Champion House - Care Home with Nursing Physical Disabilities

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last inspection we rated this key question requires improvement. At this assessment the rating remains unchanged and we identified breaches of the legal regulations in relation to safe care and treatment, staffing and recruitment. We found aspects of the service were not always safe. The provider did not always analyse, investigate, or learn from things that went wrong. Risks to people’s health and safety were not always robustly assessed and risk assessments that had been completed did not always include risks we identified during our assessment. There were not always enough suitably skilled staff to meet people’s needs safely. Medicines were still not always managed safely, and the recruitment of staff was not always safe. However, the environment was clean and well-maintained.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed views from people about whether they would feel comfortable to raise concerns with management. One person said, “I’d tell [manager], they’re usually around, or one of our staff and they’d do what they could to sort it.” However, another person said, “All we’ve got is [deputy manager] but I don’t really know them so I probably wouldn’t feel comfortable raising things. There is the residents meeting where you can raise things.”

Staff said, before the interim manager came into post, they did not have confidence in the management of the service and had not felt able to raise concerns. They told us concerns they had raised had not always been dealt with. One staff member said there were processes in place to raise concerns but didn’t know whether they would use them. However, most staff told us they would feel comfortable raising any issues with the new management team. Comments included, “[Interim manager’s] great, really supportive. I could go to them with any concerns” and “[Interim manager] is superb, uses really positive language to feed back to us on what we’re doing, what’s going well, what we could do to improve things even more.”

Governance and performance monitoring processes were not always effective in identifying or managing risks, or ensuring lessons learned were acted on. We reviewed a provider audit which identified that lessons learned were to be commenced for all safeguarding incidents. However, this had not been implemented. This meant opportunities to learn lessons were not always taken. For example, 1 person, who was known to be at risk of pressure damage, had sustained severe damage to their skin which resulted in a hospital admission. Prompt action was not taken by staff when this person’s skin deteriorated and it was not referred to safeguarding in a timely manner. Lessons learned were not carried out at the time, but when they eventually were, it identified the person had suffered avoidable harm due to a lack of prompt action.

People did not always experience safe pathways and transitions. People’s needs were not always assessed before they moved in and information about people’s needs was not always shared with other agencies when necessary. However, people did not report any concerns with accessing health professionals when required.

Feedback from staff and leaders showed safe pathways were not always in place when people were transferred from one service to another. During one of our site visits, 1 person was being transferred to another care service. We saw the ambulance transport arrive, but they were unable to take the person due to a lack of information about the equipment they required. The provider had failed to ensure information about the person’s needs had been shared with the relevant agencies, to ensure the person’s transition was effective. This did not achieve a good outcome for the person.

Overall feedback from partner agencies showed there had been improvements with how the service worked with other stakeholders. However, continued improvement was still required as, at times, progress appeared to be slow.

People did not always have safe pathways when moving into the home, and improvements were required regarding how the provider safely admitted people. The provider had an admissions, referrals and discharges process policy. This showed the procedures to be followed when a person was admitted to the service. However, we found these procedures had not been followed for the most recent admission to the service. This meant staff did not have the essential information to be able to provide safe care and treatment to this person.

Most people said they felt safe at the service. Comments included, “Yes, I’m safe here, people would come if I needed them” and “That’s never been an issue, I’ve always felt safe.” This was also reflected in the satisfaction survey that had recently been completed by people. However, 1 relative told us they felt their family member was not safe at the service and was therefore moving to a new service. We identified concerns with the person’s care on the first day of our assessment visit and made a safeguarding referral.

The interim manager had a good understanding of safeguarding procedures and took appropriate action when abuse was suspected or found. They had initiated investigations into safeguarding incidents that had occurred prior to them starting at the home. Staff told us they had completed safeguarding training and were able to explain their responsibilities, such as the concerns they would need to report. One staff member told us, “We had to do safeguarding training straight away so we would know of anything we needed to report. If people have bruises or if they’re not acting themselves, if they’re quieter than usual. Or someone could tell you something that had happened they weren’t happy about.”

Our observations in communal areas did not identify any safeguarding concerns in relation to staff approach and the delivery of care. Staff were kind, respectful and caring in their interactions with people and when providing care and support. We also saw people had their mobility aids and any equipment they needed to hand.

Systems and processes were in place to report, record and review any safeguarding incidents. However, we were not assured they always kept people safe and protected them from abuse and neglect. The provider used a safeguarding tracker, which showed incidents had been reported to the local authority safeguarding team and notified to the Care Quality Commission. However, the tracker was not up to date and outcome details had not been completed or signed off. For example, there was no evidence to show what action had been taken, whether risk assessments and care plans had been updated or lessons learned. We also identified areas of neglect during this assessment in relation to people's weight, skin integrity, use of thickener, pureed diets and medicines. We therefore made the necessary safeguarding referrals, as the provider had not identified these through their own processes. The interim manager, who had only been in post for 2 weeks at the start of the assessment, had started to address the safeguarding concerns which had not yet been resolved by the provider.

People were not always involved in the development of their risk assessments or regular reviews of their care. However, 1 person told us they had previously been resistant to support from staff with their skin integrity, until staff worked with them to understand the risks around not receiving this support.

Staff told us they did not routinely look at people’s care records, which meant they may not be familiar with people’s needs and risks. A member of night staff said they did look at care records sometimes, but they were unable to tell us details included in 1 person’s care plan about the support they required. A member of the management team told us lessons needed to be learned about the benefit of involving people in discussions around their risks and the different ways this could be done.

During our visits we found staff were not always in attendance to make sure people were protected from risk. We observed 1 person, who had been assessed as always requiring the support of a staff member, was left unattended on multiple occasions. This placed the person at risk of harm.

Risks to people's health and welfare were not always assessed and managed safely or consistently, placing people at risk of harm or injury. Examples of this included the risk of choking, weight loss, dehydration and skin integrity. People’s care records therefore did not provide staff with accurate, or sufficiently detailed information and guidance to meet their needs safely. The interim manager took action in response to our concerns around people’s records and the need to ensure adequate information was available for staff, to support people safely.

Overall, people were happy with the environment. For example, 11 people had recently completed a satisfaction survey and 10 of those people felt the environment was comfortable and they were happy with their bedrooms. However, 1 person raised concerns with us about not having access to a room people had previously used as a communal area, which had now been turned into an office. They also mentioned 2 pieces of kitchen equipment had been broken for a while and how this meant they no longer had a specific meal they had once enjoyed regularly.

Feedback from staff showed prompt action had not always been taken by the provider to address issues that had been reported about the environment. For example, the fryer had been broken for over a year and the hot water boiler had been broken for several months. These issues had been reported but had not been resolved in a timely manner. However, the interim manager responded to our concerns about this and swiftly took action.

We saw people had equipment in place they required, to meet their needs. This included overhead hoists, specialist bathing facilities and mobility aids.

Processes were in place to monitor and maintain the safety of the premises and equipment in the service. However, actions were not always taken promptly in response to concerns identified. For example, key building safety certificates listed actions to be completed. Some of these were identified in the provider’s improvement plan, however many had not yet been completed. We also identified people's pressure relieving equipment was not always set up correctly, which placed people at risk of harm or injury.

We spoke with 10 people, who told us there were not always enough staff to meet their needs. People told us the use of agency staff had increased recently, due to a lot of staff leaving and that this sometimes impacted on the care provided. Comments included, “I’m lucky that I can tell them what I need. But when I can’t understand them, and they can’t understand me, it’s difficult”, “We’ve been having lots of agency staff so you don’t always know who they are, that can be difficult” and “One weekend there was one of our staff on and six agency, all men, that didn’t feel ok. But they always seem to be short staffed, the staff just left in droves.” People said they also had to wait for care at times. Comments from people included, “When there’s enough staff, and they’re mostly our staff, they come quickly because they know what people need almost without having to ask. But sometimes it can take 10 minutes or more for someone to come” and “You can buzz [the call bell] forever and they’d never come.”

Staff we spoke with raised concerns about staffing levels, the high turnover of staff and the high use of agency staff, which they said led to people receiving inconsistent care. Comments included, “We’ve really struggled over the last 6 weeks. Lots of staff who knew people really well have left. The new overseas staff need more support. It’s not fair on them, or the people who live here” and “When you’re working with a lot of agency staff who don’t know what they’re doing it can be really frustrating, but you just have to get on with it.” A staff survey had been completed which showed 13 out of the 23 staff who completed the survey felt the workload was not distributed fairly amongst the staff team. The interim manager acknowledged that staffing was an issue but had plans in place to address this with ongoing recruitment.

On the first day of the assessment, we saw most people congregated in the dining room. Staff were present for most of the time, although there were short periods when no staff were in the room. However, we also observed people, who had been assessed as requiring 1:1 care and support, did not always receive this.

The provider did not always ensure adequately qualified, skilled and experienced staff were in place. This meant staffing levels were not always safe and effective in meeting people's needs. Recruitment processes were not robust or safe and did not always ensure staff had the skills, competence and experience required to carry out their roles. Records relating to interviews, references, inductions and training were incomplete and one DBS check was dated after the staff member commenced their employment.

People and relatives were happy with the standards of cleanliness in the home. 11 people had completed a satisfaction survey and everyone who responded gave positive feedback about the cleaning services.

Staff we spoke with had no concerns about Infection Prevention and Control (IPC) practices in the service. The interim manager told us they were in the process of arranging an IPC champion, as the staff member who previously held this role had left. Staff understood their roles and responsibilities around IPC and all staff were up to date with IPC training.

On both site visits we found the home was clean, hygienic and good standards of cleanliness were maintained.

Processes were in place to ensure infection control risks were assessed and managed safely. For example, the most recent infection control audit had scored 90%. There were some identified areas for improvement and the provider’s action plan showed these had been completed.

During the assessment we reviewed people’s medicines records. We found people had missed doses of their prescribed medicines, for varying amounts of time. The medicines were prescribed to treat a range of conditions including pain, seizures, asthma, and high blood pressure, which put their health at risk of harm.

A senior manager confirmed the electronic medicines system did not have a way to identify when medicine stocks were running low, and staff had not made daily checks on stock levels to make sure medicines were accounted for and in stock. Staff received medicine training, but some staff had not been assessed as competent at administering medicines until after the assessment visit.

The service did not manage medicines safely because the systems and processes in place for managing medicines were not always effective. For example, some people needed to be given their medicines covertly, hidden in food or drinks, or via a feeding tube. However, there was no information available, from a health care professional, for staff to follow, as to the safest way disguise or administer each individual medicine. Some people were prescribed medicines to be taken ‘when required’ or with a choice of dose. The protocols to support the safe administration of these medicines were either not in place or were not personalised, and there was no information for staff to follow to assist them to decide the most appropriate dose to administer when a choice of dose was prescribed. The service also completed audits and the most recent one had been completed a week before the assessment. However, the audit had not identified all the concerns highlighted during this assessment. After the assessment we requested some additional information to make sure that the risk of harm to people was reduced.