We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.This inspection was unannounced and took place on 3 and 6 February 2017. There were 44 people living at the service. When we last inspected on 14 November 2016, in response to some concerns raised by family whose relative lived at Heanton, we found a number of areas where improvements were needed. This included environmental issues and support and supervision of staff to ensure they had the right skills. Following the November focussed inspection we met with the provider and their management and quality assurance team on 18 January 2017 to discuss the improvements needed and future actions to be taken by the service. This included a discussion about how they had prioritised ensuring people’s clinical needs were being met and that people were safe. The provider and the staff team are now working on implementing their new model of care via a year long training course to enable staff to understand the culture and ethos of the household model. The provider sent us an action plan showing how they intended to make improvements as detailed within the previous inspection. We used this information as part of this inspection to check how well embedded any new ways of working were and whether this had impacted on the quality of care and support people were receiving.
Heanton is registered to provide nursing and personal care for up to 52 people. They mainly support people with dementia.
The provider has developed and implemented a care model based on the household model of care pioneered in the USA by LaVrene Norton, Action Pact and Steve Shields. This had resulted in the environment being divided into smaller houses to support small group living. Groups were determined based on the stage of the dementia of the person living at the home. There were four 'houses' (distinct areas within the building) which provided care for people at early stages of dementia, and people living with dementia who were experiencing an altered reality. The third area was for people who were living with dementia who were in a repetitive stage and the fourth house was designated for people who were living with advanced dementia. The provider had implemented this model with the support of specially recruited dementia practitioners. This implementation was still work in progress with staff still learning about the model of care and the environment still being adapted to suit each of the four houses.
There was a manager in post who had been the interim manager since July 2016, but had only just put in an application to register with CQC. She had previously been approved as the registered manager at this service, but made the decision to deregister at the start of this year. This was because she had, at the time wanted to take a more hands on role within the home. She said she now felt ready to take on the responsibility of being the registered manager again. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.
We found there were improvements needed with the safe storage of medicines to ensure they were being stored at the correct temperatures. We were told at the time of the inspection that medicine management had not been audited for up to one year. The provider has since said audit records show there had been some medicine audits but not as frequently as they should be. There were some gaps in the medicine administration records (MARs) which had not been picked up. Supervision records showed the manager had noted gaps in the way as needed medicines had been recorded, but this had not led to a full audit. We heard how two nurses were taking on the lead role of medicine management, which would include audits and quality checks in the near future.
We observed one occasion where, although staff were present there was no oversight on safety during the lunchtime meal. One person who was at risk of choking helped themselves to food and drink which was not suitable or safe for them to have and this resulted in them having a choking episode. We fed this back during the inspection and was assured this was immediately addressed. The provider said they were now having a member of staff in each dining area who was appointed to have an oversight on what each person was given or had access to eat and drink. On the second day of inspecting we saw lunchtimes appeared more organised with regard to ensuring people had the correct meals in a timely way.
There were still some improvements needed to make the environment suitable and comfortable for people. For example, some of the downstairs lounge chairs had an unpleasant odour and were in need of a deep clean. Some bedroom doors still had star locks which although not in use, should not be on doors. Two new bedrooms had been created; the radiators had not been covered to protect people from possible burns from hot surfaces. The star locks had been removed and radiator covers fitted by the following day of the inspection being completed.
Some parts of the home require further refurbishment. However, we also saw some good improvements since the last inspection. The lounge carpet in Bideford lounge had been replaced which had had a big impact on making the room more pleasant, homely and fresh smelling. The corridor between Bideford and Chichester had been extended out by means of knocking down some smaller rooms off the corridor. This had allowed the service to develop an alcove with further seating for people to use. This had also reduced the amount of incidents in this area. Audits of accident and incident reports had showed a reduction in incidents since this additional space had been created. This structural work had impacted in a really positive way and enhanced the living environment.
Care and support was being delivered by a staff group who had the right skills and training. There were sufficient numbers of staff on each shift to ensure people’s needs were being met in a timely and responsive way. Each house had at least two to three staff available each shift. In addition there was always one trained nurse and on some days two. Care and nursing staff were supported by a team of housekeeping and maintenance staff as well as chefs and kitchen staff. Staff reported there were sufficient numbers of staff each shift unless there was short notice of staff sickness. Relatives said they had noticed an increase in staffing numbers and were confident people’s needs were being met in a timely way.
Staff understood how to support people who were at different stages of their dementia. The household model was working well to promote people’s well-being and help staff develop their skills further. For example two staff who worked with people in the later stages of dementia had begun specialist training in best practice for end of life care. This was being completed in affiliation with the local hospice. All staff were being asked to complete a comprehensive induction book irrespective of how long they had worked at the service. This was to ensure all staff understood and were working within the framework of national standards as set by the Care Certificate.
People mattered and staff cared for people in a way which showed empathy, kindness and respect. We saw many examples of staff working with people to reassure them when distressed, providing a hug and talking to people in a compassionate and caring way.
People were supported to express their views and were involved in decision making about their care where possible. Staff understood the importance of offering people day to day choices. For example at mealtimes showing people both main meal options and asking them to choose which one they wanted.
Staff sought people’s consent for care and treatment and ensured they were supported to make as many decisions as possible. Staff confidently used the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Where people lacked capacity, relatives, friends and relevant professionals were involved in best interest decision making.
People were protected because staff understood what might constitute abuse and who they should report their concerns to. Safe recruitment processes were followed to ensure only staff who were suitable to work with vulnerable people had been recruited.
Care and support was well planned and risks had been assessed so that staff worked in the least restrictive way. People’s healthcare needs were well met and staff understood how to support people with changing healthcare needs.
People were supported to enjoy a balanced diet with flexible food and drink options available throughout the day and night.
Systems and audits were being used to help improve clinical outcomes but these had not included medicine management or identified issues in relation to the environment
There were two of breaches of regulations. You can see what action we took at the end of the report.