Archived: Ersham House Nursing Home

Ersham House provides accommodation and nursing care for up to 40 older people, who lived with a range of general health problems, such as strokes, dementia, diabetes, heart problems, Parkinson’s disease and general mobility problems. At the time of the inspection there were 16 people living at the home. It is a purpose-built home with level access throughout for those with mobility problems.

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

People’s experience of using this service:

People said, and we observed that they were safe and well cared for and their independence was encouraged and maintained. Comments included, “Good place to live, I feel safe,” and “The staff are nice and kind.”

The service had made improvements since our last inspection. This meant people’s outcomes had improved in respect of risk and medicine management. However, whilst the provider had progressed quality assurance systems to review the support and care provided, there was a need to further embed and develop some areas of practice that the existing quality assurance systems had missed. For example, updating the care plan when peoples’ needs had changed and ensuring medical equipment was ready for use.

There were sufficient staff to meet people’s individual needs who had passed robust recruitment procedures that ensured they were suitable for their role. There were systems in place to monitor people's safety and promote their health and wellbeing, these included health and social risk assessments and care plans. The provider ensured that when things went wrong, these incidents and accidents were recorded, and lessons were learned.

Staff received appropriate training and support to enable them to perform their roles effectively. Visitors told us, “Staff are really helpful, they know what they are doing,” and “The staff are great.” People’s nutritional needs were monitored and reviewed. People had a choice of meals provided and staff knew people’s likes and dislikes. People gave very positive feedback about the food. Comments included, “Nice home cooking.”

Staff treated people with respect and kindness at all times and were committed to providing a quality service that was person centred.

People were encouraged to live a fulfilled life with activities of their choosing and were supported to keep in contact with their families. People's care was now more person-centred. The care was designed to ensure people's independence was encouraged and maintained. Staff supported people with their mobility and encouraged them to remain active. People were involved in their care planning. End of life care planning and documentation guided staff in providing care at this important stage of people’s lives.

Improved audits and checks had been put in place to ensure the service was continuously striving to improve. Areas identified as needing improvement during the inspection process were immediately taken forward and action plans developed.

The service met the characteristics for a rating of ‘Good’ in four of the five key questions we inspected, with the well-led question remaining ‘Requires Improvement.’ Therefore, our overall rating for the service after this inspection has improved to "Good".

Rating at last inspection:

At the last inspection the service was rated Requires Improvement (report published 01 May 2018).

Why we inspected:

This was a planned inspection based on the rating at the last inspection. At our last inspection of the service in April 2018, improvements were needed to ensure that medicines were managed safely, that there were sufficient trained staff to deliver person centred care and that quality assurance systems were fully embedded.

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner. We will follow up on our recommendations at the next scheduled inspection.

Ersham House is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Ersham House is a detached building with the accommodation spread over two floors and at the time of the inspection people occupied rooms on the ground floor.

At our last inspection in August 2017, the service was rated Inadequate and placed in special measures and we took further enforcement. We asked the provider to take action and they sent us an action plan. The provider wrote to us to say what they would do to meet legal requirements in relation to the breaches we found. We undertook this inspection to check that they had followed their plan and to confirm that they now met legal requirements. This inspection found that whilst there were areas still to improve and embed in to everyday practice, there had been significant progress made and that they had now met the breaches of regulation. The service has been taken out of special measures.

A registered manager was not 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 and associated Regulations about how the service is run. The current manager took over in May 2017 and had been in post 11 months at the time of the inspection. They have submitted an application to become the registered manager. We have received confirmation that an interview had been organised for June 2018.

Since the last inspection quality monitoring systems had been improved and implemented so that shortfalls were being identified and acted upon. However, the provider will need to evidence that improvements can be sustained over time and when new people came to live at Ersham House.

The training programme identified that there were still staff that needed to undertake essential training to ensure that people received safe and effective care. This was an area that required improvement. Some staff supervisions recorded in 2017 were not of a high quality and, although these had improved in 2018 this improvement needs to be sustained to ensure staff are supported adequately.

There were individual care plans for people that identified their specific needs. However, we found that improvements were still needed in the care plans to guide staff in responding to people’s individual complex diabetic needs and those approaching their end of life.

We have made a recommendation that the registered provider seeks specialist training in diabetic care and end of life care to support staff in providing responsive care.

People were being kept safe from abuse. Staff understood their responsibilities in keeping people safe from abuse and had been trained. Staff knew how to report any possible concerns. People were supported safely around risks and were encouraged to take positive risks after control measures were applied. Environmental risks were managed safely and there were protections in place in relation to possible hazards such as fire. Staffing levels met people's needs and people told us that they could find staff to help them when they needed to and we observed staff were not rushed when helping people. People received their medicines safely and when they needed them by staff trained to administer them. Medicines were stored and managed safely. The risk from infection was reduced by effective assessments and cleaning rotas and the housekeeping team kept the home clean. When things went wrong the service had learned from accidents and incidents and had shared that learning with staff.

People had received an assessment of their needs and these were tracked though care plans to ensure effective outcomes were achieved. People received enough food and drink to maintain good health and they told us that they liked the food. Staff worked in partnership to provide consistent support when people moved to or from the service. People had access to healthcare professionals and were supported to maintain good health. Staff responded in a timely way when people were unwell and medical guidance was followed correctly.

The premises were suitable to meet people’s needs and there had been changes made to the environment to meet the needs of people living with dementia. People were supported to have maximum choice and control of their lives. Staff supported people in the least restrictive way possible; the policies and systems in the service supported this practice. The principles of the Mental Capacity Act were being complied with and any restrictions were assessed to ensure they were lawful, and the least restrictive option.

Staff treated people with kindness and compassion. Staff knew people’s needs well and people told us they liked and valued their staff. People and their relatives were consulted around their care and support and their views were acted upon. People’s dignity and privacy was respected and upheld and staff encouraged people to be as independent as safely possible.

There was a complaints policy and form available to people. Staff were open to any complaints and understood that responding to people’s concerns was a part of good care. People received a pain free and dignified death at the end of their lives. Staff supported people with compassion and worked with local hospice teams.

There was now a more open culture that was implemented by the management team. People and staff spoke of a friendly and homely culture that was empowering. People, their families and staff members were engaged in improvements planned and in the running of the service. There was a culture of learning from best practice, and working with other professionals and local health providers to ensure partnership working resulted in good outcomes for people.

An acting manager was in post but they were not yet registered with the commission. 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 and associated Regulations about how the service is run. The registered manager left the service at the end of October 2016. A previous acting manager had been in post from October 2016 to April 2017. The current acting manager took over in May 2017 and had been in post four months at the time of the inspection and told us they would submit an application to become the registered manager.

At the last inspection undertaken on 28 and 29 February 2017, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to; Regulation 9, people were at risk of social isolation. Regulation 11, people's care plans did not reflect their basic rights to consent and decision making. Regulation 12, evidence was not available to show that care was provided in a safe way and Regulation 17; effective systems were not in place to monitor the quality and safety of the service.

We asked the provider to take action to meet regulations 9 and 12. We took enforcement action against the provider and told them to meet Regulation 11 by 14 June 2017 and Regulation 17 by 14 July 2017. The provider sent us a report of the actions they were taking to comply with Regulations 9 and 12 and they told us they would be meeting these Regulations by 31 July 2017.

At this inspection we found the provider had made some improvements to the service and standards of care. Another activity coordinator had been recruited and staff no longer referred to people in an inappropriate manner. Prescribed fluid thickener was not left in easy reach of people. Staffing levels had increased and a dependency tool was now in place to assess what staffing levels were needed to meet people’s needs. However, many improvements had not been made and we found continuing breaches of regulations from the last inspection. We also found new breaches of regulation.

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. 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.

Prior to our inspection, we received information of concern from an anonymous source that the consistency of people’s pureed food was not in line with their assessed need as determined by Speech and Language Therapists (SALT). This is to ensure people who have swallowing difficulties do not choke. During the inspection, we observed a staff member pushing aside lumps within people’s pureed food and a member of the kitchen team advised that the blender provided was not fit for purpose.

People did not consistently receive safe care and treatment. The management of catheter care was ineffective and placed people at risk. There was a lack of guidance for registered nursing staff to follow. Nursing staff did not consistently have oversight of people’s air mattresses settings and a number of air mattresses were set at the incorrect setting which placed people at risk of their skin breaking down. Nursing staff regularly checked people’s blood sugars, but diabetic care plans and risk assessments were not in place to ensure consistent safe care.

The principles of the Mental Capacity Act (MCA) 2005 were still not consistently applied in practice. Where people had bed rails, the provider could not evidence whether they had consented to the use of bed rails or whether they were implemented in people’s best interests when people did not have capacity to consent. Relatives were signing consent forms without the appropriate authority to do so. People raised concerns about the restrictions imposed on their freedom. One person told us, “I certainly feel restricted from how I was living before. I’ve been here about five months. I’d like to go out in a taxi on my own and go shopping, then get a taxi back. I can’t see why I can’t; I did do it before I came here without any problems.”

The management of medicines was not always safe as people did not always receive their medicines on time. Protocols for the use of ‘as required’ PRN medicines were not in place and pain assessment tools had not been implemented. Medicines were not always administered in line with best practice guidelines or the prescriber’s instructions.

People's healthcare needs were met but communication with relatives was not consistently responsive. Healthcare advice had not consistently been followed by care staff. Staffing levels had increased since the last inspection in February 2017 but the deployment of staff was ineffective. People were left without staff supervision and engagement from staff. Restrictions on staffing levels meant people could not freely sit outside or access the garden. People remained at risk of social isolation. The provision of activities was not consistently meaningful and accessible to people with varying needs and preferences.

Safeguarding policies and procedures were in place but systems to ensure people were protected from harm or abuse were not consistently robust.

The provider continued to fail to maintain accurate, complete and contemporaneous records. People's daily monitoring charts were incomplete and included unexplained gaps and omissions. Staff had not all received up to date training or training to meet people's individual needs.

Whilst the quality assurance process identified and addressed some shortfalls, it remained ineffective. The provider lacked strategic oversight of the service. The management team were dedicated to making the necessary improvements, but these were not yet embedded or sustained. Shortfalls identified at the last inspection in February 2017 had not been addressed and the provider had failed to act on recommendations made at the last inspection. The lunchtime experience was not consistently positive for some people; this was because some people were having their meals sitting in the armchairs that they had spent most of the day sitting in. This didn't help people to orientate or know that it was time for their meal, nor did it aid their digestion or independent eating. We have identified this as an area of practice that needs improvement.

Staff spoke highly of the people they supported. People’s right to privacy was respected and people spoke highly of the staff. One person told us, “The staff are very caring, they cuddle me and talk to me and cheer me up because I get very tearful, because of my legs.” Advanced care plans were in place for people to discuss their wishes surrounding end of life care. However, these were not consistently completed. We have identified this as an area of practice that needs improvement.

People spoke highly of the food provided and for those who enjoyed group activities, a range of activities were on offer. These included arts and craft, card games and puzzles. Staff recruitment practice was safe.

During our inspection we found a number breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered providers to take at the back of the full version of the report. 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.

An acting manager was in post but they were not the registered manager. 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 and associated Regulations about how the service is run. The previous registered manager left the service at the end of October 2017 but they had not yet submitted an application to CQC to de-register. The acting manager had been in post four months at the time of the inspection and told us they would submit an application to become the registered manager.

At the last inspection undertaken on the 4 and 5 May 2016, we identified breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in relation to the principles of the Mental Capacity Act 2005 not being adhered to. Accurate and complete records had not been maintained and the management of medicines was not safe. The provider sent us an action plan stating they would have addressed all of these concerns by October 2016. At this inspection we found the provider had made improvements to the management of people’s medicines. However, improvements were not yet fully embedded and the provider continued to breach the regulations relating to the other areas.

The principles of the Mental Capacity Act (MCA) 2005 were still not consistently applied in practice. Bed rail risk assessments were not consistently in place and people’s capacity to consent to the use of bed rails had not consistently been assessed. Care plans were at times contradictory and failed to document and underpin whether people could consent to their care plans.

People spoke highly of the food provided and a nutritional champion was in post. Menus were devised in partnership with people and initiatives had been implemented to promote nutritional intake. However, where there was the risk of dehydration, improvements were required to the monitoring and oversight of people’s hydration needs. We have made a recommendation for improvement.

The risk of social isolation had not consistently been mitigated. The registered provider had failed to maintain accurate, complete and contemporaneous records. People's monitoring charts were incomplete and included unexplained gaps and omissions. Incidents and accidents were not consistently audited for emerging trends, themes or patterns. The management of diabetes was not consistently safe and prescribed fluid thickener had been left in easy reach of people which posed a risk.

People received their medicines on time and in a safe manner. However, documentation failed to confirm when people’s percutaneous endoscopic gastrostomy (PEG) tubes were last rotated. People felt staffing levels were insufficient and commented that staff presented as busy and the call bell was continually ringing. We have made a recommendation for improvement.

The management team were dedicated to the on-going improvements of Ersham House Nursing Home. A quality assurance framework was in place but the positive improvements were still in the process of being embedded and implemented.

People’s individual ability to evacuate the service has been assessed and evacuation plans were in place. However, people’s evacuation plans failed to highlight that the service would operate a ‘stay put’ policy at night. We have made a recommendation for improvement.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate application to restrict people's freedom had been submitted.

People told us they felt safe living at Ersham House Nursing Home and spoke highly of the staff. One person told us, “The staff are lovely and we have a laugh.” Another person told us, “The staff are ever so kind.”

People had access to relevant healthcare professionals to maintain good health. Records confirmed that external healthcare professionals had been consulted to ensure that people were supported to receive effective nursing care. People received good health care to maintain their health and well-being.

Safeguarding adult's procedures were robust and staff understood how to safeguard the people they supported from abuse. There was a whistle-blowing procedure available and staff said they would use it if they needed to. People were protected, as far as possible, by a safe recruitment system.

A range of group activities took place which people spoke highly of. One person told us, “We play dominoes, bingo and we’re going to the cinema in a couple of days.” People, relatives and staff spoke highly of the new management team. One staff member told us, “The new manager is ever so supportive and approachable.”

During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 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 manager in post who was registered with the CQC. 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.

The provider had not ensured that medicines were stored or managed safely at all times. Staff had left the medicine trolley unattended during inspection. There were gaps in the medicine administration records where staff should have signed to say they had given medicines.

The service was clean and tidy and there were effective cleaning procedures in place.

There were sufficient numbers of staff to keep people and safe and meet their needs. The provider had a system in place that allowed the registered manager to recruit more staff when the numbers of people living at the home increased.

Staff were trained to protect people from abuse and harm. Staff could identify the signs of abuse and who to report to if they had any concerns. Staff were familiar with policies and procedures to record, investigate and track any safeguarding concerns.

The principles of the Mental Capacity Act 2005 (MCA) were not consistently applied in practice. Where people were unable to give consent to aspects of their care an assessment of their capacity had not always been completed.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate application to restrict people’s freedom had been submitted and the least restrictive options were considered as per the Mental Capacity Act 2005.

People were supported to have a healthy and nutritious diet, and were given options on what they would like to eat. The provider had carried out appropriate risk assessments to identify if anyone required additional support managing their diet or eating.

People were being referred to health professionals when needed. Staff were referring people to their GP, dentists and dieticians when it was identified that a person had a change in need.

People and their relatives told us they were involved with the reviews of their care plans. Care plans were being reviewed on a regular basis. However, the provider had not ensured that effective systems were in place to record who had taken part in reviews.

People told us they were very happy with the care staff and felt supported with their care. Staff were seen to be kind and caring towards people living at the service.

People’s private information and personal documentation was not always safely stored. People’s personal information was, on one noticed occasion, left unlocked in a drawer and unattended in an area that was passed by visitors. The registered manager had not ensured that all people’s records were up to date. Staff were aware of any changes to people’s care but these changes were not always transferred to the care plans.

People at the service were encouraged to make their own choices. People were free to decorate their rooms to their own tastes and preferences. People could choose which activities they participated in during the day.

People were encouraged to give feedback on their experiences. People completed surveys that identified where improvements can be made. The provider had in place an effective system to fully investigate complaints. People and staff spoke positively about the registered manager. The registered manager had an open door policy that was used by people, relatives and staff.

On inspection we found breaches in Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary describes what people using the service, their relatives, visitors and the staff told us, what we observed and the records we looked at. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. We saw that care plans reflected issues that were identified in the assessment.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff have been trained to understand when an application should be made, and how to submit one.

We looked at the physical environment and found bedrooms and communal areas to be clean and well maintained. However, we also found the floor and walls around the oven in the kitchen were dirty with no evidence of recent cleaning. There was thick grease and grime on areas around the kitchen appliance and food debris on the floor. This indicated a lack of thorough cleaning. We have asked the provider to take action.

All of the staff we spoke with told us that staffing levels at the home were insufficient to meet the needs of the people who lived there. We were repeatedly told that due to the high dependency needs of the people accommodated, the current staffing ratio meant that staff did not have sufficient time to do, 'More than basic care.' Staff told us that staffing levels were especially challenging in the afternoons and at mealtimes. We have asked the provider to take action.

Is the service effective?

People and their relatives told us that they were happy with the care provided and felt their care needs had been met. Staff told us they understood people's care needs and that they knew them well. We read the following feedback, 'The care you provide was both professional and sensitive and it is such a relief to know [my relative] is in safe hands.'

People who were able to verbally communicate with us told us that the meals they received were generally good and they received choice at each mealtime. We saw evidence in care plans that people's nutritional needs had been assessed. During the inspection however, we observed that advice and guidelines were not always followed which meant that people were not appropriately supported with their food and drink. We have asked the provider to take action.

Is the service caring?

We saw that staff communicated with people at a suitable relaxed and considerate pace. All of the people we spoke with told us they were happy at Ersham House Nursing Home. A relative told us, 'The staff are so kind and friendly. I can't fault the care [my relative] is in good hands here.'

Is the service responsive?

Care and nursing staff told us about each person's care needs and support required. One member of staff told us, 'People are well cared for here, we know their needs.' We saw that a GP had recorded the comment, 'Excellent nursing home. Staff liaise effectively with primary care.'

Is the service well-led?

People, their representatives and staff were asked for their views about their care and treatment and they were acted on.

Quality and compliance audits were regularly conducted and included medication, accident and incidents, care plans and maintenance reviews.

We considered our inspection findings to answer questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

Is the service safe?

Systems were in place to ensure that the management and staff had learnt from issues identified at previous inspections. This reduced the risks to people and helped the service continually improve.

If the service effective?

People's health and care needs had been assessed, and people told us the staff always asked them if they needed assistance.

Is the service caring?

We saw that staff were aware of people's needs and offered kind and considerate support. One person said, "The staff are very good, they know exactly what help I need".

Is the service responsive?

A range of social activities were available for people to join in if they wished. The programme was flexible and we saw that people made choices.

Is the service well-led?

The home worked well with other agencies and sought advice and support as required.

The staff we spoke were clear about their roles and responsibilities, and they had a good understanding of people individual needs.

We used a number of different methods to help us understand the experiences of people who used the service. Some people had complex needs, which meant they were not able to tell us their experiences. However, those who spoke with us said, 'I like living here' and 'The food is very nice'.

We examined three care plans. We found that there were inconsistencies in the information recorded, and the way records were kept.

People who were able to speak to us said they were very comfortable living at Ersham House. One person said, "I am quite comfortable. We have everything we need and the staff are very good." We observed that staff were respectful and caring and asked people if they needed assistance. People decided how and where they spent their time.

We examined four care plans. We found they identified people's specific needs and that people and their relatives, if appropriate, were involved in making decisions about the care provided. Some of the care documentation had not been completed, although staff were able to demonstrate a good understanding of people's needs.

Policies and procedures for safeguarding people were in place and staff had attended the relevant training.

We looked at the management of medicines and found that the systems used were appropriate.

We looked at staff files, training records and spoke with five care workers and two nurses. The training matrix identified the training people had attended or were booked to attend.

A complaints procedure was in place and people told us they felt confident to discuss any issues with staff or the manager.