The Larches - Tiverton

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

During this assessment we identified 2 breaches of regulation in the safe key question for Safe care and treatment and Fit and proper persons employed. Improvements were needed in the quality statements of Involving people to manage risk, Safe and effective staffing and Medicines Optimisation. We identified concerns in relation to the management of people’s medicines and not all aspects of the environment were consistently safely managed. Improvements were needed in relation to infection control practice. In relation to the Fit and proper persons employed breach, staff were not always recruited safely in line with relevant legislation. However, people at the service told us they felt safe and that staff supported them well.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

People and their relatives told us they felt safe with the staff that supported them. No concerns were raised with us during our assessment. One comment received from a relative by our assessment team was, “I’m looked after, they are friendly. They will talk to me. The staff are lovely.” Another person said, “It’s a nice place. It works well.” Our onsite observations were positive.

Staff understood their safeguarding responsibilities, including the requirement to report them to an external agency such as the Care Quality Commission (CQC), if they felt their concerns were not addressed. However, previously safeguarding notifications had not been sent to CQC in line with legal requirements. This meant we did not have an overview of safeguarding incidents in the home to help us measure risk in the service. Since the inspection, appropriate safeguarding alerts have been made to the local authority linked to medication errors, with steps taken to improve staff practice.

During our assessment we observed people were at ease with the staff that supported them. Staff were mindful of people’s safety, ensuring they did not face unnecessary risk when moving around the building. We observed attentive staff used equipment safely to assist people to move.

There were current policies and processes to reduce the risk of people being exposed to harm or abuse. Guidance for staff reporting was available. The provider sent evidence demonstrating referrals had been made to the relevant local authority where concerns were identified. However, as highlighted these had not been sent to CQC as required.

People were informed about risks and supported to keep themselves safe whilst remaining independent. However, although no concerns were raised with us people and relatives we spoke with were unaware there was a care plan in place. This did not clearly demonstrate people were involved in making decisions about their care and support.

Staff assessed risks, and staff understood them. This was demonstrated by completed risk assessments, records and person centred care plans. Staff knew people well and could describe how risks were managed for individuals. We saw examples of good practice where staff had alerted health professionals to changes in people's health, which resulted in a change of equipment or the height of their bed to help them move more easily. However, records did not always demonstrate how people were involved in making decisions about their own care.

We saw staff offering choice to people regarding drinks and food and acting upon people's decisions. People were supported in a way that allowed them to remain independent where they could.

Systems and processes failed to ensure people were always supported to make decisions about their care and treatment within the principles of The Mental Capacity Act 2005 (MCA). Mental capacity assessments and best interests decisions were not always completed where people had restrictions placed on them. People’s capacity to understand decisions had not always been assessed by staff. Systems and processes failed to identify people’s Deprivation of Liberty Safeguards (DoLS). Applications had been submitted for 8 people; these were retrospective applications.

People did not raise any concerns relating to the maintenance, safety and upkeep of the service. A relative we spoke with told us, “I think with the age of the property it’s quite hard for it to be spanking gorgeous, but they are always cleaning, and I am happy with the cleanliness of [person’s identity] room."

Staff were concerned regarding the number of call outs for the lift and described incidents where the doors were unsafe. They had no guidance as what to do if someone became trapped in the lift or they were unable to move large moving and handling equipment between floors.

The observations we made during the assessment did not identify any significant environmental concerns inside the building that presented any risks to people. However, we identified the area outside of the service where there was clinical waste building up required attention. This was addressed with the provider.

Equipment, facilities and technology did not always support the delivery of safe care. Staff told us there were issues with the environment. A senior staff member told us they often faced delays and challenges with the provider to ensure the home and equipment were well maintained. For example, the outside clinical waste bins were overflowing on the date of our inspection and staff told us they had not been collected for 6 weeks. This meant there was a risk for infestation. Staff did not always follow the care documentation for checking equipment. For example, the care documentation for a person at risk of falls stated, ‘Please ensure my sensor light is working daily’ but when questioned, staff had no way to record these checks and stated they did not know they needed to be done. The service did not always have effective processes to monitor the safety of the environment. The environmental audits were not always completed. On the day of the assessment we could not see any audits or testing certificates for the equipment such as hoists or the lift. The lift was unreliable and staff reported the doors would close quickly and this had resulted in near misses in the past. The lift was working on the day of the assessment, but we were told by staff that it often breaks down. There was no contingency plan or written guidance for staff in the event of it breaking down. At the time of the assessment there was a piece of equipment in the home used for 2 people on different floors of the home. This meant if the lift was out of action people were at risk of being isolated in their rooms without adequate staff support and unable to access the equipment needed to help them transfer safely.

People and their relatives felt well supported by a competent staff team who knew them well. People said staff responded to call bells promptly but also understood there were busier times where they may have to wait. People told us they felt the staff had the skills to support them safely. One person said, “They are there, and there’s someone with you helping you. Yes, I feel confident [staff are well trained].”

Staff were positive regarding the purpose of training. However, they said there was a lack of clarity from the provider as to whether they got paid for all training or only certain topics. We asked what their contracts said with regards to training, but they said their contracts were in the process of being reviewed. The manager had made good use of external resources to enhance their knowledge which they then shared with other staff members. Where possible staff also attended this training as well when cover could be arranged. The manager had encouraged staff to complete on-line training, which was confirmed by staff and the content of the training matrix.

Staff moved people safely and used equipment to help people transfer. For example, they used safe practice when they moved people who used wheelchairs. They also acknowledged when a person was struggling with pain when moved and liaised with a GP and a clinical pharmacist so this could be addressed.

Recruitment practices were not safe as we saw staff files were missing key documents, such as police checks or appropriate references. This meant there was a risk of staff being recruited who were unsuitable to work in care. We found there was no formal induction training for new staff, nor any timescale for when mandatory training was to be completed. Newly hired staff were given 3 days to shadow a more experienced member of staff and then were signed off. This meant there was a risk staff who were new to the service and new to care were not given sufficient information to carry out their duties correctly and safely. New staff were not required to complete manual handling training before using hoists or wheelchairs presenting a risk people may receive unsafe care. The service deployed appropriate staffing levels to meet people’s needs.

No concerns were raised with us about the cleanliness of the service or staff practice. One relative when asked about the cleanliness of the service said, “I do [feel it’s clean]. It’s always been good. I have never come in and felt it smelled.” Another said, “They are always cleaning, and I am happy with the cleanliness of [person’s identity] room.”

Staff told us they understood the importance of good infection control practice and explained how soiled washing was collected and washed to maintain good infection control measures.

We found the service did not always have effective infection prevention and control measures. We found the service did not always assess and manage the risk of infection and did not have adequate processes to detect and control the risk of infection spreading. On the day of the assessment, we found the Control of Substances Hazardous to Health (COSSH) cupboard was well stocked. However, the housekeeper told us they had asked the provider for carpet cleaner but had not yet received any, presenting a risk of carpets not being cleaned when required. The staff were wearing appropriate personal protective equipment such as gloves and aprons when assisting people. New starters did not receive any training in infection control before starting work and there was no training system to ensure they received training within a specific time frame. This meant that new staff may not know what an outbreak was or how to contain it safely. However, the home was clean and there were no longstanding odours despite staff not having a carpet cleaner in the home. One person was unwell during our inspection, and we saw how care and housekeeping staff worked together to maintain the person’s dignity and ensure their bedroom was cleaned and odour free.

Infection control measures were not always effective. We saw staff using protective clothing and gloves appropriately, including disposing of them when they had finished the interaction. However, processes had not ensured storage and training was completed, this meant there was a risk of best practice not being followed.

People received their medicines in a safe and caring way. People’s individual preferences for how they liked to take their medicines were considered. However, there were some gaps in people’s records where it was not possible to tell whether these doses had been given in the way prescribed for them.

Staff told us they felt well supported regarding medicines management. Staff were trained in medicines administration and staff spoken with had recorded competency assessments. However, the manager told us these had not yet been completed for all staff but this was being addressed. Staff could describe how any errors or incidents that had been identified were recorded and followed-up.

There were some gaps in people’s medicines records that meant we were not assured people always received them as prescribed. Some of these gaps had been identified by their audits however, all the gaps we found during our assessment had not been picked up by this audit. There were no completed risk assessments for some medicines such as flammable topical preparations or blood thinning medication. Staff received training, and competency checks were underway but not completed for all staff. The service had protocols to guide staff for ‘when required’ medicines but not for all of these medicines and some lacked person-centred details. There were suitable arrangements for storage and disposal of medicines. Audits were completed and identified most, but not all of the issues we found. However, timings of medicines administration had been improved and we saw that medicines were given at appropriate times.