Archived: Dovecote Residential and Nursing Home

Dovecote Residential and Nursing Home is a care home providing personal and nursing care to 45 people aged 65 and over at the time of the inspection. The service can support up to 61 people across two floors. Nursing care was provided on each floor.

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

The provider had introduced an electronic care records system and archived people’s paper care plans. The new system did not permit staff to add more than one plan, subsequently information was missing from the records of people with more complex needs. Staff had received insufficient training and support to use the new records. This resulted in poor record keeping and people were placed at risk of receiving inappropriate treatment. During the inspection and after our site visits the management team provided reassurances actions would be taken to address the deficits. Work was started immediately to make improvements.

Recruitment of staff was safe. Staff underwent pre-employment checks before they began working in the service. Staff were supported through an induction and with supervision. Some staff needed to bring their training up to date.

The provider had systems in place to maintain people’s safety. Whilst regular fire and safety checks were carried out to ensure people lived in a safe building, there were some safety aspects of the service which needed to be addressed. The home was clean and tidy. Actions had been taken to make improvements to the bathrooms.

There were examples where people’s dignity was compromised. People told us staff acted in a kind and caring manner towards them. One person said, “All of the staff here are lovely - happy to help you and they have a joke as well, with you. They are kept very busy.” Relatives felt welcomed in the service.

Audits use to monitor the service had not found the areas of the service which required improvement.

Further work was required to develop people's communication plans so staff were able to make information accessible to people. We have made a recommendation about this.

People’s medicines were managed in a safe manner. Improvements had been made to the use of topical medicines.

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 they enjoyed the food. One person said, “I have no complaints with the food here it’s not bad at all.”

Staff worked with visiting healthcare professionals to promote people’s health and well-being.

Staff, people and relatives were complementary about the registered manager. Staff felt supported by them.

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 15 February 2019) The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, not enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

We carried out this inspection earlier than planned. This was prompted in part due to concerns received about the number of safeguarding incidents and concerns about inaccurate records. A decision was made for us to inspect and examine those risks. We found evidence that the provider needs to make improvements. Please see the key question sections of this full report.

Please see the action we have told the provider to take at the end of this report.

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.

People’s experience of using this service:

Staff and relatives were complimentary about the manager who explained to us that they understood improvements were required in the service, but they wished to build a culture of staff involvement. The manager recognised this would take time.

Records held in the service were not always accurate and up to date.

The manager and the staff team were responsive to issues we raised and took action to resolve issues during the inspection.

People could be confident they lived in a safe environment due to the number and frequency of checks carried out on the building and its contents.

Pre-employment checks were carried out to ensure staff were suitable to work in the home.

Sufficient staff were on duty. However, we found mealtimes in the upstairs area of the home were a pressured area as there were a number of people who needed support to eat. The manager agreed to address this.

People’s personal risks were identified and actions put in place to reduce the risks of harm to people. Where accidents and incidents had occurred, these were monitored to see if they could have been prevented.

Cleaning was ongoing in the home to reduce the risk of cross infection. Staff had access to personal protective equipment to support them in their duties.

Induction, training and supervision was provided to educate and support staff carry out their respective roles. The manager had involved partner agencies to develop staff skills.

Information was provided to kitchen staff about people’s dietary needs. Kitchen staff understood how to prepare food to meet individual requirements. Staff had referred people to other healthcare professionals when people had lost unexplained weight.

Staff felt they worked as a team and had communication systems in place to share information so they were up to date with people’s care needs.

Changes were in progress to improve the environment. The manager was aware of the need to create environments suitable for people living with dementia and explained their rationale for the steps they had taken.

People were supported with their health by staff who had regular contact with other healthcare professionals to discuss people’s conditions and seek advice.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. People were given choices and their decisions were respected.

Staff treated people with kindness and respected people. They protected people’s dignity and supported their independence.

People had the opportunity to give their views about the service and a complaints procedure was available.

Activities were provided in the service. An activities co-ordinator was supported by staff to engage people in meaningful activities during our inspection.

The management of the service was supported by a quality team who identified areas for improvement in the home. Audits used in the service assessed regulatory requirements.

Rating at last inspection: At our last inspection in December 2017 we rated this service as requires improvement in each key question. The report was published in May 2018.

Why we inspected: This was a scheduled inspection based on previous rating.

Follow up: We will continue to monitor the service through the information we receive. We will be speaking to the provider and the registered manager about their next steps to improve the service to an overall rating of Good.

This unannounced inspection took place on 31 October and 10 November 2017.

At the last inspection in November and December 2016 we rated the home as ‘Good’.

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. At the time of our inspection the registered manager had left the service. A new manager had been appointed and expressed their intention to register with CQC.

Equipment in the home for the monitoring of people’s health conditions was not checked by staff to see if it was in working order.

Before and during the inspection relatives told us about people losing weight. We found kitchen staff were taking the appropriate actions to fortify foods. We found meal times to be chaotic.

Observations carried out in the home showed us people were not always being given support to eat and mealtimes required increased organisation and structure so that risks of people losing weight were reduced.

We found the provider had documentation available to staff to manage the regulated activities. However not all of this documentation was completed.

During our inspection the service relied heavily on agency staff. Agency staff had not been provided with the required support to carry out their duties. The provider had not ensured effective monitoring checks were completed to ensure that agency nurses remained registered with the Nursing Midwifery Council, they had the right to work in the United Kingdom, and they had completed appropriate training.

The provider employed an activities coordinator. Due to an outbreak of vomiting and diahorrea communal activities were curtailed. We observed people with dementia either sitting sleeping or staring ahead and found there were no provision for individual stimulus in the home.

The service had appropriate systems in place to protect people from harm. Staff were trained in safeguarding vulnerable adults and staff told us they felt able to approach the manager with concerns about people’s well-being.

We found the home to be clean and tidy. Cleaning records showed there was regular and on-going cleaning of the home. During our inspection we found the downstairs clinical room required cleaning. The manager immediately delegated staff to clean the clinical room.

People’s medicines were administered is a safe manner. Arrangements were in place for the safe disposal of prescribed medicines. Medicine records were completed and there were no gaps to indicate people had missed having their medicines at the appropriate times.

There were sufficient staff on duty. The provider used a dependency tool to calculate how many staff were required to be on duty. We saw the rotas showed the numbers of staff on duty reflected the numbers required by the dependency tool.

Accidents and incidents were reviewed by the manager to determine if actions could be taken to prevent them from happening again.

Emergency plans were in place. Staff had written Personal Emergency Evacuation Plans (PEEPs) to inform and assist emergency personnel evacuate the premises.

Before staff were employed in the service the provider carried out checks to see if they were suitable to work in the home. Staff were required to provide details of their past experience and training on application forms as well as the contact details of two referees. Once employed, staff were supported through an induction, and they continued to be supported through training and supervision. We found some staff supervision meetings with their manager needed to be brought up to date.

We found the service complied with the requirements of the Mental Capacity Act. Where people were assessed as not having capacity to make specific decisions, they had best interests' decision in place. Staff had made appropriate applications to the local authority to deprive people of their liberty and therefore keep them safe.

Staff were genuinely caring toward people and were able to provide the inspection team with information about people’s backgrounds and their personal preferences. We observed staff behaved in a respectful manner towards people and approached people with kindness. However, we found staff did not always follow the information in people’s care plans to ensure people received appropriate care.

Assessments were carried out with people and their relatives before people transferred into the home. Person centred information was found in each person’s file which detailed background information about how they liked to spend their day. Each person had a care file which contained care plans to give staff guidance on how to meet people’s needs. However we found some care plans to address some people’s specific health conditions were not documented.

Complaints made about the service had been taken seriously and investigated with an outcome of the investigation provided to the complainant.

Relatives were given the opportunity to be involved in the service through relatives’ meetings.

The provider had in place arrangement to monitor the quality of the service. Surveys had been carried out with staff and relatives. The outcome of the surveys had been aggregated and actions put in place to respond to any concerns. Regular audits were carried out in the home to see if the service was meeting the provider’s required standards.

Partnership arrangements were in place with other services to meet people’s needs. Records showed there were regular visits from other healthcare professionals. The staff noted their visits on a professionals visit document and the outcomes of the discussions which took place.

During our inspection we found four 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 last inspected Dovecote Nursing Home in October 2015. At that inspection we found the service was in breach of its legal requirements.

Dovecote Nursing Home is a 61 bed care home that provides personal and nursing care to older people, including people who live with dementia or a dementia related condition.

A registered manager was in place. 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 they were safe and staff were kind and caring. People were protected as staff had received training about safeguarding and knew how to respond to any allegation of abuse. Regular checks took place to ensure the building was safe and well-maintained. When new staff were appointed, thorough vetting checks were carried out to make sure they were suitable to work with people who needed care and support.

Risk assessments were in place and they accurately identified current risks to the person as well as ways for staff to minimise or appropriately manage those risks. Staff knew the needs of the people they supported to provide individual care. Care was provided with kindness and people’s privacy and dignity were respected. Records were in place that reflected the care that staff provided.

Appropriate training was provided and staff were supervised and supported. Staff had a good understanding of the Mental Capacity Act 2005 and best interest decision making, when people were unable to make decisions themselves. People were able to make choices where they were able about aspects of their daily lives. People had access to health care professionals to make sure they received appropriate care and treatment. Staff followed advice given by professionals to make sure people received the care they needed. People received their medicines in a safe and timely way.

Changes had been made to the environment. It was brighter and many areas had been refurbished. It promoted the orientation and independence of people who lived with dementia. Activities and entertainment were available for people and people were consulted to increase the variety of activities and outings.

Menus were varied and a choice was offered at each mealtime. Staff supported people who required help to eat and drink and special diets were catered for. A complaints procedure was available. People told us they would feel confident to speak to staff about any concerns if they needed to.

Staff and people who used the service said the registered manager was supportive and approachable. They were pleased with the improvements that had been made to the service. People told us they felt confident to speak to staff about any concerns if they needed to. Communication was effective, ensuring people, their relatives and other relevant agencies were kept up to date about any changes in people's care and support needs and the running of the service.

People had the opportunity to give their views about the service. The registered manager acted on feedback in order to ensure improvements were made to the service when required. The provider undertook a range of audits to check on the quality of care provided.

We found at this inspection people were protected from the risks of unsafe or inappropriate care and treatment as the records were accurate and fit for purpose. They reflected the care and support needs of people to help staff provide individual care according to the wishes of the person.

We considered our inspection findings to answer questions we always ask:

. Is the service safe?

. Is the service effective?

. Is the service caring?

. Is the service responsive?

. Is the service well-led?

This is the summary of what we found.

Is the service safe?

An assessment of people's care and support needs was carried out before people started to use the service. This was to ensure staff had the skills and had received the training in order to safely meet the person's support requirements.

Risk assessments were in place. People were supported and encouraged to maintain their independence and this was balanced with the risk to the person. Audits were carried out to look at accidents and incidents and the necessary action was taken to keep people safe.

Information was available to show that the service worked with other agencies to help ensure people's health needs were met and to prevent admissions to hospital wherever possible.

We saw there were enough staff on duty at the time of inspection to meet the current care and support needs of people.

Is the service effective?

People commented how helpful and friendly the staff were. Records showed relatives were involved in the six monthly care reviews of people who used the service. This was to make sure the service kept them up to date with what was happening with their relative's care.

Staff were observed to be patient and supportive as they worked with people.

More detailed record keeping was needed to show the service was meeting people's needs effectively.

Is the service caring?

Most people spoken with talked well of the level of care provided by staff. Staff were helpful and offered people information and support about their care. We observed staff interacted well with people and it was evident that staff had developed a good understanding of people's communication needs and how best to communicate with them.

Is the service responsive?

Information was collected by the service with regard to the person's ability and level of independence before they moved into the service. Various assessments were completed by the manager of the service with the person and/or their family to help make sure staff could meet their needs. Regular reviews were carried out with the person who used the service and their representative to make sure plans of care were kept up to date. This helped ensure staff provided the correct amount of care and support.

Referrals for specialist advice were made when staff needed guidance to ensure the health needs of people were met.

People's individual needs were taken into account and they, or their representative if they were not able, were involved in decision making with regard to their care. They were kept informed and given some information to help them understand the care and choices available to them.

Meetings took place with staff and people who used the service and their relatives to discuss the running of the service and to try to ensure the service was responsive in meeting the changing needs of people. For example staff meeting minutes showed staff and people who used the service were concerned about staff deployment within the home at meal times. This was an issue still being addressed at the time of inspection.

Is the service well-led?

We found there was a focus from management on the provision of individual care and support to people who used the service. Staff were knowledgeable about the support needs of people, however people's care and support needs were not accurately reflected in the care records.

We saw people had the opportunity to comment on the quality of the service and that they felt able to speak to the manager and staff about any issues.

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

The dementia unit was decorated according to dementia research designed to help maintain the independence of the person.

The premises were better maintained so people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We used a number of different methods which included observation to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences.

During our observation we saw people were treated with consideration and respect.

We reviewed five care records and saw that people's preferences and care needs had been well documented. Staff were knowledgeable about the people's care needs and what they should do to support them.

We saw staff were very busy as they provided care and support to people who used the service. We spoke to four people who lived at the home who told us staff were kind and helpful but they were kept very busy. One person said;" You can just buzz. They come in and if they can't help just then they tell you how long they will be."

Another person said;" I have one thing to say. They'll do anything for you but they're run off their feet."

We found overall the building was becoming suitably designed for the needs of people who used the service but it was not well maintained in all areas.

Staff received professional development and people told us staff were well trained.

We saw the provider had systems in place to gather feedback from people, who used the service, and to regularly assess and monitor the quality of service people received.

We used a number of different methods which included observation to help us understand the experiences of people using the service, because some of the people using the service had complex needs which meant they were not able to tell us their experiences.

We visited the service early in the morning. We spoke with three people who were up during our inspection. They told us they liked to be up early. One person said: "I've always got up early. I used to when I lived at home." They said they knew they could stay in bed if they wanted to have a lie in. On the first floor we saw no person was up although we were told by a staff member a person had been up through the night as they were unable to sleep.

People we spoke with said staff were kind and helpful to them when they provided care and support. They did say they had to wait for staff to offer help as they knew they were busy, however following the inspection the manager confirmed in writing that staffing levels would be increased.

We spoke to ten people who lived at the home who told us staff were kind and helpful but they were kept very busy. They said they had to wait for staff as they were busy helping other people.

We observed staff were rushed as they tried to provide individual care to each person. Due to the low staff numbers on duty and the high dependency of many people care and support was not provided in a timely way as people had to wait for staff support. It was observed at times they were at risk. We also saw people were not able to have choice and go to bed when they wanted.