The Vines

The Vines 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 Vines is a care home registered to provide accommodation and personal care for a maximum of seventeen people. The Vines specialises in the treatment of acquired brain injury and neuro-rehabilitation for adults. The service aims to promote independence and help each resident back into the community. People required a range of support in relation to their support needs and some people had limited mobility. At the time of the inspection there were eleven people living in the service.

There was a registered manager in post. The registered manager had been in post for just over one year. 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.

We previously carried out an unannounced comprehensive inspection of this service in December 2017. The Vines was awarded an overall rating of ‘Requires improvement’ as improvements were needed in the safe, responsive and well led questions. At that inspection improvements were needed to ensure that as required medicines were managed appropriately and that changes to people’s health needs were responded to and that the quality assurance systems were further developed.

This inspection found that the necessary improvements had been made and the overall rating had improved to ‘Good’ with the well led question remaining Requires Improvement to further embed changes to care documentation and audits.

The provider undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement. Whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. This included updating care plans when an identified need or directive of care changed. We found not all care plans reflected people’s current needs and associated risks. For example, when a person had experienced seizures and unstable blood sugars.

People were comfortable and relaxed with staff. They said they felt safe and there were sufficient staff to support them. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff. Staff were knowledgeable and trained in safeguarding adults and what action they should take if they suspected abuse was taking place. Staff had a good understanding of Equality, diversity and human rights. Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service, including the care of people with diabetes and epilepsy. Formal personal development plans, including two monthly supervisions and annual appraisals were in place. Staff were supported to become ‘champions’ in areas of care delivery such as health and safety, medicines and well-being. People were supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

People were encouraged and supported to eat and drink well. There was a varied daily choice of meals and people were able to give feedback and have choice in what they ate and drank. Health care was accessible for people and appointments were made for regular check-ups as needed.

People felt well looked after and supported. We observed friendly and genuine relationships had developed between people and staff. Care and support plans described people’s preferences and needs in relevant areas, including communication, and they were encouraged to be as independent as possible. People chose how to spend their day. Activities were mixed and people could choose either small group activities or one to one sessions. People told us that they enjoyed swimming, the gym and going out to local venues. People were encouraged to stay in touch with their families and receive visitors.

Staff were asked for their opinions on the service and whether they were happy in their work. They felt supported within their roles, describing an ‘open door’ management approach, where managers were always available to discuss suggestions and address problems or concerns.

Further information is in the detailed findings below.

The Vines 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 Vines is a care home registered to provide accommodation and personal care for a maximum of seventeen people. The Vines specialises in the treatment of acquired brain injury and neuro-rehabilitation for adults. The service aims to promote independence and help each resident back into the community. People required a range of support in relation to their support needs and some people had limited mobility. At the time of the inspection there were thirteen people living in the service.

There was no registered manager in post. The post had been vacant for four months. 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. In March 2017 the provider temporarily closed the Vines to undertake essential work on the Environment. People moved back to the Vines in September 2017 once the works were completed. There has been significant changes to the management structure since our last inspection. An acting manager had been in post for a month. We have been informed that her application has been submitted. The area manager confirmed that she is visiting or in contact regularly to provide support and guidance.

At comprehensive inspections in May 2016 and February 2017 the overall rating for this service was Requires Improvement. Four breaches of Regulation of the Health and Social Care Act 2008 (Regulated Activities) 2014 were identified. The registered provider had failed to ensure that safe food practices were followed, that people were being supported to be as independent as possible, that meaningful activities were provided and that there were enough suitably skilled staff to meet people’s needs.

At this inspection we found that considerable improvements had been made and the provider was now meeting the previous breaches of Regulation. There were still improvements to be made and embedded to ensure improvements were sustained.

There was a quality assurance system in place and this had identified the shortfalls we found. However despite being identified had not yet been taken forward. This was evident from the audits, meeting minutes and discussions with the management team and staff. We had previously identified people’s records were not consistently person-centred and did not all include the information staff may require. Improvements had been made but further work was required to ensure this was fully embedded into practice. Improvements were needed to ensure all ‘as required’ (PRN) medicines were supported by a protocol and monitored for effectiveness.

Whilst work was also on-going to ensure people were able to take part in activities they enjoyed and were meaningful, we were not able to see that this had been fully embedded and sustained for a period of time and therefore is the reason the home is rated as Requires Improvement.

The management and storage of medicines was safe, and people received their medicines as prescribed. Staff were attentive to people who may be in pain or discomfort and were supported to ensure they received their medicines when they needed them.

There was a positive culture at the home. Staff were involved and updated about changes at the home through meetings and at handovers each day. The management team had good oversight of the home and knew where changes and improvements were needed.

Staff knew people really well. They had a good understanding of people’s individual needs and choices. They could tell us about people’s personal histories including their spiritual and cultural wishes. Each person was treated as an individual and their choices and rights were respected and upheld. There was a range of risk assessments in place and staff had a good understanding of the risks associated with caring for people at the home. Staff ensured people had access to external healthcare professionals when they needed it. Referrals to external healthcare professionals were made in a timely way.

People were supported by staff who were kind and caring. Staff maintained people's privacy and understood the importance of confidentiality. Relatives were able to visit at any time, and were made to feel very welcome.

There were enough staff working to meet people's needs. Staff were deployed to ensure there was a good skill mix in each team. Staff were suitably trained and supported to deliver care in a way that responded to people's changing needs.

Staff had a good understanding of the Mental Capacity Act 2005 and DoLS and how to involve appropriate people, such as relatives and professionals, in the decision making process. Best interest decisions were made when necessary.

People’s nutritional needs were met. People were provided with a choice of food and drink that met their individual needs.

There was a complaints policy in place and people and visitors told us they would raise any concerns with staff. They were confident issues raised would be addressed.

The service had a registered manager. 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 our last inspection on 1 and 2 June 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities). These breaches were in relation to safe care and treatment, dignity and respect, safeguarding people from abuse, complaints, good governance and staffing. We had requested the provider to take action. The provider sent us an action plan stating that they had addressed the concerns raised. At this inspection we found that improvements had been made and the registered provider was no longer breaching these regulations. However we also found new breaches and made some recommendations. You can see the recommendations in the main body of the report and you can see what action we asked the provider to take at the end of this report.

The provider had systems in place to protect people against abuse and harm. The provider had effective policies and procedures that gave staff guidance on how to report abuse. Staff were trained to identify the different types of abuse and knew who to report to if they had any concerns. Medicines were managed safely and people had access to their medicines when they needed them.

Food safety checks and some cleaning checks in the kitchen had not been carried out regularly. There was no menu for people to choose food from during the first day of our inspection. People had enough to eat and drink, and received support from staff where a need had been identified. People’s special dietary needs were clearly documented and staff ensured these needs were met.

The provider had not ensured that there was a systematic approach to determine the number of staff and range of skills required in order to meet the needs of people using the service. We were told that several staff members had recently left the service and had not yet been replaced. There was a high level of agency staff employed to work at the service and occasions where the lack of permanent staff affected people’s choices.

There was a lack of meaningful and structured activities on offer to people and there was a lack of therapeutic input to people’s activities. The registered manager had recruited people who were yet to start and had plans to recruit other staff members.

People were not always supported to maintain their independence. The registered manager told us that some staff were reluctant to change their working practice to empower people. The registered manager was working towards a culture change in the service.

Staff were trained with the right skills and knowledge to provide people with the care and assistance they needed. Staff met together regularly and some staff felt supported by the registered manager. Staff were able to meet their line manager on a one to one basis regularly. When staff were recruited they were subject to checks to ensure they were safe to work in the care sector.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

The staff were kind and caring. Good interactions were seen throughout the day of our inspection, such as staff sitting and sharing mealtimes with people as equals. People could have visitors from family and friends whenever they wanted. People spoke positively about the care and support they received from staff members. However, some staff members did not always promote independence.

People could decorate their rooms to their own tastes and choose if they wished to participate in any activity. Staff respected people’s decisions.

There were systems in place to monitor and respond effectively to complaints, although verbal complaints were being addressed informally and were not being recorded. Quality monitoring systems were in place but were not always being implemented effectively.

We were told that there were tensions in the service between staff and new management. We were told that this had not affected people living in the service. We found that this was an area for the registered provider to improve.

Support plans ensured people received the support they needed in the way they wanted. People’s health needs were well managed by staff so that they received the treatment and medicines they needed to ensure they remained healthy. Staff responded effectively to people’s needs.

The Vines had been without a registered manager since December 2015. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like 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 previous manager had left and de-registered. A replacement had been found but was not able to commence employment. Interim management had not been put in place and team leaders were covering the registered manager role in addition to their daily duties and responsibilities. A new manager had been recruited and was due to start work the week following inspection. The regional manager told us that the newly appointed manager would be registering with CQC as soon as they had completed their initial induction and training.

A safeguarding meeting had taken place 26 February 2016 and social services had identified areas of concern that required improvement and an action plan had been put in place for the care home to address these concerns. The action plan had not been completed in a timely way and the care provided was not consistently personalised and behaviours which challenged were not appropriately managed.

Care plans and risk assessments did not consistently contain guidance for staff on how to respond to and manage behaviours which challenge.

Activities were not planned or provided in a personalised way. People did not have individual activity plans which identified their likes, dislikes and preferences for activities.

Medicines were not always managed safely. There was a potential risk to people that they may exceed the maximum daily dose of paracetamol because it was also a homely remedy. Staff did not follow controlled drugs procedures.

The complaints policy on display was not current, it had incorrect contact information and some contact details were missing.

There were robust recruitment practises in place to ensure that staff were safe to work with people.

Policies and procedures were available for staff to support practice. There was a whistle blowing policy and staff were aware of their responsibility to report any bad practice.

Some staff had built caring relations with people and had a good knowledge of their life history which enabled them to provide personalised care.

People’s rooms were personalised and decorated to the persons preferred choice. People were able to attend monthly meetings to discuss agenda items including activities, food and events.

Pre-admission assessments were completed by the consultant psychiatrist and a general assessment of all aspects of care and support needs. People were supported to maintain their health and well-being. People had access to health and social care professionals.

During this inspection we identified a number of 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 found that the provider had made improvements to the service.

People were supported to understand decisions and to give their consent where appropriate. Where people did not have capacity to consent the provider acted in accordance with legal requirements.

The system for recording people's daily activities had been improved. We found that records were well maintained, up to date and accurate. Records were kept securely and could be located easily when needed.

We spoke with three people who told us that they were looked after at the home. One person said it was "Fine" and another said there are "No problems". A recent survey in December 2012 showed that all the people who lived there thought they were cared for.

We found that there were procedures for gaining people's consent to treatment but these had not always been used where needed. We found that decisions had been made in people's best interest but not always with regard to legislation.

People had their needs met at The Vines. There was up to date information on how to support people and we observed that staff were familiar with people and understood their needs. One member of staff told us they thought people were "Well looked after".

There were clear procedures for staff to report any safeguarding concerns. We saw that any incidents had been recorded and safeguarding authorities informed if necessary.

We found that records were stored appropriately. However, the recording of daily notes was not always taking place and this meant that there was not always proper information about people.