Ralphland Care Home

Ralphland Care Home is a residential care home providing accommodation and personal care to 22 people aged 65 and over at the time of the inspection. The service can support up to 39 people.

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

There were organisational governance processes in place to monitor the quality of the service. However, these were not always operated robustly as they did not identify concerns found on inspection.

Risks were not always managed. Environmental and Infection Prevention and Control (IPC) measures were not effective posing additional risks to people.

Nutritional needs were not always documented correctly, with conflicting information. Mealtime practices posed a risk to people who required a modified diet.

Care plans detailed how to support the person to ensure their assessed needs could be met. We found some clear plans required further work to ensure they contained current up to date information to meet people’s needs. The provider was in the process of changing their electronic care planning systems.

Safe recruitment systems and processes were in place, with relevant background checks completed. Training was provided for staff to ensure they could carry out their role safely and effectively, any gaps had been identified and addressed by the registered manager.

People and their relatives told us they felt safe. People and staff provided positive feedback on the management of the service. Staff showed a caring approach to how they supported people.

Staff had received safeguarding training and were able to demonstrate their understanding and responsibilities to reduce the risk of harm to people

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; the policies and systems in the service supported this practice.

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 inspection for this service (published 26 August 2021) was a targeted due to concerns raised regarding contingency planning in the event of an emergency. We found the provider was in breach of regulation 17. This was a targeted inspection and we did not review entire key questions; therefore, we did not review the rating at this inspection. The provider completed an action plan to show what they would do and by when to improve. At this inspection the provider remains in breach of regulations.

The last rating for this service was requires improvement (published 16 June 2021). The service remains rated requires improvement.

Why we inspected

We undertook this inspection to check whether the provider had met the breaches of Regulations 17 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014 and that the Warning Notice we previously served had been met. The overall rating for the service has not changed following this targeted inspection and remains Requires Improvement.

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 COVID-19 and other infection outbreaks effectively.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to risk management, infection control measures and governance processes 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

Ralphland Care Home is a residential care home providing personal and nursing care to 20 people aged 65 and over at the time of the inspection. The service can support up to 39 people.

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

Systems and processes to ensure effective contingency planning in the event of emergency had been ineffective. This meant shortfalls were found placing people at risk of harm.

Ineffective planning led to staff shortfalls, nutritional risk and information regarding risk to people had not been available to staff.

Medicines had been administered and Infection control practices had been well managed by staff.

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 requires improvement (published 16 June 2021).

Why we inspected

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 COVID-19 and other infection outbreaks effectively.

We undertook this targeted inspection to check on a specific concern we had about staffing and risk management. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to governance at this inspection. Full information about CQC’s regulatory response to this is added to reports after any representations and appeals have been concluded.

Follow up

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

Ralphland Care Home is a residential care home providing accommodation and personal care to 21 people aged 65 and over at the time of the inspection. The service can support up to 39 people.

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

Risks were managed and reduced. However, inconsistent recording increased the risk to people.

People and staff provided positive feedback on the management of the service. Relatives raised some concerns regarding communication; the provider was taking action to address this.

There were organisational governance processes in place to monitor the quality of the service.

Initial assessments took place, which were ongoing and reviewed. Care plans detailed how to support the person to ensure their assessed needs could be met.

Safe recruitment systems and processes were in place, with relevant background checks completed.

Training was provided or planned for staff to ensure they could carry out their role safely and effectively.

People and their relatives told us they felt safe with the staff who supported them. Staff had received safeguarding training and were able to demonstrate their understanding and responsibilities to reduce the risk of harm to people.

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; the policies and systems in the service supported this practice.

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 25 November 2020) 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 received concerns in relation to staffing, nutrition and risk management. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

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 COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Ralphland Care Home 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 re-inspection programme. If we receive any concerning information we may inspect sooner.

Ralphland Care Home is a residential care home providing personal care, it can accommodate up to 39 people aged 65 and over. There were 20 people using the service at the time of the inspection.

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

Governance systems and processes were not fully developed and operated effectively. This meant there was a risk possible issues and shortfalls would not be identified and addressed. The nominated individual had recently changed and there was no evidence that they had clear oversight of the service.

Accidents and incidents were recorded by staff. However, reviews of accident and incidents did not always take place in a timely manner which reduced the providers ability to identify trends and patterns and could increase the risk of people experiencing recurrent accidents.

Processes and systems to review the administration of medicines were not always operated effectively. This meant there was an increased risk of shortfalls not being identified. People received their medicines as prescribed, staff were trained to administer medicines.

Staff were not always recruited in line with current legislation. Checks needed to assure the provider of the previous employment history of new employees were not always undertaken.

There were sufficient staff to meet the assessed needs of people living in the service.

People’s relatives told us the care they received kept them safe and protected them from harm.

Risks were managed and reduced. For example, one person who was at risk of choking had a professional assessment carried out for swallowing. The recommendations from this assessment were written into the care plan and risk assessment to ensure choking risks were reduced.

Records were kept ensuring people who were at risk of dehydration and skin breakdown received necessary fluids and repositioning.

Infection control procedures were being followed. The staff team were following the latest government guidance regarding COVID-19. The service was clean and free of malodours.

Assessments were carried out and people had care plans which described their assessed needs.

People were supported to access healthcare services and relatives told us they were confident the staff team would ensure their relative received the care they needed.

Staff were provided with the training they required to carry out their roles safely and competently.

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; the policies and systems in the service supported this practice.

Relatives spoke very positively about the leadership of the service and felt assured that their concerns would be listened to and acted upon. All relatives we spoke with told us the service had improved since the previous inspection.

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 inadequate (published 22 May 2020).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection enough improvement had not been made/ sustained and the provider was still in breach of regulations.

This service has been in Special Measures since October 2019. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 24 and 25 September and 7 October 2019. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

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, effective and well-led which contain those requirements. 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 inadequate to requires improvement. 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 Ralphland Care Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to governance and fit and proper persons employed at this inspection. Please see the action we have told the provider to take at the end of this report.

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 following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the 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.

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

There were significant and widespread shortfalls in the governance of the service. The provider and managers had failed to identify issues we found including with health and safety and record keeping, including risk assessments. The leadership was weak, inconsistent and overbearing. Systems were ineffective in driving improvements and high quality care. The provider had failed to act on concerns identified during our inspection. This left people at risk of harm.

People were at risk of avoidable harm because risks were not recorded accurately, monitored or managed. We raised a safeguarding concern for one person who was at risk of choking, as we could not be sure this had been managed appropriately.

Health and safety was not well managed. This put people at risk of potential harm. We contacted the fire service, who attended the home and introduced measures to reduce the risk of harm to people in a fire situation. These were implemented with immediate effect. No control measures had been introduced following positive samples of legionella being found in the service.

Good outcomes were not always achieved for people living at the service. People were at significant risk of dehydration due to their low fluid intake. The environment was not suitable for the needs of people living there. Access to communal areas was limited.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

Staff did not always understand people’s care needs. They had not received sufficient training or support to equip them for their roles and responsibilities.

Care was provided in task-centred, institutionalised ways. Little consideration was given to people’s wellbeing or emotional needs. People were not always treated with dignity and respect; they were not able to have privacy in their bedrooms. People’s independence was not promoted.

People did not receive responsive care. When assistance was requested there were delays in this being provided, which caused people discomfort. People were socially isolated, with no access to the wider community.

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 10 February 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified multiple breaches in relation to safe care and treatment, fit and proper persons employed, person-centred care, staffing, dignity and privacy, premises and equipment, need for consent and good governance.

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 request an action plan for 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 overall rating for this service is inadequate and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Ralphland Care Home can provide accommodation and personal care for 39 adults of all ages including people who live with dementia and/or who have a physical disability. There were 37 older people living in the service at the time of our inspection half of whom lived with dementia.

The service was operated by a company who was the registered provider. The registered provider had appointed a business manager. They were based in the service and dealt with financial and administrative matters. There was also an acting manager and they were responsible for supervising the care provided in the service. The acting manager had applied to be registered by 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. In this report, when we speak about the company who ran the service we refer to them as being, ‘the registered person’.

Staff knew how to respond to any concerns that might arise so that people were kept safe from abuse including the risk of financial mistreatment. People had been helped to avoid the risk of accidents and medicines were safely managed. There were enough staff on duty and most of the necessary background checks had been completed before new staff were appointed.

Staff knew how to care for people in the right way and they had received most of the training and guidance they needed. People had been assisted to eat and drink enough to stay well and they had been supported to receive all of the healthcare assistance they needed.

The acting manager had ensured that people’s rights were respected by helping them to make decisions for themselves. The Care Quality Commission is required by law to monitor how registered persons apply the Deprivation of Liberty Safeguards under the Mental Capacity Act 2005 and to report on what we find. These safeguards protect people when they are not able to make decisions for themselves and it is necessary to deprive them of their liberty in order to keep them safe. In relation to this, the acting manager had taken the necessary steps to ensure that people only received lawful care that respected their rights.

People were treated with kindness and compassion. Staff recognised people’s right to privacy, promoted their dignity and respected confidential information.

People had been consulted about the care they wanted to receive and they had been given all of the assistance they needed. Staff promoted positive outcomes for people who lived with dementia. Although some people wanted more support to go out into the community most people were satisfied with the hobbies and interests they could enjoy. There was a system for quickly and fairly resolving complaints.

People had been consulted about the development of the service and quality checks had been completed. The service was run in an open and inclusive way so that good team work was promoted. Staff were supported to speak out if they had any concerns and people had benefited from staff acting upon good practice guidance.

During our visit we looked particularly at areas where concerns had previously been raised. For example the transfer of people to hospital and administration of medicines. We found medicines were administered and stored safely. We saw the home had in place procedures for transferring people and when we looked in the records found they had been followed.

Overall we observed people were supported by skilled and experienced staff who understood their roles and responsibilities.

We observed care and saw staff were responsive to people and interacted with them positively.

We spoke with a relative. They told us the staff were pleasant but very busy at times. They said they felt confident with the care their relative received.

People told us the staff were caring and looked after them well.

We observed staff offering activities to people. For example we observed a member of staff reading a magazine with a person.

We saw staff explained the care they were giving to people. For example when they offered medicines to people they explained what they were.

When we looked at the records we found there were gaps and they did not accurately reflect the care people were being given or required.

We saw people were supported to make choices and decisions about their lifestyles, and they were treated with dignity and respect.

We found people were supported to eat and drink sufficient amounts to meet their needs. People had a choice of food which took account of their individual preferences, needs and cultural requirements. One person said, 'The food is lovely, they cook things how I like.'

People were cared for, or supported by, suitably qualified, skilled and experienced staff. Throughout our inspection we observed good interactions and found people who used the service were relaxed and happy in the care of the staff.