About the service:

Limetree provides care for adults who require long-term nursing intervention and support because of an acquired or traumatic injury, or other neurological condition.

Limetree is one of six adult social care locations at Glenside which also has a hospital that is registered separately with CQC. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

One adult social care location (Pembroke Lodge) is currently closed as there were ongoing and continual issues with the provision of heating and hot water.

The hospital was also closed due to a flood caused by a major water leak. Patients from the hospital were transferred at short notice to some of the adult social care locations. Works to repair the fabric of the hospital building were currently underway. As Limetree was temporarily accommodating people from the hospital we reviewed aspects of these patients care and support in line with the expectations of their inpatient status. The ground floor at Limetree was being used to accommodate hospital patients with the upper floor for those people accommodated under the Adult Social Care (ASC) registration.

The provider notified us of the temporary arrangements for hospital patients while refurbishments were taking place. However, Limetree will not be correctly registered with CQC if these arrangements become long term. The provider will need to submit applications to CQC to register appropriately if the closure of the hospital continues.

People’s experience of using this service:

The service was rated Requires Improvement at the comprehensive inspection dated August 2018. The rating for the focus inspection undertaken on the 7 November 2018 remained the same.

People and patients were placed at risk from poor management. We found systemic overarching poor management systems and improvements were not prioritised. There had been sudden and persistent changes of senior managers. There was a lack of regulatory response from the provider. There were poor recruitment procedures, and a lack of investment with equipment and maintenance of the property. The morale of the staff was low and they were reluctant to give feedback because of fear of reprisals. This had an impact on the care people received.

On the first floor we found:

• People were not receiving continuity of care from staff recruited to work permanently at Limetree. We checked the staffing rota’s and saw that agency staff were used on a regular basis when the service was short staffed. Staff from other units at Glenside were also required to provide support to Limetree. The unit manager explained that there was recruitment taking place, however there were delays in recruitment.

• The service did not have a registered manager in post. The service was being managed by an interim manager. The unit manager was not supported by the provider to ensure they could focus on making improvements in Limetree.

• The staff were not skilled in supporting people whose behaviour changes were triggered by brain injuries. One person displayed behaviours that the staff team found too challenging to manage effectively. Staff told us that they had colleagues who were scared of the person and they would “hide in othe

We undertook an unannounced focused inspection of Limetree on 7 November 2018. After the comprehensive inspection dated 30 and 31 August 2018 we received concerns in relation to staff not having appropriate checks before starting employment, language barriers of staff, poor working and living conditions for staff working as agency staff, competency of staff undertaking maintenance checks and lack of equipment across the Glenside Manor site. As a result, we undertook a focused inspection to look into those concerns. This report only covers our findings in relation to those/this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link Limetree on our website at www.cqc.org.uk.

The team inspected the service against two of the five questions we ask about services: is the service well led and safe. This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Effective, Caring and Responsive through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Limetree provides care for adults who require long-term nursing intervention and support because of an acquired or traumatic injury, or other neurological condition.. Limetree is one of six adult social care locations at Glenside which also has a hospital that is registered separately with CQC. Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

A registered manager was 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.

At the previous inspection dated August 2018 we found a breach of Regulations 9 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider following the inspection to tell us how they were going to meet this Regulation 9 and 12. The provider failed to report on the actions to meet Health and Social Care Act 2008, its associated regulations, or any other relevant legislation on how regulations were to be met. At this focus inspection we found Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were not being met.

The CQC following the inspection formally requested under Section 64 of the Health and Social Care Act 2008 to be provided with specified information and documentation by 16 November 2018. We received some of the information requested but not all.

Quality assurance systems were inadequate. Audits were not robust and did not provide an accurate assessment of the quality of care delivered. Action plans were not developed to drive improvements. The CQC was not notified of accidents and inciden

This inspection took place on 30 and 31 August 2018 and was unannounced. Limetree provides care for adults who require long-term nursing intervention and support because of an acquired or traumatic injury, or other neurological condition. It is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

At the previous inspection in June 2017, we rated this service as Requires Improvement, with a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We received an action plan from the provider telling us how the regulation was to be met following the inspection. At this inspection we found there were some improvements, but these were not sufficient to meet the requirements of the Regulations. There was a repeat breach of Regulation 9.

This is the second consecutive time the service has been rated as Requires Improvement.

A registered manager was 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.

Systems were in place to assess and monitor the health, safety and welfare of people at the service. There were a range of quality audits undertaken and their outcomes were used by senior managers to assess set performance objectives. Where performance targets were not met, action plans were devised on how these objectives were to be met. We found at this inspection shortfalls in medicine systems and care planning existed and remained from the last inspection. Audits did not cover all areas of care delivery. For example, medicine audits were based on the clinical room but not on safe management of medicine and infection control was based solely on hand hygiene. Care plans were not audited. This meant audits did not drive improvements in all areas of health, safety and welfare of people.

Medicine systems were not managed safely and people were not consistently having their medicines as prescribed. Records of medicines administered were not consistently signed to show when topical creams were applied and thickeners used in fluids. The staff that applied topical creams were not signing the records of administration. This meant registered nurses were signing for topical creams when they could not be certain creams were applied as prescribed.

Care plans and risk assessments were combined. However, some care plans were conflicting, people’s preferences were not recorded, and guidance on meeting people’s needs were not followed. Information from the “Getting to know me” documents were not used to develop person centred care plans. Care plans were not always developed where people had mental health care needs. Records showed guidance was not consistently followed where people presented with behaviours staff found difficult to manage. People told us they had some say about their care plans during review meetings.

There was a reliance on agency staff and the registered manager told us every effort was made to ensure the same agency staff were used. Some staff raised concerns about the staff recently recruited. They said some staff were not able to communicate effectively in English. The clinical lead told us the steps taken to ensure the staff employed could speak English. The registered manager and clinical lead told us recruitment was in progress and the steps that were being taken to attract and retain staff.

Although staff said the registered manager was on duty once weekly and they were contactable by phone. Staff said there was a regular presence from the deputy manager, which they praised. Staff said since the a

Limetree is located within the Glenside Hospital grounds and can provide accommodation for up to 26 adults with acquired or traumatic brain injury, or other neurological conditions.

This inspection was unannounced and took place on the 13 June 2017.

A registered manager was in post and was recently appointed. '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 said they felt safe living at the service. Although staff knew the types of abuse and had attended training in the procedures for safeguarding vulnerable adults from abuse they were not clear on the actions needed for suspected abuse.

Risk assessments were in place for some identified risks. The staff we asked knew the actions needed to minimise risks. For example, choking and falls. The action plans were not clear on how staff were to use products such as thickeners for people at risk of choking and the settings for equipment such as air mattresses. This meant some people were at increased risk. When these shortfalls were identified the registered manager and operation’s manager took prompt action to ensure risks were mitigated. Where people's fluid was monitored the daily target or the total intake of fluid was not recorded on the fluid balance sheets. This meant the registered manager was not aware of people whose fluid intake was low.

Staff said the staffing levels were decreasing and the needs of people were not recognised which meant sufficient staff were not on duty to meet people's needs. The manger and operations manager said this was staff perception and initiatives such as task lists were introduced to show to staff they had sufficient time for task and for one to one time with people.

Safe recruitment processes were in place. Candidates were able to use their preferred method of application form which included CV to apply for vacant posts. Disclosure and Barring Services (DBS) must be approved before the staff start working at the service. A Disclosure and Barring Services (DBS) check allows employers to check whether the applicant has any convictions or whether they have been barred from working with vulnerable people. Where staff had disclosed convictions or cautions they were investigated and risk assessments completed to ensure staff were safe to work with people.

Medication administration charts (MAR) were signed to show the medicines administered. However, the charts were not signed immediately after medications were administered by the nurses. Application charts were not used by rehabilitation assistants (RA) to document the application of topical creams. The procedure was for RA to confirm to the nurse who will then sign the MAR. The operations manager said the method of recording topical cream would be reviewed. The number of medicine errors has reduced since changes of the supplying pharmacy for medicines.

Induction of new staff was detailed and there was ongoing reviewing of the process. Staff on induction said the induction was good. There was mandatory training set by the provider which staff attended to ensure they had the skills needed to meet people's needs. There was a re-validation programme for nurses.

While training was available to staff on person centred care and to meet the needs of people living with dementia not all staff had taken the opportunity to develop their skills and knowledge in this area. Staff can apply for nursing degree and during their training these staff must work at the service one shift per week.

Appraisals of staff with the registered manager were annual. Part of the appraisal system was for staff to appraise themselves. The appraisals viewed did not include the discussion with the registered manager and the action pla