Archived: River View Care Home

At our inspection on 2 June 2014 we found that improvements were needed in the areas of consent to care and treatment, care and welfare of people who use the service, records and notifications that were required to be sent to the Care Quality Commission (CQC) about events at the home. At this inspection on 30 September 2014 we looked to see if the required improvements had been made.

There were 19 people living at the home at the time of the inspection. As a part of the inspection we spoke with seven people who lived at the home. We also reviewed records relating to the management of the home, including seven people's care plans and sampled people's daily notes, fluid charts, and medication records. We spoke with eight members of staff, three members of the management team and six visiting relatives.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

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

Is the service safe?

We saw that since our last inspection significant improvements had been made to people's safety at the home. People's care plans and other records were more in depth and better reflected people's needs. This meant staff had the information they needed to care for people safely.

Risk assessments were clearer, and steps were taken to minimise risks where known. Clearer guidance was available for staff on how to support people with challenging behaviour to ensure people were kept safe. The atmosphere in the home and in particular in the dementia unit was much calmer, with staff growing in confidence in managing behaviours that were challenging.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The Deprivation of Liberty Safeguards aim to ensure that people are protected from the risk of inappropriate restraint in any form. We saw that the home had taken action to ensure proper authorisations had been applied for from the local authority.

Is the service effective?

We saw that people were being consulted about their care plans and staff were carrying them out effectively. People received the support they needed from visiting agencies and we saw evidence of healthcare provision into the home.

We saw that falls, incidents and accidents were being audited and reviewed to identify any trends that could lead to a reduction in events.

Is the service caring?

We saw that people's wishes were respected and staff supported people in ways that were respectful and good humoured. We observed staff working on both floors of the home. We saw them engaging confidently with people in a caring and supportive way. We observed staff sharing a joke with people they were caring for and responding quickly to any requests or call bells.

A relative we spoke with told us 'I am a real fan. They (staff) don't know I am there and I hear them talking to the people here. I know they look after them well and really care'.

We saw people being treated with respect. We saw one person on the dementia care floor who repeatedly made the same request to staff throughout the day. We saw that on each and every occasion staff went out of their way to engage with the person, address their anxieties and re-assure them. This told us the staff were caring, confident and patient in their dealings with this person.

We heard that before staff did anything they told the person what they were going to do and checked that they were happy with this. For example one member of staff noticed that a person had crumbs on their trousers. They said to the person 'I am just going to dust down your trousers with this cloth, to remove some crumbs, is that ok?' This told us that staff took the time to ensure people understood what they were doing, and worked with people rather than just doing things for them.

Is the service responsive?

We saw that the home responded to changes in people's needs and wishes. We saw during the day of our visit one person had requested their mattress be changed and this was being actioned. New activities were being provided in line with people's known wishes and interests. We also saw that care was taken to ensure that people received their medication when they needed it to help them control pain not just when the medication round was due.

People who lived at the home and their relatives and other supporters were being involved in the drawing up of the care plans, and care was tailored accordingly. Records were more accessible. A relative told us 'We like the yellow files in (our parent's) room. It shows what care they (the staff) are giving and we can see what is being done.' People we spoke with felt able to discuss what they wanted with the staff.

There was an active relatives' committee who were due to meet at the home the day following our inspection.

Is the service well led?

The person named as manager on the front of this report is no longer working at the home. We have asked them to submit an application to be de-registered as manager of River View. There is currently therefore not a registered manager in post. However, since our last inspection a new manager has been appointed to run the home. They are not yet registered but it is understood that an application has been submitted to do so. They have been working at the home since July 2014.

People told us how much the home had improved since the new manager had arrived. One member of staff explained that the home was 'much calmer' now. They said 'It is a lot better than it was, there is more structure, therefore it is calmer and therefore there is more time to talk to the people who live here'. This was confirmed by a person who was visiting who explained that their friend had become calmer over the summer.

Another staff member told us 'I have never been happier than working here. The manager really has got it sorted.' An agency worker we spoke with told us 'I really love it here. I always ask the agency if there are any shifts going at River View.'

We found that the home had improved. Although there were still some changes in progress we found that sufficient changes had been made to the home to remove the previously issued compliance actions.

There were 23 people living at the home at the time of the inspection. As part of this inspection we spoke with seven people who used the service, a senior manager on duty, seven staff members and seven visitors. We also reviewed records relating to the management of the home which included 11 people's care plans, daily notes, people's fluid charts, turning charts, medication records, staff rotas, the home's policies and procedures, complaints folder and quality assurance folder.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and the records we looked at.

We found that the concerns identified during our previous inspection in April 2014 had been addressed and the previously identified non-compliance had been rectified. We did, however, identify further areas of concern and non-compliance.

Is the service safe?

There were systems in place to ensure staffing levels were sufficient to respond to risks to people's safety and welfare. One person we spoke with said 'I feel safe here.' One person's relative said 'I have never worried about their safety.' People were protected against the risks associated with the unsafe use and management of medicines. People we spoke with said 'I always get my medicine on time' and 'I get my tablets on time.' One relative we spoke with said 'I have no concerns about medication.' We did find, however, that appropriate systems were not in place in relation to people's mental capacity assessments and Deprivation of Liberty Safeguards (DoLS). There were not clear support plans for the management of challenging behaviour. Records were not always kept up to date and incidents were not always recorded.

Is the service effective?

People told us they were satisfied with the care they received. We saw from care records that some care needs had been appropriately assessed and care plans reflected these needs, however this was not the case for all needs. Care plans we looked at varied greatly in the amount of detail they contained. People we spoke with said 'They give me all the care I need' and 'the staff look after me well.'

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed understanding and gave encouragement when supporting people. Staff communicated clearly and at an appropriate pace with the people they were supporting. People's preferences had been obtained by the home and were included in people's care plans. However, some people who had dementia did not have clear or consistent communication needs identified in their files. There was a lack of activities organised for people with dementia, who expressed they were bored. Relatives also told us people were bored.

Is the service responsive?

The home responded to people's changing needs and sought advice and guidance from relevant healthcare professionals. We did not, however, see this advice being used to develop care plans. Actions had been taken to respond to accidents and incidents, however, these were not always recorded. The service had taken steps to respond to concerns previously raised by CQC and had responded to concerns raised by relatives.

Is the service well-led?

Quality assurance processes were in place in the home. We saw evidence of people and their relatives being asked for feedback and this being responded to and acted on. We saw that several audits and internal inspections had been carried out and that issues identified had been acted upon. Staff told us they were asked for their feedback and felt their opinions had been listened to and used to improve the home.

However, we saw that there were not appropriate procedures in place to monitor and assess accident and incidents as these were not collated or analysed. We also found that the service had not notified the CQC of all required incidents. The Regulated Manager, named in this report, is no longer employed at the service but as they have not yet de-registered their name still appears. At the time of the inspection the service was being managed by two Senior Managers who worked in shifts.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found '

Is the service safe?

There were not enough staff on duty during night shifts to meet the needs of the people living at the home. People's care needs had not been appropriately assessed. People's safety and welfare were at risk. One member of staff we spoke with said 'People's safety is put at risk at night.'

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to nursing homes. While no applications had needed to be submitted, proper policies and procedures were in place.

Is the service effective?

Staff told us they were unable to provide adequate care to people and felt people's needs were not always being met. Care had not always been planned or delivered in a way that incorporated people's preferences. Staff said 'We're not given time to read care plans.', 'It's just poor care.', 'We don't get a chance to read the care plans.', 'Staff do not have time to complete care plans. We do our best but staffing levels make it dangerous.' And 'You cannot give adequate care.'

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. People felt, however, that staff were rushed. Staff told us they were unable to deliver person centred care because of staffing levels. One person's relative told us 'I have heard people shouting for help. I have monitored how long it takes them to respond to my relative's bell and sometimes it didn't get answered.' One member of staff said 'Buzzers were answered but we would go in and tell people we couldn't help straight away. People had to wait.' Another member of staff said 'People are having to wait.'

Is the service responsive?

Records showed that people's preferences, interests and diverse needs had not always been recorded and care and support had not always been provided in accordance with people's wishes. People's needs were not always appropriately assessed.

Is the service well-led?

The service had failed to address urgent concerns raised with them by the staff and people's relatives relating to staffing numbers for at least four weeks. The service had not adequately monitored staffing levels or the risks this caused to people's safety and welfare. Staff did not feel listened to by the management and people's relatives told us they were not asked for their feedback.

We observed people being offered food and a choice of drinks. One person told us, 'If I want something I am able to ask, if the menu is not to my liking, I can have something different'.

We found that care plans were comprehensive and reflected individual needs along with personal profile life history books.

We observed people relaxing and socialising in the communal areas, while staff were available to support as required.

We saw that there was a choice of suitable and nutritious food and drink available in sufficient quantities. The lunchtime meal looked well presented with seasonal vegetables, one person told us, 'it was really nice, they know what I like here'.

We saw the medication systems in use meant people had their medicines at the time they needed them and in a safe way. People told us that they were given their medication at regular times and were able to request pain relief at any time

Since the last inspection the registered person had introduced systems to regularly assess and monitor the quality of the services provided.

The home was registered for 80 people. On the day of our inspection seven people were living at the home and receiving care from the service. Seven care staff were on duty in the day including a relief manager, deputy manager/registered nurse, a registered nurse, four care workers and an activities coordinator. We spoke with one person, two relatives, the relief manager, the deputy manager, two senior managers, three care workers and a visiting GP. We also spent time observing care and looked at two care plans. We checked how people were looked after at each stage of their care.

A relative said 'I couldn't fault them here. I've got not problems with the place at all. You can ask them anything, any time.' A GP who had recently assessed all the people said they were 'very pleased' with the improvements made by the home. One member of staff said the home was '50 times better' and had a 'totally different feel'.

Arrangements were made by the local safeguarding team to ensure that the needs of those people who remained living at the home were met.

Relatives we spoke to were very concerned about the standards of care at the home, and about the lack of leadership. We found that people’s basic care needs such as personal hygiene, nutrition, continence and pressure area care were not being met. Care plans lacked detail which meant that staff did not have the information they needed to enable them to meet people’s needs.

Systems had not been developed that would have enabled the management team to identify and manage risks. As a result people had experienced unsafe care. The senior manager in charge at the time of our inspection showed a commitment to learning and taking appropriate action to address the risks identified.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.