Cumbria County Council Maudes Meadow Inspection report Town View Windermere Road Kendal Cumbria LA9 4QJ Date of inspection visit: 21 December 2015 Date of publication: 11 March 2016 Tel: 01539773092 Ratings Overall rating for this service Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? Good 1 Maudes Meadow Inspection report 11 March 2016
Summary of findings Overall summary This comprehensive inspection took place on 21 December 2015 and was unannounced. We last inspected Maudes Meadow in August 2013. At that inspection we found the service met all seven of the essential standards we looked at. Maudes Meadow is a residential care home that can accommodate up to 28 older people. It is close to the town centre of Kendal. The property is a two-storey building and accommodation is provided over two floors the upper being accessed by a passenger lift. There are two separate communal and dining areas on the ground floor one is designated for people who live with dementia. There was no registered manager in post at the time of the inspection. 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. The provider had made arrangements for the home to be supported by a manager that was registered with CQC from another of their homes pending registration of a new manager. During this inspection we found breaches of Regulation 12 Safe care and treatment and of Regulation 17 Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Some maintenance of the environment had not been acted upon. Two of the baths in the home required repair or replacement and another was found to be dirty. The storage arrangements for some medicines in the home were not always in line with current national guidance. Some records for peoples as required medications were not always clear about their needs. We found that there had been inconsistencies with the numbers of staff on shifts and that there was no process in place to determine the numbers of staff required to meet people's individual needs. The level of staffing observed on the day of the inspection ensured that people had their needs met in a timely manner. Information held about people's care and support was routinely recorded in four different types of records. The information recorded was not always consistent or accurate within these four types of records. The reviews of care plans and records made were not always accurate about the changing needs of people's health and support required. People living in the home spoke highly of the staff and were happy with their care and support. The recruitment procedures demonstrated that the provider operated a safe recruitment procedure to ensure that fit and proper persons had been employed. 2 Maudes Meadow Inspection report 11 March 2016
Staff told us they had received regular training and supervision to support them in their roles. However records provided relating to staff training indicated that some staff required elements of training to be updated to refresh their skills and knowledge Where safeguarding concerns or incidents had occurred these had been reported to the appropriate authorities and we saw records of the actions taken by the home to protect people. We have made a recommendation that the provider review their best interest decision making process to ensure it follows guidance outlined in the Mental Capacity Act 2005. We have made a recommendation that records relating to care are consistent to provide accurate information. We have made a recommendation that all staff are refreshed and updated in their skills and knowledge in some specific topics. 'You can see what action we told the provider to take at the back of the full version of the report.' 3 Maudes Meadow Inspection report 11 March 2016
The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? The service was not always safe. Prescribed medicines were not always managed safely. Staffing levels had been inconsistent and not based on people's individual needs. All the required checks of suitability had been completed when staff had been employed. People told us they were safe and very well cared for in this home. Is the service effective? The service was not always effective. Records relating to DNACPR decisions had not always followed best practise guidance. Staff training records showed refreshers in training had not been completed by some staff. People had their nutritional needs assessed and were appropriately supported by staff to eat and drink. Is the service caring? Good The service was caring. People told us that they were being well cared for and we saw that the staff were respectful and friendly in their approaches. Staff demonstrated good knowledge about the people they were supporting, their likes and dislikes. We saw that staff maintained people's personal dignity when assisting them. Staff also offered explanation and reassurance about what they were doing. 4 Maudes Meadow Inspection report 11 March 2016
Is the service responsive? The service was not always responsive. Information in people's care records was fragmented and did not always accurately reflect people's needs. We saw there were activities which people took part in. There was a complaints system in place but not all complaints had been recognised and dealt with using the provider's procedures. Is the service well-led? The service was not always well led. The consistency of management was not effective due to the absence of a registered manager. Not all processes in place to monitor the quality of the service were effective. Identified areas for repairs in the home had not always been acted upon by the provider. 5 Maudes Meadow Inspection report 11 March 2016
Maudes Meadow Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. This unannounced inspection took place on 21 December 2015. The inspection team consisted of two adult social care inspectors Before our inspection we reviewed the information we held about the service. We looked at the information we held about notifications sent to us about incidents affecting the service and people living there. We looked at the information we held on safeguarding referrals, concerns raised with us and applications the registered provider had made under Deprivation of Liberty Safeguards (DoLS). We did not have a Provider Information Return (PIR) when we visited. This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. The registered provider had not received the request for a Provider Information Return (PIR) before our inspection. This was the first inspection following the registered provider's recent reregistration with CQC in October 2015. During the inspection we spoke with the manager who had been newly appointed to the home, operations manager, four staff members, people who used the service and some relatives. We observed how staff supported people who used the service and looked at the care records for eight people living at Maudes Meadow. We also observed how people were supported by the staff during the day. We looked at the staff files for all staff recruited since our last visit. These included details of recruitment, induction, training and personal development. We looked at the overall training record for all staff. We also looked at records of maintenance and repair and other quality monitoring documents. 6 Maudes Meadow Inspection report 11 March 2016
Is the service safe? Our findings People living at Maudes Meadow that we spoke with told us they felt safe and did not have any concerns about the care they received. One person said "I do feel safe here, the staff are great.'' Relatives we spoke with told us they had no concerns about the safety of people at the home. One person told us "My relative is looked after really well but there are some times when I think they are short of staff. They (staff) come as quickly as they can but they have a lot to do.'' Another person told us, ''They often seem short of staff but they're (staff) all great.'' We looked at the records of medicines and their management and care plans relating to the use of medicines. We found that where changes had been made to people's medications their care records had not been always updated to reflect these changes. We also saw that medications taken as and when required (PRN) had not always been reviewed to show whether they had been effective or not and may have required changing. This meant that the information recorded about people's medication requirements was not always current or accurate. We found the fridge used for the storage of some medications had not had the temperature monitored on a regular basis to ensure the safe storage of medications. We also found in the fridge medication that was no longer in use and staff could not tell us how long it had been there. We were told by a staff member that the temperature was only recorded when the fridge was in use and required to store medication. We also noted that one of the trolleys used for the storage of medication was not securely fixed when not in use. This was a breach of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because prescribed medicines were not always managed safely. We looked at rotas for the four weeks prior to the inspection and found that staffing levels through the day had been inconsistent in the numbers of staff on duty for each shift. Staff numbers varied on a variety shifts. Although the provider told us they used a dependency tool to calculate staffing levels we did not see any evidence of this being used to provide a consistent level of staffing. We were told by the manager and operations manager that arrangements made by the previous registered manager had allowed for a number of staff to take annual leave at the same time. This left the availability of staff low in numbers. We were reassured by the operations manager that this was not the usual policy operated by the provider. There were consistently two members of staff on duty at night and this was seen as adequate to meet the needs of the people living in the home at the time of the inspection. We were told that this number of staff could, if required, be increased based on the needs of people should they vary. We also noted that the night staff held some responsibility for cleaning and laundry duties and we were told by the manager and operations manager that staff working on the night shift had clear instructions to ensure that people's needs were met in a priority to any domestic duties. Some maintenance issues had not been addressed. We found and were told about a window in an 7 Maudes Meadow Inspection report 11 March 2016
unoccupied room that had been noted for repair or replacement repeatedly to the provider. We were told by the manager the reason this had not been addressed was because the room had remained unoccupied. We found that two baths had corroded and were rusty as they had been worn down through the use of a bath seat. This had left the metal below the enamel of the bath exposed in areas. We also found that another bath was unclean. These may have posed a risk to the management and control of infection and we have considered this under the domain of well led. We looked at five staff files for recruitment and saw that the necessary checks on employment had been completed. References had been sought and we noted that they were usually from the most recent previous employer in accordance with the homes recruitment policy. Criminal Records Bureau (CRB) and Disclosure and Barring Service (DBS) checks had been conducted. Staff we spoke with had a good understanding of how to protect people from harm. They understood their responsibilities to report any safeguarding concerns to a senior staff member. We looked at records of the accidents and incidents that had occurred. We saw that where necessary appropriate treatment had been sought and notifications to the appropriate authorities had been made. 8 Maudes Meadow Inspection report 11 March 2016
Is the service effective? Our findings We spoke with people who used the service and asked them if they thought the staff were knowledgeable about the support they required. One person said, "The staff are good I'm in safe hands." We looked at the staff training records which showed what training had been done and what was required. We saw that staff had completed induction training when they started working at the home but some staff had not received regular updates on important aspects of their work such as safeguarding and moving and handling. We saw that not all the training of staff was up to date. We spoke with a recently recruited member of staff, who was a very experienced care worker, they told us their induction training was ''Really good'' and felt they had been given a thorough induction to the home and the people living there. Another member of staff told us they had received regular training and supervisions. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application procedures for this in care homes are called the Deprivation of Liberty Safeguards (DoLS). We checked whether the service was working within the principles of the MCA, and whether any conditions on authorisations to deprive a person of their liberty were being met. Two people living at Maudes Meadow were subject to DoLS safeguards at the time of the inspection and the conditions relating to the Dols were being met. We looked at care plans to see how decisions had been made and recorded around 'do not attempt cardio pulmonary resuscitation' (DNACPR). We saw that GPs had made clinical decisions as to whether or not attempts at resuscitation might be successful. We noted that some forms stated that they had been completed in the best interests of people who used the service. Guidance on how to act in people's 'best interests' is outlined in the Mental Capacity Act 2005. The act states people's levels of capacity to make important medical decisions must be measured and documented. We found that the process for best interest decisions had not always been formally noted in the written records. We also noted that some DNACPR decisions had not been reviewed in the time frame identified on the DNACPR record or when changes in people's medical conditions had occurred. We also noted that where someone lacked capacity to consent to the use of bedrails this had not been completed and recorded under the process as in their best interest. We saw that people had nutritional assessments done to assess their needs and any risks when eating. There was also information on specific dietary needs such as diabetic diets and soft and pureed meals as well. One person's record we looked at noted that they required an assessment by the speech and language 9 Maudes Meadow Inspection report 11 March 2016
therapist (SALT) in October 2015. We did not see records to show that this had been completed or a management plan put place based on their advice. We also noted that this person had required a soft diet but on a regular basis had been given jam sandwiches. We saw that after a relative had made this known to staff the frequency of jam sandwiches being given had been reduced and a more varied diet was now being given. Where people were living with dementia there was signage to show people what different areas were for. This was to help people with memory problems to be able to move around their home more easily and more independently. We saw that people had been able to bring some personal items into the home with them to help them feel more comfortable with familiar items and photographs around them. Bedrooms we saw had been personalised with people's own furniture and ornaments to help people to feel at home and people were able to spend time in private if they wished to. We recommend that all staff refresh and update their skills and knowledge on some specific topics. We recommend the provider reviews their best interest decision making process to ensure it follows guidance outlined in the Mental Capacity Act 2005. 10 Maudes Meadow Inspection report 11 March 2016
Is the service caring? Good Our findings We spent time on both units observing how staff supported and interacted with people living at Maudes Meadow we spoke with relatives and they told us they had found, at times, 'the staff to be pushed for time' to spend with people. One person told us that, ''There's not enough staff to sit and take the time to do things with them.'' However we saw that there were examples of a caring approach by staff during daily interactions. For example we saw that staff offered people reassurance when they showed signs of distress and allowed them time to express themselves. We saw as staff went around the home and carried out their duties that they took up opportunities to speak with people. People we spoke with also told us, ''Staff are polite, kind and respectful.'' One relative told us they had looked at other homes before choosing this one for their relative but liked Maudes Meadow as, ''It's friendly and has a lived in feel.'' The home advertised they used the 'Six Steps' palliative care programme. This programme supported staff to develop their skills and roles around end of life care so people receive timely care and support as their condition deteriorates. Training records indicated that this training had lapsed and not all staff had received training on supporting people at the end of life. However a health care professional stated they thought the home had provided 'exemplary palliative care' to an individual. We looked at the recent cards and letters of compliments that relatives of people who had used the service had sent to the home to express their appreciation of the care their loved ones had received there. These all made positive comments about the care people had received at the home. We saw that people's privacy was being respected and that staff protected people's privacy by knocking on doors to their rooms before entering. We saw that people were asked in a discreet way if they wanted to go to the toilet and the staff made sure that the doors to toilets and bedrooms were closed when people were receiving care to protect their dignity. Staff gave explanations to people and reassured them when providing them with support to complete any tasks. Procedures and information were in place about support agencies such as advocacy services that people could use. An advocate is a person who is independent of the home and who can come into the home to support a person to share their views and wishes if they want support. 11 Maudes Meadow Inspection report 11 March 2016
Is the service responsive? Our findings We asked people whether they felt they could raise concerns if they had any. One person said, "I don't have any concerns but if I had I can speak to any of the staff." Another person told us if they had a problem they felt happy to raise it directly with the manager. The home had a complaints procedure but no formal complaints had been recorded since September 2014. We noted from a person's care records that their relative had made a complaint relating to the variety and quality of food in October 2015. This had not been managed through the home's complaints process but had been managed informally as we saw from the records of foods eaten that this person had received a more suitable and varied diet. People we spoke with were aware of who to speak with if they wanted to raise any concerns. On the day of the inspection there was a planned activity for people to get involved in. A visiting musician and singer provided meaningful and interactive entertainment. Most people living at Maudes Meadow attended the session and we saw that they enjoyed being entertained. However a visiting relative told us that this type of activity was not held often and said they, ''Would like to see more of it.'' We saw that a full assessment of people's individual needs had been completed prior to admission to the service to determine whether or not they could provide them with the right support that people required. Care plans recorded people's preferences and provided information about them and their family history. This meant that staff had knowledge of the person as an individual and could easily relate to them. We looked at the care records for eight people. We saw that information recorded did not always provide staff with accurate and up to date information about how to support individuals. Information relating to people's care was recorded in different records which meant information for staff to access was fragmented. We saw from the records about daily care that two people who had skin integrity issues and had required more frequent moving as areas of the skin showed signs of pressure related changes. However the care plan for both people made no reference to the changes to position required. Care plans for skin integrity did not identify that more frequent changes to body position had been requested by the community nurse. We did not see records to show that the frequency of position changes had been implemented. We also noted that where reviews of care plans had taken place not all changes to people's needs had been reflected during the review process. This meant that the plans for caring and supporting people's needs were not always accurate. We could see in people's care records that the home worked with other health care professionals and support agencies such as local GPs, community nurses, mental health teams and social services. We recommend that records relating to care and support are consistent in providing accurate information to enable staff to follow the most appropriate plan of care. 12 Maudes Meadow Inspection report 11 March 2016
Is the service well-led? Our findings The home did not have a registered manager in place as required by their registration with the Care Quality Commission (CQC). Although the registered provider had ensured the home had management support in the absence of a registered manager some evidence we found suggested that that there had been a lack of consistency in the management of the home. Although there were systems in place to assess the quality and safety of the service provided in the home these had not always been effective. The operations manager for the provider also visited the home on a monthly basis to do service checks and monitor quality. Where there had been previous requests for maintenance to the property this had not been pursued. The monitoring systems used had not identified the baths requiring repair or replacement. The audits in place for care plans and care records had not detected where reviews had taken place and not identified the changes in people's care needs. Monthly reviews had been carried out on people's care plans and medication checks but these were not always effective in minimising risk and providing current information relating to PRN medicines. There had been no monitoring of the requirements for the ongoing training needs of staff in the home. This had resulted in some staff not maintaining the recommended time frames for refreshing their skills and knowledge. This was a breach of Regulation 17 Good governance of the Health and Social Care Act 2008 (regulated activities) regulations 2014 as areas of safety and quality monitoring had been ineffective and there had been lack of consistency of management in the home. The systems and processes to ensure compliance with the Regulations were not operated effectively to identify where the quality and safety of the service may be affected. There were systems in place for reporting incidents and accidents in the home that affected the people living there. We saw that these had been followed and if required CQC had been notified of any incidents and accidents and when safeguarding referrals had been made to the local authority. People who lived in the home could attend meetings for residents and could contribute to the way their home was being run. They had an opportunity to give their views at these meetings. We were told that during the visits the operation's manager had spoken with people in the home, staff on duty and any visitors to the service. This meant people were regularly given the opportunity to raise any concerns or to make suggestions about the development of the services to a senior person within the organisation. Staff we spoke with said that they really enjoyed working in the home. One member of staff told us, "I love my job, this is a great place to work." Another said, "I've worked here over 10 years seen a lot of changes but still love it.'' We saw during our inspection that the newly appointed manager was accessible to staff and spent time with the people who lived in the home and engaged in a positive and open way. 13 Maudes Meadow Inspection report 11 March 2016
This section is primarily information for the provider Action we have told the provider to take The table below shows where regulations were not being met and we have asked the provider to send us a report that says what action they are going to take. We did not take formal enforcement action at this stage. We will check that this action is taken by the provider. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 12 HSCA RA Regulations 2014 Safe care and treatment This was because care and treatment was not always provided in a safe way. Regulated activity Accommodation for persons who require nursing or personal care Regulation Regulation 17 HSCA RA Regulations 2014 Good governance This was because the quality monitoring system used to help identify and assess where quality and/or safety had been compromised had not been effective. 14 Maudes Meadow Inspection report 11 March 2016