OSJCT Athelstan House

Athelstan House is a purpose-built residential care home providing regulated activities accommodation for persons who require nursing or personal care and treatment of disease, disorder or injury to up to 80 people. The service provides support to people with dementia, older and younger people and people living with mental health needs. At the time of our inspection there were 67 people using the service.

Athelstan house is laid out over two floors, people can access these floors by stairs or a lift. Each floor is split into areas where people are supported in relation to their care needs, for example nursing or dementia needs. Bedrooms have en-suite facilities and there are communal bathrooms and toilets throughout the service. There is level access to a large, well-stocked garden from the ground floor. Communal dining and lounge areas are located on both floors. The registered manager’s office can be found on the ground floor adjacent to the reception area.

People’s experience of using this service and what we found

This inspection was undertaken to follow-up a warning notice we issued during our last inspection. We found the provider had worked to make improvements. For example, people were now supported to have their medicines as prescribed and measures were in place to monitor medicines management.

The provider had worked with external electrical engineers to ensure electrical safety was satisfactory. Additional improvements had been made to fire safety to help protect people from avoidable harm.

The registered manager monitored accidents, incidents and potential safeguarding concerns, linking notifiable incidents to a CQC reference number so they were assured statutory notifications were submitted as required. Risk assessments were now in place and provided guidance for staff about actions they should take to help keep people safe.

The provider had reviewed and increased the number of managers in the service to help sustain improvements and with the overall aim of attaining an overall ‘good’ rating at their next CQC inspection.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 26 October 2022). At this inspection we found improvements had been made and the provider was no longer in breach of regulation 17.

Why we inspected

We undertook this targeted inspection to check whether the Warning Notice we previously served in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

We use targeted inspections to follow up on Warning Notices or to check concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

OSJCT Athelstan House is a large nursing home in Malmesbury for up to 80 people. Accommodation is provided over two levels accessed by stairs and a lift. People have their own rooms and en-suite bathrooms. People also have access to communal areas such as lounges, dining rooms and gardens accessed from the ground floor. At the time of our inspection there were 72 people living at and using the service.

People’s experience of using this service and what we found

Since the last inspection there had been changes in management which had been unsettling for people and staff. There was now a registered manager in post who had worked for the provider for some years. Feedback about their approach was positive, staff told us they were approachable and “hands on” at the home.

Quality monitoring was not effective in all areas. The shortfalls we found had not been identified and action was not taken where needed. Systems were not robust in identifying areas of improvement which meant this service was rated requires improvement for the fifth consecutive inspection.

People had not always received their medicines as prescribed. There had been high numbers of medicines errors and incidents prior to our inspection, action taken in response was not always effective in preventing reoccurrence.

Risks to people’s safety had not always been managed safely as guidance to manage the risks was not in place or was not being followed. Whilst people's needs had been assessed prior to admission, some guidance was not available for staff to follow. People were able to see a GP as they visited the home regularly. We found two referrals to healthcare professionals that needed to be made in a more timely way. Staff took action during our inspection.

People and staff told us there were not enough staff at times which meant people had to wait for a staff response. We have made a recommendation about staffing. Staff had been recruited safely and provided with an induction when they started work. Training was provided to staff when required and staff could ask for more training if needed. Staff told us they had supervisions and felt supported in their roles.

Not all the staff we spoke with understood what safeguarding and whistleblowing was and what action to take if they had concerns. We have made a recommendation about safeguarding training.

The home was clean, but we did see some cobwebs in high areas and raised this with the registered manager. Staff were seen to be wearing safe personal protective equipment (PPE) and staff told us they had guidance on how to use PPE safely. Government guidance regarding testing for COVID-19 was being followed and action taken where needed for any positive test.

Mealtimes were not rushed and people told us the food was good. We saw people had access to snacks and drinks throughout the day. We observed some mealtime support was not person-centred which we shared with the registered manager.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People told us the staff were caring and worked hard. Staff told us they enjoyed working at the home and they all felt there was good teamwork. People had been asked for their views and results had been collected. The registered manager planned to discuss results with people at a ‘residents meeting’ which were held regularly.

The service had a group of volunteers who visited regularly to help with activities and maintaining the garden. Staff told us they wanted to start linking up with the local community again which the service had done prior to COVID-19.

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

Rating at last inspection

The last rating for this service was requires improvement (published 10 November 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

We received concerns in relation to the management of medicines. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of the full report.

You can see what action we have asked the provider to take at the end of this full report. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for OSJCT Athelstan House on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to person-centred care and good governance at this inspection.

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.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Athelstan House is a residential care home providing personal and nursing care to 61 people aged 65 and over at the time of the inspection. The service can support up to 80 people over four units.

People were accommodated in one purpose-built, two-storey home. The four units in the home were referred to as ‘households’ and were named after different flowers. One unit was accommodating people on a short-term basis. These were people who had been discharged from hospital, for assessment of their care needs. People had access large communal gardens, as well as each household having kitchen/dining rooms and lounges.

People’s experience of using this service and what we found

In the two weeks prior to this inspection, two people had left the building without staff support. Measures to improve safety were put in place following these incidents, but the safety shortfalls had not been identified prior to people being able to leave.

People who were accommodated in the dementia care household had been moved upstairs in the home, to the residential households. This decision was made to support hospital discharge processes during the Covid-19 pandemic, with people being discharged from hospital to the home for assessment. Staff, management, and health and social care professionals felt that this had contributed to an increase in physical altercations between people. There were plans to move people again, back to their previous household, in early November 2020.

At the last inspection, we found that people were not consistently being supported to receive food in their required texture. This increased the risk of choking. We found there had been improvements in the management of risks associated with food preparation.

At the last inspection, we also received mixed feedback about the staff availability, and the length of time it took for call-bells to be answered. At this inspection we were told by staff that there had been a recent difficult period and it had been challenging during the Covid-19 pandemic. They referred to being short-staffed and not having the staffing to enable them to do everything that needed to be done. Staff told us there had been recent improvements and we observed there to be enough suitably skilled staff to meet people’s needs.

We received mixed feedback from health and social care professionals. These included comments about staffing challenges, as well as difficulty gaining consistent communication with the home. There was also positive feedback about how people were supported to maintain family contact.

Since the last inspection in June 2019, two home managers had left the service. There were temporary arrangements in place for management team at the home while recruitment was ongoing.

People’s medicines were managed safely and administered by trained staff. People were supported to make improvements in their health conditions, including their skin and wound care. Their progress was supported and monitored by registered nurses who liaised with health care professionals.

The home was clean and tidy. There were measures in place to reduce the risk of any cross-contamination. Staff wore appropriate personal protective equipment, including masks and when needed, gloves and aprons.

A range of different quality audits took place. Checks of the service were updated to reflect changes in Covid-19 government guidance and when there was learning from accidents or incidents.

People were asked for their feedback to aid improvements and developments at the service. There were also different examples of good community engagement.

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

Rating at last inspection

The last rating for this service was requires improvement (published 14 August 2019).

Why we inspected

The inspection was prompted in part due to concerns received about how people’s safety was supported. A decision was made for us to inspect and examine those risks. We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection. At this inspection, we undertook a focused inspection to review the key questions of safe and well-led only.

The overall rating for the service has remained as requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Athelstan House on our website at www.cqc.org.uk.

Follow up

We met with the provider following this inspection, to discuss how the service will improve to a good rating. We have requested monthly action plans be provided, so progress at the home can be monitored. We will visit the service earlier than our inspection methodology to ensure the required improvements have been made.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection.

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.

Athelstan House is a care home providing personal and nursing care to 50 people aged 65 and over at the time of the inspection. The service can support up to 80 people over four units.

The units were known as ‘households’, and one household was not open at the time of the inspection, due to redesign and full refurbishment. One household was for people requiring nursing care. There were two households for people with residential care needs and the refurbished household was designed to support people with dementia.

People’s experience of using this service and what we found

Risks to the safety of people who had been assessed as requiring a pureed diet due to swallowing difficulties were not always well managed. We found one person was served a meal which was not in accordance with their dietary requirements four times in two days at lunchtime. Upon receiving our feedback about this, the management team consulted with the kitchen staff and implemented monitoring systems to prevent this happening again.

People and their relatives gave mixed feedback about whether there were enough staff available. The home was staffed according to their dependency calculations. The home was actively recruiting for more staff and there had been successful recruitment initiatives at the home. To improve consistency in staffing on the nursing household, agency nurses had been block-booked. For people to feel there were enough staff, these changes may need more time to become embedded.

We also received varied feedback about whether call bells were responded to promptly enough. There was a new call bell system which gave a transparent oversight of how long people had been waiting. However, we did receive feedback from people who required the support of two members of staff for using the bathroom. They felt their call bell was answered by one staff member, but they continued to wait for a second staff member to become available. This had left people feeling embarrassed due to not receiving timely continence support.

People’s feedback about the quality of the food they received was very mixed. The manager had introduced a group for people to attend called ‘food for thought’. The food for thought group discussed feedback about the food and menu options they would like to see.

There were plans to implement more detailed care plans to support people’s healthcare needs, such as epilepsy and diabetes. There was a consultant clinical lead working with the nursing and care staff to ensure the care plans reflected the healthcare support people required.

People had access to a visiting GP. The GP told us there had been improvements at the home and they felt the staff team were responsive to any guidance or feedback they gave.

The had been investment in the decoration and design of the inside and outside of the home. There were new carpets and kitchen/dining rooms, and landscaped gardens. We saw people using the gardens for walks and to spend time with friends or relatives. The gardens had won a community ‘in bloom’ competition.

There was an activity programme in place and an activities team of staff. People told us they attended activities where they wanted to. Activities also included community involvement, with a visiting toddler group spending time with people in the home.

People’s relatives were welcome to visit when they chose. People’s relatives attended meetings about the home. They told us they felt improvements had been made, although sometimes these were done at a slow pace.

People’s privacy and dignity was respected by staff. People told us they could choose where they wanted to spend their time.

People’s capacity to consent to their care was assessed in accordance with the principles of the Mental Capacity Act. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People, their relatives, staff and visiting professionals told us the morale and atmosphere at the home had improved in the six months prior to the inspection.

Audits of the service were completed by members of the management team and these gave the manager an oversight of the service. The manager knew where there were areas for improvement and there were plans in place to continue to address these.

The manager led by example and ensured they were a visible presence around the home. People and their relatives knew the manager and felt they were approachable. The manager had a good insight into people’s needs and their life history.

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

Why we inspected

This was a planned inspection based on the previous rating.

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 15 June 2018) with a breach of Regulation 12 for safe care and treatment. Since this rating was given, there was a change in manager and the provider notified us of action they would take to make improvements.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections. More time was needed for some of the planned improvements to be implemented and embedded into practice.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

This inspection took place on the 25 and 26 April 2018 and the first day was unannounced. The registered manager was aware of the subsequent visit.

Athelstan House is a care home providing nursing and residential care for up to 80 people. At the time of the inspection there were 53 people living at the home. 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. The home is arranged over two floors with Primrose and Lavender on the ground floor and Foxglove and Heather on the first floor. In Lavender people were receiving nursing care and residential care was mainly delivered to people in Foxglove and Heather. Re-admissions into Primrose the empty unit will be over a period of time.

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.

Safeguarding processes were in place and ensured people at the service were safeguarded from abuse. Staff had a good understanding on of the types of abuse and the actions needed where there were concerns of abuse. People generally said they felt safe.

Risk assessments were in place but not regularly monitored to assess the effectiveness of the action plan.The staff we spoke with were knowledgeable about people’s individual risks and the actions needed to minimise the risks. Individual risks to people included falls, risk of malnutrition, choking and mobility impairments.

Quality Assurance systems were in place but areas identified at the inspection were not reflected in the audits. There was inconsistent action for some people identified at risk of malnutrition and for one person that had sustained an injury. Weight monitoring charts were not in place for one person that was at high risk of malnutrition. Staff had not reported extensive bruising for one person. The registered manager took prompt action when we identified this and reported the incident to appropriate authorities. Appropriate reporting action had been taken in the upstairs units. .

The robust medicine systems in the residential units ensured safe systems of medicines. However, the same situations were not found in the nursing units. Medicine audits had identified gaps in when required medicines (PRN) but the timeframe for meeting the action was not met.

Gaps in the administration of medicines were not reported and we observed unsafe medicine administration by a registered nurse. The registered nurses comments indicated their awareness of gaps in the recording of medicines administered. checks were not taking place. Where audits had identified shortfalls these had not been actioned.

Medicine profiles included a photograph of the person and essential information such as known allergies and how the person preferred to take their medicines.

Care plans upstairs in the residential units had elements of person centred care and were reflective of people’s current needs overall. In the nursing units we found inconsistencies. For one person at high risk to weight loss the care plan stated that staff should support them to be weighed once every two weeks but this had not happened since April 2018. Mental capacity assessments were not always in place and records needed to be clearer.

The safety of the living environment was regularly checked to support people to stay safe. For example, fire risk assessments, fire safety equipment checks and fire training for staff.

Staffing rotas were designed using dependency tools. People and their relatives said there had been improvements in the staffing levels and in recruitment of new staff.

Staff said the training had improved. The trainer said training had improved and that there were one to one opportunities for staff. A moving and handling trainer was onsite. The registered nurses said they had access to training but sometimes it was difficult be assessed and maintain their competency.

The staff we spoke with knew how to ensure people were given choice and supported to make decisions. Mental capacity assessments were not always in place for crash mats and sensors. Relatives were asked to sign bed rails consents but staff were not always aware if a lasting power of attorney was in place.

There were good activities resources. The activities coordinators tracked the activities they provided. Relatives also praised the care staff for the social interactions they had with their family members. Some relatives said this was not always recognised as part of social interaction. Feedback was very positive about the caring approach from the staff. Staff were very respectful of people’s rights.

Staff said the leadership was strong and the management team and registered manager was approachable and visible. They said the deputy and head of care made a good management team. There was a strong relatives group and they told us there had been improvements since the appointment of the registered manager. Relatives praised the registered manager and deputy for their commitment and that they were visible at weekends.

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 took place on the 17, 18 19 and 23 May 2017. The first day of the inspection was unannounced and the manager was aware of subsequent visits.

A registered manager was not in post. There had been several changes in managers in a 12-month period. Staff said there had been five managers. These changes did not enable the staff to clear guidance and leadership. 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 the staff and the security of the building made them feel safe. Some of the staff we spoke with said people were not safe. These staff said they were not delivering adequate levels of care at all times. Staff said they did not felt confident to raise concerns to the provider, as they felt their concerns were not taken seriously. During the inspection, 11 staff came forward to raise concerns about the service.

People were at risk because information and record keeping was inconsistent. Staff said identified risks were assessed and action was taken to minimise the risk. We saw that risk assessments lacked detail and action plans were not followed. Where people had capacity to make decisions and were refusing textured diets, risk assessments were not developed and agreements were not reached on the foods to be eaten. Where people’s fluid and food intake was monitored the charts were not analysed or totalled at the end of each day. This left people at higher risk of dehydration. People were not supported to move position according to the risk assessment which meant they were at higher risk of developing pressure ulcers.

People expressed concerns about insufficient staffing levels and lack of effective management in the deployment of staff. They said at certain times of the day, they had long waits before help arrived. Documents provided on staffing levels indicated that in 12 months, 31 staff had left the service which included registered nurses, seniors and carers, housekeeping and catering staff. The staff raised concerns about the deployment of staff.

During our visit we noted the call bells ringing. Staff told us their hand held devises were not working effectively and they were not always aware of people summoning them for attention.

Staff expressed concerns about training. Staff said training was often cancelled and there were times when they were not able to attend as there were insufficient staff on duty to maintain staffing levels.

One to one meetings were not taking place and staff felt there was a lack of opportunities for personal development. Staff told us one to one meetings with their line manager and appraisals were not taking place. Registered nurses were not supported to maintain their registration. They said a re-validation programme was not available for them to maintain their registration.

The care plans we looked at were inconsistent and were not updated following the reviews. We found care plans were task led and had little information about people’s preferences on how people liked their care to be delivered.

Relatives were aware of the complaints procedure but were concerned that little happened when they raised a concern.

While a member of staff said their units ran smoothly and a unit lead was available for support and guidance, other staff told us there was conflict between staff and there was little support from managers. The head of care agreed there was a lack of leadership on the nursing units and the RGN’s were being helped to delegate with the introduction of allocation sheets.”

The management of medicine systems were not consistently effective. Members of staff were not signing for the administration of topical medicines. Protocols were not in place for the application of when required (PRN) topical creams and ointments.

We found parts of the home dirty. Cleaning schedules were not always completed.

An infection control audit had taken place on the 3 November 2016 and areas for improvement were identified. For example, “chairs need a good clean, carpets need cleaning and staff need to be reinforced they need to wash their hands.” A follow-up audit had taken place and some improvements had taken place.

Peoples’ opinions on the food was varied and was described as “exceptional”, “good” or “variable”, depending on who was cooking it. All staff we spoke with raised concerns about the quality of the food. There had been shortages of catering staff January 2017. We saw that the meals were not provided at the time people expected them

Reports of visits showed that people had access to specialists, GP’s and they had regular check up with the dentist and optician. The feedback from healthcare professional based at the service was generally positive about the staff.

The people we spoke with said the staff were kind, caring and well trained. We saw examples of staff supporting people in a kind and compassionate manner. However, we also received feedback from people that staff were not always caring

The rights of people were respected. Staff said people were assigned keyworkers. people dignity was maintained. Staff were aware of the day to day decisions people were able to make. Staff told us people made decisions about their meals, what they wore and activities.

The Athelstan House Improvement Team was introduced by relatives with the support of the manager to provide regular feedback of the quality of care delivered to their family members. We noted from the minutes of the meetings there were open discussions about staffing levels and the quality of the food.

Quality Assurance systems were in place to assess and monitor the standards of care delivered at the service. The standards of care were assessed against legislations and shortfalls were identified. An action plan to drive improvements was developed but action had not been taken to meet standards. Following the inspection, we met with the regional management team to discuss our concerns. After the inspection, the management team sent us action plans on how they were going to address the shortfalls.

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.

We visited Primrose Unit at Athelston House, which was where the subject of this error was cared for. They had returned to the home, following a short spell in hospital. We looked at this person's records, including daily records, multi disciplinary (MDT) notes and medication records. We looked at other documents, including the communications diary, the shift handover records and staff training records. We looked at the investigation carried out by the home, including statements from staff members. We also looked at the report from the pharmacy.

Our pharmacist inspector spoke with staff about medicines management, checked medicines records and observed a medication round. We found the arrangements in place for ordering medicines had not been followed and systems in place for checking medicines had not been followed consistently. A small number of medicines administration records had not been completed fully so in these cases it was not clear whether people had received their medicines as prescribed.

We spoke with the registered manager and the area operations manager. We were concerned that home's investigation of the error had not been sufficiently thorough and was incomplete. Although we were told that some processes had been amended in the light of the error, no feedback, guidance or further training had been provided to the staff involved and other staff employed in the home, to ensure that mistakes like this did not happen again.

We found that on the whole the management of medicines was in line with good practice although we have suggested that the provider make additional improvements in order to audit medicines returned to the Pharmacy.

Athelstan House was designed around the needs of older people with physical disabilities and sensory impairment and was a suitable environment for the 80 people who lived there.

We looked at recruitment files to check that safe procedures were followed before staff were appointed to work in the home. Appropriate checks were undertaken.

People were made aware of the complaints system and a copy of the complaints policy was placed in an information folder in each room. A suggestion box was also sited at the main entrance.

All records we asked to look at were provided promptly. Care records provided a clear and accurate account of the care and support provided to each person, were kept up to date and were fit for purpose.