This inspection took place on 21 & 23 May 2018 and was unannounced on the first day. At the last inspection in July 2017 the service was rated overall as Requiring Improvement as we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was in relation to infection control, trip hazards and issues around evacuation in the event of a fire. We judged that the systems to monitor quality in the home had failed to identify these matters in a timely manner.
We asked the provider to complete an action plan to show what they would do and by when to improve the key questions of Safe and Well-led to at least Good.
At this inspection we found the actions required to address these particular issues of the July 2107 inspection had been completed with the exception of on-going issues in Regulation 17 set out below.
During this latest inspection of 21 & 23 May 2018 we found two further breaches. Regulation 18: Staffing as we found there were insufficient staff to meet people’s needs; Regulation 9: Person centred care as people were not receiving care that met all their needs and preferences. We also found that the service continued to be in breach of Regulation 17: Good governance because the provider and the service did not have effective quality assurance systems in place and Regulation 12: Safe care and treatment as hazards in the environment were not sufficiently identified.
The home continues to have the rating of Requires Improvement.
Stilecroft Residential Home (Stilecroft) is a care 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 provides personal care and accommodation for up to a total of 44 people. On the day of the inspection there were 38 people residing at Stilecroft. Accommodation is provided over three floors and the Victorian building has been extended and adapted for the purpose. The ground floor unit specialise in supporting people living with dementia.
There was a registered manager in post. A registered manager is a person who has registered with the (CQC) 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.
We found that there were insufficient staff available to meet people’s needs. We found that the registered person had not ensured sufficient numbers of suitably qualified, skilled and experienced persons were deployed in order to meet people’s needs. This was in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
People told us that at times there were not enough staff available to answer their call bell and provide support when they needed it. We observed that staff were very busy and were working under pressure. Care and support was mainly based around completing tasks and did not always take account of people’s preferences or to meet their social and recreational needs. We found this to be the case in particular within the main house with staff also reporting being “over stretched” on this floor. At times some people had to wait to be given personal care, such as support to go to the toilet. The downstairs unit for people living with dementia we judged as having sufficient staff to meet people’s needs.
We found insufficient staff levels had a detrimental impact on other areas such as record keeping. While people’s health and support needs were documented in their care plans we found some records had not been fully updated or reviewed after changes to a person’s condition had occurred, such as after a fall. We also found this to be the case with records for supporting people with behaviours that were challenging to the service.
We observed that some people were left for long periods of time without staff supervision or stimulation. Those people who used wheelchairs spent significant periods without being transferred to other chairs or given a change in position.
Staff were trained in end of life care and we saw evidence to show that this was being done with sensitivity. The home had links with the Hospice at Home team and had specifically developed plans to put in use when people were approaching the end of their life. However, some of the care plans to support people at the end of their life were incomplete and required more detail to inform staff.
The provider told us that the activity coordinator organised on average two trips out per month during the summer season and could use the mini bus shared with the providers sister home for this. However, on a day to day basis we found the majority of people did not leave the home unless friends or relatives took them out
The home had a part time activity person and people told us they enjoyed the sessions she put on. This person also offered additional support to people at mealtimes and with drinks.
We made a recommendation at the last inspection that the service seeks expert advice from a reputable source in developing a dementia care strategy for the home, that would encompass staff training, approach, the environment and activities. This had not been put in place.
People were not provided with care that met their individual support needs and preferences. This included being offered appropriate opportunities or meaningful activities based on person-centred care that met their needs and reflects their personal preferences. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The majority of people told us that the quality and choice of the meals on offer had deteriorated over recent weeks. We were told that the food supplier had recently been changed and the provider was addressing quality issues with the new supplier. We found the meals did not look appetising, fresh fruit was not freely available and snacks offered to people were of a poor nutritional value.
We found that the nutritional assessments on admission were basic and needed to be in more detail and following on from this people’s preferences and nutritional support needs needed to be recorded in more detail.
We found this to be a breach of Regulation 9: person centred care as people were not being offered a choice of food and drink that meets each persons preference and assessed nutritional and hydration needs to support their well-being and quality of life.
At the last inspection we pointed out hazards in the environment and on this inspection we continued to find that people were exposed to potential hazards. A near miss had occurred in February 2018 whereby a person had managed to drink a small amount of a potentially hazardous substance.
This is a breach of Regulation 12: Safe care and treatment as the provider had not done all that was practically possible to mitigate risk.
Local health care practitioners were called on to see people and to give advice. People also saw other health care professionals like chiropodists and opticians, and referrals to other healthcare professionals had been made. We did receive feedback from a number of professionals about the not always receiving referrals in a timely manner and communication not always being effective.
People who lived at Stilecroft and their relatives told us staff were caring and their privacy was respected by staff. We saw and heard positive interactions between people and staff throughout our inspection. However, people’s dignity was at times compromised due to having to wait for personal care and by some of the responses from staff.
We made a recommendation about ensuring the home has measures in place to protect people’s dignity.
People told us that their family could visit whenever they liked and were made to feel welcome.
The processes used for identifying how best interest decisions were made for people who lacked the capacity to make complex decisions for themselves had not always been recorded. We found the records on people’s capacity to make decisions could be improved.
We have made a recommendation about assessing people’s capacity to make decision and recording of this to ensure the guidance outlined in the Mental Capacity Act 2005 is followed. People were only deprived of their liberty if this had been authorised by the appropriate body or where applications had been made to do so.
Where safeguarding concerns or incidents had occurred these had been reported by the registered manager to the appropriate authorities and we could see records of the actions that had been taken by the home to protect people. Staff understood how to recognise and report abuse which helped make sure people were protected.
Staff had completed a variety of in-house training that enabled them to improve their knowledge and were supported to take national care qualifications. We found that some of the in-house training was at a basic level. For example, dementia training was at a basic level. Staff worked between both areas of the home and some staff needed more training on dementia care.
Suitable arrangements were in place to ensure that new members of staff had been suitably vetted and were the right kind of people to work with vulnerable adults. Staff received regular supervision to support them in their job.
Systems were in place for the safe administration and disposal of medicines. The majority of records showed people received their medicines as prescribed and in their preferred manner.
We made a recommendation about the safe use of prescribed drink thickeners and recording of some medicines.
The provider had a suitable complaints policy and procedure in place. However, we made a recommendation about recording informal and verbal complaints, as