Whittington Care Home is a residential care home and provides care to 48 older people with a range of age related conditions including dementia.

At the last inspection, the service was rated as ‘good’.

At this inspection we found the service remained ‘good’.

Whittington Care Home is registered to care for 48 older people. At the time of the inspection there were 47 people living there.

People were kept safe by staff who knew how to mitigate risk and to provide safe care. They also knew how to respond should they suspect abuse. There was sufficient staff on duty to meet people’s needs and wishes in a timely manner.

Medicines were stored and administered safely. Staff had clear information on medicines and were able to explain to people why they needed to take them.

Staff were trained to meet people’s needs and care was delivered in a kindly manner. People’s rights were protected because staff knew and followed the requirements of the Mental Capacity Act. Where appropriate people’s mental capacity was established and the principles of the MCA were followed when people lacked the mental capacity to make specific decisions. Deprivation of Liberty safeguards were used appropriately.

People’s heath was promoted through good nutrition and people had access to health and social care professionals to ensure their on-going mental and physical health.

People were cared for by staff who knew them and cared for them in a manner that promoted their dignity and independence. Staff were kind and compassionate. Staff got people’s consent to care before care was provided.

People’s physical and mental health care needs were assessed and care plans were drawn up and reviewed on a regular basis. This was done to guide staff on how to best care for people. Where possible people or their representatives were involved in the planning of care. People’s social needs were considered and people had the opportunity to partake in activities such as gardening and quizzes. Those people who were not able to partake in these activates spent some time with staff. A hairdresser visited the service regularly.

There was a complaints system in place. People were aware of this and how to use it. The service had received many compliments. Visitors were welcome to freely visit the service.

The service was well led. There was an established workforce and staff turnover was low. The registered manager was available to people, staff and visitors and spent part of the day talking with people and staff. This enabled them to be aware of people’s changing needs and staff’s development. People confirmed they found the registered manager easy to talk with and said they were available should they be needed. No one we spoke with had any concerns or worries about the service.

Staff received regular supervision and were positive about how they were managed.

Systems were in place to review and where necessary improve the service. Accidents and incidents were monitored and where appropriate actions to reduce risks were taken.

Further information is in the detailed findings below.

This inspection took place on 9 February 2015 and was unannounced.

Whittington Care Home provides accommodation, nursing and personal care for up to 48 older adults. This includes people living with dementia. At our visit, 34 people were living in the home, including 26 people receiving nursing care. There is a registered manager at this service. 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 our last inspection in June and July 2014, we found that the provider’s staffing arrangements were not sufficient for people’s needs to be safely met or to protect them from the risks of unsafe or inappropriate care and treatment. We also found that people’s medicines and their health and personal care needs were not always being safely managed or met and that people’s consent was not always properly obtained or authorised for their care. These were breaches of Regulations 22, 13, 9 and 18 of the Health and Social Care Act 2008 (Regulation Activities) Regulation 2010. The provider told us about the action they were taking to address this and the registered manager sent us regular progress updates. At this inspection we found that the required improvements had been made.

People were protected from harm and abuse. People felt safe in the home and relatives and staff were confident that people received safe care in safe surroundings. All were confident and knew how to raise any concerns about people’s care and safety in the home if they needed to. Arrangements for staff recruitment and deployment were robust and sufficient to meet people’s needs.

People were safely supported and potential or known risks to their safety from their health conditions were identified before they received care. Action was taken to mitigate any risks to people’s safety through robust care and emergency planning arrangements. This informed staff about people’s health conditions and their related care and support needs.

People were supported to maintain and improve their health and their medicines were safely managed. People received sufficient and nutritious meals and they were safely supported to eat and drink. There were plans to review the use of aids and equipment to optimise people’s independence at mealtimes. External health professionals were consulted and staff followed their instructions for people’s care and treatment when required. Staff received the information, training and supervision they needed to perform their roles and responsibilities. Improvements were being made to develop and tailor people’s dementia care through staff training.

Staff understood and followed the Mental Capacity Act 2005 (MCA) to obtain people’s consent or appropriate authorisation for their care when required. People’s capacity to consent to their care was properly considered and decisions were appropriately made in people’s best interests when required.

People received care and prompt support from kind and caring staff who, knew them well and respected and promoted their rights. People’s relatives were asked for their views and they were appropriately involved in people’s care. People’s relatives knew how to raise concerns and complaints and they were kept informed and involved in people’s care. The provider actively sought people’s views about the care provided and listened and acted on what they said to make improvements when needed. Staff supported people to interact and engage with others in a way that met with recognised practice for dementia care.

People, relatives and staff were confident and positive about the management of the home and the on-going service improvements during the previous six months. The home was well managed and the quality and safety of people’s care, was regularly checked. This information was being used to inform, plan and make care and service improvements when required. Records were robust and safely stored. The provider notified us when important events occurred in the service when required.

Staff understood their roles and responsibilities and they were regularly asked for their views. Staff, were confident in the management and leadership of the home and they understood and were motivated by the recent care and service improvements.

During our visit, we were not able to speak in detail with people who lived at Whittington Care Home, due to medical conditions. We spoke with relatives of three of the forty five people using the service. They shared some of their experiences and their relatives’ experiences at the home. We spoke with three members of staff of different grades.

This is a summary of what we found.

Is the service safe?

We saw that people were being cared for in an environment that was safe and clean.

Staff personnel records contained the information required by the Health and Social Care Act 2008. This meant the provider could demonstrate that the staff employed to work at the home were suitable and had the skills and experience needed to support the people living there.

CQC monitors the operation of the Deprivation of Liberty Safeguards. The Deprivation of Liberty Safeguards (DoLS) are part of the Mental Capacity Act 2005. The aim is to make sure that people in care homes and hospitals are looked after in a way that does not restrict their freedom inappropriately. The safeguards should ensure that a care home or hospital only deprives someone of their liberty in a safe and correct way. This would only be done when it is in the best interests of the person and there is no other way to look after them. There were no authorisations restricting the freedom of anyone living at the home at the time we visited. The provider had policies and procedures in place and the DoLS Code of Practice was available for staff to refer to. Relevant staff understood when an application should be made and how to submit one.

Is the service effective?

The family members we spoke with told us that they were happy with the care their relative received and that their needs had been met. All spoke positively about the care their family member received and the staff who supported them. It was clear from what we saw and from speaking with staff that they had a good understanding of the care and support needs of the people using the service. We saw from the training records we viewed that staff had received training to enable them to meet the needs of the people living at the home.

Is the service caring?

We saw that the staff showed patience and gave encouragement when they were supporting people and that people were able to do things at their own pace and were not rushed.

Is the service responsive?

People’s needs had been assessed before they moved into the home. The records we saw confirmed that people’s preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people’s wishes. People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

Throughout our visit we found the atmosphere was homely. We observed how the staff and the people who used the service worked together and it was clear that there were good relationships between them.

We saw that people’s rooms were spacious, light and clean. People had personalised their rooms with their personal belongings. Their names were on the doors and some doors had knockers on them. We observed staff knocking on doors before entering people's rooms. We saw that rooms could be locked from the inside for privacy. There was a lift to safely transport people throughout the home. There were three dining areas and two lounges. These were spacious and light with large windows and doors leading to the gardens. The gardens were large with seating areas and some pets. There was a ramped entrance for easy access.

Is the service well-led?

We found from speaking with staff that they had a good understanding of the home’s values. They told us about their roles and responsibilities and they were clear about these. We saw that quality assurance processes were in place to make sure that the provider monitored the care provided and made improvements where necessary. For example, satisfaction surveys had been completed by people using the service and their families. The results had been analysed and were displayed in the home.

A variety of information was displayed, such as minutes of recent meetings with people who used the service, meetings with family members and the results of the recent satisfaction survey (as referred to above). We also noted that there were details of dignity in care and information about how staff could become a dignity champion, a mission statement and code of conduct. There was information about local wheelchair services and Alzheimer’s services. There were photographs on display of activities people had participated in, such as baking and skittles. Doors had large coloured pictures on them so that people could identify what the room was used for. There was a board with photographs of all the staff with their names and grades.

Many of the people who live at Whittington Care home have dementia. As a result we used an alternative method to assess how people were being treated and cared for.

We carried out a Short Observational Framework for Inspection (a SOFI) during this inspection visit. A SOFI inspevction involved observing activity in the care home for an hour over the lunch period. This enabled us to see how the staff spoke with people who live at the home, and how they offered help and support. Our observations showed that people were treated with respect, and that staff had positive relationships with the people who live at the care home.

At our last inspection visit on 3 April 2013 we identified concerns in three outcome areas – Respecting and involving people, Infection control and safety and suitability of premises. We found at this inspection visit that the concerns raised at the previous inspection had been addressed and the issues had been dealt with.

We also received information of concern relating to people being treated with dignity and respect and offered choice. We considered those concerns alongside the concerns raised at our inspection visit of 3 April 2013.

At the time of our visit there were 41 people receiving care or treatment in the home. As all of the people living in the home had dementia, it was not possible to consistently obtain their views about their care and treatment. As a result we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. We observed that people’s privacy and dignity was respected by staff and that staff were positively engaging with people whilst providing support and assistance throughout the home.

People’s needs were assessed and people received care that ensured their safety and welfare. We saw that people reacted positively to staff. We found that care records were completely accurately and stored securely, however they did not always contain person centred information, such as people’s preferences for their care.

We found that people were being care for in a clean, hygienic environment however there were a number of areas of the home in need of refurbishment.

There were appropriate systems in place to identify and manage the risks to the health, safety and welfare of people using the service and others, including regular audits.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a Care Quality Commission (CQC) inspector joined by an Expert by Experience who has personal experience of using or caring for someone who uses this type of service.

People who used the service lived with varying levels of dementia, so not everyone was able to tell us about their care and support. To help us understand people's experiences we used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people who could not talk with us.

We saw examples of staff treating people with respect for their dignity. We observed staff explaining to people what action they were taking, for example, when transferring a person using the hoist. Staff told to the person what they were doing, and reassured the person throughout the procedure. However, we also observed times when staff did not respect people’s dignity as they did not interact at all with the person or explain what they were doing when using the hoist.

Everyone spoken with spoke very highly about the food provided. One person told us, “It’s the best food I’ve ever had.” Another said, “You’re really spoiled in here with the food.” The four people spoken with told us they looked forward to all their meals and a choice was always offered. One person told us, “You can always have sandwiches if you don’t fancy a big meal.” Everyone spoken with was happy with the times of the meals and refreshments.

We saw care workers asking people what choice they would like from the menu, and showing people pictures of the meals to help them make a choice. This practice supported people with dementia and communication needs to make a choice about their meal. We observed people being supported with eating and drinking, where appropriate, and the support was not rushed.

All four people told us they were happy living at Whittington Care Home. Three people told us they felt safe, but one person did not, following a recent incident. They knew this was unlikely to happen again as staff had put appropriate safeguards in place, but they still felt nervous.

Staff had a good understanding of the forms of abuse people would need protecting from. They knew how to use the procedures in place to identify and prevent abuse occuring. Staff told they us they had no concerns to share with us about any risks to the safety of people who used the service.

Two of the people spoken with and all of the relatives felt at times the staff seemed very busy and one person said, They could do with another couple of staff when it’s busy.” However, no one spoken with had personal experience of staff not being able to meet their own care needs. Staff told us they thought the staffing levels were sufficient to meet people's needs.

We saw that people's nutritional needs and risks was assessed. We saw that if people were identified as at risk of losing or having lost weight, food and fluid diaries were kept. These diaries were not always completed in detail or for across the 24 hour period.

We carried out a responsive inspection of Whittington Care Home on 11, 12, 26 June and 4 July 2014, because of concerning information we received about staffing levels and the safety of people’s care there. There were 34 people receiving nursing care, which included nine people receiving continuous nursing care and 12 people receiving personal care.

All of the people living at Whittington Care Home were living with dementia and most were not able to tell us about their care and experiences. Because of this, we spent time observing how staff interacted with and supported people and spoke with staff and some people’s relatives about the care provided. We also looked at the arrangements for people’s medicines and some records, which included people’s care plans and staffing records. Below is a summary of what we found.

Was it safe?

We found that the staff did not always follow the Mental Capacity Act 2005 to make sure that people were asked for their consent before they received care. Where people did not have the capacity to consent, the provider did not always act in accordance with legal requirements. We saw some staff assisting and supporting people safely and in a way that met with their needs and known preferences. This included supporting people with their mobility needs and meals and drinks. However, we found that people’s care was not always planned and delivered in a way that was intended to ensure their safety and welfare.

People’s care records that we looked at had showed they had a range of health conditions and disabilities, which could present risks to their welfare and safety. We found that people’s risk assessed needs and written care plans were not always kept up to date or revised where changes were needed. This included nutrition, wound care, hygiene and continence needs. Records were not properly completed about peoples' nutrition and fluids or to confirm they had been turned over in bed, where this was needed. People were not fully protected against the risks associated with unsafe medicines practice because the provider did not have wholly appropriate arrangements in place to manage medicines. The provider had not ensured that there were, always enough qualified, skilled and experienced staff to meet people’s needs and to ensure cleanliness and hygiene in the home. This meant that insufficient staffing arrangements had a negative impact on people’s care and placed them at risk from unsafe or inappropriate care.

Was it effective?

People’s care plans did not account for their individual type of dementia or provide information about this to help staff understand how each person’s condition affected them. We saw that one person’s care plan stated that staff needed to ‘promote their mental health needs and assist the person with decision making.’ However, there was no description for staff, about what the person’s mental health needs were or how staff should to assist them.’ There was no formal method used to carry out a needs analysis and risk assessment, as the basis for deciding sufficient staffing levels.

Was it caring?

Three people’s relatives told us that staff, were caring and helpful. One person said; ”Staff are fantastic; they work really hard and are so caring.” We saw that staff mostly interacted in a respectful manner with people and at a relaxed pace, which ensured their dignity and privacy. We saw that some staff interacted with people, in a manner which recognised and supported each person’s own reality and experiences, which is important for people living with dementia. However, we saw three occasions where staff ignored people, who were not able to directly verbalise their needs, but who were trying to communicate their needs with them. During the course of our visit we saw that some people were unshaven. Many wore clothing that was soiled or marked and/or had no foot wear on.

Was it responsive?

People’s relatives we spoke with all felt that meaningful social and recreational activities for people were lacking and did not readily meet with their dementia care needs. We did not see staff engaging people in any social or recreational activities during our visit. People’s recorded needs assessments did not consistently account for their communication needs or their social, cultural and lifestyle needs and preferences. One person’s relative told us they had made a complaint to the manager as they had sometimes visited and found the person wearing soiled clothing or other people’s clothing. They said their complaint had not been properly acted on. We spoke with the manager, who confirmed they had received the complaint but that this had not been recorded in their complaints record, or acted on.

Was it well led?

We looked at the provider’s monthly risk monitoring report dated 15 May 2014, of their checks of the quality and safety of people’s medicines. The report showed that medication audits (checks) were regularly carried out by the deputy manager, but the system used for checking medicines was not robust enough. From this, a revised auditing method was introduced, to include daily medicines audits. However, we found these were not being completed. The manager told us that the number and needs of people living in the home rose considerably during April and May 2014 and that staffing levels and skill mix had not been properly adjusted meet with care demand from this. The registered manager was a general manager. There were only two full time nurses employed to work in the home, with reliance on the planned use of agency staff. Three additional nurses, including a clinical lead had been recruited and were due to commence work in the home, subject to required vetting checks. There was no clinical nurse lead, because the established senior nurse clinical lead had moved from Whittington Care Home to work in another of the provider’s registered homes. We looked at the provider’s investigation analysis report and action plan relating to an accident and serious injury to one person living in the home in April 2014. This was also investigated by local authority safeguarding vulnerable adults’ procedures. The provider’s report showed that staffing resources and work conditions contributed directly to the incident. The action taken by the provider as a result of their investigation findings did not include staffing resources.