Archived: Limetree

Limetree provides care for adults who require long-term nursing intervention and support because of an acquired or traumatic injury, or other neurological condition.

Limetree is one of six adult social care locations at Glenside which also has a hospital that is registered separately with CQC. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

The hospital is currently closed due to flooding, caused by a major water leak. People from the hospital were transferred at short notice to some of the adult social care (ASC) locations on the same site. Works to repair the fabric of the hospital building are currently underway. As Limetree was temporarily accommodating people from the hospital we reviewed aspects of these peoples care and support in line with the expectations of their inpatient status.

People’s experience of using this service:

People were not safeguarded from abuse and were placed at some risk of harm.

There were concerns about the competencies of some staff to manage the complex care needs of people living at Limetree. There were concerns about the medical cover provided to people who should have been accommodated in the hospital particularly where people had potential medical conditions.

Incidents and accidents were not responded to in line with expectations and requirements. There was a risk that people were being restrained inappropriately.

People were not receiving the one to one support that they required and that commissioners were paying for

The service was not well led. The management had not taken action in response to events that had or could cause harm to people. There have been persistent changes of senior managers. There was a lack of regulatory response from the provider.

Rating at last inspection:

The overall rating was changed to Inadequate at the focus inspection dated March 2019.

Why we inspected:

This inspection was brought forward due to information of risk or concern; following the last inspection, in March 2019. After the inspections in August & November 2018 and March 2019 CQC requested assurances from the provider about the action they would take to improve the service. The responses provided by the provider did not give assurances that the service would improve.

Enforcement:

Following the last inspection we imposed a condition on the providers registration to submit monthly improvement action plans to CQC. The action plans provided did not give assurances that the service would improve.

Section 31 of the Health and Social Act 2008 allows the Commission to serve a Notice of Decision upon providers if it has reasonable cause to believe that, unless it acts any person will or may be exposed to the risk of harm.

The Commission used its powers pursuant to the urgent procedure (for suspension, or imposition or variation or removal of conditions of registration) under Section 31 of the Health and Social Act 2008. Although the provider told us they intended to close the service we continued to urgently remove the regulated activity from the registration.”

Follow up:

This service has been placed in special measures. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

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.

Full information about CQC's regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

Limetree provides care for adults who require long-term nursing intervention and support because of an acquired or traumatic injury, or other neurological condition.

Limetree is one of six adult social care locations at Glenside which also has a hospital that is registered separately with CQC. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

One adult social care location (Pembroke Lodge) is currently closed as there were ongoing and continual issues with the provision of heating and hot water.

The hospital was also closed due to a flood caused by a major water leak. Patients from the hospital were transferred at short notice to some of the adult social care locations. Works to repair the fabric of the hospital building were currently underway. As Limetree was temporarily accommodating people from the hospital we reviewed aspects of these patients care and support in line with the expectations of their inpatient status. The ground floor at Limetree was being used to accommodate hospital patients with the upper floor for those people accommodated under the Adult Social Care (ASC) registration.

The provider notified us of the temporary arrangements for hospital patients while refurbishments were taking place. However, Limetree will not be correctly registered with CQC if these arrangements become long term. The provider will need to submit applications to CQC to register appropriately if the closure of the hospital continues.

People’s experience of using this service:

The service was rated Requires Improvement at the comprehensive inspection dated August 2018. The rating for the focus inspection undertaken on the 7 November 2018 remained the same.

People and patients were placed at risk from poor management. We found systemic overarching poor management systems and improvements were not prioritised. There had been sudden and persistent changes of senior managers. There was a lack of regulatory response from the provider. There were poor recruitment procedures, and a lack of investment with equipment and maintenance of the property. The morale of the staff was low and they were reluctant to give feedback because of fear of reprisals. This had an impact on the care people received.

On the first floor we found:

• People were not receiving continuity of care from staff recruited to work permanently at Limetree. We checked the staffing rota’s and saw that agency staff were used on a regular basis when the service was short staffed. Staff from other units at Glenside were also required to provide support to Limetree. The unit manager explained that there was recruitment taking place, however there were delays in recruitment.

• The service did not have a registered manager in post. The service was being managed by an interim manager. The unit manager was not supported by the provider to ensure they could focus on making improvements in Limetree.

• The staff were not skilled in supporting people whose behaviour changes were triggered by brain injuries. One person displayed behaviours that the staff team found too challenging to manage effectively. Staff told us that they had colleagues who were scared of the person and they would “hide in other people’s bedrooms” to avoid them. There were risks to the safety of people and staff due to staff not being able to support the person effectively.

• Medicines records were unclear as to why a sedative-hypnotic was administered. While the medicine could cause the person to be more compliant with their care the notes for the following day confirmed that the person remained in bed for most of the following day.

• People we spoke with were happy with the care and support the received. One person said, “This is the best place I have lived. The staff are marvellous.”

• People’s care plans included their preferences and usual routines. Guidance from health and social care professionals was incorporated into the care planning.

On the ground floor for the hospital patients we found :

• People were not kept safe as staff did not follow systems and processes to identify and act on harm. We identified one person who had bruising. No recent safeguarding referrals had been made. There was no evidence that robust action had been taken by staff in response to the bruising.

• Guidance was lacking on how staff were to respond accordingly to risks. Records for one person with diabetes showed their blood sugar levels in the evening were frequently above a normal range. We asked a nurse on the unit how they knew what the person’s normal blood sugar range was, they told us it was in the diabetes care plan. We checked the care plan and this information was not recorded.

• There were areas of the home that were not sufficiently secure for people detained under the Mental Health Act. These individuals were placed at risk of potential harm due to a number of items not securely stored. These included items that could have posed a ligature risk. We found a door to a smoking area unlocked that should have been locked which meant others were able to leave and enter the home freely. In the smoking area we found glass greenhouses which were a risk to these patients.

• We saw where risks had not been consistently mitigated. We saw examples where incidents were reported but should have been entirely avoidable. For example, we found concerns documented in patient records that had not been recorded as incidents, for example the missing lead from a patient room, which could present a ligature risk.

• There were incidents where staff had not managed situations correctly. We saw two incidents where staff had refused patient’s a drink of their choice which had both escalated into deteriorating behaviour and meant both patients required restraint.

• There was little evidence to show how standards of cleanliness and hygiene were maintained. There was no process, checklist, or audits completed within the organisation relating to infection control. Safety systems were not implemented to protect patients effectively from communicable diseases or to maintain infection control and hygiene. Staff didn’t always decontaminate their hands immediately before and after every episode of direct contact. Staff were not always bare below the elbow.

• Staffing levels were not adequate. Patients who were to receive 1:1 care did not always get it.

• People’s individual care records, including clinical data, were not written and managed in a way that kept people safe. Information needed to deliver safe care and treatment was not available to relevant staff in a timely and accessible way. Care plans were not always updated as the provider required. Nursing assessments and documentation were not in keeping with standards for nursing.

• Medicines were not always safely managed. The service did not always make sure that people had their medicines recorded appropriately. For one patient who was an insulin dependent diabetic, we found four prescription charts in use, which presented a risk of medications being missed. There were good security processes in place, as both the prep room (where drugs were stored) and the drugs cupboards themselves were locked and secure.

• There was little emphasis on the safety and well-being of staff for example when staff were pregnant. Staff did not feel valued. Staff told us that staff were very negative about the provider and this caused friction among staff. Also, as patients from the hospital had been transferred to other wards, not necessarily their speciality, staff felt there were unrealistic expectations placed on them for patient needs outside their scope of experience.

• Staff told us they had no confidence in senior management as there was no communication, however, the newly appointed CEO was perceived as someone who would listen to the staff.

• Staff were concerned that the hospital (which was closed due to a flood) would not re-open and their jobs would be at risk.

Rating at last inspection:

This service was rated Requires Improvement at the comprehensive inspection dated 30 August 2018. Due to the concerns identified the rating from this inspection is now Inadequate

Why we inspected:

This inspection was brought forward due to information of risk or concern; following the last comprehensive inspection, in October 2018, CQC have received on going whistleblowing concerns. After the last inspection CQC requested assurances from the provider about the action they would take to improve the service. To date these assurances have not been forthcoming. We did not inspect the key questions Effective, Caring and Responsive because ongoing monitoring did not raise any information about risks or concerns in these areas.

Enforcement:

Following the focus inspection in November 2018 we imposed a condition on the providers registration. The provider was required to submit monthly improvement action plans to CQC from February 2019. We also issued four warning notices following the focus inspection at Glenside Hospital in November 2018.

Follow up:

The rating of the service is Inadequate. We therefore placed the service in Special Measures. The purpose of special measures is to:

The team inspected the service against two of the five questions we ask about services: is the service well led and safe. This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Effective, Caring and Responsive through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Limetree provides care for adults who require long-term nursing intervention and support because of an acquired or traumatic injury, or other neurological condition.. Limetree is one of six adult social care locations at Glenside which also has a hospital that is registered separately with CQC. Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

A registered manager was in post. 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.

At the previous inspection dated August 2018 we found a breach of Regulations 9 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider following the inspection to tell us how they were going to meet this Regulation 9 and 12. The provider failed to report on the actions to meet Health and Social Care Act 2008, its associated regulations, or any other relevant legislation on how regulations were to be met. At this focus inspection we found Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were not being met.

The CQC following the inspection formally requested under Section 64 of the Health and Social Care Act 2008 to be provided with specified information and documentation by 16 November 2018. We received some of the information requested but not all.

Quality assurance systems were inadequate. Audits were not robust and did not provide an accurate assessment of the quality of care delivered. Action plans were not developed to drive improvements. The CQC was not notified of accidents and incidents reportable under the Care Quality Commission (Registration) Regulations 2009: Regulation 18. Reports of incidents for other locations which included theft and medicine errors were not included in the incident reports we received on the 22 November 2018. The provider had also failed to report an incident where fire safety services were called to the Glenside Manor site. This supports the findings that GEMS was not monitored adequately. Due to this we could not be assured that any incidents at Limetree had been recorded, reviewed and reported appropriately.

Recruitment procedures did not ensure the staff employed at the home were suitable to work with vulnerable adults. The CQC received whistleblowing concerns about staff not able to speak sufficient English and that agency staff were working without appropriate checks. We found there were some staff working across the site without the appropriate disclosure and barring checks or references in place. Relatives also expressed concerns about staff not able to speak or understand English.

Agency staff were used to maintain staffing levels. The provider information records (PIR) dated 29/08/2018 revealed that a significant number of agency staff were used to maintain staffing hours for the 28 day period before the 29 August 2018. The manager’s meeting minutes dated 18 September 2018 stated that “agency usage is the highest and recruitment was ongoing”. This indicated that new staff or agency staff were being used to maintain staffing levels.

New staff did not always have an induction to prepare them for the role they were employed to perform. The training matrix provided during the inspection showed five staff were undertaking an internal induction. However, there was no evidence in five staff files of the induction completed or in progress. We were not able to verify that these staff had an appropriate induction before starting work. We were informed that not all staff had received an induction or mandatory training due to the level of the English they spoke and understood. It was said that the training staff would be unable to sign these staff off as their English was so poor. Staff responsible for training were not able to sign new staff as competent due to their English speaking skills being poor.

There were people whose behaviours had changed due to their brain injury or neurological conditions. This meant some people presented with difficult behaviours when they expressed their frustrations and anxiety. The undated physical intervention report listed five incidents of significant risk in relation to one person. We noted where it was documented that verbal de-escalation was not effective. While the training matrix demonstrate that all staff had attended MAPA training not all staff including agency staff were included in the training matrix. MAPA (Management of Actual or Potential Aggression) programme teaches management and intervention techniques to help staff manage escalating behaviour in safe manner.

Staff morale was poor and staff told us they feared about their jobs as they had witnessed other staff being dismissed almost daily. The staff survey indicated that 13 of the 38 staff responding would recommend the home.

The CQC received whistleblowing concerns about the competency of the staff undertaking maintenance checks of systems and equipment. The CQC requested proof of the competency of these staff from the provider. The documentation provided did not give CQC reassurances that staff undertaking maintenance checks were skilled or competent.

Feedback was received from relatives regarding concerns about care and treatment delivered to their family members. These concerns related to other Glenside Manor locations. However, the concerns from these relatives were not consistent with the Glenside complaints log provided under section 64.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. 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.

At the previous inspection in June 2017, we rated this service as Requires Improvement, with a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We received an action plan from the provider telling us how the regulation was to be met following the inspection. At this inspection we found there were some improvements, but these were not sufficient to meet the requirements of the Regulations. There was a repeat breach of Regulation 9.

This is the second consecutive time the service has been rated as Requires Improvement.

A registered manager was in post. 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.

Systems were in place to assess and monitor the health, safety and welfare of people at the service. There were a range of quality audits undertaken and their outcomes were used by senior managers to assess set performance objectives. Where performance targets were not met, action plans were devised on how these objectives were to be met. We found at this inspection shortfalls in medicine systems and care planning existed and remained from the last inspection. Audits did not cover all areas of care delivery. For example, medicine audits were based on the clinical room but not on safe management of medicine and infection control was based solely on hand hygiene. Care plans were not audited. This meant audits did not drive improvements in all areas of health, safety and welfare of people.

Medicine systems were not managed safely and people were not consistently having their medicines as prescribed. Records of medicines administered were not consistently signed to show when topical creams were applied and thickeners used in fluids. The staff that applied topical creams were not signing the records of administration. This meant registered nurses were signing for topical creams when they could not be certain creams were applied as prescribed.

Care plans and risk assessments were combined. However, some care plans were conflicting, people’s preferences were not recorded, and guidance on meeting people’s needs were not followed. Information from the “Getting to know me” documents were not used to develop person centred care plans. Care plans were not always developed where people had mental health care needs. Records showed guidance was not consistently followed where people presented with behaviours staff found difficult to manage. People told us they had some say about their care plans during review meetings.

There was a reliance on agency staff and the registered manager told us every effort was made to ensure the same agency staff were used. Some staff raised concerns about the staff recently recruited. They said some staff were not able to communicate effectively in English. The clinical lead told us the steps taken to ensure the staff employed could speak English. The registered manager and clinical lead told us recruitment was in progress and the steps that were being taken to attract and retain staff.

Although staff said the registered manager was on duty once weekly and they were contactable by phone. Staff said there was a regular presence from the deputy manager, which they praised. Staff said since the appointment of the registered manager staffing levels had improved.

The registered manager told us there was continuous learning from accidents and incidents. They said that challenges included the recruitment and retention of staff. Senior managers were taking steps to improve the service’s sustainability.

People felt safe because they had confidence in the staff. The staff we spoke with knew the types of abuse and where to report their concerns. They said they had attended safeguarding adults training to help them recognise the signs of abuse and about reporting concerns.

Where possible, people made day to day decisions and relatives said they supported their family members to make decisions. Mental capacity assessments were undertaken for complex decisions. Deprivation of Liberty Safeguards (DoLS) applications were made to the supervisory authority where people were subject to continuous supervision and for accommodation at the service.

People and relatives were positive about the skills of the permanent staff. The staff told us the training was good and there were opportunities for professional qualifications.

People had access to healthcare services as required. Relatives told us they were kept informed about GP visits and about important events.

We saw some good interactions between people and staff. Mealtimes were relaxed and people made decisions on where to eat their meals. At mealtimes, we saw that staff were standing while assisting one person instead of sitting down. We noted that people were using adapted plates to eat their meals. However, as people were eating their meal with a knife and fork, adapted crockery was not needed.

People told us who they would approach with concerns. Relatives told us they would complain to staff. The complaints procedure was on display. There were no complaints made since the last inspection.

Activities were appropriate for adults and were person centred. When people were admitted, the activities coordinator met with the person to establish their preferred interests and hobbies. There were one to one activities for people that were not able, or preferred not to participate in group activities.

We found 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.

This inspection was unannounced and took place on the 13 June 2017.

A registered manager was in post and was recently appointed. '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 said they felt safe living at the service. Although staff knew the types of abuse and had attended training in the procedures for safeguarding vulnerable adults from abuse they were not clear on the actions needed for suspected abuse.

Risk assessments were in place for some identified risks. The staff we asked knew the actions needed to minimise risks. For example, choking and falls. The action plans were not clear on how staff were to use products such as thickeners for people at risk of choking and the settings for equipment such as air mattresses. This meant some people were at increased risk. When these shortfalls were identified the registered manager and operation’s manager took prompt action to ensure risks were mitigated. Where people's fluid was monitored the daily target or the total intake of fluid was not recorded on the fluid balance sheets. This meant the registered manager was not aware of people whose fluid intake was low.

Staff said the staffing levels were decreasing and the needs of people were not recognised which meant sufficient staff were not on duty to meet people's needs. The manger and operations manager said this was staff perception and initiatives such as task lists were introduced to show to staff they had sufficient time for task and for one to one time with people.

Safe recruitment processes were in place. Candidates were able to use their preferred method of application form which included CV to apply for vacant posts. Disclosure and Barring Services (DBS) must be approved before the staff start working at the service. A Disclosure and Barring Services (DBS) check allows employers to check whether the applicant has any convictions or whether they have been barred from working with vulnerable people. Where staff had disclosed convictions or cautions they were investigated and risk assessments completed to ensure staff were safe to work with people.

Medication administration charts (MAR) were signed to show the medicines administered. However, the charts were not signed immediately after medications were administered by the nurses. Application charts were not used by rehabilitation assistants (RA) to document the application of topical creams. The procedure was for RA to confirm to the nurse who will then sign the MAR. The operations manager said the method of recording topical cream would be reviewed. The number of medicine errors has reduced since changes of the supplying pharmacy for medicines.

Induction of new staff was detailed and there was ongoing reviewing of the process. Staff on induction said the induction was good. There was mandatory training set by the provider which staff attended to ensure they had the skills needed to meet people's needs. There was a re-validation programme for nurses.

While training was available to staff on person centred care and to meet the needs of people living with dementia not all staff had taken the opportunity to develop their skills and knowledge in this area. Staff can apply for nursing degree and during their training these staff must work at the service one shift per week.

Appraisals of staff with the registered manager were annual. Part of the appraisal system was for staff to appraise themselves. The appraisals viewed did not include the discussion with the registered manager and the action plan on goals for the year was not included in the appraisal records. This will ensure staff were confident and skilled to perform their role.

People were subject to continuous assessments. Staff's awareness of Deprivation of Liberty Safeguards (DoLS) procedures was variable and their knowledge depended on their role in this area. Staff's understanding on the principles of the Mental Health Act was based on how to support people with making day to day decisions.

People's ongoing healthcare needs were met and referrals to specialist healthcare professionals were made for further investigations. We saw that following visits healthcare professionals documented the outcome of their visits. People had access to internal support e.g. Speech and Language therapists and Occupational therapists.

Care plans were varied and were not person centred. Clinical needs were made clear in the care plans but they lacked person centred approach. While people's background histories, relationships and preferred routines were gathered the information was not used to develop care plans. Care plans lacked people's preferences on how staff were to deliver their care. This meant staff were not given information that identified the person as an individual.

Behaviour management plans were in place and the quality of the information was variable. For one person the information was inconsistent with other documents that related to the same area of need. Staff recorded incidents of aggression on Patient Observation (OS) charts which showed behaviour management plans were not consistently followed. There was no evidence that the charts had been analysed and the care plan reviewed following an incident. We were shown the charts to be introduced and will give more detailed information for staff to identify triggers. We were told the new formats will allow for analysis of frequent behaviours.

People knew who to approach with complaints. There were processes for making complaints to be used for the investigation of formal and informal complaints. Complaints received were investigated to a satisfactory outcome.

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