Archived: Arden Court

Arden Court is owned by Ramos Healthcare Limited and is located on a busy main road in Eccles, Greater Manchester. The home provides care for people with nursing, residential and continuing care needs. The home is close to local shops, bus routes and has adequate car parking facilities located at the front of the building.

At our last inspection of Arden Court in February 2017, the home was rated as Requires Improvement overall and for each of the five key questions we inspect against. We identified breaches of the regulations with regards to person centred care, safe care and treatment, good governance and staffing. This inspection looked at the progress made since our last visit, to ensure the requirements of the regulations were being met.

During this inspection we identified two (continuing) breaches of the regulations with regards to safe care and treatment and good governance. You can see what action we have asked the provider to take at the back of this report.

At the time of our inspection, there was no registered manager in post, however the current home manager had submitted an application to register with CQC, which was in progress with our registration team 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.

Improvements were still required to the handling, recording and storage of people’s medication.

We found that accurate and contemporaneous records were not always being maintained in certain areas such as oral and personal hygiene, when people had received a shave and when they had their finger nails cut/cleaned . Staff were not always consistently signing people’s fluid intake sheets to ensure the amounts consumed were sufficient and records regarding when people’s drinks had been thickened were not being maintained consistently. This meant we could not be certain if people’s care needs were always being met.

Since our last inspection, in June 2017, a person passed away at the home and their death was referred to the coroner for further investigation. The concerns related to the management of falls. Subsequently, a Regulation 28 report was issued to the home by the coroner which identified future deaths could occur unless the necessary action was taken to keep people safe. The home manager had provided a written response to the coroner, detailing any action that would be taken. We reviewed this response as part of the inspection.

People who used the service and their relatives told us they felt the service was safe. There were appropriate risk assessments in place with guidance on how to minimise risk. Staff recruitment was robust with appropriate checks undertaken before staff started working at the home.

At our last inspection, we received feedback (mainly from staff and visitors) that staffing levels were not adequate to safely meet the needs of people living at the home. Since then, we found staffing levels had increased with an additional member of staff added to both the day and night shift. Everyone we spoke with during the inspection including people living at the home, visitors and staff said there were currently enough staff working at the home to care for people safely.

We found staff received sufficient training, supervision, appraisal and induction to support them in their role. The staff we spoke with told us they were happy with the training they received and felt supported to undertake their work. At the last inspection we found not all staff were trained in moving and handling, however this training had now been provided.

We found appropriate DoLS applications were made to the local authority where people had been assessed as lacking capacity to make their own choices and decisions. The staff we spoke with had a good understanding in this area and told us they worked in people’s best interests where possible. The relevant paperwork regarding these applications was held within people’s care plans.

The people we spoke with said the food served at the home was of good quality and we saw people being supported to eat by staff. People were weighed on a regular basis and more frequently if they were identified as being at risk of losing weight.

We found the home worked closely with other health professionals and made appropriate referrals if there were concerns. Details of any visits from other professions was recorded within people’s care plans.

At our last inspection, people reported there was a lack of continuity of care due to a high turnover of staff and regular use of agency staff. Since the last inspection, the home had recruited lots of additional members of staff and all of the staff working at the home during the inspection were permanent.

We received positive feedback from people we spoke with about the care provided at the home. People said they felt treated with dignity and respect. Staff were also able to describe how they aimed to do treat people well when delivering care.

Each person living at the home had their own care plan in place which provided an overview of their care requirements and any associated risks. These were updated each month or when people’s care needs changed.

During our last inspection, there was a lack of consistency with regards to the recording of people’s likes, dislikes and preferences as this information wasn’t captured for each person. Additionally, the care plans we looked at did not demonstrate that families had been involved in them and whilst reviews were done, they were signed off by staff and did not involve people living at the home and their families. People’s preferred choices of activities also weren’t clearly documented in their care plans. We found this information was now clearly recorded in people’s care plans for staff to refer to.

During the inspection we observed several activities taking place which people participated in. This included a quiz in the afternoon which people seemed to enjoy.

There were systems in place to monitor the quality of service being provided to ensure good governance, with a range of audits being undertaken by the home manager.

Staff meetings took place on a regular basis, giving staff the opportunity to discuss their work and raise any concerns about practices within the home. We also observed a handover taking place where the lead nurse provided an update on people’s care needs.

Staff spoke positively about management at the home and said the manager was supportive and approachable. Staff said said the manager had made changes for the better since starting working at the home.

Policies and procedures were in place and were being reviewed regularly.

At our last inspection of Arden Court in May 2016, the home was rated as ‘Inadequate’ overall and for the key questions ‘Safe’ and ‘Well-led’. The key questions for ‘Effective’, ‘Caring’ and ‘Responsive’ were rated as ‘Requires Improvement. Due to the overall rating of inadequate, the home was placed in special measures. We also issued three warning notices with regards to safe care and treatment, good governance and staffing. This inspection looked at any improvements made since then.

Although we found the provider had made improvements, we did identify continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to person-centred care, safe care and treatment , good governance and staffing. You can see what action we told the provider to take at the end of the full version of this report.

At the time of our inspection, there was no registered manager in post. The home had a manager that had applied to the Care Quality Commission (CQC) to register and they had their registered manager interview scheduled the following week. 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 who used the service and their relatives told us they felt the service was safe. There were appropriate risk assessments in place with guidance on how to minimise risk. Staff recruitment was robust with appropriate checks undertaken before staff started working at the home.

We found the arrangements to manage people’s medicines were not consistently safe. This was because PRN (when required) protocols were not always in place and prescribed creams were not stored securely. There had also been two separate instances where people had run out of their medication because appropriate ordering systems weren’t in place.

We received a poor response from people living at the home, staff and visiting relatives with regards to the staffing levels at the home. Whilst a formal dependency tool was used to determine staffing numbers, the agreed numbers of staff on duty each day was not consistent. Whilst staff said they felt people’s care needs were not compromised as a result, they reported feeling rushed and unable to spend time with people. This was reflected in our observations during the inspection. We have made a recommendation with regards to staffing levels in the detailed findings of this report.

We found staff received training in areas such as safeguarding, infection control, dementia and fire safety which were accurately recorded on the training matrix. There was no record however to confirm staff had undertaken recent first aid training and eight members of staff had not yet completed practical training in relation to moving and handling. Three of these members of staff worked at the home at night and were required to provide pressure care by supporting people to re-position during the night.

The expectation at the home was that staff would receive supervision six times a year and an annual appraisal. These hadn’t been taking place consistently as identified in the homes policy and whilst we saw evidence of some group supervision, this meant staff weren’t consistently being given the opportunity to discuss their work confidentially.

The people we spoke with said the food served at the home was of good quality and we saw people being supported to eat by staff. People were weighed on a regular basis and this increased and was more frequent when they were identified as being at risk of losing weight.

People had been given the opportunity to express the foods they liked and didn’t like, however we found instances where these choices and preferences hadn’t been respected by staff.

We found the home worked closely with other health professionals and made appropriate referrals when there were concerns.

We found DoLS (Deprivation of Liberty Safeguard) applications were made as necessary by the home manager, although staff were not always aware of the people subject to DoLS. The manager told us they would look at ways to disseminate this information to staff.

The people we spoke with and their relatives, said they thought staff were kind and caring but reported a lack of continuity of care due to a high turnover of staff and regular use of agency staff. We also observed interactions in communal areas to be limited as staff seemed rushed and unable to engage and stimulate people throughout the day unless the interaction was task led.

People living at the home said they felt treated with dignity and respect. Staff were also able to describe how they aimed to treat people well when delivering care.

In the care plans we looked at, there was inconsistency with regards to the recording of people’s likes, dislikes and preferences. Additionally, the care plans we looked at did not demonstrate that families had been involved in the planning of people’s care and whilst reviews were done, they were signed off by staff and did not involve people living at the home and their families. This meant that staff would be unable to deliver care that was personal or met people’s individual needs and would hinder staff engaging with people in a meaningful way.

We found the activities coordinator demonstrated a good knowledge of people’s life history and , needs but they told us this was disseminated verbally amongst the staff team and not captured on a document to plan care and treatment.

During the morning of the inspection, we saw people were sat in lounges unaccompanied by staff and observed little stimulation offered to people living at the home. In the afternoon, we observed 14 people in the dining room downstairs receiving a hand massage and people’s nails being painted by the staff and care coordinator.

The home had an activities coordinator in post that scheduled and planned activities but we noted that this was not decided or planned in conjunction with people living at the home. The activities coordinator told us that there wasn’t an activities timetable and activities were scheduled dependent on whether people presented as being likely to engage that day. If people were tired, the activities coordinator did not schedule an activity and took people individually in to the community or spent one to one time with people.

We looked at how the manager audited the quality and safety of the service. We found the medication audit had not been effective. We also found the audit of records just looked at whether the care intervention had been completed rather that look at the content to ascertain that care had been delivered in line with people’s preferences. We found audits had not consistently been effective in identifying and rectifying some of the issues we found during this and previous inspections. For example, we saw no recent audits of care plans, staff training, supervision or medication. We had found some concerns with care plan documentation such as a lack of consistency with regards to life histories and consent forms being signed. There were also gaps in both staff training and supervision. Some of these issues also weren’t rectified as a result of provider audits.

We identified several continuing breaches of the regulations in areas such as the management of medicines, quality assurance systems, staffing and storage of confidential information. A robust auditing and quality assurance system would identify these concerns and ensure people received an improved quality of service as a result.

Staff spoke positively about management at the home and said the manager was supportive and approachable. Staff said the manager had made changes for the better since starting working at the home.

Arden Court is owned by Ramos Healthcare Ltd and is located on a busy main road in Eccles, Greater Manchester. The home provides care for people with nursing, residential and continuing care needs. The home is close to local shops, bus routes and has adequate car parking facilities located at the front of the building.

At our last inspection of Arden Court in November 2015, we rated the service as ‘Requires Improvement’ overall and in three of the five keys questions against which we inspect. These included Safe, Effective and Responsive. We also identified a breach of regulation 17 (2) (c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Good Governance. This was because we found the service maintained poor records in relation to people’s food and fluid intake.

Prior to the inspection we had been informed by the local authority that the provider had started to restrict admissions to the home, due to various concerns being raised about the quality of care being provided. The provider had also recently recruited a ‘crisis manager’, to oversee the daily running of the home. We also received information of concern from different sources regarding staffing levels, record keeping, the environment, management and infection control. We used this information as part of our inspection planning.

During this inspection we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 with regards to staffing, safe care and treatment, seeking consent, premises/equipment, person centred care, and good governance). You can see what action we have asked the provider to take at the back of this report.

We observed there were insufficient staff available to care for people living at the home. We observed several people having to wait to be taken to the toilet whilst staff appeared busy. Another person, who required re-positioning by two members of staff told us that on occasions, only one member of staff completed this task and that they didn’t always use a slide sheet, as stated in their care plan. Feedback from staff about current staffing levels was poor.

We identified several instances of poor practice with regards to infection control. This included dirty soiled bed sheets being stored in a trolley in bathroom areas and on one occasion, in a person’s bedroom whilst they were in bed. We also observed staff didn’t wash their hands at appropriate times, such as after handling different people. This could increase the risk of the spread of infection.

People who lived at the home required staff to check that their pressure relieving mattresses and bed rails were safe and in good working order. This would help people prevent people developing pressure sores and falling from their bed. According to the homes paperwork, these needed to be completed twice during the day and once at night. We were unable to see these checks were being undertaken to ensure people remained safe.

The service did not always mitigate risk well. On the day of the inspection, building and renovation work was taking place at the home. As a result, the home had implemented a risk assessment for this on going work. However we found specific control measures identified weren’t followed. For example trailing wires needed to be neatly kept, signage about the on going work needed to be displayed and tools weren’t to be left unattended. We found these measures weren’t followed during the inspection, with secure doors also propped open.

The majority of people who lived at Arden Court were required to be re-positioned every two to four hours to prevent the risk of them developing pressure sores. However, when looking at records, we were unable to establish if this had been taking place as required. We found gaps in eight people’s charts that we viewed. This could place people at risk.

We found three peoples risk assessments had not been reviewed each month, as was required. These were in relation to Waterlow, nutrition and Malnutrition Universal Screening Tool (MUST). Another person’s care plan wasn’t updated following a fall. This could place people at risk due to staff not having up to date information to refer to in care plans.

We saw staff had access to training such as safeguarding, moving and handling, infection control, and Health and Safety. Staff told us they were happy with the training available to them. However we observed two members of staff who, according to the training matrix, had out of date moving and handling training. We observed these staff assisting people during the inspection. Our specialist advisor (SPA) also case tracked a person who used a catheter, and we couldn’t see any evidence staff had completed any training in this area. We also noted only 18 (50%) of current staff had completed training in the Deprivation of Liberty Safeguards (DoLS), whilst only nine (25%) had completed training in dementia.

We spoke with a nurse working at the home who said they aimed to ensure people drank a minimum of 1500 millilitres of fluid each day, however we found records did not support this had been offered to people. There was also no evidence if people had refused a drink. This could place people at the risk of dehydration. On certain days, people only had porridge or yogurt recorded as being the only thing they had eaten. This placed people at risk of becoming malnourished and again, there were no records of food being refused.

We identified five people who needed to be weighed each week to ensure staff could closely monitor their weight and ensure they remained safe. Despite this, we found inconsistent records to demonstrate this was being done as required. One person’s care plan stated staff needed to monitor their food intake to ensure they did not become malnourished, however a nurse told us this had not been done.

The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. We saw appropriate DoLS applications had been made, with confirmation they had been authorised.

We saw staff did not always seek consent from people when delivering care.

There were a limited number of adaptations to the environment to make it more accessible to people living with dementia. There had not been improvements in this area since our previous inspection. The general manager said this was being considered as part of the ongoing refurbishment programme.

Prior to our inspection, we received information of concern that night staff were expected to wash and dress people as early as 5am in the morning, regardless of it being their personal choice. The information also stated this was an expectation of day staff, who would often be unhappy if this wasn’t done. A member of staff confirmed with us this was the case, with this also being written in two people’s daily records. This was not recorded in people’s care plans as being their choice and did not demonstrate person centred care was being provided.

We observed staff did not always respond to people’s requests in caring manner. For example, when providing assistance to people at meal times.

People we spoke with told us they liked living at Arden Court. People said they felt staff treated them with dignity and respect. During the day, we observed staff had a caring approach towards people living at home. We found interactions in areas such as the upstairs lounge, were limited throughout the day. This lounge area was often left unsupervised for long periods with staff appearing unable to interact and engage in conversation with people, due to being busy with other things.

People had care plans in place, which provided an overview of their care requirements. We found some of these were updated regularly, however three people’s care plans we case tracked had not been updated since January or February 2016. These should be completed each month. We had also raised this concern during our previous inspection.

There was an activity schedule in place and we saw people engaging in an activity during the afternoon of our inspection in lounge. On the day of our inspection, it was a warm sunny day and this would have been a good opportunity for people to sit outside in the large garden area at the back of the building. However we saw people weren’t encouraged to sit outside at any point during the day.

There was a registered manager in post, although they weren’t present during the inspection. Our inspection was facilitated by the general 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.

In the absence of the home manager, there was a lack of visible leadership during the day. There were two nurses working at the home, however they were completing medication rounds for long periods and completing paperwork at the nurses station. Staff did not always seem well organised in their deployment, such as when leaving lounge areas unattended regularly.

On the day of the inspection audits undertaken by the home manager could not be located, as they were stored electronically on a computer. We requested these were sent to us shortly after the inspection. These were sent and covered areas such as pressure sores, peg feeding, catheters and falls. However we saw no evidence of audits undertaken to cover staff training, car