Silversprings

The service provides residential and nursing care for up to 64 people, some of whom are living with dementia. The premises is divided into three units, Bluebell, Tenpenny and Caroline. Bluebell provided accommodation for people who required nursing care. Tenpenny provided accommodation and support to people with a diagnosis of dementia and Caroline provided support for older people. At the time of our inspection 49 people were using the service.

We found the following examples of good practice.

People told us they were supported to maintain contact with family and friends. There were safe visible visiting arrangements in place. Friends and family had access to a range of information via the providers website, the services newsletter and on site telling them about visiting arrangements and what to expect.

Processes were in place to ensure people were admitted to the service from hospital and from the community safely.

People and staff were regularly tested for COVID-19 and where positive results had been returned the registered manager had acted quickly to to mitigate the risks to others catching the infection. The service was fully staffed and able to manage future coronavirus and other infection outbreaks, and winter pressures.

The registered manager had maintained a good stock of PPE and staff told us they felt supported by the management team. Infection prevention and control (IPC) champions had been appointed to support staff in their understanding of good infection prevention and control guidelines. A range of ‘How to’ cleaning guides had been developed for staff to ensure the premises and equipment were clean and hygienic.

Silversprings provides residential and nursing care for up to 64 people, some of whom are living with dementia. The premises are divided into three units, Bluebell provides nursing care, Tenpenny provides care and support to people living with varying levels of dementia. Caroline provides support for older people. At the time of our inspection 52 people were using the service.

People’s experience of using this service:

Governance systems had improved since our last inspection. However, further improvements were needed to ensure these were used robustly to demonstrate how the quality of the service continually improved and developed to provide good outcomes for people. Poor outcomes identified in safeguarding concerns, complaints, incidents and accidents were looked at in isolation, rather than looking at the root causes in relation to a lack of staff training, poor recording, communication and ineffective leadership on the units.

Staff lacked knowledge and understanding on how to support people with dementia, including managing high levels of anxiety. Therefore, staff were not always providing care that was effective and person centred. People were treated with kindness and respect; however, staff were focussed on completing tasks rather than focussing on promoting people’s independence and emotional wellbeing, and they did not always respect people’s privacy and dignity.

Although sufficient staff were employed, there were key times throughout the day where more staff were needed, specifically on Tenpenny unit, to ensure people’s needs were met and to keep them safe. People with advanced dementia were not sufficiently supported at mealtimes to ensure they ate enough and were protected from malnutrition, and risk of choking.

Care records did not contain enough information for staff around supporting people’s wellbeing or complex, long term specific needs, such as dementia. People’s past life, hobbies and interests was not used to help them lead fulfilled and meaningful lives, through activity, therapy and social inclusion. Although the provider had consulted with other reputable resources for guidance and support in identifying activities for people with dementia, and how to engage effectively, these had not yet been imbedded to drive the required improvements.

Where things had gone wrong, systems were in place to share learning across Care UK services in the Essex region. Whilst this was a good initiative, the process needed expanding to reflect the root cause of the issues and how changes in practice had improved outcomes for people.

Management and senior staff had inconsistent understanding of the legal framework, relevant consent and decision-making requirements of the MCA 2005 and associated best interest decisions. The registered manager was working with people and their relatives to complete Preferred Priorities of Care (PPC) forms to plan for their future end of life care.

Safeguarding concerns had been managed well. Systems were in place to manage people’s medicines safely and to reduce the risks associated with the spread of infection. People had access to various healthcare professionals, when they needed them.

People, their relatives and staff were engaged in the service and had been consulted on and created a set of vision and values specific to Silversprings that puts people at the centre of the service. The values focused on being passionate, caring and developing good team work.

Rating at last inspection: The scheduled inspection on 27 March 2018 and 29 March 2018 was rated Requires Improvement (Report published 17 May 2018)

The focussed inspection on 19 September 2018 and 03 October 2018 was brought forward due to information of concern; about people’s catheter care. The rating remained, Requires Improvement (Report published 20 November 2018)

This service has been rated Requires Improvement at the last three inspections, since 11 May 2017. Following this inspection, the rating, Requires Improvement has not changed.

Why we inspected: This inspection was brought forward due to information of concern about people’s care and welfare.

Follow up: During this inspection we found whilst some improvements had been made, further improvements were needed, in relation to good governance, staff training, dementia care and deployment of staff. We will continue to monitor all intelligence received about this service to ensure that the next planned inspection is scheduled accordingly.

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

Silversprings 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 service provides residential and nursing care for up to 64 people, some of whom are living with dementia.

The premises is divided into three units, Bluebell, Tenpenny and Caroline. Bluebell provided accommodation for people who required nursing care. Tenpenny provided accommodation and support to people with a diagnosis of dementia and Caroline provided support for older people. At the time of our inspection 48 people were using the service.

There was 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.

Following our previous inspection on 27 March and 29 March 2018 the service was given an overall rating of requires improvement. Although, the provider was not in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 we found improvements were needed in relation to the allocation of staff, specifically in Caroline unit. Additionally, the morale of staff was low, because they did not feel supported. At this inspection we found whilst improvements had been made to support staff, systems to assess and respond to risk, specifically in relation to catheter and PEG care, had not been consistently applied or managed to protect people from harm, or the risk of harm occurring.

On the first day of the inspection we continued to find issues with people’s clinical care, despite the safeguarding concerns that had been raised about poor catheter care. Changes in the management team meant there had been periods of time where there was a lack of clinical leadership on the premises. We found ongoing issues, in relation to staff skills, recording and documentation around catheter care and where people had a Percutaneous Endoscopic Gastrostomy (PEG) in place. This is a tube which is passed directly into a person's stomach to provide a means of feeding when oral intake is not adequate, because of poor swallowing. Whilst it is recognised improvements, had been made by the time of our second visit, routine visits by the quality development manager, and monthly documentation audits carried out by the management team had not identified the ongoing issues. The provider had a range of audits in place for monitoring the quality of performance, risks and regulatory requirements, however we found these were not robustly used to identify failings in the service.

The registered manager had been open and transparent and worked well with the local authority safeguarding team to investigate what went wrong in relation to the failings associated with the poor catheter care. They had completed an investigation, a ‘route cause analysis’ to understand what went wrong and developed an action plan to prevent this type of incident happening again.

People received their medicines, when they needed them and as prescribed by their GP. Policies and procedures for management of medicines, including recording and storage of medicines reflected professional guidance and were current, but not always being followed by staff. We have made the following recommendations about the management of medicines.

We recommend that the medicines policy should be readily accessible for all members of staff responsible for administering medicines and that staff are trained to follow the policies and procedures correctly.

We recommend that the service considers current guidance on ‘storage of medicines’ and take action to update their practice accordingly.

There were enough staff to meet people’s needs. Staffing numbers specifically on Caroline unit had increased. Systems for recruiting new staff were carried out safely to ensure potential employees were suitable to work at the service.

The results of the 2018 staff survey, which had a 100% response rate confirmed staff morale had improved. Staff told us they felt supported, appreciated and understood what was expected from them. Group supervisions had taken place to ensure staff had the skills and knowledge they needed to provide the right care to people using the service. This had included, continence management, catheter care documentation and recording. A template for ‘pre- catheterisation considerations’ and a ‘how to catheter guide’ had been used to aid group supervisions and provide additional guidance for nursing and care staff. Additionally, care staff had completed a self-assessment with regards to catheter care, completed training and had been observed providing catheter care.

Staff understood their responsibilities to raise concerns, and demonstrated a good awareness of safeguarding procedures, how to recognise and report signs of neglect or abuse.

People, their relatives and staff were encouraged to share their views and provide feedback about the service. People’s comments, referred to good food, a clean home, staff were pleasant and made them feel at home. Relatives had mixed views about how well they were kept informed about their loved ones, but were overall positive about the service provided.

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 overall rating of the service. At this inspection we found although the provider had taken action to improve the rating of some domains inspected, further improvements were still necessary in order to fully meet all regulatory requirements.

Silversprings 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 service provides residential and nursing care for up to 64 people, some of whom are living with dementia. At the time of our inspection 50 people were using the service.

There was 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.

During the inspection, we observed there was sufficient staff to keep people safe and we found call bells were answered in a timely manner. However, we did still receive mixed feedback in relation to staffing particularly on Caroline

Medicines were now managed safely and the provider had procedures in place so they were stored securely, administered in line with recommended guidance and recorded.

Robust recruitment procedures were in place and all staff completed an induction when they started work. People told us they felt safe living at the service with the support from staff. There were safeguarding policies and procedures in place. Staff were knowledgeable about what action they should take if they suspected abuse. We saw there were risk assessments in place to identify specific areas of concern.

Mechanisms to provide staff with training and supervision, and appraisals were in place to support staff to be effective in their role. However, not all staff always felt supported by the registered manager and deputy manager, this meant for some staff morale was low.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) including the Deprivation of Liberty Safeguards (DoLS), and to report on what we find. Applications had been made on behalf of some people to restrict their freedom for safety reasons in line with the Mental Capacity Act 2005. Most staff demonstrated an understanding of the MCA and worked within its principals, including gaining consent to care for people who lacked mental capacity. We have made a recommendation about supporting staff to gain a better understanding of this area.

People enjoyed a balanced healthy diet. Their healthcare needs were fully met and the service worked well in partnership with other health professionals to ensure people received good healthcare.

People were complimentary about the way staff interacted with them. Independence, privacy and dignity was promoted and respected. Staff took account of people’s individual needs and preferences and people were encouraged to be involved in making decisions about their care.

Staff knew people well, could describe their routines and preferences and understood how to provide care and support that was tailored to each individual. People were provided with opportunities to engage in activities which reflected their interests and preferences both within the service and out in the community. We saw that the registered manager investigated and managed complaints thoroughly and in a timely manner.

The provider and the registered manager undertook regular quality assurances checks. The registered manager had responded to our feedback positively in relation to staff feedback and low morale of some staff and was planning some team building activities.

The service provides residential and nursing care for up to 64 people, some of whom are living with dementia. The service had recently changed its registration to include the provision of nursing care. At the time of our inspection 57 people were using the service including one person on a respite stay.

We carried out this inspection in response to concerns related to the management of medicines raised by Essex County Council Quality and Improvement team. We carried out a comprehensive inspection and looked at all areas of the service as well as looking in detail at the management of medicines. The previous inspection of this service had been carried out on 11 May and 9 June 2016 and the service had been rated Good overall but improvements had been required with regard to the safety of the service.

A registered manager was not in post but a manager had been recruited and was due to begin their employment in the next few weeks. A temporary manager had been employed at the service since October 2016. 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 this inspection we continued to have concerns regarding the safety of the service and the management of medicines in particular.

Medicines were not managed safely and recent improvements made in response to a safeguarding issue raised by Essex County Council had not been applied to other areas of the service. This placed people at risk of harm.

Staffing levels, and the deployment of staff, were significant concerns for many people who used the service, relatives and staff and we observed people failing to receive prompt care and treatment to meet their needs. There was a lack of strategy related to the deployment of staff.

Risks were assessed and documented in care plans but staff did not always manage risks effectively as set out in people’s care plans.

Infection control measures were in place and staff had a good understanding of how to limit the risk and spread of infection.

Staff were trained in safeguarding people from abuse and the manager referred incidents appropriately to the local authority safeguarding team for investigation.

Staff received a good induction and training to help them carry out their roles. However, some relevant training was not provided to all staff. Staff were supported with regular meetings, supervision and appraisal.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals and relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. Some practice related to MCA and DoLS was very good but some staff demonstrated a lack of understanding with regard to DoLS.

People who used the service praised the food and people were referred to dieticians if they required this. Support at mealtimes for people who needed help or encouragement to eat and maintain their weight varied, but in most cases was good. Oversight of people’s nutritional needs was good.

People were supported to access the healthcare support they needed promptly. There was evidence of good partnership working with the district nursing team and improved communication with the local GP service was seen as a priority by the manager.

Most staff were very caring and treated people respectfully, ensuring their dignity was maintained. Others were less caring and demonstrated a lack of respect.

People who used the service, and their relatives, were involved in planning and reviewing their care and had opportunities to feedback about the service.

People were supported to follow a range of hobbies and interests. However, people living with dementia and those unable to go out independently lacked stimulation. Staff understanding of the needs of people living with dementia varied.

A complaints procedure was in place and complaints were very well managed with information shared with staff and lessons learned.

The current manager had been brought in to stabilise the service after many management changes and to drive improvement. They had worked hard to bring about change and improvement but the staff team was not working cohesively and staff were stressed and not well motivated.

Audits were in place to monitor the safety and quality of the service but some were not effective in identifying concerns and effecting change. The manager had innovative ideas and was skilled and experienced but was not managing to successfully bring about the cultural change required within the staff team.

We found two breaches of regulation during this inspection. You can see what action we have told the provider to take at the back of this report.

Silversprings provides accommodation and personal care for up to 64 older people and people who may be living with dementia. The service did not provide nursing care at the time of our first inspection but preparations were in hand to open a nursing unit. At the time of our inspection there were 46 people using the service.

There was a registered manager in post at the service. 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.

People were safe because the management team and staff understood their responsibilities identifying abuse. People received safe care that met their assessed needs.

People were safe because staff supported them to understand how to keep safe and staff knew how to manage risk effectively. However, there were occasions where risk management plans were not always followed effectively.

There were sufficient staff who had been recruited safely and who had the correct skills and knowledge to safely meet people’s needs.

The provider had systems in place to manage medicines and people were supported to take their prescribed medicines safely.

People’s health and social needs were managed effectively with input from relevant health care professionals and people had sufficient food and drink that met their individual needs.

The Care Quality Commission (CQC) monitors the operation of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) which apply to care homes. We found the provider was following the MCA code of practice.

The management team supported staff to provide care that was centred on the person and staff understood their responsibility to treat people as individuals.

People were treated with kindness and respect by staff who knew them well.

Staff respected people’s choices and took their preferences into account when providing support. People were encouraged to enjoy pastimes and interests of their choice and were supported to maintain relationships with friends and family so that they were not socially isolated.

Staff had good relationships with people who used the service and were attentive to their needs. People’s privacy and dignity was respected.

There was an open culture and the management team encouraged and supported staff to provide care that was centred on the individual.

The provider had systems in place to check the quality of the service and take the views and concerns of people and their relatives into account to make improvements to the service.

People were aware of how to raise concerns and there were opportunities available for people to give their feedback about the service.

The manager was visible and actively involved in supporting people and staff. Staff were positive about their roles and their views were valued by the management team.

Below is a summary of what we found. The summary is based on our conversations with the manager, regional director, three staff, six people who used the service, two relatives, two visiting health professionals and from looking at records. Where it was not possible to communicate with people who used the service we used our observations to gather information.

Is the service safe?

Records contained detailed assessments of people's needs that had been carried out prior to them moving to the service. This ensured that the staff had the relevant skills and knowledge required to meet the individual's identified needs. A visiting health care professional, "The home is very good, 'Staff follow instructions and advice we give to them relating to people's health care needs." We saw that care plans included people's likes, dislikes and what time they liked to get up and go to bed. The manager told us people were involved in the regular reviews of their care plans and risk assessments. The people we spoke with confirmed this.

Where people did not have the mental capacity to provide consent the provider complied with the requirements of the Mental Capacity Act 2005. Staff had received training in this area. The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. We saw records that confirmed that one application had needed to be submitted and that proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve. One person said, "I am happy here."

Is the service effective?

It was clear from what we saw, and from speaking with staff, that they understood people's care and support needs and that they knew people well. A person who used the service told us, "The staff are polite, caring and they treat me with respect."

People's health and care needs were assessed with them, and they were involved in writing their plans of care, where they were unable to do so staff had spoken to their relatives or friends to gain their views. Specialist dietary needs had been identified in care plans where required.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff showed patience and gave encouragement when supporting people. People's preferences, interests, religious and faith needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

Where people's care needs had changed appropriate referrals to the doctor, district nurse and dentist had been made and any recommendations had been acted on. The manager had regular contact with the relatives of people who used the service and health care professionals. Both of the health care professionals we spoke with were complimentary about the professionalism of the manager and the staff. They told us, "The home makes appropriate referrals to us."

Is the service well led?

The service worked well with other agencies and services to make sure people received their care in a joined up way. Health care professionals who we spoke with told us, "The staff had kept them informed of people's changing health needs.

We saw the responses from the stakeholder survey. People had commented positively about the quality of the care provided to the people who lived in the home. The service had a quality assurance system in place. Records seen by us showed that identified shortfalls were addressed promptly. As a result the quality of the service was continuously improving.

The three staff we spoke with told us they were clear about their roles and responsibilities and they received excellent training, support and supervision from the manager. They told us that this enabled them to provide excellent care and support to people who used the service. We saw that staff had a good understanding of the aims of the service. This helped to ensure that people received a good quality service at all times.

People we spoke with were positive about the care that they received and felt involved in planning how their care needs were met. One person told us: 'I can't fault the girls [staff] they are wonderful'.

We found that not all care records we looked at fully reflected the needs of people who lived in the home. Although staff demonstrated a good understanding and knowledge of the care and support people required.

The medication administration, recording and storage were all in good order and ensured people received their medication as prescribed.

The premises were well maintained, clean and safe.

There was a recruitment procedure in place which ensured that only people suitable to work with vulnerable people were employed. Staff received a wide range of training which equipped them for their role.

Staffing number were adequate to meet the needs of the people currently living at Silversprings.

The provider had a complaints system in place and people were given the opportunity to raise any concern or compliments they had.

During our inspection we spoke with people and relatives who told us the home was nice, one relative told us they had seen 'positive changes' at Silversprings Care Home. We saw that people smiled and appeared relaxed and comfortable with staff and others living at the home.

During our inspection we saw that people received good care and that staff treated them with respect. One person told us, 'Oh I think so [staff being respectful]; I really haven't got any complaints about the staff.'

Relatives and people we spoke with told us there were always a range of drinks available for people. One relative told us the activities at the home were reasonable.

During our inspection we saw that new records and care plan systems had been implemented at the home.