Archived: Tarvin Court

The inspection was prompted from information the commission received regarding a failure by the registered provider and manager to report safeguarding incidents.

Tarvin Court 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.

Tarvin Court accommodates up to 28 people in one adapted building divided in to two units. At the time of our inspection 14 people were living at the home. Tarvin court is a two storey building with a single storey extension to the rear of the property. There are 22 single rooms and three double rooms. It is situated in Littleton.

The service has 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 the last inspection on 7 February 2017 we found that there were a number of improvements needed in relation to safe care and treatment, staffing, consent and good governance. These were breaches of Regulation 12, 18, 11 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective and Well-led to at least good. The provider sent us an action plan that specified how they would meet the requirements of the identified breaches.

This inspection was done to check that improvements after our comprehensive inspection on 7 February 2017 had been made. The team inspected the service against two of the five questions we ask about services: Is the service Safe and Well Led? During this inspection we found some improvements had been made, however we found a number of areas of ongoing concerns relating to poor practice that had not been identified or addressed by the manager or registered provider. You can see what action we took at the end of this report.

No risks, concerns or significant improvement were identified in the remaining Key Questions through our on-going monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

The registered manager had introduced regular audits that included medicines, infection control, care plans and accidents and incidents. However, although these were regularly completed and some areas for development and improvement had been identified and actioned, trends and patterns had not been identified to keep people protected from future risks.

Accidents and incidents were not analysed by the registered manager to identify trends and patterns. Action had not been taken to mitigate future risks.

Gaps in staff training and skills had been identified but not addressed, which meant all staff were not up to date with the knowledge and skills required for their role. Staff had not completed up to date safeguarding training.

Safeguarding policy and procedures were in place and staff demonstrated some understanding of these. However, investigations had identified that the management team had not consistently reported all safeguarding concerns in accordance with the local agency or registered provider’s processes. There had been a number of safeguarding concerns that had been investigated by the relevant agencies and substantiated.

Staff recruitment procedures were followed. Employment checks had been undertaken that included references from up to date employer and a DBS. However, we found that there were not enough recruited staff to meet the needs of the people living at the home and there was a high level of agency staff use. This meant people were not always supported by staff that fully understood their individual needs.

Staff meetings, supervision and appraisal took place regularly. Daily handover meetings took place to ensure staff had up to date information about each person living at the home. Staff told us they felt supported by the management team. However, we found that there was clear evidence of disharmony within the management team that was causing division within the home.

Improvements had been made to the management of medication. Medicines were managed in accordance with good practice guidelines. There were clear procedures for ordering, storing, administering and disposing of all medicines. Staff had received training and been assessed as competent. People told us they received their medicines on time.

Improvements had been made to minimise the spread of infection. The carpet in the medicines room that had previously been identified as an infection risk had been replaced.

Health and safety checks were regularly undertaken. Equipment was checked and serviced in accordance with good practice guidelines.

The registered provider had policies and procedures in place that were accessible to staff to offer them clear guidance in their role. These were up to date and had been reviewed. The Statement of Purpose and Service User Guide were up to date and available to people and their relatives.

The registered provider lacked effective oversight of the management of the home and they had not ensured all requirements of their registration were being met.

We found that we had not always received notifications in a timely manner to inform us of significant events that had occurred at the home.

Tarvin Court provides accommodation for up to 28 older people who require personal or nursing care. It is situated in Littleton on a main bus route into Chester. The property is a two storey building with a single storey extension at the back. There are 22 single rooms and three double rooms. At the time of this inspection there were 14 people living at the service.

The service does not have a registered manager. A new manager has been in place since 9 January 2017 and has applied to be registered with the Care Quality Commission. 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.

The last inspection was undertaken on 20 and 21 June 2016. During that inspection we found that the registered provider was not meeting legal requirements. There were breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in respect of the control of infection, cleanliness of the premises and equipment; safety and maintenance of the premises and governance of the service.

After the inspection, the registered provider sent us an action plan that specified how they would meet the requirements of the breaches identified. They advised us that they would meet all the legal requirements by October 2016. During this inspection we found some improvements had been made but not all areas had improved.

Medicines were not administered safely however, medicines were stored appropriately.

Staff did not have a good understanding of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Care records did not demonstrate people's involvement in decision making. Mental capacity assessments were not completed and best interest meetings had not taken place for people who lacked capacity.

Quality assurance systems were not robust. They did not identify areas for improvement and development.

The statement of purpose and service users guide was not up to date and contained inaccurate information. Policies and procedures in place also contained inaccurate information and needed to be reviewed.

Staff had received initial training, however refresher training was not up to date and this meant that staff had not remained up to date with their knowledge and skills required to their role. Formal supervision had not been undertaken.

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

There was enough staff on duty during the inspection to meet the needs of the people living at the service.

The service had safe recruitment practices in place. Appropriate checks were carried out before new staff started their employment. This ensured only staff suitable to work with vulnerable adults was employed. All new staff received an induction which included a period of time shadowing experienced staff.

Individual risk assessments were completed to ensure people and staff were protected from the risk of harm. Staff managed risk effectively and supported people’s decisions, so they had as much control and independence as possible.

Staff had received training in adult safeguarding and understood how to recognise and report potential abuse.

People’s care plans provided staff with guidance on to how to meet their needs.

People had enough to eat and drink. People who had been identified as at risk of weight loss or weight gain were weighed regularly and people’s health and well-being was closely monitored and any changes were responded to promptly.

Daily records were completed and included information on people’s daily activities, medication administration, as well as any concerns relating to that individual.

People were supported to participate in activities of their choice. People told us they were treated with kindness and respect by staff. We observed positive interactions between staff and people living at the service.

People knew how to raise concerns and make complaints and felt confident to do so. People believed any concerns or complaints would be dealt with.

Tarvin Court provides accommodation for up to 28 older people who require nursing or personal care. It is situated in Littleton on a main bus route into Chester. The property is a two storey building with a single storey extension at the back. There are 22 single rooms and three double rooms. At the time of this inspection there were 22 people living at the service.

There was no registered manager in place at this service. The current manager who has been in post for seven months is in the process of applying to become registered with CQC. The manager was waiting the outcome of her application and interview. 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 last inspection on 12 November 2015 we found that a number of improvements were required. These were in relation to the inadequate maintenance of equipment and premises and the registered provider had no quality assurance audit systems in place. We asked the registered provider to take action to address these issues.

After the inspection the provider wrote to us and told us what they would do to meet the legal requirements in relations to the breaches identified. They informed us that they would meet all the relevant legal requirements by the end March 2016.

During our visit we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we have told the provider to take at the back of the full version of the report. Two of these breaches are repeated from the previous inspection. These relate to the inadequate maintenance of equipment and premises and the quality assurance audit systems in place not identifying or effectively monitoring the safety and welfare of people who used the service.

The home was not always clean. Equipment and furnishings were not clean, two bedrooms had a strong smell of urine. There was a risk of cross contamination where fittings and equipment were chipped and damaged. The management of infection control was poor.

Although some refurbishment and redecoration had taken place within the home, communal areas had damaged walls and furniture that was in need of replacement. Externally the garden and pathways were overgrown with weeds, window frames had bare wood exposed and peeling paint and the patio was uneven which was a potential trip hazard.

The registered provider’s quality assurance audit systems failed to monitor the quality of the service provided. The systems in place did not always identify areas of concern or where improvements were required. Policies, procedures and other documents such as the service user’s guide and brochure were not up to date and this meant that people who lived at the home did not have access to up to date information.

The manager had limited knowledge about the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS).We found 11 people who were living with dementia of which nine were being deprived of their liberty without appropriate authorisations being in place. Staff had completed DoLS e-learning training, however they told us that they did not really understand this and further training was needed.

Staff had completed a range of training courses, however, concerns remained that refresher training had not been undertaken to maintain and develop staff’s knowledge and skill base. Staff had access to supervision sessions and staff meetings were undertaken.

Care plans identified where people required the use of an air flow mattress to aid their skin integrity. We found that details of these mattresses or the correct settings required were not recorded in the care plans. Robust checks were not completed. We looked at four people’s mattresses and found that all were at the incorrect setting. This meant that people’s skin integrity could be at risk by resting on a mattress that was not set at the correct pressure.

People, visitors and staff told us that the manager was approachable but that many people didn’t know who she was, had not spoken with her or had the opportunity to meet her. On the days of the inspection the manager’s presence was not evident within the main area of the building and staff and visitors were at times unaware she was in the building.

People received their medication as prescribed and medication administration was safe. Medication was stored in a safe and secure way.

Staff recruitment processes were in place which included checks of prospective employees. These included a Disclosure and Barring Service check and references. This meant that people could be confident that appropriate recruitment processes were in place.

People told us that they were happy with the care they received at the service. People told us that the staff were kind, friendly and caring towards them and supported them to meet their needs. However, we found that people did not always receive effective care.

People said they felt safe at the home with the staff team. Staff had been trained to recognise and report any signs of abuse. Safeguarding issues that had arisen at the service since the last inspection had been appropriately reported and actioned.

The staffing levels were not sufficient as there was an insufficient number of domestic staff working in the home to maintain adequate standards.

People told us the food was good and that they had access to drinks whenever they wanted them. Care plans showed that a nutritious diet was encouraged.

The display of rating following the previous inspection was not available when we arrived at the service. This was brought to the attention of the manager who said they would address this. On the second day of inspection this had been addressed and the current rating was displayed.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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 looked at four care records and all had assessments of their health and social needs completed. There were individual support plans and risk assessments in place.

The expert by experience spoke with six people who lived at Tarvin Court, a relative and several staff together with general observations during their visit.

General observations by the expert by experience included during lunchtime observed people who lived in the home being treated in a dignified manner and with good responses to requests. People told the expert by experience 'I love my breakfasts' and 'Particularly the full English.' The meal was nutritious, well served, hot and with choices available. We saw that people were treated with dignity and that requests for support such as for a drink or to go to the toilet were answered quickly and pleasantly.

Care workers supported people to take their medicines safely and in ways that met the individual needs and preferences of people who lived in the home. Nobody that we spoke with raised any concerns about how their medicines were handled.

All staff had received training in safeguarding adults and a new file of safeguarding policies and procedures had been produced so that staff had sufficient information available to protect people from abuse. We saw documentation that showed staff had received regular supervision and this meant that staff had been supported by the management team to ensure they provided good care and support to the people who lived at Tarvin Court.

A new quality monitoring system had been purchased by the providers which included up to date policies and procedures and a complete quality assurance package which included questionnaires for people who used the service, relatives, staff and other professionals. The questionnaires had been sent to relatives and other professionals and the manager stated this would be completed by end March 2013. We saw a sample of care plans that showed these were being regularly reviewed so that people's needs could be met.

We spoke with eight service users, four relatives and nine members of staff including the manager. People who lived at Tarvin Court told us that the staff were very kind and caring and that they were given the support they needed. People confirmed that they felt safe living at Tarvin Court. People said "The staff are very good and able to do their jobs well", "The home is good", "The food is good" and "My room is very nice."

Relatives spoken with said "The staff are very friendly here", "We chose this home after looking at several in the area. The staff are very friendly. The room is very nice', "It is a very 'homely' home" All relatives confirmed that if they had a concern they would speak to a member of staff or the manager.

Staff spoken with said "I love my job. The staff team are very supportive of each other", "The days fly by here.'

During a tour of the home we found that in some areas it was in need of redecoration and refurbishment. An action plan had been produced by the manager and some of the work had started to be undertaken.

We found that the manager and staff were not aware the correct protocols for reporting suspected safeguarding incidents. Staff were not aware of the home's policies and procedures regarding abuse in the home which meant that people who used the service were put at risk.

Concerns were raised by the HMCoroner following a recent inquest regarding a person who used the service. We looked at staff training and supervision. We also reviewed the outstanding compliance action with regard to recruitment of staff.

We spoke with the care manager and four staff members during this visit.