inspection report · when you read this report, you may find it useful to read the sections towards...

| Inspection Report | Potton House | May 2014 www.cqc.org.uk 1

Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

Potton House

Potton Road, Biggleswade, SG18 0EL Tel: 01767314782

Date of Inspection: 22 April 2014 Date of Publication: May 2014

We inspected the following standards as part of a routine inspection. This is what we found:

Consent to care and treatment Action needed

Care and welfare of people who use services Action needed

Cleanliness and infection control Action needed

Requirements relating to workers Met this standard

Staffing Action needed

Assessing and monitoring the quality of service provision

Action needed


Details about this location

Registered Provider Health & Care Services (NW) Limited

Registered Managers Ms Ida Antwi

Ms Mandy Parsons

Overview of the service

Potton House is a nursing home that provides accommodation and nursing care for up to 24 older people living with dementia.

Type of service Care home service with nursing

Regulated activities Accommodation for persons who require nursing or personalcare

Diagnostic and screening procedures

Treatment of disease, disorder or injury


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 6

More information about the provider 7

Our judgements for each standard inspected:

Consent to care and treatment 8

Care and welfare of people who use services 11

Cleanliness and infection control 14

Requirements relating to workers 16

Staffing 17

Assessing and monitoring the quality of service provision 19

Information primarily for the provider:

Action we have told the provider to take 21

About CQC Inspections 24

How we define our judgements 25

Glossary of terms we use in this report 27

Contact us 29


Summary of this inspection

Why we carried out this inspection

This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, carried out a visit on 22 April 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific wayof observing care to help us understand the experience of people who could not talk with us.

What people told us and what we found

Our Inspector gathered evidence to help answer five key questions; Is the service safe? Is the service effective? Is the service caring, Is the service responsive? Is the service well led?

Below is a summary of what we found based on the evidence gathered during our inspection carried out on 22 April 2014. This included speaking with people who used the service, some of their relatives and members of staff who supported them and by looking at records.

The detailed evidence that supports our findings can be read in the full report.

Is the service safe?

We saw that risk assessments had been completed and regularly reviewed in relation to a range of issues relevant to people's care needs. These included assessments relating to the management of medicines, nutrition and hydration, mobility, physical and mental health.

However, we saw that not everybody who lived at the home appeared to have received care and support at a time that best suited them or their individual needs and personal circumstances. Many people remained in bed throughout the morning of our inspection as they required the support of two members of staff to help them get up and complete their personal care.

One member of staff said, "We are still getting people up and its past lunchtime so dinner will be pushed back. We don't have time to chat [with people] or do one to one work or


activities. We do eventually meet people's needs but mostly it's late and not necessarily when they need it"

A range of policies had been put in place that gave staff guidance, information and advice about infection control practices and procedures. We also looked at records which showedthat most staff employed at the home had received infection control training. Members of staff confirmed they had received training appropriate to their role and were knowledgeable about the infection control procedures used at the home.

However, during our inspection we toured the home and checked people's bedrooms, including their en-suite facilities, toilets, bathrooms and communal areas. We found that in some areas the required standards of cleanliness and hygiene had not been met. For example, the carpets and toilet bowls in some bedrooms were dirty and heavily stained.

We saw that effective recruitment policies and procedures were in place to ensure that staff employed at the home were of good character and appropriately skilled to meet people's needs. This included carrying out appropriate checks before staff began work.

Most of the people we spoke with during our inspection expressed concerns that staffing levels had not always been sufficient. A relative of a person who lived at the home said, "They [the provider] need more staff. Often I need assistance but can't find anyone because they are all too busy."

Is the service effective?

During our inspection we saw that staff explained to people what was happening by using a range of both verbal and non-verbal communication methods. They made efforts to establish people's wishes and obtain their consent before care and support was provided.

However, we looked at the 'Do Not Attempt Cardio Pulmonary Resuscitation' (DNACPR) records in respect of five people who lived at the home. In all cases we found it unclear as to whether or not valid consent about the decision not to resuscitate had been properly obtained in line with the provider's own policy, published guidance and the Mental Capacity Act (MCA) 2005.

We looked at care records relating to seven of the 24 people who lived at the home. We saw that people's individual care and treatment needs had been assessed, documented and reviewed on a regular basis. They were personalised and gave staff clear guidance about the care and support people needed in most cases.

However, some relatives expressed concerns about the length of time it had taken to get people up and the delays experienced in meeting their care and support needs. One relative commented, "I often arrive late afternoon and they [staff] are still getting people up.They meet my [family member's] needs but are always late doing so."

Is the service caring?

During our inspection of Potton House we saw that in most cases the people who lived at the home were supported in a kind and caring manner. We spoke with staff who demonstrated a good knowledge and understanding of people's individual welfare requirements, health needs and personal circumstances.

Most people who were able to communicate with us said they were happy at the home and


had been well looked after. One person told us, "I love it here. The staff are absolutely first class. They work wonders and I get looked after very well." A relative commented, "I think people are well looked after in general. They are very good at getting doctors in quickly if there is a problem and following up on medical issues. All of the staff are dedicated, caringand good."

However, when we observed lunch being provided in the communal dining room we saw that staff were rushed and that people were not offered a choice of meal or drink.

Is the service responsive?

The provider had put a complaints policy and procedure in place. People told us they knewhow to complain if the need arose and we saw that information and guidance about the process had been prominently displayed in communal areas.

Staff told us that some of the people who lived at the home frequently displayed challenging, aggressive and occasionally violent behaviour towards other people and staff.We looked at the care records relating to one person who had displayed such behaviour on a regular basis.

Most of the care plans made reference to behaviour that often resulted in the person acting aggressively or violently in a way that made both them and others vulnerable to injury. Some plans gave staff guidance on how to deal with challenging behaviour if it arose, for example through distraction or by encouraging the person to go elsewhere in thehome. However, we saw that plans had not been put in place to help staff recognise potential triggers to aggression or effectively manage the the behaviour.

Is the service well led?

The provider had some arrangements in place to identify and manage risks to people who used the service and to monitor and assess the quality of care and support they provided.

However, we were told that some weeks prior to our inspection the manager had been given the additional responsibility of managing another care home which meant that the leadership and management at Potton House may not have been as consistent and effective as it could have been.

We found that some of the systems used had not always been effective at protecting people against the risks of inappropriate or unsafe care and treatment. For example, audits had been carried out in relation to the environment and infection control. However, we found that problems identified with poor cleanliness and hygiene had been been responded to or dealt with effectively.

You can see our judgements on the front page of this report.

What we have told the provider to do

We have asked the provider to send us a report by 03 June 2014, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.

Where providers are not meeting essential standards, we have a range of enforcement


powers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Consent to care and treatment Action needed

Before people are given any examination, care, treatment or support, they should be asked if they agree to it

Our judgement

The provider was not meeting this standard.

It was not clear in all cases whether before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

Where people did not have the capacity to consent, the provider had not acted in accordance with legal requirements in all cases.

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.

Reasons for our judgement

Most of the people who lived at Potton House at the time of our inspection lived with significant dementia related needs. Some people were either unable to communicate or experienced difficulty in communicating verbally. We spoke with people who were able to tell us about their experiences of the home, some people's relatives and members of staff. We observed how staff supported people in various situations throughout the home and looked at people's care records.

During our inspection we saw that staff explained to people what was happening by using a range of both verbal and non-verbal communication methods. They made efforts to establish people's wishes and obtain their consent before care and support was provided. One person who lived at the home said, "Although [they are] very busy, the staff always ask me about what I need or want to do. I am quite free to decide how I spend my time. They [staff] help me when I ask."

A relative of a person who lived at the home told us, "It's very difficult but staff do try their best to find out what [family member] wants." A relative of another person commented, "They [staff] all talk to [family member] and try and involve them as much as possible….they have got to know people really well which helps them figure out what they want and need."

The provider had put policies in place dealing with how consent should be obtained and documented before care, support or treatment was provided. These included information about how consent should be obtained in circumstances where people lacked the mental


capacity necessary to make their own decisions. We saw that the policies reflected both published guidance and the requirements of the Mental Capacity Act (MCA) 2005.

We looked at records which showed that most staff employed at the home had received MCA 2005 awareness training. One member of care staff told us, "I have had my mental capacity training. [We] give people choice about what they want to do….we involve people and their families."

A senior member of staff told us that advanced decisions, about what action should be taken in the event of a life threatening medical emergency, had been obtained and documented in respect of 19 out of the 24 people who lived at the home. Documents known as 'Do Not Attempt Cardio Pulmonary Resuscitation' (DNACPR) had been used to record decisions made by either the people concerned or representatives legally entitled toact on their behalf.

We looked at the DNACPR records in respect of six people who lived at the home. In all cases we found it unclear as to whether or not valid consent about the decision not to resuscitate had been properly obtained in line with the provider's own policy, published guidance and the MCA 2005.

For example, we saw that a mental capacity assessment form had been partially completed in respect of one person who lived with dementia and who had a DNACPR in place. Entries on the form indicated that the assessment had been carried out in order to determine whether the person had sufficient capacity to make decisions about their care and treatment.

However, sections of the form used to record key elements of the capacity test, the best interest checklist and whether or not the person lacked capacity had not been completed. This meant that it was unclear if the person concerned had the capacity necessary to make their own decisions about not only the care and treatment they received but also the DNACPR.

We looked at the DNACPR form relating to the same person and saw that the section used to record their involvement in the decision had not been completed. Another entry on the form indicated that a relative of the person had agreed to the decision. However, it wasnot clear from the information provided whether the person concerned lacked the capacity necessary to make their own decision or whether the relative had been legally entitled to act on their behalf.

Entries in the other DNACPR records we looked at were equally unclear as to whether or not the people concerned had capacity to make their own decisions. It was also unclear, incases where decisions had been made by people's relatives, whether or not they had beenlegally entitled to do so in the circumstances. This meant that suitable arrangements had not been put in place to ensure that valid consent was obtained and that the requirements of the MCA 2005 were followed in all cases.

We also looked at the care records relating to seven people who lived at the home. We saw that in most cases, sections of the care plans used to record people's signatures, or other evidence of their consent or agreement to the care provided, had not been completed.

We saw that people's care plans and risk assessments had been reviewed and re-


evaluated on a regular basis. However, we saw little or no evidence that people, or representatives legally entitled to act on their behalf, had either been involved in the process or had provided their agreement or consent.

This meant that was unclear whether or not valid consent had been obtained regarding thesupport, care or treatment people had received.


Care and welfare of people who use services Action needed

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement


Care and treatment had not always been planned and delivered in a way that ensured people's safety and welfare.



During our inspection we saw that in most cases people who lived at the home were supported in a kind and caring manner. We spoke with staff who demonstrated a good knowledge and understanding of people's individual welfare requirements, health needs and personal circumstances.

Most people who were able to communicate with us said they were happy at the home andhad been well looked after. One person told us, "I love it here. The staff are absolutely first class. They work wonders and I get looked after very well." A relative of a person who livedat the home commented, "I think people are well looked after in general. They are very good at getting doctors in quickly if there is a problem and following up on medical issues. All of the staff are dedicated, caring and good."

A GP who frequently visited the home told us they had no concerns about the levels of care and treatment that people received at the home. They commented, "Requests for our services are appropriate and timely. They [staff] follow our advice and guidance. Nursing isgood and the carers are excellent."

We looked at care records relating to seven of the 24 people who lived at the home. We saw that people's individual care and treatment needs had been assessed, documented and reviewed on a regular basis. They were personalised and gave staff clear guidance about the care and support people needed in most cases. This included detail about people's dietary requirements, continence and mobility needs, personal care, medicines and health needs.

We saw that risk assessments had been completed and regularly reviewed in relation to a range of issues relevant to people's care needs. These included assessments relating to the management of medicines, nutrition and hydration, mobility and mental health.

Records also showed that people had access to specialist health care where necessary and appropriate. For example, we saw that people had been supported by speech and


language therapists, community dieticians, podiatrists and mental health workers. We also saw that people had been given access to opticians and dental care.

However, we saw that not everybody who lived at the home appeared to have received care and support at a time that best suited them or their individual needs and personal circumstances. Many people remained in bed throughout the morning of our inspection as they required the support of two members of staff to help them get up and complete their personal care.

For example, we saw that two people remained in bed until they were helped to get up by staff at 1:25 pm. Staff told us there was not a fixed time for lunch as it depended on how long it took them to get people up and complete their personal care. One member of staff said, "We are still getting people up and its past lunchtime so dinner will be pushed back. We don't have time to chat [with people] or do one to one work or activities. We do eventually meet people's needs but mostly it's late and not necessarily when they need it."

Another member of staff commented, "Most people have breakfast in their rooms. We struggle to get everybody up by two [pm]. It's not their choice, some would like to get up but it takes us too long. Most people need two carers and others have very challenging behaviour. People are calling out and pushing call bells but there is only so much we can do."

We spoke with relatives who also expressed concerns about the length of time it had takento get people up and the delays experienced in meeting their care and support needs. Onerelative told us, "I am concerned that they [staff] are getting people up very late. I have mentioned this before at meetings and reviews….at lunchtime very few people are actuallyup." A relative of another person commented, "I often arrive late afternoon and they [staff] are still getting people up. They meet my [family member's] needs but are always late doing so."

We looked at care records for two people who were not supported to get up and complete their personal care until after 1:00 pm. We saw that both had been assessed as being at a very high risk of developing pressure sores due to their physical health, continence and mobility needs. An entry in one of their care plans highlighted the importance of encouraging and supporting mobility in light of the risks identified. This meant that people may not have received effective care and support that best suited their individual needs in all cases.

Staff told us that some of the people who lived at the home frequently displayed challenging, aggressive and occasionally violent behaviour towards other people and staff.We looked at the records relating to one person who had displayed such behaviour on a regular basis.

Most of the care plans we looked at made reference to the person acting aggressively or violently in a way that made both them and other people vulnerable to injury. We saw that some of the plans gave staff basic guidance on how to deal with the challenging behaviour should it arise but very little information about potential triggers.

For example, staff were advised to distract the person or encourage them to move elsewhere in the home. However, plans had not been put in place to guide staff on how to recognise potential triggers to aggression or how to deal effectively with incidents of challenging or inappropriate behaviour.


We saw that entries in some care plans advised staff to keep the person occupied and under constant observation at all times in order to prevent them from causing harm to themselves or others. However, records showed that over a six week period the they had been involved in 36 reported incidents where they displayed aggressive, challenging or violent behaviour. We also saw that they had on occasion sustained some minor injuries inunknown circumstances. These had been referred to both the Commission and the local safeguarding authority where appropriate.

Throughout our inspection we saw that the person concerned often moved about the homewithout the support, involvement or constant observation of staff. At no time did we see them involved in any meaningful activities with other people at the home or staff. However,we did see them enter other people's bedrooms, uninvited, on a number of occasions where they often displayed aggressive or inappropriate behaviour toward the occupants.

For example, on one occasion we saw them trying to get into somebody else's bed while that person slept. On another we found them lying on the floor with their head and upper body underneath another person's bed.

On both occasions we found it necessary to summon the assistance of staff to deal with the situation in order to make sure that people were provided with appropriate levels of care and support. One member of staff commented, "[The person] has caused chaos today, going into people's rooms with very challenging behaviour."

This meant that people did not always receive effective, safe and appropriate care and support that had met their individual needs.


Cleanliness and infection control Action needed

People should be cared for in a clean environment and protected from the risk of infection

Our judgement


People had not always been cared for in a clean, hygienic environment.



A range of policies were in place that provided staff with guidance, information and advice about infection control practices and procedures. We also looked at records which showedthat most staff employed at the home had received infection control training. Members of staff confirmed they had received training appropriate to their role and were knowledgeable about infection control procedures used at the home.

We saw that where necessary and appropriate staff wore personal protective equipment, such as disposable gloves and aprons to reduce the risk of cross infection. Liquid hand soaps, sanitizers and paper towel dispensers were also available in bathrooms, toilets andcommunal areas throughout the home.

Two members of domestic staff were employed at the home with shared responsibility for cleaning duties. One provided cover on weekdays while the other worked weekends and one evening each week. We saw that equipment such as mops, buckets and cloths had been colour coded to ensure they were only used to clean designated areas. This reducedthe risk of cross infection. We spoke with one member of the domestic staff who was knowledgeable about infection control procedures. They also knew which bucket and mop should be used for each area in the home.

During our inspection we toured the home and checked people's bedrooms, including theiren-suite facilities, toilets, bathrooms and communal areas. We found that in some areas the required standards of cleanliness and hygiene had not been met.

We saw that carpets in most of the bedrooms we checked were dirty, badly soiled and stained. Some had significant amounts of food waste and other debris visible on the surface. We were told that the machine used to deep clean the carpets had broken down and had therefore not been available for use.

We spoke a member of the management team who agreed that the carpets in question were beyond cleaning. They told us that immediate steps would be taken to replace them and that a new cleaning machine had been purchased but not yet delivered.


We saw that some of the toilet bowls located in people's en-suite facilities, and elsewhere in the home, were badly stained and fell below the required standards of cleanliness and hygiene. Staff told us the bowls had become difficult to clean and that the stains could not be removed despite frequent attempts using a variety of cleaning methods and products.

We found that spare or additional bed mattresses had been stored on the floor of en-suite toilet facilities in most people's rooms. This practice was not only unhygienic but also madeaccess to the toilet facilities difficult. Some of the toilets we looked at were visibly dirty and presented strong and unpleasant odours. In one room we looked at the en-suite toilet facility had been used as a wardrobe to hang and store the persons clothes. Again, this practice was both inappropriate and unhygienic.

In some of the en-suite toilet facilities we found discarded items of used personal protective equipment such as disposable gloves and aprons. We also found items of rubbish, discarded packaging and clean unused continence pads on toilet floors. We saw that in some cases toilet floors appeared dirty and heavily stained. This meant that people had not been adequately protected against the risks of health care associated infection.

We saw that the bed linen in some people's rooms appeared to be clean and fresh whereas in others it was visibly dirty and stained, despite the bed having been made. We also saw that, in two cases where people had already received personal care and left their rooms, the bottom sheets, duvet covers and pillowcases were visibly wet. This meant that the required standards of cleanliness and hygiene had not been met.

We looked at records which showed that systems were in place to reduce the risks associated with health care associate infection and to maintain the required standards of hygiene and cleanliness. However, we found that these had not been operated effectively because the required standards had not been reached or maintained in some cases.

Staff told us that standards of cleanliness and infection control had declined over time and that cleaning procedures, practices and areas of responsibility were not as clear as they once were or should have been. We looked at the cleaning schedules currently used and saw that they did not provide staff with clear guidance about the standards of cleanliness and hygiene required.

Although cleaning schedules were in place, there were no robust systems to check they were being followed correctly or that all areas of the home, particularly people's bedrooms,were cleaned and maintained to an appropriate standard. This meant that systems put in place to manage and reduce the risks of health care related infection were not as effective as they should have been.


Requirements relating to workers Met this standard

People should be cared for by staff who are properly qualified and able to do theirjob

Our judgement

The provider was meeting this standard.

People were cared for, or supported by, suitably qualified, skilled and experienced staff.


We saw that effective recruitment policies and procedures were in place to ensure that staff employed at the home were of good character and appropriately skilled to meet people's needs. This included carrying out appropriate checks before staff began work.

One person who lived at the home told us, "The staff are absolutely first class….they knowwhat they are doing." A relative of a person who lived at the home commented, "The staff here are very good at what they do. They all seem very able and experienced."

We looked at records which showed that candidates for employment at the home were required to complete detailed application forms. This included a medical questionnaire about their physical and mental fitness to perform the role applied for. They were also required to attend interviews during which their qualifications, skills, experience and suitability were assessed.

Successful applicants were not allowed to start work until all necessary character, identity and reference checks had been satisfactorily completed. This meant that people were keptsafe and their health and welfare needs had been met by staff who were fit and able to do their job.


Staffing Action needed

There should be enough members of staff to keep people safe and meet their health and welfare needs

Our judgement


There were not always enough qualified, skilled and experienced staff to meet people's needs.



At the time of our inspection 24 people lived at Potton House. They were supported by a nurse, five members of care staff and an activity co-ordinator. Most people lived with significant dementia, mobility and complex health related needs. In addition, we saw that some people frequently displayed challenging, difficult and inappropriate behaviour. This meant that most people had high dependency needs and required the help and support of two members of staff.

The provider had put policies in place which gave guidance on how to manage staffing at the home. This included how to deal with unforeseen absences. However, we saw no evidence that staffing levels had been calculated or determined on the basis of people's individual needs and or dependency levels.

Most people we spoke with during our inspection expressed concerns that staffing levels had not always been sufficient to meet people's needs. One person who lived at the home told us, "They [staff] are too busy and lunch seems to get later and later. I will be very hungry by lunch but it's just one of those things."

A relative commented, "They [the provider] need more staff. Often I need assistance but can't find anyone because they are all too busy. Some residents are very aggressive and incapable but [there are] not enough staff to cope." A relative of another person said, "The staff are always rushing around. I have never seen carers spend time talking with people. They are too busy. Staff don't have quality time to spend with people." A GP with recent experience of the home told us that staff were stretched at times because of the high levels of dependency and challenging behaviour they were required to deal with.

This meant that it had not always been possible to meet the care and welfare needs of people who lived at the home in a timely manner.

We saw that two people, both of whom had had complex health needs which meant they were at a high risk of developing pressure sores, had not been supported to get up and


complete their personal care until shortly before 1:30 pm. We also saw that many people in the communal dining room were not served lunch until nearly 2:30 pm.

One senior member of staff told us, "There's not enough staff. Five in total to get 24 peopleup, many [of whom] need two carers. We are struggling to get everyone up by two. We [the day shift] don't start until eight [am] so were up against it straight away." Another member of staff said, "Today people are still getting up at nearly two o'clock, that's ridiculous." Another member of staff commented, "There's not enough staff, that's why we are getting people up so late."

We also saw that staff were unable to deal effectively with situations that involved a personwho displayed challenging, aggressive and inappropriate behaviour on a number of occasions. There was insufficient staff available to keep them under constant observation in line with guidance contained in their care plan. This meant that their care and support needs were not met in a safe or appropriate way. We saw that failures to manage the person's behaviour effectively also had an adverse effect on the privacy, dignity and enjoyment of other people who lived at the home.

We saw that the activity co-ordinator worked with small groups of people in a room that had been set aside for activities. The activities provided were appropriate for people with dementia related needs. The co-ordinator also visited people in their rooms to involve them in one on one activities, such as reading books and listening to music.

However, throughout our inspection we saw that many people sat in communal lounges forlong periods of time without meaningful stimulation or interaction with staff. Other people moved about the home without any obvious signs of meaningful support, stimulation or purpose.

There were not enough members of staff available to provide the levels of support people required at lunchtime. During our observations we saw that at times only two members of staff had been available to meet the needs of 14 people in the dining room; most of whom needed help and support to eat and drink.

This meant that people were left unsupported for long periods of time as staff rushed to collect and serve meals. We saw that most people were given their food and drink without the opportunity to express any choice or preference. We also saw that a nurse, on a medicine round in the dining room, was frequently distracted from the task by people who required help or support.

This meant that people did not always have their health, support and welfare needs met bysufficient numbers of appropriate staff.



Action needed

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

Our judgement


The provider had not put effective systems in place to identify, assess and manage risks tothe health, safety and welfare of people who used the service and others.



The provider had put arrangements in place to identify and manage risks to people who used the service and to monitor and assess the quality of care and support they provided. However, we found that some of the systems used had not always been effective at protecting people against the risks of inappropriate or unsafe care and treatment.

We looked at records which showed that the manager regularly completed audits in a widerange of areas to identify, monitor and reduce risks. These included risks associated with the environment, management of medicines, standard of care records, accidents and incidents, complaints, staffing levels and infection control.

We looked at an infection control audit completed on 22 January 2014 which identified thatsome carpets in the home needed to be replaced. However, we saw that these remained in situ at the time of our inspection, three months after the audit had been carried out. The fact that the machine used to deep clean carpets had also been noted. We were told that anew one has been purchased but had not yet been delivered. People's bedrooms were assessed as having been clean and stain free. However, we found numerous examples of toilet bowls and flooring that appeared to have become stained and dirty over a long period of time.

We saw that, although care records had been audited, the apparent lack of people's involvement in and agreement with, DNACPR's decisions, care planning and reviews, had not been identified. The home audit tool had also been used to assess a number of staffing factors such as sickness levels and turnover. However it did not take account of dependency levels or whether there was sufficient numbers of appropriate staff available to meet people's needs at all times.

We looked at an environmental audit that had been completed on an unknown date in February 2014. It assessed most areas throughout the home as having either met or exceeded the required standards of cleanliness and hygiene. It had not identified or


recorded any problems in relation to the stained toilet bowls, stained flooring or dirty carpets found during our inspection.

We saw that the manager held a safety, quality and compliance meeting with key members of senior staff each month. Agenda items included health and safety, training, feedback from surveys and meetings, incidents of concern and areas for improvement.

We looked at minutes relating to the meeting held on 17 April 2014 and saw that a numberof concerns had been raised and discussed. One problem highlighted was that sufficient numbers of staff had not always been available to support people in communal areas because they were busy getting people up and providing personal care. The minutes also highlighted that call bells had not been working in all bedrooms, a problem that we found persisted during our inspection. This meant that, although problems and potential risks hadbeen identified, prompt and effective steps had not always been taken to resolve them.

The provider had put a complaints policy and procedure in place and people told us they knew how to complain if the need arose. We saw that information and guidance about the process had been prominently displayed in communal areas throughout the home.

We looked at records which showed that the manager had last held a meeting with nursingstaff on 06 September 2013 and with other members of care staff on 23 October 2013. Wesaw that staff had been encouraged to contribute to agenda items which included care practices, audits, roles and responsibilities, staffing and infection control.

Meetings were also held on a regular basis with people who lived at the home and their relatives. We looked at minutes for a meeting held with relatives on 09 April 2014. We sawthat concerns were expressed about the condition of some bedrooms, delays in getting people up in the mornings and that people were often left unsupported for long periods in communal areas.

According to the minutes, the manager informed the meeting that staff had struggled to cope with increased occupancy levels at the home. This meant that, although people had been encouraged to put forward their concerns, it remained unclear what if any action had been taken to address or resolve them.

We looked at records which showed there had been a significant increase in the number ofincidents at the home involving people who had displayed challenging, aggressive or violent behaviour. Some resulted in people sustaining minor injuries which had been reported to both the Commission and local safeguarding authority where appropriate.

However, although it had been recognised that staff struggled to cope with increased occupancy levels together, high levels of dependency and challenging behaviour, the provider had not taken prompt or effective steps to protect people against the risks identified.

We were told that the manager had been given additional responsibility for managing another care home which meant they were required to split their time and travel between the two. The leadership, management and decision making at Potton House may therefore, not have been as consistent and effective as it could have been. This meant thatpeople may not always have benefitted from the operation of effective systems designed to protect them from unsafe or inappropriate care, support or treatment.

This section is primarily information for the provider


Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activities Regulation

Accommodation for persons who require nursing or personal care



Regulation 18 HSCA 2008 (Regulated Activities) Regulations2010

Consent to care and treatment

How the regulation was not being met:

The provider did not have suitable arrangements in place for obtaining, and acting in accordance with, the consent of service users, or the consent of another person who is able lawfully to consent to care and treatment on that service users behalf.Regulation 18 (1) (a)





Regulation 9 HSCA 2008 (Regulated Activities) Regulations 2010

Care and welfare of people who use services


The registered person had not taken proper steps to ensure that each service user was protected against the risks of receiving inappropriate or unsafe care by planning and delivering care thatmet thier needs and ensured their welfare and safety.Regulation 9 (1) (b) (i) and (ii)








Cleanliness and infection control


The registered person had not ensured that service users, staff and others were adequately protected against the risks of health care associated infection. The systems put in place to assess the risk of and prevent, detect and control the risk of health care associated infection were not as effective as they should have been and appropriate standards of cleanliness and hygiene had not been maintained at the home.Regulation 12 (1) and (2) (a) and (c) (i)






Staffing


The registered person had not taken appropriate steps to ensurethat, at all times, there were sufficient numbers of suitable qualified, skilled and experienced staff available for the purposesof carrying out the regulated activities.Regulation 22.



Diagnostic and screening




The registered person had not protected service users and



procedures


others against the risks of inappropriate or unsafe care and treatment by operative effective systems to identify, assess and manage risks relating to thier health, welfare and safety.Regulation 10 (1) (b) and (2) (b) (i) and (iii).

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider's report should be sent to us by 03 June 2014.

CQC should be informed when compliance actions are complete.

We will check to make sure that action has been taken to meet the standards and will report on our judgements.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact.

Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

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