About the service:

Lauriston is a purpose built, fully adapted service registered to accommodate up to 60 people who require nursing or personal care. The service specialises in providing nursing care to older people with age related conditions, including dementia. The service is divided into four units spread over two floors, with access to the upper floor via stairs and a lift. There is a car park to the front of the building and gardens to the rear. There were 53 people living at the home at the time of the inspection.

People’s experience of using this service:

The providers’ governance systems had not consistently identified the shortfalls found at this inspection. There was a lack of clear and accurate records regarding some people's care and support. For example, wound care and pressure care management. The management of behaviours that challenge were not always documented clearly and lacked details to manage them effectively. The leadership within the service had been impacted on by the fact that there had been no registered manager for nine months and several short-term managers. We have been informed that a new manager had been recruited and would be starting employment soon and registering with the Care Quality Commission (CQC).

Risk of harm to people had not always been mitigated as good practice guidelines for the management of continence, wound care and pressure care management. There was a lack of guidance and analysis in managing some people’s behaviours that challenge and there was no evidence of what strategies worked and what staff could try next time, This meant that people's safety and welfare had not been maintained at all times.

There were sufficient staff to meet people’s individual needs, however the deployment of staff had not always ensured that peoples’ needs were met in a timely manner. Staff had passed robust recruitment procedures which ensured they were suitable for their role.

Whilst there were areas of care planning and assessing risk to people that needed to be improved, there were also systems to monitor people's safety and promote their health and wellbeing, these included health and social risk assessments and care plans. The provider ensured that when things went wrong, lessons were learned.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

Staff received appropriate training and support to enable them to perform their roles effectively. Visitors told us, “The care seems really good, they seem well trained and competent,” and “I know the staff get training, I have no worries or complaints.”

People’s nutritional needs were monitored and reviewed. People had a choice of meals provided and staff knew people’s likes and dislikes. People gave positive feedback about the food. Comments included, “We get choices, the food is good most of the time, it can’t be easy to please all of us.”

People and relatives told us staff were ‘kind’ and ‘caring’. They could express their views about the service and provide feedback. One person said, “I am very happy living here, the staff are nice ad friendly and very kind.”

People were encouraged to live a fulfilled life with activities of their choosing and were supported to keep in contact with their families. One person told us. “I have a mobile phone and staff make sure its charged and ready in the morning, then I can ring my family if I want to.”

People's care was person-centred. The care was designed to ensure people's independence was encouraged and maintained. The dementia unit was designed to enable people who lived with dementia to walk safely and the provision of items on walls and in corridors provided stimulation and interest.

Staff supported people with their mobility and encouraged them to remain active. One visitor told us that since coming to Lauriston their relative was more mobile

The inspection took place on 22, 25 and 31 January 2018 and was unannounced.

Lauriston is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Lauriston is a purpose built, fully adapted service registered to accommodate up to 60 people who require nursing or personal care. The service specialises in providing nursing care to older people with age related conditions, including dementia. The service is divided into four units spread over two floors, with access to the upper floor via stairs and a lift. There is a car park to the front of the building and gardens to the rear. There were 49 people living at the home at the time of the inspection. There were 17 people on the dementia unit, 17 on the nursing unit and 14 people who required support.

At the last inspection on 11 November 2016 the service was rated Good. At this inspection we found the service remained Good with requires improvement in well-led.

There were processes and procedures for monitoring the quality of care provision. However, some improvements were needed to ensure action was promptly taken when issues were identified. This was because staff had not ensured that as ‘required medicines’ were all supported by a protocol and pain chart to ensure they were used safely. This was addressed immediately. Risk assessments did not always demonstrate a framework that supported people to take everyday risks. There had been an increase in safeguarding notifications over the past eight months. These were recorded but lacked a root core analysis and follow through to demonstrate learning from these situations. Root cause analysis is a collective term that describes a wide range of approaches, tools, and techniques used to uncover causes of problems.

There were enough staff to provide safe and effective care that met people's needs. Recruitment procedures ensured staff were qualified and safe to work with people who lived in the home. Staff understood their safeguarding responsibilities and the action they should take if they were concerned a person was at risk of harm.

The provider used a variety of risk assessment tools to identify any potential risks to people's health and safety. Risk management plans guided staff on how to manage those identified risks. Daily records to support risk management were consistently and accurately completed. Accidents and incidents were recorded by staff and analysed by the deputy manager to identify any emerging trends or patterns, so appropriate action could be taken to minimise identified risks.

People received care from staff who had the knowledge, skills and competencies to support their health needs. Medicines were ordered, received, stored, administered and disposed of in accordance with good practice. Staff understood their role and responsibilities in relation to infection control and hygiene. The provider assessed people's capacity to make their own decisions if there was a reason to question their capacity. Staff and the registered manager had a good understanding of the Mental Capacity Act. Where possible, they supported people to make their own decisions and sought consent before delivering care and support. Where people's care plans contained restrictions on their liberty, applications for legal authorisation had been sent to the relevant authorities as required by the legislation.

Staff supported people to eat and drink enough to maintain their health and referred people to other healthcare professionals when a need was identified. Managers and staff worked with other healthcare professionals to ensure people could remain at the home at the end of their life and receive appropriate care and treatment.

Staff were caring and compassionate. They knew people well so they could deliver care in the way people preferred and in a way

Lauriston provides nursing and personal care for up to 60 people, some of whom lived with dementia. The home had been divided into three units over two floors. The first floor unit provided nursing care and support for 25 people with a range of illnesses, such as Parkinson’s disease, Multiple Sclerosis and strokes, some of whom were also receiving end of life care. The ground floor residential units were divided by a locked door and provided personal care and support for up to 15 people living with dementia and six people who were physically frail. Lauriston also provides short stay care known as respite care. At present there are five beds that are blocked by the local authority for residential short stay.

A registered manager is in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

We carried out an unannounced comprehensive inspection at Lauriston on the18 and 20 February 2015. Breaches of Regulation were found and Lauriston was rated as inadequate. A further inspection was undertaken on 30 June and 01 July 2015 to follow up on whether the required actions had been taken to address the breaches identified. We found that the breaches of regulation had been met but needed time to be embedded in to everyday care delivery and Lauriston therefore was rated as requires improvement.

This unannounced comprehensive inspection was carried out on the 14, 18 and 20 October 2016 to see if the improvements had been sustained. We found that the improvements had been sustained.

People spoke positively of the home and commented they felt safe. Our own observations and the records we looked at reflected the positive comments people made.

Care plans reflected people’s assessed level of care needs and care delivery was person specific, holistic and based on people's preferences. Risk assessments included falls, skin damage, behaviours that distress, nutritional risks including swallowing problems and risk of choking and moving and handling. For example, cushions were in place for those that were susceptible to skin damage and pressure ulcers. The care plans also highlighted health risks such as diabetes and epilepsy. Visits from healthcare professionals were recorded in the care plans, with information about any changes and guidance for staff to ensure people's needs were met. Staff had received training in end of life care supported by the organisations pastoral team. There were systems in place for the management of medicines and people received their medicines in a safe way.

Nurses were involved in writing the care plans and all staff were expected to record the care and support provided and any changes in people's needs. The manager said care staff were being supported to do this and additional training was on-going. Food and fluid charts were completed and showed people were supported to have a nutritious diet.

Staff had a good understanding of people's needs and treated them with respect and protected their dignity when supporting them. People we spoke with were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and they responded to staff with smiles. People previously isolated in their room were seen in communal

lounges for activities, meetings and meal times and were seen to enjoy the atmosphere and stimulation.

A range of activities were available for people to participate in if they wished and people enjoyed spending time with staff. Activities were provided throughout the whole day, seven days a week and was in line with people's preferences and interests.

The provider had progressed quality assurance systems

Below is a summary of what we found during our inspection. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We saw that people were treated with respect and dignity by the staff at Lauriston. Safeguarding policies and procedures were in place and staff understood how to safeguard the people they supported. Effective systems were in place to make sure that the manager and staff learnt from events such as accidents, incidents and investigations. This reduced the risks to people and helped the service to continually improve. 97.2% of staff had received training on the Mental Capacity Act and Deprivation of Liberty Safeguards. Staff told us they had been trained to understand when an application should be made, and how to complete a referral. We saw that appropriate applications had been made as required and a mental health assessment completed and kept in the persons file. This provided a baseline for the monitoring of peoples mental health. This meant that people had been safeguarded as required.

Is the service effective?

People’s health and care needs had been assessed on admission and reviewed monthly or more regularly if required. Families and appointees were involved in decision making where people had been assessed as not having the capacity to make informed decisions in respect of their care. The documentation evidenced that people had access to specialist health professionals when necessary, for example, speech and language therapists. People’s specific dietary, mobility and equipment needs had been identified in care plans where required. The dementia wing had developed the facilities available for providing mental stimulation and promoting independence. The training programme for staff was comprehensive and this meant that the staff had the knowledge and experience to provide effective and safe care to the people they care and support. The care plan documentation had improved with the introduction of new care plan format and guidance sheets, but as detailed in the report outcome areas there were still some areas that require improvement.

Is the service caring?

People were supported by kind, attentive and qualified staff. By direct observation we saw that staff were kind and attentive whilst delivering care and support. People who were receiving end of life care were treated with respect and empathy. People’s preferences, interests and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. We saw a comprehensive social activity programme that included one to one sessions that meant peoples social needs and mental well-being had been considered and promoted. One person told us, “We do get the opportunity to have fun, and meet other people who live here.” Another person told us, “I prefer to stay in my room, but they always tell me what’s going on so I can attend if I want to.” One staff member told us that, “The cinema afternoon is very popular.”

Is the service responsive?

People’s needs had been assessed before they moved in to the home. This meant that the home had the skills and facilities to meet peoples’ identified needs. We were told that that the regular monitoring and risk assessing of peoples’ health and social needs identified when specialist input was required , such as tissue viability nurses (TVN) and dementia and community mental health services. This meant that the service was responsive to peoples’ individual needs. Records confirmed people’s preferences and that care and support had been provided in accordance with people’s wishes. We saw evidence of learning from incidents, accidents and safeguarding investigations. Visiting health professionals told us that communication with the service had improved and that appropriate action was taken if they had any concerns.

Is the service well-led?

The service has introduced a new improved quality assurance system that is gradually being embedded into practice. Records seen by us showed that identified shortfalls were now addressed promptly. As a result the quality of the service was continuing to improve. Staff told us they were clear about their roles and responsibilities. This helped to ensure that people received a good quality service at all times. The training provided was comprehensive and the matrix identified that the percentage of staff undertaking training was monitored by the manager. Regular staff meetings and supervision sessions were being held, and staff told us, “We feel supported and work well as a team,” and “We get feedback about our performance, sometimes positive and sometimes not so good, but it means we improve our care.”

The home provided support for a wide range of care needs, from those people who required minimal support, to those who required nursing and dementia care. We used a number of different methods to help us understand the experiences of people using the service, because some people using the service had complex needs which meant they were not able to tell us their experiences. We spoke to eight people who used the service. We also spoke to the relatives of two people who were able to contribute their views on outcomes for the people who used the service. People told us, "Very clean and staff are friendly," and "Nice surroundings and good food."

We saw that where possible people were involved in planning their care. We found that care and treatment was planned and delivered in a way that ensured people’s safety and welfare.

We saw that there were sufficient qualified and experienced staff on duty to deliver the care and support required.

Staff had received the training and support necessary for them to perform their role in the home.

There was an effective complaints system available. We saw that comments and complaints people had made, had been responded to appropriately.

Staff records and other records relevant to the management of the service were accurate and fit for purpose.

The home provided support for a wide range of care needs, from those people who required minimal support, to those who required nursing and dementia care.

We spoke to ten people during our inspection visit. We also used a number of different methods such as observation of care and reviewing of records to help us understand the experiences of people who used the service.

People told us that the home was warm and comfortable and the food was very good. We were also told that it was clean and that staff were kind and helpful.

Comments included, “a very nice place to live”, “I’m very happy here” and “its okay but I want to go home”.

A visitor told us that the home staff were welcoming and informative.

Some people we spoke with were able to tell us that they enjoyed living in the home, and were happy. We were told “everyone is very nice” “I am really happy here” and “the food is always very good”. Other comments included “the food is not as good lately” “activities not good anymore” “lots of changes”.

We carried out an unannounced comprehensive inspection at Lauriston on the18 and 20 February 2015. Breaches of Regulation were found. Details of previous breaches will be found under each of the five question headings. As a result we undertook an inspection on 30 June and 01 July 2015 to follow up on whether the required actions had been taken to address the previous breaches identified. We found improvements had been made and these will need to be embedded to ensure they are consistently met.

You can read a summary of our findings from both inspections below.  

Comprehensive Inspection of 18 and 20 February 2015.

We inspected Lauriston on the18 and 20 February 2015. Lauriston provides nursing and personal care for up to 60 people, some of whom lived with dementia. The home had been divided in to three units over two floors. The first floor unit provided nursing care and support for 25 people with a range of illnesses, such as Parkinson’s disease, Multiple Sclerosis and strokes, some of whom were also receiving end of life care. The ground floor residential units were divided by a locked door and provided personal care and support for 15 people living with dementia and six people who were physically frail. Lauriston also provides short stay care known as respite care.

People spoke positively of the home and commented they felt safe at the home. Our own observations and the records we looked at did not always reflect the positive comments some people had made.  

There was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.  

People’s safety was being compromised in a number of areas. Staffing levels were insufficient to meet people’s individual care and social needs. Staff were under pressure to deliver care in a timely fashion and was seen to be more task orientated than person specific.

The delivery of care suited staff routine rather than individual choice. Care plans lacked sufficient information on people’s likes, dislikes, what time they wanted to get up in the morning or go to bed. Information was not readily available on people’s preferences. End of life care lacked the holistic and inclusive approach.

Staff did not fully understand the principles of consent and therefore had not always respected people’s right to refuse consent. Not all staff working had received training on the Mental Capacity Act 2005 (MCA) and mental capacity assessments were not consistently recorded in line with legal requirements. Deprivation of Liberty Safeguards (DoLS) had not been submitted for all that required them.  

People we spoke with were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and people responded to staff with smiles. However we also saw that many people were supported with little verbal interaction and many people spent time isolated in their room.  

Activities though provided for an hour to two hours daily did not reflect people’s hobbies and interests. The dementia unit lacked the visual stimulation and dementia signage that enabled people who lived with dementia to remain independent.  

Although a quality assurance framework was in place, it was ineffective. This was because it did not provide adequate oversight of the operation of the service.  

Staff told us the home was not well managed at present, staff morale was low and many staff spoken with became tearful.  

Training schedules confirmed staff members had received training in safeguarding adults at risk. Staff knew how to identify if people were at risk of abuse or harm and knew what to do to ensure they were protected.  

Robust recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.  

People’s medicines were stored safely and in line with legal regulations. People received their medicines on time and from appropriately trained senior care staff or a registered nurse.  

Feedback was regularly sought from people, relatives and healthcare professionals.  

Comprehensive Inspection on 30 June and 01 July 2015

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After our inspection of 18 and 20 February 2015, the provider wrote to us to say what they would do to meet legal requirements in relation to care and welfare, assessing and monitoring the quality of service provision, respecting and involving people

and meeting people’s nutritional needs.  

We undertook this unannounced  inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found significant improvements had been made and they had met the breaches in the regulations.  

A manager was in post and has submitted their application to CQC to be registered. Senior managers of the organisation support the manager and have time on each unit observing care delivery and fed back to the manager and staff. Staff felt that this was really positive and welcomed the feedback. One staff member said, “It means we are important to the organisation, I feel valued.”  Staff confirmed there was always someone to approach with any concerns or worries.  

People spoke positively of the home and commented they felt safe. Our own observations and the records we looked reflected the positive comments people made.  

People were safe. Care plans reflected people’s assessed level of care needs and care delivery was person specific and holistic. Staff had received training in end of life care supported by the organisations pastoral team.

The delivery of care was based on people’s preferences.

Care plans contained sufficient information on people’s likes, dislikes, what time they wanted to get up in the morning or go to bed. Information was available on people’s preferences.   

Staff we spoke with understood the principles of consent and therefore respected people’s right to refuse consent. All staff working had received training on the Mental Capacity Act 2005 (MCA) and mental capacity assessments were consistently recorded in line with legal requirements. Deprivation of Liberty Safeguards (DoLS) had been submitted and there was a rolling plan of referrals in place as requested by the DoLS team.  

Everyone we spoke with was happy with the food provided and people were supported to eat and drink enough to meet their nutritional and hydration needs. People received a varied and nutritious diet. The provider had reviewed meals and nutritional provision with people, the chef and kitchen and care team. The dining experience was a social and enjoyable experience for people on all units.  

People we spoke with were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and they responded to staff with smiles. People previously isolated in their room were seen in communal lounges for activities, meetings and meal times and were seen to enjoy the atmosphere and stimulation.  

People we spoke with were very complimentary about the caring nature of the staff. People told us care staff were kind and compassionate. Staff interactions demonstrated staff had built rapport with people and people responded to staff with smiles.  

Activity provision was provided throughout the whole day and was in line with people’s preferences and interests. Staff had worked together to provide a dementia unit that was colourful, comfortable and safe. There was visual and interactive stimulation available in corridors and communal areas that people engaged with supported by attentive staff. The dementia unit now had visual signage that enabled people who lived with dementia to remain independent  

Feedback had been sought from people, relatives and staff. Residents and staff meetings were held on a regular basis which provided a forum for people to raise concerns and discuss ideas. Incidents and accidents were recorded, and consistently investigated. Staff told us the home was well managed and robust communication systems were in place. These included handover sessions between each shift, regular supervision and appraisals, staff meetings, and plenty of opportunity to request advice, support, or express views or concerns. Their comments included “Really improved, I had left but now have returned, its great here now, senior staff work with us, we work as a team, really supportive manager.” Another staff member said, “Things are going well.”