Larchwood Nursing and Residential Home

Larchwood Nursing and Residential Home is care home providing personal and nursing care to 34 people aged 65 and over at the time of the inspection. Some of those people were living with dementia. The service can support up to 48 people.

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

People we spoke with were very happy living at Larchwood. One relative we spoke with said, “I’ve been very impressed with [Family member’s] care. Staff are lovely and delightful.”

Overall improvements had been made to the medication processes. Although we did find improvements were required in the records, the peripatetic manager provided evidence that these had been dealt with appropriately.

Systems ensured that people's risks were well managed, and lessons were learnt when things went wrong. There was an open culture within the service, where people and staff could approach the peripatetic manager who acted on concerns raised to make improvements to people's care.

The peripatetic manager notified the CQC of incidents they were required to. The peripatetic manager and staff promoted satisfactory infection control and cross contamination processes.

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 2 May 2019).

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 improvements had been made and the provider was no longer in breach of regulations.

The service remains requires improvement. This service has been rated either requires improvement or inadequate for the last four inspections.

Why we inspected

We undertook this focused inspection to check they had made the necessary improvements and to confirm they now met the legal requirement. This report only covers our findings in relation to the Key Questions Safe and Well-led.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion 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.

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.

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

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

• Larchwood Nursing and Residential Home is a care home that was providing personal and nursing care to 28 people aged 65 and over at the time of this inspection. Some of those residing at the service were living with dementia. It is registered to provide care and accommodation for up to 48 older people.

People’s experience of using this service

• The service had made improvements since our last inspection but needs to continue to do so to ensure a consistently good quality service is delivered. This needs to be sustained.

• An incident that had occurred shortly before our inspection had had a negative impact on the health and wellbeing of some of the people who used the service. This meant people had not received their medicines as prescribed for one administration round.

• The management of medicines did not fully adhere to good practice guidance and some discrepancies were found in the administration of one person’s insulin.

• Most people received a planned person-centred service however improvements were required in how the service managed people’s diabetes and, for one person, their wound care.

• Staff had been trained and provided with ongoing support. However, clinical staff required further clinical training and their competency assessed in these areas. Staff had not received training in specific health conditions that those using the service had been diagnosed with.

• The service did not fully comply with the Mental Capacity Act 2005 (MCA).

• No registered manager was in place as required by conditions on the service’s registration.

• Improvements had been made to many areas of the service delivery including meeting nutritional needs, infection prevention and control, staff culture and team working abilities and the environment.

• Risks had been identified, managed and mitigated including those associated with people who used the service, working practices, equipment and premises.

• Procedures were in place to help protect people from the risks associated with abuse and recruiting staff not suitable to work with them.

• There were enough staff to meet people’s needs and those staff had received support to do so.

• Staff demonstrated kindness and compassion when supporting people and we saw that people’s dignity and privacy was maintained.

• People had been involved in the planning of their care but this needed to be better recorded.

• The service worked with health and social care professionals to help achieve good outcomes for those that used the service.

• Activities were available and based on people’s needs.

• There had been unstable management at the service and, at the time of this inspection, a regional support manager was managing the day to day delivery of the service. Recruitment was underway for a permanent manager.

• Adherence to action plans and a quality monitoring system had been effective at driving improvement.

• All the people we spoke with both before, and during, our inspection told us the service had made improvements. The people who used the service, and their relatives, were happy with the service provided and staff demonstrated commitment and a positive attitude.

• For more information on our inspection findings, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk.

Rating at last inspection

• At the last inspection the service was rated as inadequate (report published on 24 December 2018). At this inspection the service has seen an improvement to its rating.

• This service has been in Special Measures. Service that are in Special Measures are kept under review and inspected again within 6 months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Why we inspected

• This was a planned comprehensive inspection based on the previous rating.

• The regular action plans the provider sent us as part of previous enforcement showed that improvements should have been made by the time of this inspection.

Enforcement:

• Please see the ‘action we have told the provider to take’ section towards the end of the report.

Follow up

• We will continue to closely monitor this service and liaise with partner agencies in doing so.

• The conditions we imposed on this service as part of previous enforcement will be removed.

• The service is in breach of the Health and Social Care Act 2008 (Regulated Activities) 2014 and we will follow this up at our next inspection.

Larchwood Nursing and Residential Home is a ‘nursing and residential home’. People receive accommodation and personal care as a single package, and some people receive nursing care as a separate package. CQC regulates both the premises and the care provided, and these were looked at during this inspection.

Larchwood Nursing and Residential Home accommodates people in individual rooms, each with an en suite toilet and basin facility. Each floor has some communal bathrooms and toilets in addition, as well as a dining area and lounge.

The service had a recent history of non-compliance. Our inspection in September 2017 found the home to be inadequate in four areas with eight breaches of Regulations of the Health and Social Care Act 2010 (Regulated Activities) Regulations 2014 and one breach of CQC Registration Regulations 2009. We placed additional conditions on the provider’s registration requiring them to submit monthly reports to us setting out how they would assess, monitor and, where required, take action to improve the quality and safety of the care and support provided to people living at Larchwood.

At our last inspection on 12 March 2018, we found that improvements had been made in some areas, following the inspection on 19 September 2017, where there were serious concerns about this service. Following that inspection, we took action against the provider and met with them to confirm what action they would take to improve the service. We served a Notice of Decision to impose positive conditions on their registration, which they have complied with.

At our last inspection on 12 March 2018, some improvements had been made but the provider remained in breach of four Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there was inconsistent management and oversight of the service, and there were concerns around infection control and the management of risks to people. Further improvements were also required to ensure people received person-centred care, and to ensure there were enough staff deployed effectively to care for people.

At this inspection on 6 November 2018 we found four repeated breaches of Regulations and one further breach of Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

There was poor leadership in place, with concerns not being identified. The registered manager was not often visible throughout the home and was not aware of all areas requiring improvement. Staff working in the home were not always well supported.

Staff working in the home were not always deployed so that a mix of competency and experience worked together. New staff and agency staff were not always supported to gather enough knowledge of people before working as part of the staff team. This resulted in there not always being competent staff available to people when they required care.

Risks to people because of their health conditions had not all been identified and mitigated, and there was no guidance around some of these in people’s care plans. Risks to people due to their environment, such as unsafe equipment, had not always been identified. There remained poor infection control practices and unclean areas and equipment.

People were not supported to eat and drink enough, and drinks and meals were consistently left out of reach for people. People were not always given choices of what they were going to eat, or communicated with about what their meal was. There was poor recording around eating and drinking when people were at risk of malnutrition or dehydration. Where further action was needed, such as weekly weights, this was not always completed.

Staff had not always considered people’s mental capacity to make important decisions to ensure their rights were upheld. There was contradictory information about people’s mental capacity in some people’s care plans. The service was therefore not adhering to the Mental Capacity Act 2005 (MCA).

People were supported to see a doctor if they required, however people were not always referred to specialists such as a dietician in a timely way when required.

Care plans were not always person-centred and did not contain sufficient guidance for staff around people’s conditions. People were not always able to choose how to spend their time and staff did not always listen to people. As a result, people did not consistently receive support as they preferred.

Relatives and people knew who to complain to if they required. However, not all people, relatives or staff felt as though they could raise any concerns.

The systems in place for checking, monitoring and improving the service were not robust and had not led to a sustained, suitable level of improvement. Many concerns found on the inspection were not identified by the provider, and previous improvements made to the service had not been sustained.

There were activities on offer for people, both within the home with the activities coordinator, and external outings. The activities coordinator completed one to one activities with some people in their rooms, and group activities such as bingo and flower arranging.

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. In two key questions the service is still rated ‘Inadequate’, and for the remaining three key questions, the ratings are ‘Requires Improvement.’

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Larchwood Nursing and Residential Home is a ‘nursing and residential home’. People receive accommodation and personal care as a single package, and some people receive nursing care as a separate package. CQC regulates both the premises and the care provided, and these were looked at during this inspection.

Larchwood Nursing and Residential Home accommodates people in individual rooms, each with an en suite toilet and basin facility. Each floor has some communal bathrooms and toilets in addition.

We last inspected this service on 19 September 2017. At that inspection, we found eight breaches of the Health and Social Care Act 2008, and one breach of the Care Quality Commission (CQC) Registration Regulations 2009. The service was rated ‘Inadequate’ in four areas, which were safe, effective, caring and well-led. The service was rated ‘Requires Improvement’ in responsive. The overall rating for this service was ‘Inadequate’ and the service was therefore in ‘special measures’. Services in special measures are kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, are to be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Following that inspection we took action against the provider and met with them to confirm what action they would take to improve the service. We served a Notice of Decision to impose positive conditions on their registration, which they have complied with. During this inspection, we checked to see if the provider had made sufficient improvements. We found there were five continued breaches, however improvements had been made. The provider was no longer in breach of the remaining four regulations.

There was not a registered manager in post. A registered manager is a person who has registered with the CQC 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. However, there was a manager in post who had been appointed in January 2018, who was applying to register with the CQC. They will be referred to as the ‘manager’ throughout the report. During the inspection, a representative from the provider’s organisation was also at the location. For the purposes of this report, they will be referred to as the ‘provider’.

At this March 2018 inspection we found that the provider had not made all the improvements required since our last inspection, in a timely manner. However, auditing and quality assurance systems had improved and were in place. We found at this inspection that whilst they identified some concerns, they did not pick up all of the areas where the provider remained in breach. As the manager had only been in post a short space of time, we remain concerned about the sustainability of the improvements to the service.

Further improvements were needed around infection control processes. Despite improvements made, there were not always good infection control practices within the home. The kitchen was dirty and there were poor hygiene standards with regards to storing laundry.

The safety of people living in the home had improved, however further improvements were needed. These were especially in relation to pressure care, and risk management. There were improvements in the management of risk, however some pressure care was not always carried out and recorded.

There were some improvements needed to fire safety within the home, such as ensuring that evacuation plans were up to date and equipment was tested. There were some unsecured prescribed medicines around the home. On the whole, medicines administration had improved but improvement in the oversight of medicines was still needed.

There had been improvements in the provision of activities, and further improvements were needed to ensure these were tailored to people’s preferred hobbies and interests. People did not always receive care that was individualised and met their preferred needs. The care plans did not always reflect people’s needs accurately. The care plans were undergoing improvement by the staff.

There were not enough staff to fully mitigate risks to people and to supervise communal areas of the home, however improvements had been made to increase staffing since the last inspection. Staff received training and supervisions relevant to their roles and they were aware of their responsibilities.

Falls risk assessments were in place, and some were more detailed than others. A new care planning format outlined specific risks to people and guided staff on how to mitigate these. The manager had prioritised those at highest risk when they carried out the redoing of care plans. The existing care plans contained some information about how to mitigate risks to people.

Significant improvements in the management of people’s diets had taken place, where people had been identified as being at risk of weight loss. Further improvement was still needed with regards to people’s records to demonstrate they were regularly offered snacks and they received their supplements properly. People had enough to drink. People were often given choices of food, however there remained times when staff did not offer this.

There were caring interactions within the home, but some staff did not always have a caring approach to people. There were overall improvements to people’s dignity being upheld within the home since our last inspection. The manager had a good understanding of people’s mental capacity and staff asked for consent before delivering care.

Staff were well supported by the manager, who was visible throughout the home. They had made contact with people’s families to involve them in their relative’s care, and address the concerns following the last inspection. The manager had arranged meetings for people living in the home and their families, and had an open door policy so people and staff could raise concerns easily.

The manager had taken disciplinary action where appropriate, and was working with other organisations such as the CQC to improve the home.

The overall rating for this service is ‘Requires Improvement’. The rating for ‘well-led’ in this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. For the remaining four key questions, the ratings are ‘Requires Improvement.’

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 home is run.

We had previously inspected this service in August 2016. We found that the provider was meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the service was rated ‘Good’. During this 2017 inspection, we found the registered provider was in breach of eight regulations. These included those for safe care, staffing, safeguarding, nutrition, mental capacity, dignity and respect, person-centred care and good governance.

The service was not safe. Individual risks to people had not been identified or managed in a safe way. People’s risk assessments were not reviewed regularly and assessments to determine people’s risk of pressure ulcers and malnutrition were not carried out frequently. Where people were at risk of developing a pressure ulcer, records around repositioning were incomplete, and there were no clear plans in place to minimise this risk. This included for people who had already developed serious pressure ulcers.

People’s level of dependency was not assessed appropriately and staffing levels were not calculated to support people in the safest way possible.

People’s medicines were not managed or administered in a safe way. The service had no records of any topical creams. People did not always receive a GP review in a timely manner when they needed it and people’s ‘as required’ (PRN) medicines records were not always accurate.

Some staff demonstrated a lack of knowledge around safeguarding people and how to report concerns The registered manager had not reported pressure ulcers to safeguarding when they should have.

Risks relating to eating and drinking were not managed appropriately or mitigated. People did not receive a diet according to their dietary needs. Records relating to food and fluids were inaccurate. Choice was not always offered to people at mealtimes.

People’s mental capacity assessments were no longer relevant and had not been updated. There were no best interests decisions for some people, and staff did not have good knowledge of the Mental Capacity Act 2005 (MCA).

Staff did not always treat people with dignity and respect, and people were not involved with their own care. People did not receive individualised care based on their own preferences and needs.

Care records were incomplete, out of date and did not contain adequate guidance for staff.

The registered manager did not know people or their needs, and people did not know who the registered manager was. There was poor leadership in place, and there were no systems in place to identify concerns or drive improvement.

People’s preferred hobbies, histories and interests were not always recorded or known by staff. There were some activities on offer but for people in their rooms, this was limited. No trips outside of the home were available to people.

There were practices in place which ensured suitable staff were employed with checks in place. People were supported to access healthcare services.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Larchwood Nursing and Residential Home provides residential and nursing care for up to 48 people, some of whom may be living with dementia. Accommodation is over two floors with a lift to the first floor. The home has a number of communal areas including dining rooms, lounges and an activities room. At the time of our inspection, 40 people were living in the home.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

We last inspected this service on 29 and 30 June 2015 where we found that the service was not meeting the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider was in breach of the regulations relating to meeting nutritional and hydration needs and good governance.

Following the inspection in June 2015, the service sent us a plan to tell us about the actions they were going to take to meet the above regulations.

At our inspection in April 2016, we found that the service had made improvements and that they were no longer in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were supported by staff that had been recruited following appropriate safety checks. Staff had received the training and support required to ensure they demonstrated the appropriate skills, required for their roles. Good team work was evident and staff told us morale was good and that they enjoyed working at the Home. There were enough staff to meet people’s individual needs.

Staff demonstrated a kind, caring and compassionate approach and knew the needs of the people they supported. People were given choice, their independence was encouraged and their privacy and dignity maintained. We observed respectful interaction between the staff, visitors and people who used the service. Visiting relatives and professionals told us they always felt welcomed into the home.

The service had processes in place to protect people from the risk of abuse. Staff demonstrated knowledge of the types of abuse and their possible symptoms and the correct reporting procedure should they have any concerns. The service demonstrated that past concerns had been recorded, reported and investigated as required.

The individual risks to people who used the service, visitors and staff had been identified, assessed and regularly reviewed to reduce the risk of harm. People received their medicines as the prescriber had intended and good practice procedures were followed. The service managed medicines safely and could account for medicines at any one time as clear and accurate records were kept.

The CQC is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and report on what we find. Although the service had not recorded the capacity assessments they had made on the people they supported, the principles of the MCA had been adhered to. Applications had been made to the supervisory body for consideration and the service had involved appropriate people in best interests decisions. These had been recorded. Staff understood the importance of receiving people’s consent before supporting them but their knowledge of the MCA and DoLS was variable.

People, and where appropriate, their relatives, had been involved in the planning of the care and support they received. Care plans were accurate, person-centred and gave staff detailed information on how to meet people’s needs in an individualised manner. They had been reviewed on a regular basis. People’s life histories and the support they required to maintain good physical and emotional wellbeing was also fully recorded.

There was an activities coordinator in post and the service provided activities and events to suit people’s needs. People told us they enjoyed the activities but would like more. People’s families were encouraged to participate in the activities and we saw that staff were fully engaged when supporting people to join in.

People benefited from having access to a number of healthcare professionals to maintain their wellbeing. We saw that staff assessed people’s needs and gained the medical intervention required.

The management team encouraged an open culture and people told us they were approachable, visible and available to talk to. The registered manager demonstrated knowledge in their role and people told us they had a professional approach. The service requested feedback on the service and gave people a number of ways to do this.

Effective quality monitoring auditing systems were in place and these had been completed on a regular basis with action plans in place for any identified issues. The senior management team completed comprehensive audits that assessed against the five key questions contained in this report. This demonstrated knowledge in regulations and that they had an overview of the service being delivered.

This is a summary of what we found:

People were generally pleased with the service and felt that they received good care. Most people described themselves in terms of being, 'Very happy here' and, 'Well looked after.'

We saw that people's care was planned and delivered in accordance with their wishes and was regularly reviewed to ensure that it continued to meet their needs.

Is the service responsive?

We found that the service was responsive to people's wishes and their diverse needs. Care plans were agreed with the people using the service, or their representatives, and adjusted in response to any changes in these needs. Feedback was sought and acted on.

Is the service safe?

Families of people who used the service generally agreed that their relatives felt safe. We saw that people's care plans contained the information needed to provide them with safe care. Risks to people in their daily lives, for example if they experienced problems with breathing or with moving around, were assessed and actions specified to reduce these risks. This helped staff to be aware of the care and assistance people needed to keep them safe.

We saw that the provider had carried out the necessary checks to ensure that staff were of good character and had the training and guidance needed to provide safe care and support. Training was provided to staff on mental health legislation, including the requirements of the Deprivation of Liberty Safeguards (DoLS) and in recognising signs that people may be suffering abuse. Staff we spoke with were confident that they had received the training to enable them to carry out their duties and to keep people safe.

Is the service effective?

People received the care and treatment they needed. A popular programme of activities helped them to enrich their lives. Two people described how their quality of life had improved since they started using the service.

Care records were written in detail and provided clear guidance to staff. When accidents or incidents occurred it was evident that these were learnt from, with actions taken to reduce the risk of recurrence.

Is the service well led?

Staff felt well supported. They received appropriate supervision and training and were clear about their responsibilities.

Effective systems were in place to regularly check and monitor the quality of the service.