, 'I come and go when I want but always let the staff know where I am. I even go to church every week.' 'I feel safe, I'm not worried about anything.' 'Staff are very good on the whole.' 'I think my X is well happy here.'

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

People who used the service and their relatives completed satisfaction surveys where shortfalls or concerns raised were addressed.

Is the service responsive?

People completed a range of activities inside and outside the service regularly. People were taken out on trips and visits to local attractions and places of interest.

People we spoke to were aware of the complaints procedure. Though there were no recorded complaints, people told us they were confident any issues would be addressed by the service. People can therefore be assured that complaints would be investigated and action is 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. We saw evidence of communication with health professionals and access to local mental health support groups.

The service had quality assurance systems in place to monitor the quality of the service delivered. Any shortfalls identified were addressed promptly. As a result the quality of the service was continually improving.

Staff told us they felt valued and supported and were clear about their roles and responsibilities. They felt that staffing levels were appropriate to meet peoples' needs. This helped ensure people received a good quality service at all times.

People were encouraged to make their own decisions and choices, where they were able. People told us they were ''well looked after". People told us they felt there were enough staff to meet people's needs and that they were confident their views would be acted on.

We found that the provider had appropriate arrangements in place to manage medicines. Two people told us they liked managing their own medication.

The support worker we spoke with told us they were happy working at the home and they thought the care was of a good standard. Staff told us they encouraged people to be as independent as possible and they encouraged them to do as many activities of daily living for themselves as possible. One person told us, "I have just been away for a few days visiting family. It was great to be able to do this. I thoroughly enjoyed myself. I'm looking forward to a day trip out soon".

We saw that improvements had been made to the system in place to monitor the quality of the service provided. People in Cairn House were encouraged to express their views and participate in decisions about how the service was run.

Staff told us they supported people and encouraged them to carry out their hobbies and interests. One person told us, "We had a great holiday this summer and I have been away for a few days to visit family too. I have a good time."

Staff had training that was relevant to the work they undertook. They had the knowledge and skills to meet the needs of the people they supported in a confident and competent way.

We had minor concerns that the systems in place to monitor and review the quality of the service provided were not sufficiently robust. People living in Cairn House were encouraged to express their views and participate in decisions about how the service was run.