Archived: Laverstock Care Centre

This inspection took place on 1 and 2 December 2016 and was unannounced.

At the last comprehensive inspection in June 2016 we identified that the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because risks people faced were not managed effectively, people’s medicines were not always safely managed, there were not always sufficient staff deployed in the home, care plans did not always contain up to date information about people’s specific needs, staff did not always treat people with dignity and respect and quality assurance systems did not always identify shortfalls in the service provided. We issued requirement notices as a result of the concerns we identified.

Action had been taken to improve the safety of the medicine management systems, although further work was needed to ensure medicated topical creams were managed effectively and medicine administration was recorded accurately.

Improvements had been made to the way risks people faced were managed. Staff had identified most risks and had planned with people using the service how those risks should be managed. Staff had a good understanding of the risks and the action that was planned. The plans were regularly reviewed and updated when people’s needs changed. However, we identified further work was needed in relation to the support for people to stay safe when the fire alarm was activated.

Staffing levels had been reviewed and there were sufficient staff deployed to meet people’s needs. During our observations we saw that staff were available to provide support to people when needed. Staff were available to provide support for people to eat, drink and move around the home safely. Requests for assistance from people were responded to promptly. People and their relatives were positive about staffing levels in the home. Comments included, “Staff come quickly when I use my call bell”, “The staff all work together very well” and “There are enough staff around. They always hoist (my relative) and they know what they’re doing. They provide good pressure care and turn her every two hours”.

Staff told us there were enough of them available to be able to provide safe care and meet people’s needs .Comments from staff included, “Generally staff cover is good. There is enough time to sit and chat to residents”, “We are now able to provide the care that people need. There is better team work. It is much better than at the last inspection” and “We were short staffed but this has improved over the last two months. We are able to provide the care that people need”.

We found that the provider had taken action to improve the information set out in the care plans, but further work was needed to ensure plans always reflected people’s specific needs. Most plans contained clear information about people’s needs and there was evidence that the plans were updated when people’s needs changed. We saw two examples of plans relating to people’s dementia care needs that did not give staff clear, specific information about the support that was required.

People told us they were treated well and staff were caring. Comments included, “I am very happy here. The staff are kind and treat me well” and “They (staff) are very kind to me”. Most relatives we spoke with were also positive about the caring approach of staff, with comments including, “The care here is exemplary” and “I am very happy with the care (my relative) receives”. One relative was not happy with the approach of some staff. Although we did not see any examples of poor care, we made the registered manager aware of these concerns. The registered manager said they would continue to work with the person to address their concerns.

People who were at risk of malnutrition and/or dehydration were supported to ensure they had sufficient food and fluid intake. People were offered regular drinks and where they required support with these, staff assisted them.

Staff were taking suitable action when they identified that people did not have capacity to consent to their care or treatment and had made applications to authorise restrictions on people’s liberty.

Staff told us they received training and support which gave them the knowledge and skills needed to do their job effectively. Comments from staff included, “Training is good quality and we are able to keep our skills up to date”, “There’s lots of on-line training, but I’m not a big fan of this. We do have face to face sessions as well, which helps us to address specific issues” and “The dementia training is very good”. Registered nurses told us they were able to maintain their continuous professional development, to ensure they kept up to date with current best practice.

Staff felt the changes that had been made to the management of the service since the last comprehensive inspection had been positive. Comments from staff included, “There is now better support from management (since the last inspection) and a higher staff presence. (Management) is very supportive”, “It is more organised than before and staff are more professional. Residents are respected” and “It’s a lot better now – a different place. (The management team) have given us the correct tools and we now have good direction. I feel residents and staff are happier and we have fewer incidents. I’m happy to work here now”.

At this inspection we found that action had been taken to improve the quality assurance systems in the service. The registered manager told us she had reflected on the findings of the inspection in June 2016 and had worked hard to address the concerns. However, despite the improvements that had been made, there were still areas of the service that required further improvement, which had not been identified by the quality assurance systems.

Following the last comprehensive inspection in June 2016 we placed the service in 'special measures' because it was rated as inadequate. Following this inspection we have removed the service from special measures, because of the improvements that have been made and because no area of the service was assessed to be inadequate. However, further work is needed to improve the service and ensure people receive a consistently good service.

During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for which we are taking action and will report on this when it is concluded.

This inspection took place on 8 June 2016 and was unannounced. We returned on 9, 13 and 21 June 2016 to complete the inspection.

At the last comprehensive inspection on 28 and 29 April and 1 May 2015, we identified the service was not meeting a number of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people were not being supported with decision making in line with the Mental Capacity Act 2005 and the planning of care was not always done in such a way to meet people’s individual needs. In addition, potential risks to people’s safety were not being properly identified and addressed. Following the inspection, the provider sent us an action plan, which detailed how improvements would be made. During this inspection, we noted some improvements had been made but others had not been sustained.

There was a registered manager 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. The registered manager is responsible for the day to day management of the home and was available throughout the inspection.

Before the inspection, concerns were raised about alleged institutional abuse within the home. The concerns were reported to the local safeguarding team and were in the process of being investigated. People told us they felt safe. However, there were some concerns raised by a relative and some staff about the attitude and practice of some staff. This feedback was given to the registered manager and the management team to consider accordingly.

Risks to people’s safety continued not to be satisfactorily identified or addressed. Action in response to some incidents was not always sufficient to minimise reoccurrence. Clear plans to minimise and manage some people’s challenging behaviour were not in place. Staff had not received training in managing such behaviour, which increased the risk of escalation and harm to people. There were other incidents within the inspection, which did not promote people’s safety. This included a person being supported to eat, whilst not being alert. This increased their risk of choking.

Not enough staff were available at all times to meet people’s needs effectively. There were times when people were not adequately supervised or supported. On one occasion, the impact of this was that people had spilt their drinks and had dropped food to the floor. There were various occasions when staff were “borrowed” from other units to assist, particularly when staff took their breaks. This did not ensure consistency of care and some staff were not fully aware of people’s needs, due to not working with them regularly.

People’s medicines were not safely managed and not always administered as prescribed. One member of staff gave people their medicines but did not ensure they were taken before signing the records. Another member of staff gave medicines to another staff member to give to people. This practice was not safe due to the risk of error. The medicine administration “round” was lengthy which meant some people received their medicines late. This impacted on the timescales of the next administration. Medicines were not always stored securely and records did not demonstrate clear guidance for staff in relation to “as required” medicines or topical creams.

Care was not always responsive to people’s needs or provided in a person centred manner. Pain was not always sufficiently managed and documentation did not clearly state people’s wishes in relation to their end of life care. People’s care plans regarding areas such as minimising the risk of pressure ulceration were not always followed. Not all people were supported to have sufficient fluids doing the period of hot weather. This increased their risk of dehydration and associated conditions such as urinary tract infections.

Staff did not always respond or interact with people in a way which promoted dignity and respect. Some staff talked to each other and over people rather than promoting involvement. Other interactions were more positive and there were complimentary comments from people and relatives about the staff.

There were a range of systems to assess and monitor the quality of the service. However, not all were effective in identifying and addressing shortfalls. Accidents and incidents were being analysed yet action to minimise reoccurrence was not always sufficient.

Staff generally felt well supported and there were formal systems in place to discuss staff’s performance. Some staff felt these sessions were useful, while others did not feel such benefits. Some staff felt teamwork could be improved upon. A range of training was arranged to increase staff’s knowledge and help them to do their job more effectively. Other than the omission of challenging behaviour training which was being addressed, staff were happy with the training provided.

People and their relatives knew how to make a complaint and were encouraged to give their views about the service. People had enough to eat and were able to choose what they wanted from various choices. Systems were in place to monitor people’s weight and if concerns were noted, these would be discussed with the GP. People were supported to access a range of services to meet their health care needs. A record of such appointments was maintained.

During our inspection we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 for which we are taking action and will report on this when it is concluded. Three of these breaches were repeated from the last inspection as sufficient action had not been taken to address the shortfalls. The overall rating for this service is ‘Inadequate’ and the service is therefore 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.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the care staff gave and from looking at records. If you would like to see the evidence supporting our summary please read the full report.

Is the service caring?

Staff spoke to people in a caring and friendly manner. There were some positive interactions including sensitively waking a person up to have a drink and offering reassurance to reduce a person's agitation.

The deployment of staff at certain times meant people were not consistently supported in a person centred way. Staff felt the quality time they had with people was sometimes restricted.

Is the service responsive?

Staff were not fully responsive to people's needs. They did not give people assistance to change their position at regular intervals according to their care plan. This increased people's risk of pressure ulceration.

One person displayed challenging behaviour. This was disruptive to others and at times caused injury to staff. These incidents were not documented and there was no clear management plan in place. Further guidance from specialist health care personnel had not been sought.

Is the service safe?

Staff were fully aware of their responsibilities to keep people safe. They were aware of how to recognise abuse and what to do if abuse was suspected.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Whilst the majority of the home was clean, less visible areas and some equipment was not. There were areas which compromised infection control principles.

Is the service effective?

Staff did not consistently monitor people's fluid intake to minimise the risk of dehydration. There was no evidence to show those people at risk of a urinary tract infection were encouraged to consume additional fluids.

Staff did not consistently monitor the dietary intake of those people who were nutritionally compromised. There were gaps in people's food charts and no evidence people were offered snacks between meals or an alternative if they had declined their meal.

Staff did not promote people's dignity. They did not consistently support people in a timely manner and did not always interact with people effectively.

Is the service well led?

Visitors said they would have no hesitation in raising a concern with the manager if they were unhappy about the service.

There were regular staff meetings to share and discuss information. Staff had been assigned specific roles, which had been clearly adopted.

There were a range of systems which monitored and assessed the quality of the service. Audits identified some shortfalls in provision and action plans were in place to ensure improvement. Not all deficits however, were being identified.

During our visit, we did not see any evidence that people's personal care needs were not being met. People told us they were happy with the service they received. People were well presented with clean clothing, manicured nails and nicely brushed hair. Staff supported people to change their position to minimise the risk of pressure ulceration.

There were many positive interactions between staff and people who used the service. Staff responded to people in a friendly, caring and attentive manner. Staff gave people time and promoted discussion. They were attentive to people's needs. Staff assisted people with snacks when requested and regularly offered a choice of drinks.

Care plans generally gave details of people's health and personal care needs and the support they required. There were assessments which demonstrated people's risk of falling, malnutrition and developing pressure ulceration. Information identified the measures in place to minimise any risks identified.