The Mead is a care home that provides accommodation to six people with mental health care needs. At the time of the inspection five people were living at the service. 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.A registered manager was not in post and the recruitment process was is in place to employ a registered manager. A service manager with day to day management responsibilities was appointed on 15 January 2018. 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.’
Staff told us there had been five changes of managers in 12 months. While staff said they “held the home together” during this period, the records showed they were not knowable about fundamental standards, how to introduce changes of legislation and partnership working. For example, enabling people and working with regulators.
There were systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of people who used the service. However, these systems were not fully effective as they failed to identify the shortfalls in all areas of service delivery. Where shortfalls were identified and action plan were devised the progress made on the improvements were not monitored.
Safeguarding processes were not always followed by the staff because when people made allegations of abuse the staff had not reported them to the lead authority in safeguarding. The staff told us and training matrix showed staff had attended safeguarding of adults training. Their comments indicated they knew how to recognise the types of abuse and their duty to report abuse. However, when people asked staff not to report allegations of abuse, the staff had not reported the allegations. The head of services said their instructions to reporting these allegations were not followed. This meant a multidisciplinary meeting to discuss strategies with the person did not take place and opportunities to establish the appropriate support were missed.
Risk management systems were not robust and placed people at risk of potential harm. Individual risks to people included exploitation, addiction, self-harm and eating disorders. While risk assessments detailed how people viewed the risk. Action plans were not in place on managing individual risks or on supporting people to take risk safely. There was a lack of clarity on the staff’s responsibility to update records. Safety management plans that accompanied the risk assessments were poorly completed and lacked guidance for consistency and to keep people safe from potential harm. Where there were potential risks to others risk assessment were in place. For example, the symptoms of a deteriorating mental health or the actions from staff to protect other people from harm such as distraction techniques and moving people from the vicinity.
Where there had been incidents of self-harm risk assessments were not reviewed or updated. We saw there had been an investigation following the reporting of some incidents. There had been a post incident discussion with the person but no further action was taken to minimise the risk.
Staff were not given guidance on consistently administering medicines prescribed to be taken “as required” (PRN). The medicine procedure gave direction for staff to develop “As and When required medication plans.” Medication plans were not developed for PRN medicines prescribed for pain relief, depression and to reduce anxiety. This meant PRN protocols were not developed on how staff were to recognise when people might need these medicines.
The staff were not supported to develop the appropriate skills and knowledge needed to meet the needs of people accommodated. The training matrix showed that not all staff were trained in mental health care awareness. For example, records showed one member of staff had attended mental health awareness training in 2016. Two staff had not attended this training since 2010. Another had not had any training in this area. Specific eating disorder training, addiction to drugs and alcohol training was not provided to staff although people were accommodated with complex mental health care needs. This meant staff were not up to date with current practices.
People accommodated had capacity to make complex decisions. Consent was signed by people to share information, photographs and for the administration of medicines. The training matrix showed staff had attended training in the Mental Capacity Act (MCA) 2005. Conversations with staff indicated gaps in their understanding of the principle of the act. Where complex decision were to be made staff did not participate with enabling or empowering people to reach these decisions. For example, giving people informed choices or discussing the consequences of unwise decisions.
There was an expectation that people self-cater their meals. The staff told us people prepared weekly menus and were provided with a weekly budget for food shopping. A member of staff said there was some support with testing recipes if requested. The self-catering procedure stated that “service users complete a weekly menu planner supported by staff if required. This will detail what meals the service user is planning to eat for the week and ingredients needed. This is an ideal opportunity to discuss menu ideas and healthier options.” Menu plans in place did not follow the procedure and were brief and incomplete. For example, olives were the only item recorded for lunch on one day. Menus did not show people were being supported to maintain a balanced diet. Also one person was not developing menu plans and there was little evidence to show staff were supporting this person with healthy eating.
Some systems did not provide people the opportunity to receive person centered care. For example, where staff administered medicines people were not asked about their preferences on where their medicines were to be administered. People had to go to the office for their medicines.
Support and safety management plans did not fully reflect people’s physical, mental, emotional and social needs. The agreed outcomes specified within social workers comprehensive care plans were not used to develop with the person support plans. Staff told us they followed the “Integrated Support and Safety Planning” procedures. They said risk management plans for risks were developed once discussions and agreements were reached with the person. People were also given the opportunity to set goals and with staff support to measure and review goals. Where people refused to develop action staff did not help them understand their care and treatment needs.
People’s records were securely stored. They were password protected and protocols were in place for staff including bank and agency for accessing relevant records. Some records were not complete and information was not detailed. On the first day of the inspection we were given hard copies of the support and management plans and staff confirmed these records were the most up to date copies. On the second day we were told there were more up to date records and these were online. On the third day we were told a management system was used to record support plans which gave access to senior manager to review the plans in place. This meant the records covered on first day had to be reviewed on subsequent days.
People were supported to self-administer their medicines. One person told us a lockable space was provided in their bedroom for the safe storage of medicines. They said an assessment of their competency had taken place and there were checks by the staff to ensure medicines were taken correctly. Competency assessments records completed by the staff detailed people’s ability to continue with self-administration of medicines.
Staffing rotas were designed for higher staffing levels during the day. Two staff and the service manager were on duty until 5pm and from then onwards there was lone working. There was no waking staff available to people from 10:30 pm onwards but can be woken if an incident occurs. This meant the deployment of staff restricted opportunities for people to participate or join evening activities within the community with staff if requested. For example, clubs. The service manager said staff are committed to work flexibily as required.
Steps were being taken to improve how staff were to support people develop and progress to independent living. An overarching improvement plan was devised by the head of services on themes identified within services. A further plan was develop by which complimented the homes improvement plan devised by the service manager. The service manager told us they had made a commitment to develop safeguarding processes, one to one supervisions with staff and the management of risk.
Staff told us the team was stable and they worked well together. They told us that since the appointment of the head of services and service manager improvements had taken place.
The staff told us arrangements to discuss their performance and personal development was in place. They told us since the appointment of the service manager one to one meetings had happened. A member of staff said the service manager had made them aware that “there will be reflective practice” which showed there will be opportunities for continuous learning.
We saw people seeking staff attention and reassurance. Staff supported people when they became distressed and responded to requests for support and assistance. Staff knew people’s preferences and how to ap