The Care Quality Commission
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Archived: West Hallam Care Home

Overall: Requires improvement read more about inspection ratings

8 Newdigate Street, West Hallam, Derbyshire, DE7 6GZ

Provided and run by:
Ashmere Care Group

All Inspections

25 October 2016

During a routine inspection

This inspection took place on 25 and 27 October 2016. The service was last inspected on 30 October and 4 November 2015 when they were rated as Requires Improvement, and we found a breach of Regulation 12 and a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. On this inspection, we found that improvements had been made in respect of the breach of Regulation 12. However, evidence demonstrated there was a continued breach of Regulation 17. The first day of our inspection visit was unannounced.

West Hallam Care Home is a 31 bed residential home. It has two parts: the main building provides residential care for 19 people, and the extra care unit (within the main building) provides specialist residential care for 12 people living with dementia. At the time of our inspection, there were 22 people living in the service. 10 people were living in the extra care unit and 12 people were in the residential area of the home.

The service had a registered manager at the time of our inspection visit. 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 provider had systems to monitor and review all aspects of the service, and these were undertaken regularly. However, the systems did not always identify where areas of care needed to be improved. This meant the provider was not always able to identify areas for improvement, and to make changes to improve the quality of the service for people.

People’s care needs were assessed and recorded and risks identified. However, risk assessments and care plans did not consistently identify steps staff should take to reduce the risk of avoidable harm, and were not always up to date.

The systems for managing medicines was not consistently safe. The provider had not taken steps to ensure that people had medicines available when needed, or that medicines were given in accordance with prescribing instructions.

People were happy with staff who provided their personal care. They were cared for by sufficient numbers of staff who were suitably skilled, experienced and knowledgeable about people’s needs.

The provider took steps to ensure checks were undertaken to ensure that potential staff were suitable to work with people needing care. Staff received supervision and had checks on their knowledge and skills. They also received an induction and training in a range of skills the provider felt necessary to meet the needs of people at the service.

Staff worked in cooperation with health and social care professionals to ensure people received appropriate healthcare and treatment in a timely manner.

Appropriate arrangements were in place to assess whether people were able to consent to their care. The provider met the legal requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DOLS).

People felt care for by staff who treated them with dignity and respect. People were supported to be involved in their care planning and delivery. The support people received was tailored to meet their individual needs, wishes and aspirations. People, their relatives, and staff felt able to raise concerns or suggestions in relation to the quality of care. The provider had a complaints procedure to ensure that issues with quality of care were addressed.

You can see what action we told the provider to take at the back of the full report.

30 October and 4 November 2015

During a routine inspection

This was an unannounced inspection which took place on 30 October and 4 November 2015. We had previously carried out an inspection on 26 February 2014 when we found that the service had breached the regulation relating to the management of medicines. On this inspection we found that the provider had taken action in relation to this.

West Hallam Care Home is a 31 bed residential home. It has two parts: the main home provides residential care for 19 people, and the extra care unit provides specialist care for 12 people with dementia. There were 24 people living in the service at the time of our inspection. 12 people were living in the extra care unit and 12 people were in the residential area of the home.

The service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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. There was a newly appointed manager in post at the time of our inspection, and they were in the process of applying to become a registered manager with CQC. The previous registered manager left on 8 May 2015.

We found a breach of regulation 12 and a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations.

People told us they felt safely cared for. Staff were trained and knew how to recognise people at risk of harm. They knew how to report concerns.

There were safe recruitment procedures in place. The provider carried out checks to ensure that suitable people were recruited. Staff undertook a probationary period before being assessed as competent to provide care. The provider had policies and procedures in place if staff did not meet the standards expected of them.

People and their relatives felt there were enough staff employed to provide care. Staff held mixed views on this, and the evidence that we saw showed that there were times when there was a risk of people not receiving the support they needed due to the way staff were deployed.

Medicines were stored, administered and disposed of safely and in accordance with professional guidance. We found that staff did not always keep records relating to “as required” medicines. Staff received training in the safe administration of records.

People were supported by staff who received training and supervision to ensure that they had the skills the provider felt necessary for their role. The interaction we saw between people and staff demonstrated that people’s independence was promoted.

Staff obtained consent from people before providing support. Where they were not able to do this, not all staff understood the requirements of the Mental Capacity Act. This meant that there was a risk that best interest decisions did not meet with legislative requirements.

Staff knew people well and understood how to provide care that was person centred. People were involved in planning their care.

People were supported to have a well-balanced diet. They had regular drinks and snacks, and diets to meet their health needs. Staff provided alternative meal choices and people were involved in discussions about the menu.

Staff communicated well with people and provided care in a kind and compassionate manner.

A wide range of activities were on offer, and families and friends were welcome in the home. This meant that people could continue with their hobbies and interests, remain active and maintain relationships that were important to them.

The provider sought feedback about the service from people, their relatives, visitors and staff. There were a variety of ways people could make their views known. The provider demonstrated how they listened to people and responded to improve the service, but the recording of this was variable.

There were systems in place to monitor and review all aspects of the service. However, these had not always been carried out. This meant identifying areas of good practice and areas for improvement was inconsistent.

26 February 2014

During a routine inspection

During the lunchtime we used the SOFI tool to help us see what people's experiences at mealtimes were. We found that people had positive experiences. The staff supporting them knew what support they needed and they respected their wishes if they wanted to manage on their own.

People were not always protected against the risks associated with medicines as not everybody received the medication they needed at the time required.

The provider had effective recruitment and selection procedures in place and carried out relevant checks when they employed staff.

There were enough staff who knew the needs of the people using the service, meaning that people using the service had a consistency of care.

The provider had clear systems in place to obtain feedback from all persons involved in the service as well as auditing their own service. This shows that the provider had systems in place to monitor the quality and safety of service provided.

17 October 2012

During a themed inspection looking at Dignity and Nutrition

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an Expert by Experience who has personal experience of using or caring for someone who uses this type of service.

A number of people who used the service had varying levels of dementia, so not everyone

was able to tell us about their care and support. Therefore we spent some time observing

how people were treated and how they were involved in their care and treatment. This

helped us to understand the experiences of people who could not talk with us.

People told us they were treated with respect and dignity. They told us staff knocked on doors before they entered their rooms and also closed the bedroom door and curtains when delivering personal care. We saw that staff's approach towards people was caring, and when they interacted with people it was always in a positive way. We saw that each person was approached in an individual manner, which showed the staff on duty knew each person very well.

We observed people sitting in small groups in both lounge areas within the service. We saw that the majority of people had their own private room. One person told us "I have a nice little room which is private."

We observed people being offered snacks, meals and drinks throughout our visit, as well as a choice of meal at lunch time. People told us they enjoyed the meals provided at West Hallam Care Home. One person told us 'I love the food, they do everything I like, I've got to have a pudding and they do that.' This person also said 'We always eat in the dining room, four of us at table, like a family.' Another person said 'The food is ok ' definitely, it's quite good actually.'

People told us they had 'settled in' to living at West Hallam Care Home, and had no concerns about the care and service they received. They told us the staff were nice and very kind, and that nothing was too much trouble. Relatives spoken with told us they had no concerns about staff practice. One person told us 'The staff listen to me if I have any problems, I have no safeguarding worries, never ever, the staff are doing their best and I visit unannounced and I have never heard any dissent from a member of staff.'

We observed a mutual respect between people and members of staff. We heard genuine conversations going on between people and staff over the lunch time period, which included really laughing and joking both ways between them.

Staff had a good understanding of the forms of abuse people would need protecting from. They told us the manager dealt with any incidents quickly and professionally, and they would have no hesitation reporting incidents to her.

Staff had an awareness of the Mental Capacity Act 2005 (MCA) but lacked in-depth knowledge. However, we saw that people's capacity to make decisions about their lives was recorded in the care records.

We observed interactions between care workers and people who used the service. These were at a pace in line with each person's needs and people who we spoke with did not raise any concerns that their needs were not responded to at any time. We saw that care workers were unhurried and had time to act respectfully.

We saw there were care records for each person who used the service, and these included information about their identified needs and identified risks, and how staff should support them. The records included information about peoples' health, their support needs and individual preferences.

We saw that people's nutritional needs and risks was assessed. We saw that if people were identified as at risk of losing or having lost weight, food and fluid diaries were kept. Records were kept securely and could be located promptly when needed.