Handsale Limited - Silver Trees Also known as Laurel Court

Handsale Limited – Silver Trees is a residential care home providing regulated activities of nursing care to up to 62 people. At the time of our inspection there were 58 people using the service.

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

People’s records were not always accurate and up to date to provide assurance that people were having their needs assessed and met. Governance arrangements were not always identifying these shortfalls.

People had personal evacuation plans in place; however, improvements were required to some fire doors and the loft area. The registered manager confirmed action was being taken to address this following our inspection and they were awaiting confirmation of the work required. People were at risk of not receiving adequate care and support due to no assessment or support plan being in place in relation to their individual specific health needs.

Medicines were not being managed safely, and body maps were not in place for people supported with topical creams. Following our inspection action had been taken to implement body maps for people and staff had received training in applying topical creams.

Improvements were required to recruitment procedures. Not all staff had a reference in place and risk assessment before starting work. People on the nursing floor had no dining room set up on the first day, so they could eat their meals in a communal dining experience.

People were supported with optometrist and podiatrist appointments, and GP rounds were conducted weekly. Referrals to speech and language therapy were not always made when the need arose. Following the inspection the registered manager confirmed the speech and language therapy team have visited those who have been identified as needing a review. This team were working with the service to embed these improvements.

Improvements were required to ensure staff received training in the Care Certificate along with refresher training and identified training. People were supported by staff who felt well supported.

The registered manager was accessible to people, relatives and staff. They were open to CQCs feedback. People were supported to keep in touch and receive visits from family and friends.

During the inspection, the registered manager took action to address some of the issues raised as part of the inspection. This included updating some of the paperwork and liaising with the GP and so that improvements could be made.

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 (published 12 March 2019)

Why we inspected

This inspection was prompted by a review of the information we held about this service. We received concerns relating to safe care and treatment. A decision was made for us to inspect and examine those risks.

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 assure CQC that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.

Enforcement

We have identified breaches in relation to safe care and treatment, training, best interest decisions, records, and good governance at this inspection.

We recommend the provider seeks training to ensure staff have the skills and competency to undertake their role.

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 meet with the provider and request an action plan. 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.

People’s experience of using this service: People enjoyed the variety of activities provided and going out of the service with staff shopping or for walks. People spoke positively about the food provided. Mealtimes were relaxed and sociable.

People were well cared for and had their needs met. Staff were kind, caring and knew people well. The use of agency staff had reduced significantly due to successful recruitment. Changes in the staff team had brought new ideas and positive changes. Staff said the atmosphere and culture had improved as a result.

The environment had been considered to support people needs. People were supported to maintain their independence and make their own decisions.

Visitors were welcomed at the service. The service was clean and tidy. We highlighted some refurbishment needed in communal bathrooms.

Feedback was sought from people, relatives and staff through a variety of systems such as surveys, meetings and a suggestions box. Actions taken in response to feedback was displayed in the entrance area. Relatives said the service communicated well with them. People felt comfortable in raising any concerns or issues.

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

Rating at last inspection: Good (November 2016)

Why we inspected: This was a planned inspection based on the previous rating.

Follow up: We will continue to monitor the service through the information we receive. We will inspect in line with our inspection programme or sooner if required.

We last visited Silver Trees 18 and 19 February 2016. A number of breaches of legal requirements were found. After the inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The Regulations that were breached were Regulation 11, Need for consent; Regulation 9, Person-centred care; Regulation 12, Safe care and treatment; Regulation 17, Good governance and Regulation 18, Staffing.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (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. People told us that they felt safe living at the home.

Staff were knowledgeable about the procedures to ensure that people were protected from harm.

Staff were also aware of whistleblowing procedures and would have no hesitation in reporting any concerns.

People received their medication as prescribed.

There were sufficient numbers of suitably qualified staff employed at the home.

The provider's recruitment process ensured that only staff who had been deemed suitable to work with people at the home were employed.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and to report on what we find.

We found that the senior management team were knowledgeable about when a request for a DoLS application would be required. The registered manager told us that there were applications which had been submitted to the relevant local authorities and they were awaiting the outcome.

Staff respected and maintained people's privacy.

People were provided with care and support as required and people did not have to wait for long periods of time before having their care needs met. This meant that people's dignity was respected and that their care needs were met in a timely manner.

People's assessed care and support needs were planned and met by staff who had a good understanding of how and when to provide people's care whilst respecting their independence.

Care records were detailed and up to date so that staff were provided with guidelines to care for people in the right way.

People were supported to access a range of health care professionals. Examples included appointments with their GP and a chiropodist.

Risk assessments were in place to ensure that people could be safely supported at all times.

People were provided with a varied menu and had a range of meals and healthy options to choose from. There was a sufficient quantity of food and drinks and snacks made available to people.

People's care was provided by staff in a respectful, caring, kind and compassionate way.

People's hobbies and interests had been identified and staff supported people to take part in their chosen hobbies and or interests to prevent them from becoming socially isolated.

The home had a complaints procedure available for people and their relatives to use and staff were aware of the procedure. Prompt action was taken to address people's concerns and prevent any potential for recurrence.

There was an open culture within the home and people were freely able to talk and raise any issues with the registered manager and staff team.

People, their relatives, staff and stakeholders were provided with ways that they could comment on the quality of care provided. This included regular contact with the registered manager, staff and completing annual quality assurance surveys.

There is 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. Residential care was provided on the first floor and nursing care on the ground floor.

Medicines were being administered by qualified nurses and by senior healthcare assistants, but competencies which should have been checked annually, were not available. As a result of our concerns, the registered manager arranged for agency nurses to cover shifts until the necessary competency checks could be completed.

People who were at high risk of developing pressure ulcers were using air mattresses which were not set correctly, thus increasing the risk of developing pressure ulcers. Gaps in wound care plans meant there was no information to show whether a wound was healing or deteriorating or what treatment had been provided, and people may not have received the care and treatment they needed as a result.

Several records contained contradictory information. For example care plans said people needed both a pureed diet and a normal diet, which meant the person could have been given the wrong type of food. Care plans from the nursing unit did not provide staff with enough detail about people’s individual needs and contained limited personal preference details.

Staff rotas showed there were days when staff numbers were short. People were complimentary about staff and said they were very kind and considerate. Not all staff had received training in how to recognise and report abuse. However, all staff we spoke with had a clear understanding of what may constitute abuse and how to report to the registered manager or a senior. There was an effective recruitment procedure for new staff.

Not all staff had an understanding of the Mental Capacity Act 2005 (the MCA) and how to make sure people who did not have the mental capacity to make decisions for themselves had their legal rights protected. A nurse and a team leader had signed one bed rail risk assessment used to authorise the use of bed rails. This is poor practice because the process to protect people from unauthorised restraint had not been followed, which meant the person was effectively deprived of their liberty.

People said they were supported by kind staff who respected their privacy and dignity.

Although staff would report any complaints to the nurse on duty, staff had not learned from previous complaints. Audits had failed to identify the concerns we found, such as the unsafe practice around medicines, lack of consent and incorrect settings for air mattresses. Audits of records had not identified the gaps in records or the lack of information for staff in care plans.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

During this inspection we looked at the arrangements made for following up concerns, for example when a complaint or an allegation of abuse is made. This helped us to answer the questions:

' Is the service safe?

' Is the service well led?

At the previous inspection of Silver Trees in June 2014, people were not fully protected from the risk of abuse. In particular, a complaint alleging poor care had not been appropriately responded to and followed up. Improvements were needed and we visited Silver Trees again to check on the action that had been taken.

Below is a summary of what we found. Please read the full report if you want to see the evidence supporting our summary.

Is the service safe?

The risk of abuse was being identified and action taken to protect people. People at the home could be confident that allegations of abuse would be responded to and followed up appropriately.

Is the service well led?

Complaints were managed effectively by the registered manager. There was learning from complaints which helped to improve the service.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We observed staff assisted people with their need in a safe and suitable way. We saw staff gave people support when they administered their medicines to them. We saw that staff sat with people who required extra support with their mobility needs

Risk assessments were completed that identified risks that people may face as well as the preventative actions required. There were also risk assessments that identified environmental hazards that may impact on people's health and safety in the home. We saw that staff assisted people with their needs in the ways that had been identified in their risk assessments and care records. For example staff were observed following safe procedures when they assisted people with their mobility needs.

The provider had taken suitable steps to ensure that people were protected from the risks of unsafe staff. There were recruitment procedures in place that aimed to ensure that only safe and suitable people were employed to work at the home.

Systems were in place to make sure that the manager and the staff learned from events such as accidents and incidents. However we found that there was a lack of assurance that safeguarding allegations were properly reported. This was because we found that a serious complaint that related to alleged poor care practises at night and that this had not been reported as a safeguarding allegation to the Local Authority. On the day of our inspection the manager made a safeguarding referral retrospectively to the Local Authority. We also followed this up and spoke directly to the Local Authority about this referral.

Is the service effective?

The feedback from people who used the service was generally positive about how they felt their needs were being met. Examples of comments that were made included 'they encourage me to have a bath or a shower, which I agree with' 'the food is excellent and we're given a choice' and 'at meal times the staff see the glass is empty and tip it up'.

We saw staff assisted people with their needs with a calm and attentive manner. Staff were observed responding promptly when people required support and assistance

We saw that menu choices were planned, based on people's likes and dislikes. The people who we spoke with expressed a variety of positive views about the meals served at the home. For example one person told us "the food is excellent here".

Is the service caring?

People who used the service and relatives had generally positive views of the staff who assisted them with their needs. Examples of comments made included, 'the home is constantly being decorated it is a very happy home a lovely little corners in the garden', 'I feel that I am safe and can trust the staff' and 'a well-kept place, very clean'. We saw that people who used the service were shown politeness from the staff who were attentive in manner when they were assisting people with their needs.

We saw that people received assistance with their needs and staff were caring and attentive in their approach towards them. For example, we heard staff ask people how they felt when they went to see them to assist them with their needs. We also heard staff ask people what time they wanted assistance and what meals they would like to have that day.

Is the service responsive?

We saw that a regular church service was held in the home on the day of our inspection. This was well attended and a number of people who lived at Silver Tress told us it was important for them to attend.

We saw that people had their call bells in reach if they needed to ring them for staff assistance. We heard people ring their call bells and staff responded to them without undue delay.

Is the service well led?

The manager was open and accessible in their approach. They made time so that people could see them when they needed to.

There were systems in place to ensure that the overall quality of care and the service that people received was being effectively monitored. This was to ensure people were receiving a safe and suitable service

People knew how to make a complaint if they were unhappy. However we found a complaint that was serious in nature had not been investigated in the manner set out in the providers own complaints procedure. This set out that an investigation would be carried out and a report completed. The manager told us they had verbally investigated the complaint. However there was no investigation report to demonstrate if suitable actions had been taken in response. This could impact on the overall quality of care in the home if there was no assurance that complaints were properly and formally investigated.

We returned to the service in November 2013 and found that improvements had been made. We checked the files of four people who required support and saw that the relevant paperwork was in place to support staff in meeting their needs. This included a repositioning chart, clear support plan and systems for checking that it had been completed appropriately.

We read a total of six people's care files, including people who received nursing care and those people living on the residential floor of the home. We found that support plans reflected a person centred approach to care and gave good information about the ways in which people should be supported. We found that for people who needed support with repositioning, there wasn't always clear information recorded in their daily notes about when staff had supported them with this.

People were protected from the risks associated with poor nutrition because risk assessments were in place and people's weight's monitored. Food provided at meal times was appetising and staff responsible for food preparation were knowledgeable about the nutritional needs of people in the home.

We saw that the home was cleaned to an appropriate standard and that cleanliness was monitored through a monthly infection control audit. Overall, there were systems in place to monitor the quality and safety of the home and this included gathering feedback from people using the service.

People that we spoke with were positive about the care they received and most people said that staff come quickly when required. Two people said 'it depends how busy they are'.

Observations we made showed that people were well supported and their needs were met. One the nursing floor, one member of staff was absent through sickness but the remaining staff worked hard to ensure the impact of this on people was minimised.

We saw that staff received training and supervision to support them in their roles. Some staff expressed concern about recent changes in the way that manual handling training was delivered and this was fed back to the manager. We saw that staff's manual handling skills were observed by senior staff before being signed off as competent.