The Croft (RCH) Limited The Croft (RCH) Limited Inspection report Hooke Hill Freshwater Isle of Wight PO40 9BG Tel: 01983752422 Date of inspection visit: 06 September 2016 Date of publication: 14 November 2016 Ratings Overall rating for this service Is the service safe? Is the service effective? Is the service caring? Requires Improvement Inadequate Requires Improvement Good Is the service responsive? Requires Improvement Is the service well-led? Requires Improvement 1 The Croft (RCH) Limited Inspection report 14 November 2016 Summary of findings Overall summary This inspection took place on 6 September 2016 and was unannounced. The home provides accommodation for up to 21 people with mental health needs. There were 18 people living at the home when we visited. Most bedrooms were for used for single occupancy and some had en-suite facilities. People had access to two lounge dining rooms, accessible bathrooms and there was also an accessible garden area. At our previous comprehensive inspection in November 2015 we found the provider did not have an effective system to ensure the safe management of medicines and people's legal rights had not always been assured when care was provided. At this inspection we found adequate action had not been taken or not maintained to ensure medicines were managed safely and additional concerns were identified regarding records and management quality monitoring systems were not robust. The home did not have a registered manager. 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. The manager told us they were planning to register with CQC and initiated the process to do this soon after the inspection. The management team had taken action to address immediate concerns when they took over the running of the home in May 2016 and were committed to rectifying the situation and ensuring people received a service which met their needs. The previous management team had left without notice and removed or deleted electronic records. There were limited formal quality assurance systems. This meant that whilst some areas of concern had been identified and action was planned other areas of concern had not been identified and people may not have received the care they required. Many records relating to the safe organisation and running of the home were inadequate or not present. Staff shortages meant the manager had been working some care shifts. This impacted on their ability to undertake all of their management functions. Medicines were not always managed effectively meaning that people had not always received all medicines as prescribed by their medical practitioner and their health needs were not being met. Although, staff were aware of people's individual care needs and preferences the care plans and related records of the care people had received were incomplete. They did not provide information about how people wished to be cared for, or how their health care needs should be met. The manager regularly worked with care staff providing informal monitoring of the care people received. The recruitment process did not ensure that all necessary pre-employment checks had been completed to ensure staff were suitable for their role. Training for all staff was planned via an external training provider. Staff were not receiving formal supervision or appraisals although they had regular support from the 2 The Croft (RCH) Limited Inspection report 14 November 2016 manager who often worked directly with them. People felt safe and staff knew how to identify, prevent and report abuse. Legislation designed to protect people's legal rights was informally followed although formal mental capacity, best interest and consent assessments had not been documented. This meant people's legal rights may not be assured in respect of decisions made on their behalf. Staff offered people choices and respected their decisions. People were supported and encouraged to be as independent as possible and their dignity was promoted. People and relatives were positive about the care people received. People were positive about meals and the support they received to ensure they had a nutritious diet. People and relatives were able to complain or raise issues on a formal and informal basis with the manager and were confident these would be resolved. Visitors were welcomed and there were good working relationships with external professionals. Staff worked well together, which created a relaxed atmosphere that was reflected in people's care. We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken in the full version of this report. 3 The Croft (RCH) Limited Inspection report 14 November 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? Inadequate The service was not safe. Medicines were not managed effectively. Risks to people were not formally assessed and plans had not been put in place to assess or manage all risks. People were not protected from the risk of infection and the home was not clean. Recruitment practices had not ensured that all pre-employment checks were completed before new staff commenced working in the home. Staffing levels were appropriate to meet people's needs although the manager was working care shifts meaning they did not always have time to complete management tasks. People were protected from the risk of abuse; staff knew how to identify, prevent and report abuse. Is the service effective? Requires Improvement The service was not always effective. New staff shadowed experienced staff however they had not completed the care certificate to give them formal training in care. The provider was contracting with an external training provider to update all staff training. People were supported to access healthcare services when required, although recording systems did not evidence follow-up on all occasions. Staff informally followed legislation designed to protect people's rights and freedoms but had not recorded their assessments and decisions made on behalf of people. The environment was being refurbished to make it safe and people had access to the outdoors and fresh air. People received a varied and diet and they were supported appropriately to eat and drink. Is the service caring? The service was caring. 4 The Croft (RCH) Limited Inspection report 14 November 2016 Good People were cared for with kindness and compassion. Staff knew people well, and interacted positively with them. People and their relatives were positive about the way staff treated them. People were treated with respect. Dignity, privacy and independence were promoted. Is the service responsive? Requires Improvement The service was not always responsive. Care plans and related records were incomplete and did not demonstrate that people received a responsive care service. Staff had a good understanding of people's individual needs and responded when people required day to day support. People were able to participate in a range of group or individual activities which provided both mental and physical stimulation but this had not always been possible previously. Systems to seek people's views about the service were mainly informal. There was a complaints policy in place and people knew how to raise concerns although no formal complaints had been made since the manager took over in May 2016. Is the service well-led? The home was not always well led. Records relating to the running and organisation of the service were inadequate and those in place were not all up to date. There were limited effective quality assurance systems although the manager regularly worked with care staff providing informal monitoring of the care people received. The management team were approachable. People and visitors felt the home was run well. Staff understood their roles, and worked well as a team. 5 The Croft (RCH) Limited Inspection report 14 November 2016 Requires Improvement The Croft (RCH) Limited 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 is 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 inspection which took place on 6 September 2016, was completed by three inspectors and was unannounced. Before the inspection we reviewed previous inspection reports and notifications we had been sent by the provider. A notification is information about important events which the service is required to send us by law. We spoke with 11 people and four relatives of people living at the home. We also spoke with the provider's representative, the manager, four care staff, activities staff, the housekeeper, laundry staff member and the cook. We looked at care plans and associated records for five people and records relating to the management of the service. These included staff duty records, staff recruitment files, records of complaints, accidents and incidents, and quality assurance records. We observed care and support being delivered in communal areas and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us. 6 The Croft (RCH) Limited Inspection report 14 November 2016 Inadequate Is the service safe? Our findings At the last inspection in November 2015 we found the provider did not have an effective system to ensure the safe management of medicines. People did not always receive their medicines in a timely way and systems were not in place to ensure people received 'as required' medicines consistently. At this inspection, we found that people were at continuing risk of not receiving their medicines as prescribed. People did not receive their medicines safely. The Croft had developed their own medicine administration records (MARs) onto which the administrator typed the medicines that were to be administered. Where subsequent additions or amendments were required to the MARs these had been handwritten. In both cases (typed or handwritten) there was no signature of the staff member adding the information or a second staff member to verify the information was correct. Guidance issued by the National Institute for Health and Care Excellence (NICE) managing medicines in care homes section 1.14.9 states 'Care home providers should ensure that a new, hand-written medicines administration record is produced only in exceptional circumstances and is created by a member of care home staff with the training and skills for managing medicines and designated responsibility for medicines in the care home. The new record should be checked for accuracy and signed by a second trained and skilled member of staff before it is first used'. We found the information on some of the MARs were incorrect and did not always reflect the information on the boxed medicines as dispensed by the pharmacist and prescribed by the person's doctor. The failure to ensure medicines were recorded as prescribed by the general practitioner and stated on the pharmacy label placed people at risk that their health needs would not be met. Where people were prescribed medicines to take several times each day there was no system to record the time these were actually given meaning they could be administered without a sufficient gap between doses, in line with the manufacturer's instructions. Some medicines were prescribed to be administered only when the person required them (PRNs). Several people were prescribed a medicine for use when they were agitated. There was no information to guide staff as to when they should administer this medicine. Other people were prescribed medicines for constipation and, again, there was no guidance for staff as to when these should be administered. Some people at The Croft were living with dementia and care staff confirmed they were not all able to state when they were in pain and needed PRN pain relief medicines. A pain assessment tool or individual guidance was not available to help staff determine when pain medicine should be administered. Senior care staff who were responsible for medicines administration were able to verbally give individual information as to when they may decide to administer PRN medicines. However, the lack of written guidance meant people would not have received this consistently when different care staff were responsible for medicines administration. One person had been prescribed an anticonvulsant medicine by their general practitioner but the MAR showed they had not received this for eight days. We were shown notes in the handover book showing that care staff had contacted the general practitioner and pharmacy to try to obtain several medicines for different people. However, the person was placed at risk as care staff did not take any action to support the person such as contact a health profession or risk assess the fact that they were without their medicine and therefore there was an increased risk of seizure. We undertook a stock check of some boxed medicines. We checked the number of tablets remaining against those signed as administered and those received into the 7 The Croft (RCH) Limited Inspection report 14 November 2016 home. For three people the number of tablets remaining was more than there should have been indicating that staff had signed medicines as administered when this had not occurred. For some other medicines it was not possible to undertake a stock check as there was no date when the packets had been commenced in use. Medicine administration records had not been fully completed with staff having not recorded whether they had administered all medicines or not. Staff completing the MAR sheets after the errors had not brought the recording errors to the attention of the management team or address the issue directly with the staff member concerned. This meant prompt action could not be taken to investigate and ensure people had received their medicines. Prescribed topical cream charts were in use; however, there was inadequate information to direct staff as to when these should be applied. Records of application did not show that these were applied on a regular and consistent basis. Staff did not always record the date prescribed topical creams containers were opened this meant these may not be discarded in a timely way. The creams may not have been effective as the manufactures guidance for disposal once opened had not been followed. We found one packet of PRN tablets, which stated it should have been used by May 2015. Although the person had not received these recently no other supplies of this medicine were available for the person meaning the out of date medicines may have been administered when the person required these. We asked care staff and the manager about medicines audits and were told that these had not been undertaken. The failure to ensure medicines were managed safely was a continuing breach of regulation 12 of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Suitable arrangements were in place for the safe storing of medicines. Staff administering medicines told us they had received training although this had not been updated in the previous year meaning staff may not be updated about any changes in safe medicine administration procedures. Care plans did not include risk assessments which were, relevant to the person, identified the risks to the person and specified the actions required to reduce the risk. These included risks such as the risk of people falling in the home, smoking in their bedrooms, going out alone, nutrition and developing pressure injuries. Where people placed themselves or others at risk there were no risk assessments to inform staff how these risks should be managed. Within a few care files we found some moving and handling risk assessments within the 'bed rest record'. These were however very brief and did not provide clear information as to how the risk should be managed. The failure to ensure individual risks were identified and assessed placed people at risk of receiving unsafe care and placed them at risk of avoidable harm or risk of harm. People were not always protected from risks relating to the environment. In one person's bedroom there was a large hole in the carpet immediately in front of the door. It measured approximately 8" by 4" with the flooring below exposed. The edges of the hole were frayed and provided a trip hazard. None of the environment risk assessments had been reviewed since 2013. For example, the control of substances hazardous to health (COSHH) risk assessment had not been updated since July 2013. New health and safety guidance, including the management of COSHH was published in July 2014 and June 2016. Therefore, people may be at risk of harm or of receiving unsafe care and treatment because staff did not have access to appropriate up to date guidance to enable them to support people effectively. The failure to ensure risks were managed safely was a breach of regulation 17 of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014. On an individual basis the day to day risks of people falling were managed effectively. Staff knew the support each person needed when mobilising around the home and provided it whenever needed. We observed 8 The Croft (RCH) Limited Inspection report 14 November 2016 equipment, such as moving and handling equipment being used safely and people were encouraged and reminded to use walking aids where necessary. Staff said that the use of moving and handling equipment and repositioning was always undertaken by two staff and we saw that two staff were available to support people when required. The provider did not have an effective recruitment process in place to help ensure that staff they recruited were suitable to work with the people they supported. We spoke with one member of staff who had been working in the home since April 2016. They said they had come for an interview with a member of the previous management team. They said they had completed an application form but no Disclosure and Barring Service (DBS) check was done. A DBS check will identify if prospective staff had a criminal record or were barred from working with children or vulnerable people. They said they had given the details of two references but did not know if these were contacted. The care staff member said they had applied for their DBS within the two weeks prior to our inspection. We spoke with one of the provider's representatives and asked to see this member of staff's files. They were unable to find it or any of the appropriate documents. They confirmed that the member of staff had only just applied for their DBS and that it had not come back yet. We looked at the file for another member of staff who started work at the home on 21 August 2016. We had observed this member of staff working on their own providing care to people in various rooms within the home. Their file contained a completed application form, with a full employment history and two forms of identification. However, there were no references or the result of a DBS check. We spoke with the provider's representative about the lack of references and DBS for this member of staff. They were unable to show us any DBS record or references. They said the DBS "Is due back any day now". Two other staff files we looked at did not contain a relevant DBS check or references. The provider's representative was unable to show us any DBS record or references relating to these members of staff. They told us they recognised the need to review all of the files to ensure all of the required pre-employment checks for each member of staff had been completed The failure to ensure that people employed by the service were of good character is a breach of regulation 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were not protected from the risk of infection. Providers are required to take account of the Department of Health's publication, 'Code of Practice on the prevention and control of infections'. This provides guidance about measures that need to be taken to protect people from the risk of infection, including the need to carry out an infection control risk assessment, audit and complete an annual statement regarding compliance with infection control good practice. It also contains guidance on maintaining a clean and appropriate environment that facilitates the prevention and control of infections. The manager told us they were the infection control lead for the home. They told us that there was no record of the previous manager having completed an infection control risk assessment, infection control audit or annual statement. They said that they also had not had the opportunity to complete any of these since taking over in May 2016. People's bedrooms were not clean and presented an infection control risk. The walls and ceiling in one person's bedroom were dirty and stained with black streaks. The manager told us the person, who was allowed to smoke in their bedroom, had complex health issues which meant they frequently refused staff access to their room. The sink unit was old, dirty and stained with chipped laminate exposing the wood below. There were tiles missing from the sink splash back. This meant the sink unit and splash back could not be cleaned properly, creating an infection control risk. The two pillows on the bed were dirty, covered 9 The Croft (RCH) Limited Inspection report 14 November 2016 with brown staining and the mattress was dirty, stained and the underneath was wet. The manager told us the wetness and staining was "Probably urine". The carpet beside the bed was also dirty and stained and the manager said the room was "disgusting" and "not fit for [the person]". They immediately called the provider to show them the state of the room and the mattress was changed immediately. The other bedrooms we looked in were in a similar state of disrepair. We raised our concerns about people's bedrooms with the manager who told us they had identified the concerns when they took over the home in May 2016 and had a plan to renovate all of the bedrooms. Communal areas of the home including corridors and bathrooms were also not clean and presented an infection control risk. This was predominately due to damaged tiles and flooring which could not be adequately cleaned. In the downstairs lounge the cushion on a three seater sofa had a large split across the width of the cushion, exposing the foam below. This meant it could not be cleaned properly and created an infection control risk. The cushions on another sofa in the same room were also dirty and stained. We checked under the cushions of a third sofa and found old food and other detritus. The manager agreed they had not been cleaned for some time. The failure to ensure that people were protected from the risk infections is a breach of regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. One person said, "I can feel unsafe here, this is because of the other residents, not the staff". Another person said "I feel safe here all of the problem people have gone now so I am safe". We spoke with four relatives who all told us they had no concerns about the safety of people living at The Croft. Staff knew how to identify, prevent and report abuse, and how to contact external organisations for support if needed although they required update training which had been booked. One care staff member said "If I was concerned about something I would not hesitate in reporting the concerns, I would contact CQC or the local safeguarding team myself if I needed to". Another care staff member said "I would tell my manager verbally and in writing and if they didn't do anything I would tell safeguarding". The manager described the action they would take should a safeguarding concern be brought to their attention. The actions described would help ensure people remained safe. One person told us "The staff are lovely but they don't come quickly enough if I need help – they have too many people to look after". Care staff told us that they had not had time to meet everyone's physical and mental health needs. However, they felt this would improve once six identified people moved to nursing homes. Prior to our inspection the manager had contacted the local authority and requested support to find alternative accommodation for six people living at The Croft who required a high level of care. These people were subsequently assessed by health care professionals as requiring nursing care. Care staff were aware that people had not received the support to enjoy activities within or outside the home as often as would be desirable. On the day of our inspection staff were able to take one person shopping and later another person went with a staff member to a local pub for an afternoon drink. During the inspection we saw staff supporting people in a timely way. Following the reduction in the number of people with nursing care needs and the provision of a temporary staff member to support these people there were now sufficient staff to meet people's day to day care needs. The manager told us that staffing levels were based on the needs of the people using the service. There was a duty roster system, which detailed the planned cover for the home. This provided the opportunity for short term absences to be managed through the use of overtime and agency staff. The manager was also available to provide extra support when appropriate although time they spent supporting care staff meant they had not completed all their management tasks. In addition to care staff ancillary staff including a cook, laundry worker, cleaners, maintenance and an administration staff member were also 10 The Croft (RCH) Limited Inspection report 14 November 2016 employed. One staff member was also employed to provide activities for people. 11 The Croft (RCH) Limited Inspection report 14 November 2016 Requires Improvement Is the service effective? Our findings At the last inspection in November 2015 we found the provider did not have an effective system to ensure that care and treatment were only provided with the correct legal consent. The principles of the Mental Capacity Act 2005 (MCA) had not been complied with. At this inspection, we found that documentation in respect of people's legal rights was not in place. Staff followed the principles of the Mental Capacity Act (MCA) although information about people's ability to make decisions was not always formally assessed or recorded. The 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 decisions made on their behalf must be in their best interests and as least restrictive as possible. Some people had a cognitive impairment and were not able to make certain informed decisions. These included decisions around the delivery of personal care and the administration of medicines. However, there were no records of the assessment of the person's ability to make these decisions or any action taken to support the person to make decisions. In some care files we saw a 'Restrictive Practice Chart'. These forms highlighted what restrictions were in place, why and if it was in the person's best interests. For example, bed rails, leaving the home unaccompanied and medication. These were tick box charts and provided no detail of why or who had made decisions to implement restrictive practices. People were therefore at risk that decisions which restricted their rights may not be legally made in their best interests. 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. Care staff told us that following the advice of the community mental health team they had used seclusion for one person when they were very unsettled. However, there were no records of risk assessments, best interest documents or records relating to this decision. Staff said the instruction had been recorded in a handover book. Within care files we found DoLS request forms, however these were not fully completed. Neither senior staff nor the manager were able to tell us if these forms had been submitted to the local authority for approval. There were no records of the completion of submission of these applications. The failure to follow legal procedures to restrict people's liberty meant people may be restricted unnecessarily and unlawfully. DoLS training had been booked for the day following our inspection. Within the viewed care files there was no evidence of records of consent from the people or those acting legally on their behalf in relation to, the use of bed rails, medicines or health care etc. Both the manager and the senior care staff member agreed that consent forms for these areas were not in place. Records of care people had received were inadequate and incomplete meaning we could not be sure that people were receiving all the health and personal care they required. On viewing one care file there was a 12 The Croft (RCH) Limited Inspection report 14 November 2016 record that the care staff had made contact with the mental health team on the 14 July 2016 and a call back had been requested. There was no record of the call back being received and had not been followed up by the staff. For another person we found a behaviour recording chart was in place. There was an entry on the 16 July 2016 and then nothing until 21 July 2016 when it stated 'still in hospital'. Within their care records we could not see any information about the person having been admitted to hospital or why this had occurred. However, when asked care staff were able to provide details in relation to the hospital admission. In one care file we read that the person was receiving end of life care. There was no information as to how the person's end of life care needs should be met. The failure to ensure that records demonstrating that people's legal rights were protected or relating to their care needs is a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff sought verbal consent from people before providing care and support by checking they were ready and willing to receive it. One person said "They always ask before they do anything". A person needed moving with the use of a hoist. This was completed by two staff and consent was verbally gained from the person before staff completed this task. Records confirmed that staff complied with people's wishes. For example, daily records and medicine administration records recorded when people had declined care or medicines. Staff described how they respected the person's decision and would then return shortly after and try again. A care staff member said "If people say no, we just go back later, or someone else [another care staff member] will try". People were supported by staff who had received an effective induction into their role, which enabled them to meet the needs of the people they were supporting. Each member of staff had undertaken an induction programme, including a period of shadowing a more experienced member of staff who assessed their suitability to work on their own. However, staff new to care were not supported to complete their Care Certificate. The Care Certificate is a set of standards that health and social care workers adhere to in their daily working life. One member of staff said, "I did start my care certificate but never finished it. I only did the first page of it". The failure of new care staff to undertake recognised induction training meant they may not have the necessary skills to meet people's needs safely. There are no records available prior to May 2016 which identified what training staff had completed or when training needed to be repeated. The manager had commenced a new schedule of training in order to ensure staff had the correct skills to meet people's needs. This included some immediate training, using an external training company for all staff in infection control, medicine awareness, MCA & DoLS Health & Safety and Safeguarding. One member of staff said they had, "Done manual handling training, personal care, mental health awareness, first aid and I am currently doing my medication level two". They added "I have done advanced first aid training, which includes people with epilepsy or seizures". We recommend that the provider seek advice and guidance from a reputable source on adopting the latest best practice guidance in respect of staff induction and the completion of the care certificate to ensure care staff have the necessary skills to meet people's needs safely. Most people were supported to access healthcare services when needed although we found a letter from a community mental health professional which showed that a person had missed an appointment at the end of June 2016. Care staff were unable to explain why this had been missed. One person told us "If you need a doctor they [staff] will sort it out". Relatives all told us care staff contacted doctors when people required this and kept them informed about the outcome of any medical appointments. General health information such as people's medical history was known by staff although this was not always recorded and available in 13 The Croft (RCH) Limited Inspection report 14 November 2016 care files meaning this information may not be readily available to new or agency care staff. When required, staff consulted GP's and out of hour's services, such as paramedics and 111. The manager had arranged for an optician to visit the home enabling everyone to have their vision checked and purchase new spectacles if required. The manager had also arranged for a mobile dentist to attend the home. People were positive about the meals at The Croft and received the support they required when necessary. A person told us 'the food is quite nice, I get plenty and there's a good choice' and another person said 'If I don't like what I am given they will get me something else'. A range of drinks and snacks were offered frequently to people and staff encouraged people who were reluctant to drink. We observed one person being assisted to drink; the staff member sat next to the person and gave the person time and engaged them in conversation. At lunch time we observed staff providing individual support for a person. The staff member did not rush the person and spoke to them pleasantly about the meal they were eating. The cook was aware of people's preferences and dietary needs. They told us that "People can have drinks whenever they want, all day or night. There is plenty to choose from, we have milk, tea, coffee, Horlicks, Ovaltine, juice, fresh juice and milk shakes". They added "We have a diabetic who chooses non diet drinks. They know the risk but it is their choice. So I ask them to come back and see me after so I know they are alright". The cook decided on the main meal each day as they were aware of people's preferences. They adjusted the meals to suit each person's likes. For example on a fish day the cook would make fish pie for most people but one person had fish cakes and another preferred fish fingers. They said, "People can have different meals dependent on their choices. Today is roast chicken with BBQ sauce, topped with cheese, peas and carrot. [One person] will have vegetarian sausage; [another person] just plain chicken; [another person] a chicken sandwich; [another person] has a ham and cheese omelette; and [name person] mushroom soup". The manager told us they were changing some meal times to ensure they were appropriately spaced and flexible to meet people's needs. People were able to choose where and when they ate their meals. Some were happy to eat in the dining area, and other others in their bedroom. People were able to receive food at times other than the set meal times. One person told us they often asked for and received eggs on toast at 9pm and daily records showed another person was provided with sandwiches in the evening. The provider was undertaking refurbishment and redecoration of areas of the home including communal areas and bedrooms. Discussions with the provider and manager showed they had an understanding of how to make the environment suitable for the people living there. With the exception of four bedrooms all people were accommodated on the ground floor of the home. People accommodated in the first floor bedrooms were all able to use stairs independently. People had access to a courtyard and small rear garden, which had suitable outside furniture providing an opportunity for fresh air. We saw people enjoying this area during the inspection. 14 The Croft (RCH) Limited Inspection report 14 November 2016 Good Is the service caring? Our findings People were cared for with kindness and compassion. One person said of the staff, "I am happy when I am well and feel safe when I am with the carers". Another person said the "Staff are nice" they added "They look after me". Relatives also spoke positively about the care staff. One said "The staff are brilliant, really caring and know how [my relative] likes to be looked after, they really care". These comments were echoed by other people and relatives we spoke with. Without exception, all the interactions we observed between people and staff were positive and friendly. Care staff appeared friendly and spoke with people in a caring and dignified way. We saw staff kneeling down to people's eye level to communicate with them. Staff gave people time to process information and choices were offered. Staff did not rush people when supporting them. We heard good-natured banter between people and staff showing they knew people well. People were clearly relaxed and comfortable in the company of staff. Staff spoke positively about people and knew what was important to them. For example, at lunch time one care staff member asked another "Where is [name person]'s fizzy water". This showed they knew what the person, who was unable to say, like to drink with their meal. Care staff where aware of what may make a person agitated and described how they would support them. The care staff were relaxed around people and responded to their needs. During a hoist transfer the staff members explained to the person what they were going to do and what was going to happen. During this transfer care staff provided lots of reassurance and distraction. They talked to the person about their family showing they knew the person well. One person became unsettled and anxious. A staff member sat and talked quietly with them, the staff member reassured the person and informed them they had contacted their mental health practitioner and would let them know what they said when they called back. As a result the person became calmer. Staff spoke respectfully to people and took time to listen to them. One person was anxious about going to their room alone so the care staff member offered to go with them and offered reassurance. This person told us "I can't be in my room alone as it scares me; staff listen to me when I am frightened. I sleep in the lounge sometimes and they [the manager] are looking to change my room". This was confirmed by the manager. Care staff gave clear information and instruction when supporting people; support was provided in a calm and relaxed way. People's privacy was respected at all times. Before entering people's rooms, all staff knocked, waited for a response and sought permission from the person before going in. Confidential care records were kept securely and only accessed by staff authorised to view them. One bedroom was shared by two people. Privacy screens were available and all bedroom doors were always closed whilst staff provided personal care. People told us staff always remembered to close curtains and doors before providing care. However, in one shower room we noted there was no shower curtain to help protect people's privacy and dignity. This was raised with the manager who agreed to provide a shower curtain in this room. Staff treated people with dignity and respect and described the practical steps they took to preserve 15 The Croft (RCH) Limited Inspection report 14 November 2016 people's dignity when providing personal care. These included keeping people covered as much as possible and telling people what they were about to do. A care staff member said "I ask people if it is okay. With certain people you use pictures or a head shake. If I am unsure I will ask a senior to come with me and check. I don't want to do something they don't want me to". Staff were able to tell us if people preferred a specific gender of care staff to provide personal care and staff said they were able to meet these preferences. Staff were seen to respect people during interactions. For example, people were offered the choice, and informed, before clothing protectors were used at lunch time. After lunch a staff member noted a person had some food on their chin. They discreetly passed them a serviette which the person used to wipe their face. People were supported to express their views and offered choices about day to day events. One person told us "I went out and knew I wouldn't be back at lunch time so I asked them to keep my food for me for later". People told us they had a choice about meals and one said, "You have a choice; you don't have to have the same as everyone else". At lunch time we saw people received a variety of meals. One person was not sure what they wanted for pudding. Staff made a suggestion which was not on the menu which the person readily accepted saying "Oh yes I like that". This showed that care staff knew what people liked and people were not restricted to set menu options. We saw in the afternoon people were asked by the care staff what they would like for their evening meal. They were offered alternatives that were not on the menu if people preferred these. People's independence was promoted. At lunch time staff encouraged a person to eat without taking over. Two spoons were provided one for the care staff member and one for the person. The care staff member encouraged the person to hold the spoon. When it was clear they did not want to use it to eat with the staff member provided the necessary support to ensure the person ate their meal. This was done in an unobtrusive and non-obvious way which also protected the person's dignity. We saw cutlery, crockery and drinking utensils were brightly coloured meaning they would be easier to see for people with vision needs. These also reflected current good practise in terms of meeting the needs of people with limited vision or who were living with dementia. These supported people to eat independently without appearing to be specialist equipment. The Croft supported people to maintain family relationships. Family members said they were always made to feel welcome and could visit at any time. For example, one visitor told us how they could visit in the evening if they were not able to do so during the day. Family members told us they were kept up to date with any changes to the health of their relatives. Systems were in place to support people to meet their spiritual needs. A representative from the local church attended the home every Sunday for a short service and was available at other times should people require this. The manager was aware of how to contact leaders of other faiths if this was requested or required by other people. 16 The Croft (RCH) Limited Inspection report 14 November 2016 Requires Improvement Is the service responsive? Our findings All care files we viewed contained out of date or inaccurate information. There was limited information about the person as an individual such as their life history, preferences or needs both physical and emotional. Care records were not completed and we were unable to follow the care people had received from these. For example, one person had a food monitoring chart in place which was discontinued on the 8 August 2016. Staff were unable to explain why it was originally in use or why its use was discontinued. A care staff member told us that "[The person] has always eaten well". For another person there was a regular behavioural observation chart in use which was discontinued on the 17 August 2016. There was no information as to why this had been required or why it was discontinued and staff could not provide an explanation. Daily records were completed by the senior on duty and not always by the staff member who had provided the care. These records were brief and contained minimal information about what care the person had received or any other significant information such as activities or mental state. The failure to maintain full records of the care people had received meant subsequent staff may not be aware of what care had been provided or what care people needed to receive. Changes in the person's mental or physical health may also not be identified in a timely way. The failure to maintain an accurate and contemporaneous record in respect of each service user including a record of the care and treatment provided and of decisions taken in relation to the care and treatment provided is a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Staff verbally demonstrated a good awareness of people's individual support needs and how each person preferred to receive care and support. For example, they knew which people needed to be encouraged with personal care and those that required more support. Staff were also aware of people's preferences with regard to receiving care such as the times they liked to get up or go to bed. They recognised that some people's mobility or cognitive ability varied considerably from day to day and were able to assess and accommodate the level of support they needed at a particular time. Care staff told us they felt they had enough information to meet the needs of people at The Croft. However, very little of this information was recorded in people's care plans or their records of care. Staff responded when people required support. For example, one person told a staff member they thought they required the toilet. Care staff immediately guided the person to the bathroom and ensured they received the support they required. Another person said they felt cold and care staff asked them if they would like a jumper. They checked with the person that it was ok to go in their bedroom and then returned with three jumpers. The person was helped to make a choice and assisted to put on the jumper. At 10am we saw care staff quietly opening a bedroom door and then closing it again. They told us the person was still sleeping and they would support them to get up once they were awake. At lunch time care staff encouraged and supported people to move to the dining tables reminding them this would make it easier and safer for them to eat their meal. One care staff member told us "Everyone gets really well cared for and all the staff are caring. It has been better since two of the residents with higher needs have moved as we have more time to provide care to the others". 17 The Croft (RCH) Limited Inspection report 14 November 2016 Staff told us they had not always had sufficient time to ensure people received the mental and physical stimulation they required however, they felt this would improve once the people with nursing care needs moved to alternative care homes. One staff member was assigned to do activities with people. They told us "I have set times to do this and am not included in the care staff numbers during this time. If I am going to go out with a person I arrange this in advance so there are enough care staff to provide the day to day care needs to the people". During the inspection we saw two people being given the opportunity to go out. We also saw the activities staff member offering and providing individual activities, such as art work and conversation. This was tailored to people's individual wishes. The provider had arranged for an external activities company to undertake a range of activities in the home. This included music, exercise and visiting pets. The activities provider also had a service whereby individual visitors could be organised for people who did not have regular visitors and would benefit from this service. The manager was meeting with them to arrange this for several people living at The Croft. The manager sought and acted on feedback from people informally, such as in the colour they would like their bedrooms redecorated and the redecoration of the communal areas. A service user meeting was planned for the week following our inspection. The manager subsequently told us this had occurred and changes requested by people such as ad hoc activities including a dart board were being organised. Menus and plans for celebrating Christmas had also been discussed. People knew how to complain and there was a suitable complaints procedure in place. A relative told us that if they had any concerns they would approach the manager who they were confident would take any necessary action. There was information about how to complain available for people or visitors in the home's hallway. The manager said there had not been any complaints since they had taken over managing the service in May 2016. The manager explained that by speaking with people on a daily basis, and relatives when they visited, they were able to rectify most minor concerns before they became formal complaints. 18 The Croft (RCH) Limited Inspection report 14 November 2016 Requires Improvement Is the service well-led? Our findings Records relating to the management of the home were not always accurate or contemporaneous. An emergency evacuation bag in the downstairs hallway next to the fire panel contained out of date information. The fire risk assessment had not been updated since 2014. The bag also contained personal emergency evacuation plans (PEEPs), which provide information to emergency services on how to evacuate people safely from the home. Some of these PEEPs were out of date for example the PEEP for one person, which was dated 26 January 2015, stated the person spent most of their time in the lounge and could leave the home in an emergency 'but with guidance'. However, the manager told us this was not correct as they had been cared for in bed since September 2015. The file also contained PEEPs for people who were no longer in the home. Records relating to risks associated with the running of the home were not always up to date and reflecting the latest best practice. For example, the environment risk assessments for the control of substances hazardous to health (COSHH) had not been updated since July 2013. New health and safety guidance, including the management of COSHH was published in July 2014 and June 2016. We raised this with the manager who confirmed that none of the environment risk assessments had been updated since 2013. Policies and procedures were also out of date and had not been updated to reflect the latest guidance or working practises in the home. The failure to ensure that records relating to the management of the home were accurate and contemporaneous is a breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There was now a system in place to monitor the quality and safety of the home however this had not yet been embedded into normal working practices. The manager told us that there had been no records of auditing process in place or audits being undertaken prior to them taking over the home in May 2016. Since then they have carried out an assessment audit across the whole service, which has led them to raise a service wide safeguarding alert, and develop a business/crisis response plan for dealing with all of the issues identified, which included the development of a structured auditing process. A health and safety audit carried out in July 2016 identified concerns with the carpets and waste management. As a result of the audit an external cleaning company had been brought in to deep clean the carpets and secure enclosure built to hold the home's large waste bins. The manager also showed us a new cleaning performance report they have developed, which is about to be put into place. In addition, monthly audits had been commenced in respect of water temperature, fire alarms, emergency lighting and escape routes. However the new audits had not identified some of the concerns we found in respect of medicines management, recruitment checks and infection control. In May 2016 the nominated individual and the registered manager left The Croft's employment without giving notice. Although a limited company, The Croft is essentially family owned and two members of the provider's family immediately became actively involved in the day to day management of the home. Both were present throughout the inspection with one having taken responsibility for the administration and 19 The Croft (RCH) Limited Inspection report 14 November 2016 environment and the other, a registered mental health nurse, responsibility for the management of care people received. They told us they were intending to register with CQC as the registered manager and commenced this process soon after the inspection. The management team have been open about the issues facing the service and informed the local authority social services team and CQC about these concerns. Relatives were also aware of the changes in the management of the home showing there was an open culture at the home. People were positive about their experience of living at The Croft and felt that it was well run. Everyone said they were happy with the service they received. One person said "I like it here". Another person said "It's [The Croft] the best place I have ever been and I am very pleased to be here. The manager is superb". All four of the relatives we spoke with were very positive about the changes in management at the home. Relatives were aware of who the manager was and said they felt able to discuss any concerns or issues with them. We saw the manager interacted positively with people who lived at The Croft and people responded well to them. Staff told us they enjoyed working at the home. We observed staff worked well together, which created a relaxed atmosphere and was reflected in people's care. Staff said the aim of The Croft was to provide a home for people where they were safe and looked after well. We saw positive, open interactions between the manager, staff, and people who appeared comfortable discussing issues in an open and informal way. The manager told us they regularly worked as a member of the care staff team and was aware of people's needs. Staff spoke highly of the manager. One care staff member said "They [manager] is very supportive and will help us when needed". They described how the atmosphere in the home had changed following the changes in the management in May 2016 and said they now enjoyed coming to work. Senior care staff told us they had each been allocated specific responsibilities within the home such as care plans or medicines. They also told us that the manager would ask them for their views and those they now held morning meetings to talk about everything and what needed to be done. Another staff member said "I'm confident that the manager and deputy would take any concerns that I had about the people seriously and would act on them". 20 The Croft (RCH) Limited Inspection report 14 November 2016 This section is primarily information for the provider Enforcement actions The table below shows where regulations were not being met and we have taken enforcement action. Regulated activity Regulation Accommodation for persons who require nursing or personal care Regulation 12 HSCA RA Regulations 2014 Safe care and treatment The registered provider has failed to ensure medicines were managed safely and has failed to ensure people were protected from the risk of infections. Regulation 12 (1) The enforcement action we took: Imposed condition provider must submit action plans monthly Regulated activity Regulation Accommodation for persons who require nursing or personal care Regulation 17 HSCA RA Regulations 2014 Good governance The registered person has failed to maintain an accurate record in respect of each service user of the care provided and of decisions taken in relation to the care and that people's legal rights have been protected. They have also failed to ensure risks were managed safely. Regulation 17 (1) The enforcement action we took: Imposed condition provider must submit action plans monthly Regulated activity Regulation Accommodation for persons who require nursing or personal care Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed The registered person has failed to ensure that recruitment procedures were followed to ensure all staff were suitable to work with vulnerable people. Regulation 19 (2) The enforcement action we took: Imposed condition provider must submit action plans monthly 21 The Croft (RCH) Limited Inspection report 14 November 2016