Archived: Blackdown Nursing Home

Blackdown Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. We regulate both the premises and the care provided, and both were looked at during this inspection. The service provides care and accommodation for up to 33 people who may require nursing care or who are living with dementia. On the first day of the inspection there were 31 people staying at the service.

The home is a detached property located in the small town of Mary Tavy, near Tavistock. There are two lounges and a large dining room for people to use. There is a large garden with views of surrounding countryside.

At the last inspection in August and September 2017 we found the provider in breach of four Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the provider had not ensured people’s care and treatment were appropriate and their needs and preferences met. People had limited opportunities to take part in activities suitable to stimulate and engage them. The provider had not ensured the premises were safe for use and did not have effective systems in place to assess, monitor and improve the quality and safety of the service provided.

The service was rated as requiring improvement overall and in the safe, responsive and well-led domains. The effective and caring domains were rated as good.

Following the inspection, the provider developed an action plan to ensure improvements were made. The service had also worked in partnership with the local authority quality assurance and improvement team (QAIT) to improve their systems and processes and put in place a service improvement plan (SIP). At this inspection we found the provider had completed the actions and were no longer in breach of the regulations. They were continuing to use their SIP and had prioritised actions needed.

There was a 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 2008 and associated Regulations about how the service is run. The registered manager had been registered with CQC in July 2017.

The registered manager had put in place comprehensive quality assurance systems which identified when improvements were needed. The providers regularly visited the service and undertook quality checks and were kept informed about the running of the service.

The provider had made improvements which ensured people were protected from the risks of unsafe and unsuitable premises. Fire safety precautions were in place and followed. There were plans and procedures in place to safely deal with emergencies. Checks and audits were undertaken to ensure the environment was safe. Learning from incidents and accidents took place and appropriate changes were implemented.

There were appropriate infection control processes in place. The home was clean and homely. People received their prescribed medicines on time and in a safe way. Staff ensured people were referred promptly to health professionals when required.

The activity provision at the home had improved. A full-time activity person had been recruited. They had developed a programme of activities which people said they enjoyed doing. The programme included activities which were assessed and meaningful to people.

People felt safe living at the home and with the staff who supported them. There were sufficient staff on duty to meet people’s needs and keep them safe. Staff were knowledgeable about how to recognise signs of potential abuse and were confident any concerns raised would be acted upon. They had completed training to ensure they had the right competencies, knowledge and skills to support people at the home.

People were supported to eat and drink enough and maintain a balanced diet. Positive improvements had been made to the dining experience at the home. Individual risk assessments were completed. Staff had put in place preventative measures where people were identified at an increased risk of skin damage or weight loss.

Staff treated people with respect and were kind and compassionate and maintained their dignity when helping them with daily living tasks. They addressed people by their name and personal care was delivered in private in people’s rooms. They knew the people they cared for well and when supporting people at the end of their life they were cared for in an individualised and dignified way.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. Capacity assessments were undertaken and best interest decisions were being recorded. This helped to protect people’s rights. Staff gained people’s consent and involved the person before they provided care. They listened to people’s opinions and acted upon them. Visitors were made welcome and could visit without time restrictions.

Care and support was planned and delivered in a way the person wished. Care plans identified people’s care and support needs and how they wanted staff to support them.

People were supported to maintain their personal appearance. This included support with shaving and hairdressing appointments. The registered manager had improved staff recording of personal care on the computerised system. Senior staff undertook spot checks each day to ensure people’s personal needs had been completed.

People knew how to share their experiences and raise a concern or complaint. They were confident the registered manager would take action as required.

Everyone said they had confidence in the registered manager. They had implemented a lot of improvements since the last inspection. They had worked with staff to improve the team work at the home in line with the provider’s website.

The first day of the inspection was unannounced. We informed the registered manager of the date of the second day of the inspection so they could be present.

At the last inspection in December 2016 we found three breaches of regulation and the service was rated as requiring improvement overall and in the safe, effective, responsive and well-led areas. Caring was rated as good. As a result, requirements were made to ensure the service complied with the Mental capacity Act; to ensure risks to people’s health and safety were properly assessed, recorded and acted upon and aspects of medicines management were improved. A requirement was also made to ensure the quality monitoring systems in place were improved.

Following the inspection, the provider had developed an action plan to ensure improvements were made. The service has also worked in partnership with the local authority quality assurance and improvement team to improve their systems and processes. Prior to this inspection we met with the provider and registered manager to review their action plan. We found some improvements had been made at this inspection. However further improvements were still needed.

This comprehensive inspection was brought forward as prior to this inspection the registered manager had notified us of two incidents, which resulted in harm to people using the service. We wanted to ensure risks to people’s health and wellbeing were appropriately managed. We also received anonymous concerns about practice which indicated people’s preferences about when personal care was delivered may not be met.

A new manager was appointed at the service in May 2017 and registered with the Care quality Commission in July 2017. 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.

People received their medicines safely and when they needed them. However some medicine practices could be improved.

The registered manager had introduced a range of audits and systems to enable them and the provider to monitor the quality of the service provided. These were beginning to have an impact. However, the quality assurance system was not always effective because issues identified at the inspection had not been recognised. Improvements were needed to ensure people were protected from the risk of fire and that all parts of the premises were clean and odour free.

Improvements were required to ensure people’s daily personal care was always personalised and responsive to their needs. Mealtimes were not always well organised or sociable occasions. The physical environment of the service had not been adapted to meet the particular needs of people living with dementia and maximise their independence. People living with dementia would benefit from activities based on current good practice guidance for dementia care.

People said they felt safe. Improvements had been made to ensure assessments identified people’s specific needs or risks, and showed how risks could be reduced. There were systems in place to review accidents and incidents and the registered manager ensured action was taken where necessary to reduce future risks.

Staff had been trained to recognise abuse. The registered manager and staff understood their responsibilities to report any concerns. There were sufficient staff to ensure people’s needs were met, when there were no unplanned staff absences. Staff had opportunities for regular training to enhance their skills and knowledge.

Improvements had been made to ensure people’s rights were protected as the registered manager acted in accordance with the Mental Capacity Act 2005.

People’s nutritional needs were met. People had access to a variety of health professionals for specialist advice and support when appropriate. The service had developed good working relationships with health and social professionals.

People said the staff were friendly and kind. We observed staff speaking to people in a friendly, warm and politely way. People knew how to raise concerns and the registered manager dealt with concerns in a timely way to resolve them quickly where possible.

Improvements had been made in relation to some records. Care plans contained detailed information about people’s health needs and how these should be met. Records showed that staff had taken appropriate actions to alert health professionals where risks to health had been identified.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We have made a recommendation relating to the management of medicines.

You can see what action we told the provider to take at the back of the full version of the report.

A registered manager was employed to manage the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our inspection in November 2015 found a breach of the regulations. People did not always give consent for care and treatment and the provider did not act in accordance with the Mental Capacity Act 2005. At this inspection we found staff told us they often made decisions in people’s best interests and records showed best interests decisions had been made on behalf of people. However, mental capacity assessments were not always in place to identify why the person was deemed unable to make the decision themselves, the rationale for decisions made in people’s best interests was not recorded and people’s care plans did not always contain information to guide staff about people’s preferences. Staff told us they sought consent from people but this was not always observed to be the case during the inspection.

People received their medicines on time from staff who were patient and understood their needs. However, people’s medicines were not always stored or disposed of safely and there was no audit in place to help ensure medicines administration followed best practice. Following the inspection, the provider sent us details of a new medicines audit to be used in the home.

People were observed to have their healthcare needs met but risk assessments were not always clear or reflective of people’s current needs; and actions taken to help mitigate any risks were not always recorded. Tools to monitor people’s health needs were not always complete or up to date and action was not always taken in response to possible concerns, for example weight loss or regular falls.

A record was kept in people’s rooms of their likes, dislikes and preferences but it was not clear that staff were using this information to provide meaningful activities for people. There was a programme of planned entertainment for people but outside of these times people were observed to have little to keep them cognitively active.

People and relatives described the service provided as being particularly caring and spoke highly of the staff and the support they provided. The provider had a clear philosophy that people should be treated as family members. This was reflected in the ways staff spoke about their work and comments received by relatives. Compliments received by the service stated, “I never ever saw anything but love for all the patients under your care” and “Thank you for the wonderful care and love you showed mum”

People were supported by staff who were knowledgeable about their needs and had regular training to update their skills and knowledge. Staff told us they felt well supported by the provider and registered manager. One member of staff told us, “If there’s something I’m unsure about, I can ask the manager or the owner for advice. I feel confident I can ask.”

People told us they felt safe using the service. Staff had received training in how to recognise and report abuse and were confident any allegations would be taken seriously and investigated to help ensure people were protected.

People were kept safe by suitable staffing levels. Relatives told us there were enough staff on duty and we observed unhurried interactions between people and staff. This meant that people’s needs were met in a timely manner. Recruitment practices were safe. Checks were carried out prior to staff commencing their employment to ensure they had the correct characteristics to work with vulnerable people.

Feedback received by the service was used to improve the quality of the service and complaints were taken seriously and acted upon. Relatives confirmed, “I can find no fault at all” and “Everything I‘ve mentioned to staff, they’ve listened to.”

The registered manager regularly audited care plans and risk assessments but this had not highlighted that some were not reflective of people’s current needs. There were no audits of medicines, falls or incidents in place to help ensure all appropriate action had been taken or that improvements were made from any trends identified. The provider had not monitored the service effectively to identify areas for improvement. Following the inspection, the provider informed us of several new audits or procedures which would be put in place.

We found breaches of regulation. You can see what action we told the provider to take at the back of the full version of the report. We will also meet with the provider to discuss action they intend to take and carry out a further inspection in the near future.

We carried out a follow up visit to Blackdown Nursing Home on 24 October 2013 and found little documentation that people consented to the restriction of locked doors or capacity assessment around that decision. We discussed with the provider the need for immediate action to implement suitable arrangements for obtaining, and acting in accordance with, the consent of people using the service in relation to the care and treatment provided for them.

We carried out a further visit on 15 November 2013 to check that the provider had taken action as stated in his action plan we received on 4 November 2013. We found care plans had been amended and only one was awaiting signatures for consent to care and treatment, and two for consent to being kept safe by the restriction of locked doors. This showed the provider was putting in place suitable arrangements to ensure people or their representative were asked for their consent to how they were cared for and how they were treated.

During this visit we found that the standard of cleanliness and infection control was improved. The premises were safer and afforded people more safe outdoor space. However, further work was needed as the extensive grounds remained mostly unavailable to people. Time out of doors without staff or family remains impossible without risk. One person said "Much better that the path is mended now."

The standards of care and treatment were high and there was evidence of nurse expertise which improved people's lives. People enjoyed engagement with staff instead of restrictions of movement from the lounge as we had seen at our last visit. We saw one person laughing, sharing a game with staff. Care plans were more person centred and included social needs and how they would be met. Most people were unable to tell us about the home but people's family told us "Marvellous. Everything she asked the staff for she got". This meant people were treated with respect.

For a second time we found that people were not always consenting to their care and treatment. We found staff were not following the legal requirements relating to the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards when people were unable to consent.

People told us, "it's wonderful here", "I'm well looked after and there is a feeling of friendliness". One person said, the food is "excellent - I'm putting weight on here!". Staff told us, "there is always someone to talk to". Relatives said, "staff do their best".

We found people were not always involved in decision making about their care and treatment. We found staff were not following the legal requirements relating to the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards.

We found people's dignity, privacy and independence were not always upheld. We found people's care could be more individualised and promote positive risk taking and independence.

We found there were not systems in place to monitor cleanliness and hygiene in relation to equipment.

We found people were unable to move freely around the home and grounds because there were areas which were not safe for them alone.

We found people were cared for by staff who were trained and supported to deliver care and treatment safely.