Gloucester House

Gloucester House is a residential care home providing accommodation and personal care for older people and people living with dementia. The service can support 54 people across four different units, called 'villages'. Each village has its own facilities such as a small lounge and ‘café’. There were 41 people living in the service at the time of inspection. Many people required nursing care and were living with dementia or had diabetes. Some people had complex nursing needs such as a tracheostomy, which was in place to help them to breathe, and others had a tube into their stomach as a means of providing nutrition when they were not able to take food by mouth. Some people were cared for in bed, some needed help with moving around and others were able to mobilise independently.

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

There were some areas of the service that needed to improve. When these areas had been identified during inspection, the manager started to put measures in place to improve straight away. The manager demonstrated how these improvements would be sustained.

People told us they felt safe in the service. A relative told us, “My mother feels very safe and so do we”. Staff were aware of people's needs and how to keep them safe.

People were safeguarded from the risk of abuse. Risks to health and safety had been managed and people received safe care and treatment. Sufficient staff were deployed and safe recruitment practices were in place. Medicines were managed safely in line with national guidance. Infection was prevented and controlled. Lessons were learned when things went wrong.

The manager promoted an open-door culture where people, relatives and staff felt they could speak to them at any time and they would be listened to. A relative told us, “The managers are visible”. Relatives and staff were mainly positive in their comments about the management team.

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 requires improvement (published 09 December 2019) and there were two breaches of regulation. 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 10,11,12 September 2019. Breaches of regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 coronavirus and other infection outbreaks effectively.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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

Follow Up

We will continue to monitor information we receive about the service until we return to visit as per our inspection programme. If we receive any concerning information we may inspect sooner.

Gloucester House accommodates up to 54 people across four different units, called ‘villages’. Each village has its own facilities such as a small lounge and drink and snack making facilities. There were 39 people living at the service at the time of inspection. Many people required nursing care and were living with dementia, had diabetes, or experienced seizures. Some people had complex nursing needs such as a tracheostomy, which was in place to help them to breathe, and others had a tube into their stomach as a means of providing nutrition when they were not able to take food by mouth. Some people were nursed in bed, some needed help with moving around and others were able to mobilise independently.

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

There were some areas of the service that needed to improve. When these areas had been identified during inspection, the registered manager started to put measures in place to improve straight away.

Risks within the premises and environment had not always been identified to make sure management plans were in place to reduce the risks to people. Guidance was not always available for staff to make sure individual risks were controlled.

Opportunities were missed through the provider’s monitoring and auditing systems to identify the areas of quality and safety that needed improvement, so that action could be taken in a timely manner.

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; however, the policies and systems in the service did not support this practice by making sure the appropriate records were maintained. This is an area identified as needing improvement.

Staff were aware of people’s needs and how to keep them safe. People told us they felt safe and were supported by staff who knew how to support them. Nurses were conscientious in making sure people received their medicines safely.

There were enough staff to meet people’s needs and people confirmed they did not have to wait if they needed help, staff attended quickly. Staff said they could spend time with people, to chat in a relaxed way. Safe recruitment practices were followed.

People met with the management team before they moved into the service to check that nurses and staff would be able to meet their needs. Each person had a care plan that contained information about their choices and preferences and these were reviewed regularly.

Trained nurses monitored people’s health and referred people to relevant healthcare professionals when necessary. People were supported to eat a balanced diet and to keep as healthy as possible.

The premises were kept in good condition and were being refurbished to a high standard. People were involved in decisions about the refurbishment so the environment suited people’s needs.

Staff were supported through one to one meetings with their manager and regular team meetings. Their personal development was considered important and nurses and staff had access to extra training in addition to the training that was considered essential.

Staff knew people well and the atmosphere in the service was relaxed and happy. Relatives felt welcome and said they were also supported well by staff. People and their loved ones were involved in all elements of their care. People’s end of life wishes were recorded and their loved ones were included in the plan.

The activities staff supported a full activities programme where there was something to meet everyone’s interests. They continued to find ways to develop this further. People knew how to complain if they needed to and said they were confident their concerns would be listened to and acted upon, if they had any.

The registered manager promoted an open-door culture where people, relatives and staff felt they could speak to them at any time and they would be listened to. The registered manager was keen to make sure the service provided was person centred and inclusive. People, relatives and staff were overwhelmingly positive in their comments about the registered manager and the management team.

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 14 March 2017).

Why we inspected

This was a planned inspection based on the previous rating. The inspection was prompted in part by notification of a specific incident. The information CQC received about the incident indicated concerns about the management of a ligature risk within the service. This inspection examined those risks. We found no evidence during the inspection that people continued to be at risk of harm as a result of ligature risks, as measures had been put in place immediately to protect people by removing the risk.

Enforcement

We have identified two breaches in relation to the management of risk and monitoring systems at this inspection.

Please see the action we have told the provider to take at the end of this report.

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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The service is split in to four units known as villages over two floors connected by a lift and each village accommodates up to 12 to 14 people. The individual villages are named after villages in Kent. There were 45 people in Gloucester House at the time of our inspection.

A registered manager is 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 and associated Regulations about how the service is run.

We carried out an unannounced comprehensive inspection at Gloucester House in March 2016. Breaches of Regulation were found and Gloucester House was rated as requires improvement overall. This was because there were not a sufficient number of suitably trained staff deployed to ensure that people's needs were consistently met to keep them safe. Appropriate assessments of people's mental capacity and best interest meetings were not carried out and documented when necessary. The quality assurance systems needed to be developed to ensure that they identified areas for improvement. We received an action plan from the provider that told us that they were taking action to ensure the health and safety of people who lived at Gloucester House.

This unannounced comprehensive inspection was carried out on the 21 and 24 February 2017 to see if the breaches of regulation had been met. This inspection found that improvements had been made and the breaches of regulation met.

People spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made.

The Care Quality Commission (CQC) is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. The provider, registered manager and staff had an understanding of their responsibilities and processes of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

Staff and relatives felt there were enough staff working in the home and relatives said staff were available to support people when they needed assistance. The provider was actively seeking new staff, nurses and care staff, to ensure there was a sufficient number with the right skills when people moved into the home. The provider had made training and updates mandatory for all staff, including safeguarding people, moving and handling, management of challenging behaviour, pressure area care, falls prevention and dementia care. Staff said the training was very good and helped them to understand people's needs.

All staff had attended safeguarding training. They demonstrated a clear understanding of abuse; they said they would talk to the management or external bodies immediately if they had any concerns, and they had a clear understanding of making referrals to the local authority and CQC. Pre-employment checks for staff were completed, which meant only suitable staff were working in the home. People said they felt comfortable and at ease with staff and relatives felt people were safe.

Care plans reflected people’s assessed level of care needs and care delivery was based on people's preferences. Risk assessments included falls, skin damage, behaviours that distress, nutritional risks including swallowing problems and risk of choking and moving and handling. For example, cushions were in place for those that were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and Parkinson’s. Visits from healthcare professionals were recorded in the care plans, with information about any changes and guidance for staff to ensure people's needs were met. Staff had received training in end of life care supported by the organisations pastoral team. There were systems in place for the management of medicines and people received their medicines in a safe way.

Registered nurses were involved in writing the care plans and all staff were expected to record the care and support provided and any changes in people's needs. The manager said care staff were being supported to do this and additional training was on -going. Food and fluid charts were completed when required and showed people were supported to have a nutritious and varied diet.

Staff had a good understanding of people's needs and treated them with respect and protected their dignity when supporting them. People we spoke with were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and they responded to staff with smiles. People were seen in communal areas for activities, meetings and meal times and were seen to enjoy the atmosphere and stimulation.

A range of activities were available for people to participate in if they wished and people enjoyed spending time with staff. Activities were provided throughout the whole day, six days a week and were in line with people's preferences and interests.

The provider had progressed quality assurance systems to review the support and care provided. A number of audits had been developed including those for accidents and incidents, care plans, medicines and health and safety. Maintenance records for equipment and the environment were up to date, such as fire safety equipment and hoists. Policies and procedures had been reviewed and updated and were available for staff to refer to as required. Staff said they were encouraged to suggest improvements to the service and relatives told us they could visit at any time and, they were always made to feel welcome and involved in the care provided.

Staff said the management was fair and approachable, care meetings were held every morning to discuss people's changing needs and how staff would meet these. Staff meetings were held monthly and staff were able to contribute to the meetings and make suggestions. Relatives said the management was very good; the registered manager was always available and, they would be happy to talk to them if they had any concerns

The service is split in four wings (‘villages’) across two floors connected by a lift and each village accommodates up to 12 to 14 people each. There were 49 people in Gloucester House at the time of our inspection, 43 of whom had nursing needs and 27 of whom lived with dementia. Not all of the people living in the service were able to express themselves verbally and communicate with us.

This inspection was carried out on 03, 04 and 07 March 2016 by three inspectors and an expert by experience. It was an unannounced inspection.

There was a new manager in post who was registered with the Care Quality Commission (CQC) since June 2015. A registered manager is a person who has registered with the CQC 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 knew how to recognise signs of abuse and how to raise an alert if they had any concerns. Risk assessments were centred on the needs of the individual. Each risk assessment included clear measures to reduce identified risks and guidance for staff to follow or make sure people were protected from harm.

Accidents and incidents were recorded and monitored to identify how the risks of recurrence could be reduced.

People, relatives and staff told us there were insufficient staff deployed to consistently meet people’s needs. Staffing levels had not been calculated taking into account the dependency and complexity of needs for people living with dementia and who may have nursing requirements or behaviours that challenge.

There were thorough recruitment procedures in place which included the checking of references.

Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.

Staff knew each person well and understood how to meet their support and communication needs. Staff communicated effectively with people and treated them with kindness and respect. People were able to spend private time in quiet areas when they chose to.

The premises needed re-decorating and this was planned to take place following the conversion and renovation works planned over the next 12 months.

Staff had not yet received all essential training although this training was in process and monitored to ensure its completion by all staff within a set time frame. All members of care staff received regular one to one supervision sessions. Nursing staff had not yet received this support; however a newly appointed deputy manager had scheduled this to take place.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options had been considered. Staff sought and obtained people’s consent before they helped them. However people’s mental capacity was not assessed nor documented appropriately when necessary about particular decisions; meetings with appropriate parties were not held or recorded to make decisions in people’s best interest, as per the requirements of the Mental Capacity Act 2005.

The staff provided meals that were in sufficient quantity and met people’s needs and choices. People praised the food they received and they enjoyed their meal times. Staff knew about and provided for people’s dietary preferences and restrictions.

People’s individual assessments and care plans were reviewed monthly or when their needs changed, although not all people’s care files were up to date. There were plans for key workers to involve people at monthly reviews and invite their relatives or legal representatives to participate in annual reviews that were scheduled.

Clear information about the service, the facilities, and how to complain was provided to people and visitors.

People were promptly referred to health care professionals when needed. Personal records included people’s individual plans of care, life history, likes and dislikes and preferred activities. The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

People were involved in the planning of activities that responded to their individual needs. People’s feedback was actively sought at relatives and residents meetings. However a satisfaction survey carried out four months ago by an external assessor had still not been returned and analysed.

Staff told us they felt valued by the registered manager and they had confidence in her leadership. The registered manager was open and transparent in their approach. They placed emphasis on continuous improvement of the service.

There was a system of monitoring checks and audits to identify the improvements that needed to be made. The management team acted on the results of these checks and was in the process of making changes to improve the quality of the service and care.