Arbory Residential Home

Arbory Residential Home is a care home providing accommodation and personal care to up to a maximum of 60 people. The home does not provide nursing care. At the time of our inspection there were 39 people using the service, most of whom were living with dementia.

The accommodation at Arbory Residential Home is arranged over 2 buildings. The Lodge has accommodation over 2 floors and is an older building that has been repurposed into a care home. The Court is a newer, purpose built building where the accommodation is arranged over 3 floors. There are communal lounges, dining areas and a garden area.

People’s experience of using this service and what we found

We continued to find concerns about how some risks were assessed, monitored, and mitigated. There were still insufficient numbers of staff deployed to meet people’s needs at all times. Staff understood how to protect people from avoidable harm or abuse. Some reviews and investigations into incidents could have been more thorough to help ensure every opportunity for learning was taken.

Legal frameworks regarding consent, were still not being implemented fully. The premises and equipment within it were still not well maintained. Staff did not consistently receive an induction or probationary reviews. Work was underway to embed a more comprehensive programme of supervision. Whilst the provider offered staff a range of training which most staff were up to date with, a number of staff told us they would value more face to face training. Some care plans lacked completeness or contained conflicting information whilst others were more reflective of people’s needs. Improvements were needed to develop better partnership working with healthcare professionals to meet people’s healthcare needs.

We have made a recommendation that staff inductions, and the supervision program are developed in line with best practice guidance.

People were not consistently receiving person centred support and did not have access to meaningful activities on a regular basis. Governance systems were in place, and there was evidence local leaders were working hard to deliver improvements, however, many of the required improvements had been hindered by continued shortfalls in staff across all departments. Improvements to the environment were underway, but more needed to be done to deliver these within a suitable time scale to ensure people’s care and support was provided in a safe, clean, and well maintained environment.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 8 February 2023). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about the quality and safety of people’s care, the cleanliness of the home and staffing levels. A decision was made for us to inspect and examine those risks. As a result, we undertook this focused inspection to review the key questions of safe, effective, and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service remains requires improvement.

We have found evidence the provider needs to make improvements. Please see the safe, effective, and well led key question sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Arbory Residential Home on our website at www.cqc.org.uk.

Enforcement and recommendations

We have identified continuing breaches in relation to the suitability of the premises, consent, safe care, and treatment, staffing and governance. We identified 1 new breach in relation to person centred care.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Arbory Residential Home is a care home providing personal care to up to a maximum of 60 people. The home does not provide nursing care. At the time of our inspection there were 42 people using the service, some of whom were living with dementia. The accommodation at Arbory Residential Home is arranged over 2 buildings. The Lodge has accommodation over 2 floors and is an older building that has been repurposed into a care home. The Court is a newer, purpose built building where the accommodation is arranged over 3 floors. There are communal lounges and dining areas and a secure garden area.

People’s experience of using this service and what we found

Staff had not always assessed, monitored and managed people’s safety well and some environmental risks were not being adequately managed. There were insufficient numbers of staff deployed to meet people’s needs. Medicines were administered by suitably trained staff and in a person centred manner, but some improvements were needed to ensure that people always received their medicines as prescribed. Visiting could take place flexibly and booking was no longer required. Staff understood how to protect people from avoidable harm or abuse. Staff understood their responsibility to report safety related incidents. Some reviews and investigations into incidents could have been more thorough to help ensure every opportunity for learning was taken.

Improvements were needed to ensure that the MCA was fully understood and implemented in line with legal frameworks. The provider had not ensured that the premises and equipment within it were clean, secure and properly maintained. There was evidence that the provider was investing in the service and was undertaking a refurbishment programme, staff told us this was starting to make a difference. We saw some positive interactions where care and kitchen staff were encouraging and supportive when helping people to eat and drink. However, we also saw some examples, where the lunch service was more chaotic, and less person centred. The provider had not ensured that all staff received an induction when they first starting working at the service. There was no embedded programme of supervision being used to develop and motivate staff and review practice and performance. The provider offered staff a good range of training and most staff were up to date with this. Some care plans lacked completeness or contained conflicting information whilst others were more reflective of people’s needs. Staff worked with health care professionals to meet people’s healthcare needs.

Governance systems had not been operated reliably or effectively the provider had not maintained adequate oversight of the quality and safety of all aspects of people’s care. Statutory notifications had not been submitted appropriately to CQC. The provider has implemented a number of changes to address this. Feedback about the new manager was positive. Staff expressed a growing confidence that they were trying to make improvements. Permanent staff knew people well and promoted their independence. However, more needed to be done to ensure that a varied and meaningful programme of activities was provided.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was good (published 24 December 2020).

Why we inspected

We received concerns in relation to the quality of people’s care, the management of falls, the cleanliness of the home, staffing levels and the quality of the food. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement with 6 breaches based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well led key question sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Arbory Residential Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to safe care and treatment, governance, staffing, the premises and the need for consent. We also identified a breach due to the lack of notifications.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Arbory Residential Home had been identified for use by the local authority as a designated care setting in response to the Winter Plan for people discharged from hospital with a positive Covid-19 status with 19 beds available. During this inspection we only looked at the identified designated setting. At the time of inspection there was no one staying in the designated care setting which is one floor with a separate entrance and lift.

We found the following examples of good practice.

There was a separate entrance, exit and lift for the designated setting. There was a separate entrance to the laundry and clear procedures in place to ensure laundry from designated setting will only be taken to the laundry after all other laundry has been completed.

The provider has learnt from their other designated settings that people tend to not stay very long, five to six days on average. People come with an onward plan already in place so the provider will liaise with the relevant people to support transition.

The provider will support people to maintain their skills as much as possible; the aim will be for people to leave with the same skills they had on going into hospital (as they are aware that there may have been a decline as a result of hospital stay and they may need additional support). They will assess people on an individual person centred basis and provide a detailed risk assessment.

The provider had also identified, from their other designated settings, that people’s contact with relatives had been inconsistent by the time they come to them. One of the first things they do is support people to call/contact their relatives. Setting up chat calls to family they found was a really important part of settling in.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Further information is in the detailed findings below.

The Arbory is a care home, without nursing, accommodating up to 60 people. The accommodation is arranged over two separate units. The Lodge is a converted manor house and supports people living with dementia and mental health needs. The Court is a purpose-built extension focusing on supporting people living with dementia. People have their own rooms and access to communal areas such as lounges and dining areas. There is a garden and a central patio. The Arbory is owned by Coate Water Care who, throughout this report, are referred to as the provider. Coate Water Care took over the management of the Arbory in April 2019 and since that time have been undertaking a programme of improvement and refurbishment which is ongoing. At the time of our inspection there were 46 people using the service.

People’s experience of using this service and what we found

We identified some concerns regarding the systems in place relating to the administration and documentation of medicines. The registered managers are acting to address these concerns.

During the inspection we observed that there were sufficient staff available to meet people's needs in a patient and non-hurried manner. Staff provided mixed feedback about staffing levels, but we did not identify evidence to suggest safety was compromised. Some staff also expressed a lack of confidence with managing behaviours which might challenge and felt this was an area where further training would be helpful.

Improvements were needed to ensure that all of risks relating to the premises were managed effectively. We have made a recommendation that the provider review their legionella risk assessment in line with relevant guidance. Risks relating to people’s health and wellbeing were assessed and planned for.

The provider had invested in developing the environment, for example, they had installed a new laundry and specialist bathing facilities. Work was underway to redecorate and refresh communal areas and 50% of bedrooms had so far been completed. The provider had an ongoing refurbishment plan to continue to address the areas which were worn or in need of updating.

We saw a number of areas of good practice in relation to infection control and with regards to the management of risks relating to COVID 19.

Records were kept of incident and accidents that had occurred within the service. The managers monthly report did include an analysis of incidents and accidents and provided some evidence of learning from incidents and actions taken in response.

Staff displayed a commitment to protect people from harm and the registered managers had developed a safeguarding tracker to effectively monitor the progress of safeguarding alerts and the outcomes of these in terms of learning.

Where there was doubt about people’s ability to make significant decisions about their care, mental capacity assessments had been completed to check whether people could consent to the care and support being provided.

A range of audits, checks and meetings took place on a regular basis. These helped to ensure that the registered managers and provider maintained oversight of care quality indicators and emerging risks within the service. Despite these systems, there had been missed opportunities to utilise these governance arrangements to their full potential in terms of driving improvements.

The feedback about the registered managers was consistently positive and demonstrated that people, their relatives and health care professionals had faith and confidence in their ability to ensure the delivery of person-centred care. Staff told us they felt valued, that morale and team work was generally good. Staff were confident that they could raise concerns with the registered managers and that these would be addressed.

The registered managers told us they worked effectively together and shared ideas which helped them to perform well and achieve their best. Both felt well supported by the provider who they said had brought a range of improvements to service since they took it over in April 2019.

The leadership team were well supported by the provider who proactively sought opportunities to develop the skills and knowledge of the leadership team and of staff. A future leader’s course was offered by the provider to develop staff who displayed potential and ambition to progress within the organisation.

The service worked in partnership with other organisations to meet people’s needs and develop its staff.

Rating at last inspection (and update)

The last rating for this service was good (Published April 2018).

Why we inspected

We carried out this unannounced, focussed, inspection of this service on 11 November 2020 as we had received a number of concerns and complaints about the service. We needed to assure ourselves that the service was safe and well led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

This report only covers our findings in relation to the key questions safe and well-led. We reviewed all the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.

The ratings from the previous comprehensive inspection for those key questions were not looked at on this occasion and were used in calculating the overall rating at this inspection.

The overall rating for the service has remained the same. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for the Arbory on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service and we will continue to work with partner agencies. We will return to visit in line with our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Arbory Residential Home 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.

The Arbory Residential Home accommodates up to 60 people who are living with dementia. Accommodation is in two adjoining buildings, the Court, a purpose built three storey extension and the Lodge, an adapted building over two floors both were accessible with stairs and passenger lifts. There are extensive accessible grounds and gardens. When we inspected 58 people were living at the service.

There was a registered manager in post. A registered manager 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 were kept safe from harm and staff were trained in safeguarding and knew how to report concerns. Risks were assessed and actions taken to minimise residual risks without impacting on people’s rights.

There were sufficient trained staff deployed to support people and provide high quality care. Recruitment practices were robust and appropriate checks and training were in place before staff commenced in post.

People were supported to maintain their health and well-being and their nutritional needs were met.

People were given choices and control over their lives. The service complied with the principles of the Mental Capacity Act and Deprivation of Liberty Safeguarding. Controls in place were in the best interest of people and were the least restrictive option.

Positive working practices were in place with other professionals such as district nurses, community psychiatric nurses and GP’s. A multi-disciplinary approach was taken when risk assessing and care planning.

Medicines were safely managed. Staff were trained in giving medicines and were checked for competence before administering them unsupervised.

There were activities to involve and entertain people both within the home and the local community that were appropriate to their needs.

People received person-centred care that was delivered with kindness and compassion. Staff were caring and empathetic towards people. Behaviours were managed as ‘fear behaviours’ and staff changed their approach to support people.

There was a positive and inclusive culture in the service. The service’s ethos was to provide a home, not a care home and people were friends and not patients. This was embedded in and evident in staff practice.

The Arbory Residential Home is a care home on the outskirts of Andover, Hampshire. The home is registered to provide accommodation and personal care for up to 60 older people who may be living with dementia. The home is made up of two buildings; The Court and The Lodge. At the time of our inspection 58 people were living at the service.

There was 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.

Although staff were able to tell us about the strategies used to keep people safe, risk assessments relating to behaviours that challenged were not always robust and require improvement.

People told us that they felt safe. Staff had a good understanding about the signs of abuse and had confidence in their manager to take concerns raised seriously.

People were supported by staff that had the skills and knowledge to meet their assessed needs. Staff received a thorough induction before they started work.

The provider had employed skilled staff and took steps to make sure care was based on local and national best practice. Information regarding diagnosed conditions was documented in people’s files.

Recruitment practices were safe and relevant checks had been completed before staff commenced work. Staff worked within good practice guidelines to ensure people’s care, treatment and support promoted good quality of life.

The provider had appropriate arrangements in place to assess people’s capacity to make decisions about their care and treatment. Staff were knowledgeable about the requirements of the Mental Capacity Act 2005. Fifteen people were subject to DoLS at the time of our inspection and the registered manager was in the process of making more referrals to the local authority for DoLS assessments.

People who required assistance to eat and drink were supported effectively. Appropriate assessments had been conducted for anyone who had difficulty in swallowing their food. Interactions between staff and people during meals times were respectful and dignified.

Multi-disciplinary teams including mental health workers and occupational health were involved in reviewing and updating people’s risk management plans.

Medicines were managed safely. Any changes to people’s medicines were prescribed by the service’s GP and psychiatrist. People were involved before any intervention or changes to their care and treatment were carried out.

People had access to activities that were important and relevant to them. Records showed people’s hobbies and interests were documented and staff accurately described people’s preferred routines. There was a range of activities available within the home and community.

The provider actively sought, encouraged and supported people’s involvement in the improvement of the service. People’s care and welfare was monitored regularly to make sure their needs were met within a safe environment. The provider had systems in place to regularly assess and monitor the quality of the service provided.

People told us the staff were friendly and management were always visible and approachable. Staff were encouraged to contribute to the improvement of the service. Staff told us they would report any concerns to their manager and said the management and leadership of the service very good and very supportive.

At this visit we saw that people were supported patiently and sensitively to eat and drink sufficient quantities. We spoke with two people who used the service and the relatives of three people who all commented positively about the standard and choice of meals. One person when asked about the food at Arbory said: 'It is extremely good we couldn't get better, we've got a new chef and he is absolutely great.'

The mealtimes we observed appeared well organised with sufficient staff available to provide support for those people who could not eat or drink independently.

At this inspection we saw that there had been appropriate assessments of people's capacity. Where there had been doubt about a person's ability to make a particular decision at a certain moment in time a Mental Capacity Act 2005 (MCA) assessment had taken place.

We had received concerns about the care being provided at the home. This led us to look at the way people's care had been assessed planned and delivered. Staff we spoke with demonstrated their knowledge of the care and support plans and people's individual needs. This included social, emotional and health related needs. We observed that staff interacted positively with people using the service and communicated effectively with them.

During our observations at this inspection we became concerned about the how people were being supported at mealtimes. Where people received one to one support to eat their meals this was provided in a patient and sensitive way. However people were not always provided with appropriate support to eat and drink sufficient quantities.

At this visit we looked at all areas of the home and looked at how the infection control systems were working. We found that the provider had completed all the improvements they told us about in their action plan. Floor coverings had been replaced in some areas and new cleaning equipment had been purchased.

We spoke with seven people who lived at the home and six relatives. Everybody was very positive about the care that was provided at The Arbory. One of the people we spoke with told us: "I have been here about a year and we are well looked after". One of the relatives we spoke with told us: "There is nothing here to find fault with".

We carried out two visits, one during the week arriving while night staff were still on duty and one on a Saturday afternoon. This gave us the opportunity to see how the home operated at different times with different staffing levels. We judged that there were sufficient staff to meet people's needs. People were being supported in a calm unhurried way. Staff told us: "We work as a team now".

We were aware of odours that existed in parts of The Lodge. Staff told us that 'deep cleans' were carried out on a regular basis and at other times when necessary. Cleaning schedules showed that carpets were shampooed regularly however this had not effectively removed the odour.

We used a number of different methods to help us understand the experiences of people using the service because the people had complex needs which meant they were not able to tell us their experiences. We observed interactions between staff and the people living at the home.

Staff told us that they had put a lot of work into developing care plans. One member of staff told us: 'We have worked hard to make improvements, the biggest improvement is with the care plans and risk assessments, they are all reviewed and audited.'

Staff we spoke with were clear about how to recognise signs of abuse and how they would report any concerns they may have. Overall staff were very positive about the support they received and felt they could discuss any issues they may have with the registered manager. One staff member said of the registered manager: 'Their door is always open.'

Relatives had been asked to complete a questionnaire about the service. Comments were generally positive about the care and support provided by the home. We saw that the registered manager had taken action to address any concerns that had been raised.

Most of the relatives we spoke with said they were happy with the care the home provided. However we had concerns as some care plans and risk assessments did not contain relevant information relating to people's care or support needs.

One relative told us that when they visited they were often invited to join their family member for a meal. They said 'the meals are really good'.

Staff were knowledgeable about the various types of abuse. Training in safeguarding had also been made a priority for staff. However we found that not all incidents were reported to the relevant authorities appropriately.

One relative told us "Since the change of management things have improved. Staff are more motivated and professional in their approach."

Staff felt supported by senior staff but not everybody had taken part in formal supervision or appraisal. Although this was identified at our last inspection staff supervision had still not taken place for all staff.

The provider had carried out some quality monitoring of the service and had sought the advice of relatives about the running of the home. However information received through audits, surveys, reports and monitoring was not always acted upon.