Archived: Chilterns Manor

Chilterns Manor is a residential care home providing accommodation and personal care to up to 22 people. The service provides support to older people and people with dementia. At the time of our inspection there were 14 people using the service. Chilterns Manor accommodates people in one adapted building.

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

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

People were not protected from the risk of avoidable harm. For example, portable heaters were in use in bedrooms. In one room, the radiator was extremely hot to touch and could have caused serious injury. Risk assessments had not always been put in place where risk was evident, for example use of anti-coagulant medicine to thin blood, use of bed rails and choking risks.

People could not be confident they would be repositioned safely by staff. Moving and handling competency assessments had been done under training scenarios where staff practiced on each other, rather than in real life situations where people’s movements and behaviour are likely to be unpredictable. One person had been injured in an accident when staff had failed to provide their walking frame. We observed another person was poorly assisted getting off the stairlift.

People were not sufficiently protected against the risk of fire. The provider could not assure us recommendations in the fire risk assessment had been fully addressed or were in action. Fire drill records showed demonstration of what staff might do but did not indicate simulated rehearsal and obstacles they may encounter, so that these could be addressed before an emergency arose.

Medicines were not consistently managed in line with good practice. Two end of life medicines had not been logged in to the home. This meant there was no record of quantities received and would prevent accurate auditing of their use. Some entries on medicines records indicated they had not been given. When this was queried with the provider, they told us the medicines were not required. One of the medicines was an antipsychotic medicine, another a vitamin; both were prescribed for regular use therefore they should have been given.

There were sufficient numbers of staff on duty and recruitment checks had been undertaken. However, it was not clear how some new staff had been assessed as suitable where they had no background in adult social care and references and application forms did not provide information about suitability. We observed staff with poor English skills and speaking in their first language in front of people. Staff did not always engage well with people. For example, we saw some staff standing up to assist people with drinks and meals, sitting on the arm of chairs and sometimes not talking to people whilst sitting next to them.

People could not be confident they would be protected from the risk of abuse. Incident reports did not always provide information about the extent of injuries referred to and who other people were who were injured or affected. The provider was unable to send us information to assure us people were adequately safeguarded when we asked for these details. We also found some of these incidents should have been referred to the local authority. We had not always been informed about all events the provider was obliged to report to us.

There was little evidence of engaging with people to consult with them and seek their views. Relatives reported communication from the home was still an area that needed attention.

Management oversight and governance processes were not robust enough to examine the quality of people’s care and identify areas for improvement. Concerns we found as a result of the inspection had not been picked up as part of monitoring. There was a lack of understanding around risks to people and looking at care from people’s perspective.

There was some evidence of contacting people when things went wrong. However, the provider did not fully act in an open and transparent manner (duty of candour) by offering an apology and saying what actions they would take to prevent recurrence.

Relatives expressed a mix of experiences of the home. Comments included “Always clean and well-fed and well-cared for,” “No complaints, seem to be very kind” and “Staff seem very nice.” Others told us there was no rapport with some staff and that staff did not engage well with people. Some themes where they felt there could be improvement included the poor condition of the garden and activity provision.

Improvements had been made to infection prevention and control measures.

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.

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 Inadequate (report published 14 October 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended the provider follow good practice where people lacked mental capacity. Improvements had been made in this area. A further recommendation was made to improve people’s mealtime experiences. Actions taken were not sufficient.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating.

The overall rating for the service remains Inadequate.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement and Recommendations

We have identified continued breaches in relation to safeguarding people from abuse, safe care and treatment, recruitment practice, being open and transparent (duty of candour), governance of the service and notifying us of significant events.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Chilterns Manor is a residential care home providing accommodation and personal care for up to 22 people. The service provides support to older people and people with dementia. At the time of our inspection there were 18 people using the service. Chilterns Manor provides accommodation in one adapted building.

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

People did not receive safe care. We found staff did not consistently follow good hygiene practices at the home, to prevent the spread of infection. There had not been any training on infection control or correct use of personal protective equipment (PPE).

The home did not have robust recruitment procedures. Some of the personnel files did not contain evidence of all required checks. One member of staff was unable to understand English, some others had poor interactions with people. We could not see how they could have demonstrated they had the skills and experience for the roles they were appointed to.

A visiting professional told us some people said staff did not treat them with dignity and respect. People said they did not always feel listened to and staff did not talk to them much. We observed this during the first day of our inspection.

People lived in a building which had not always been maintained to a safe and comfortable standard. For example, a fire exit door was obstructed in the dining room and the route it led out to was unsafe and enclosed by construction fencing. We reported our concerns to the fire service, who visited the home and required action to be taken.

The premises looked uncared for. We found bags of rubbish in the garden and cigarette ends by the front door and in the garden. Some of the furniture was worn and needed replacing.

Regulatory requirements were not being met. For example, the provider had not notified us of events they were required to, such as an unexplained head injury and missing antipsychotic medicine. We found medicine prescribed to be given by injection had been administered by two of the staff team, who were nurses. However, this was not permitted under the home’s registration status. We asked the provider to stop this with immediate effect. Accidents and incidents had not always been recorded. Injuries and safeguarding concerns had not consistently been reported to the local authority.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Applications were made to the local authority where people were deprived of their liberty. We have made a recommendation regarding checking who has lasting power of attorney.

The provider was not proactive in seeking and responding to feedback to improve people's care. Monitoring and auditing processes were ineffective. Care practice was either not being monitored or poor practice was not always recognised. For example, we observed a mealtime where pop music was being played on the television and people had not been supported to maintain appropriate posture to manage their meal comfortably. We have made a recommendation to improve mealtimes.

Care records were not always written in a person-centred way to ensure individual needs and preferences were taken into account and met by staff. Records were not always accurate or in sufficient detail to document people’s care. There was a lack of understanding about the requirement to be open and transparent under duty of candour.

The quality of people’s care had deteriorated significantly from the previous inspection. Feedback about the home from relatives was negative. People had concerns about the quality of care. In a couple of cases, families told us they were considering moving their relative to another care home.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (report published 17 October 2018).

Why we inspected

We received concerns in relation to an injury a person sustained. As a result, we undertook a focused inspection to review the key questions of Safe and Well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to inadequate based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-led sections of this report.

You can see what action we have asked the provider to take at the end of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chilterns Manor on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to safeguarding people from abuse, safe care and treatment, recruitment practice, being open and transparent (duty of candour) and governance of the service. The provider additionally failed to notify us of significant events.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We previously inspected the service in August 2017. The service was not meeting the requirements of the regulations at that time. There were breaches of the regulations in relation to how it investigated and recorded complaints about the service, monitoring of people’s care, recruitment procedures and ensuring staff received appropriate support and training. We asked the provider to submit an action plan which outlined the improvements they would make.

Chilterns Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a 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 is registered to provide care for up to 22 older people and people with dementia. Eighteen people were living there at the time of our visit.

The service had a registered manager in post. 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 received positive feedback from people about the staff who supported them. Comments included “All the staff are very nice,” “(The carers) are all very good” and “They’re nice people here.” Relatives’ and visitors’ comments included “They know exactly where (my friend) is when I arrive and what she is doing” and “She’s very well looked after here.”

We saw improvements had been made to recruitment of staff and the support they received. This included staff training and supervision meetings, to discuss individual performance. However, we found the home had not enrolled new workers onto the Care Certificate. The Care Certificate is an identified set of standards that health and social care workers need to demonstrate in their work. We have made a recommendation about this.

There were systems for the safe management of medicines. We observed some areas where staff had not consistently followed good practice when they administered or recorded medicines. These were mentioned to the registered manager, in order for them to take appropriate action.

Risks to people’s safety and welfare had been assessed, to prevent the likelihood of injury or harm. Measures were put in place where risks had been identified. Staff had received training in safe ways of working. This included how to move people safely.

Staff had received training to recognise and respond to safeguarding concerns. Staff told us they would report any concerns they had to managers or external organisations.

People were supported by sufficient numbers of staff. Staff were kind and caring towards people and knew their needs well. Care plans had been written, to record people’s needs and their preferences for how they wished to be supported. These were up to date to reflect changes in people’s needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff followed good infection control practices, to help prevent the spread of infection. The home had been awarded a ‘Good’ rating by the Food Standards Agency, following their inspection this year.

Nutrition and hydration needs were being met. People were supported with their healthcare needs. Records were kept of any visits by healthcare professionals. The home had not established any links with community services who provided palliative care. We have made a recommendation about this, as a good practice.

The building complied with gas and electrical safety standards. Equipment was serviced to make sure it was in safe working order. Evacuation plans had been written for each person, to help support them safely in the event of an emergency. We found the garden was untidy and not in a suitable condition for people to use, as some preliminary building work had started. We have asked the provider to write to us about this.

Improvement had been made to monitoring of the service. The provider regularly visited and checked the quality of care at the service. Audits were also undertaken. Improvements had been made to the recording of people’s complaints and storage of records.

We observed improvement could be made to handling of people’s confidential information. Staff handover took place in an area where people could overhear what was being said. We have made a recommendation about this.

We looked at whether the service ensured people had access to the information they needed, in a way they could understand it. This was to comply with the Accessible Information Standard. The Accessible Information Standard is a framework put in place from August 2016 making it a legal requirement for all providers to ensure people with a disability or sensory loss can access and understand information they are given. Whilst some work had been carried out, we have recommended further work is undertaken, to comply with this standard.

Chilterns Manor is a care home without nursing for up to 22 older people and people with dementia. Eighteen people were living at the home at the time of our visit.

The service had a registered manager in post. 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 received positive feedback about the service. Comments from people included “I think they do their best,” “They are all very nice, we’re like family and always get on together” and “Very friendly and conscientious.” One person told us “The home is lovely and so are the staff members. They take time to make it feel like home for the residents and have really good relationships with both residents and family.” Two of three healthcare professionals we spoke with provided positive feedback about the service. The third shared concerns about moving and handling practice.

People were protected against the risk of abuse. There were safeguarding procedures and training on abuse to provide staff with the skills and knowledge to recognise and respond to safeguarding concerns. None of the people we spoke with or staff had any concerns about how people were treated.

Risks to people’s safety and welfare had been assessed. Written risk assessments had been prepared to reduce the likelihood of injury or harm to people during the provision of their care. People’s medicines were handled safely and given to them in accordance with their prescriptions. We found some people had recurring falls at the service. There were no records of any preventative action. We have made a recommendation for the service to follow good practice in relation to falls prevention practice.

We found staff had not always been recruited using robust procedures. Some staff had started work before all required checks had been returned. We were unable to see any contingency plans to protect people until these checks had been received at the home. Staff support was inconsistent. Records showed some staff had received a structured induction, regular supervision and an annual appraisal of their performance, but not all. The provider had outlined mandatory training for new staff. In some cases we could not see that this had been fully completed.

The building complied with gas and electrical safety standards. Equipment was serviced to make sure it was in safe working order. Evacuation plans had been written for each person, to help support them safely in the event of an emergency. Regular fire safety checks were carried out including practice drills.

Care plans had been written, to document people’s needs and their preferences for how they wished to be supported. We found some care plans had gaps in information about support needs.

People were supported to take part in a wide range of social activities. Staff supported people to attend healthcare appointments to keep healthy and well.

People told us they would speak with various members of staff or their family if they had any concerns about their care. We found issues people had spoken to staff about had not been recorded anywhere. We were unable to see if any action had been taken in response to these matters.

The registered manager had been working on night shifts for several weeks prior to the inspection. We found there was some lack of awareness by management of what was happening during the day. Whilst the issues did not affect people’s care whilst we were present, there was potential for poor practice to develop. For example, staff handover took place in a communal area where confidential issues may be overheard.

We found monitoring of the service was not effective in highlighting all areas where improvements were needed.

We have made a recommendation to improve how records are filed and stored.

We have made a recommendation for the service to follow good practice in sharing the results of user and stakeholder surveys.

We found breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to staff support and training, recruitment practice, management of complaints and monitoring of the service.

You can see what action we told the provider to take at the back of the full version of this report.