Archived: Greenfield Care Home

During this inspection, we reviewed the actions that the provider told us they had taken to gain compliance against the breaches in regulations identified at the previous inspection in June 2017. We saw that significant work had taken place since our last inspection to improve the safety, effectiveness and quality of the service. We found improvements had been made in order to meet the regulations in relation to medicines management, staff training and the provider was compliant in these areas.

However, we found a continuing breach of the regulations. These were in relation to the management of risks to receiving care. We also found the provider had failed to make statutory notifications of notifiable incidents to CQC. You can see what action we told the provider to take at the back of the full version of the report.

Greenfield Care Home is a purpose built care home, registered to accommodate up to 112 people, with varying needs, who require 24 hour nursing and/or personal care. The home is split into four units known as ‘houses’ for people with different levels of need, including people who are living with dementia. The home is located in Ingol, close to the city of Preston and is accessible by road and public transport. Ample car parking is available at the home. There were 57 people who lived there at the time of our inspection.

The home did not have a registered manager in post. The last registered manager had left two years ago. A new manager had been appointed however, they had not started working at the time of our inspection. The regional support manager was providing managerial cover supported by a team of ‘service recovery’ managers. 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.

Before this inspection, we had received some concerning information in relation to the lack of reporting of safeguarding incidents to the local safeguarding authority and the accuracy of people’s care records. We looked into these areas during the inspection.

We spoke to people and their relatives and received positive feedback about the care provided at Greenfield Care Home. Safeguarding adults’ procedures were in place however staff did not always understand their responsibilities in relation to reporting incidents to safeguarding authorities.

In majority of the cases, we found risks associated with people’s care were identified and assessed. However, this was not always consistent across all four units. There was a whistle-blowing procedure available and staff said they would use it if they needed to. There was a disciplinary procedure in place however, this had not always been operated effectively.

There had been a significant improvement in the management of people’s medicines. People's medicines were managed appropriately and according to the records seen people received their medicines as prescribed by health care professionals.

The service had recruitment policies and procedures in place to help ensure safety in the recruitment of staff. These had been followed to ensure staff were recruited safely for the protection and wellbeing of people who used the service. Records we saw and conversations with staff showed the service had adequate care staff to ensure that people's needs were sufficiently met.

People were protected against the risk of fire. Building fire risk assessments were in place and firefighting equipment had been maintained.

Staff had completed an induction programme when they started work and they were up to date with the training that the provider had deemed necessary for the role. The service followed the requirements of the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. There were appropriate arrangements in place to support people to have a varied and healthy diet. People had access to a GP and other health care professionals when they needed them.

People told us that staff treated them in a respectful and dignified manner. We observed people were happy, comfortable and relaxed with staff. A significant number of people who had previously been confined to their beds or bedrooms had been encouraged and supported to sit in communal areas with other people on a regular basis. This was an improvement.

We noted ongoing improvements in care plans. The care plans and risk assessments provided guidance for staff on how to meet people’s needs and were reviewed regularly. Care plans showed how people and their relatives were involved in discussion around their care. However, some improvement will be required to ensure care record plans are updated when a review shows significant changes in people’s care needs. People were encouraged to share their opinions on the quality of care and service being provided. There were a variety of activities provided to keep people occupied.

The environment had been adapted to suit the needs of people who lived at Greenfield Care Home.

We observed that significant improvements had been made sustained in various areas of care. We received positive feedback from people, relatives and staff regarding management of the service. Staff morale had improved and care staff felt supported by management. There were established management systems at the service. The general manager had provided oversight of duties they delegated to other staff. However, improvements were required in respect of oversight on the management of safeguarding incidents.

Quality assurance systems were in place and various areas of people’s care been audited regularly to identify areas that needed improvement. There was a business contingency plan to demonstrate how the provider had planned for unexpected eventualities, which may have an impact on the delivery of care and treatment.

During this inspection we reviewed actions the provider told us they had taken to gain compliance against the breaches in regulations identified at the previous inspection in December 2016. We also looked to see if improvements had been made in respect of the breaches. During this inspection we saw that significant work had taken place since our last inspection to improve the safety, effectiveness and quality of the service.

However we found three continuing breaches of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These were in relation to the safe management of medicines, management of risks to receiving care and failure to ensure staff received appropriate support, and training. We made a recommendation in respect of system and processes for managing internal safeguarding investigations in the service. We also found that the work being done was still in its early stages and needed to be sustained to ensure a consistent delivery of safe care and treatment that could be evidenced in the longer term. You can see what action we told the provider to take at the back of the full version of the report.

Greenfield Care Home is a purpose built care home, registered to accommodate up to 112 people, with varying needs, who require 24 hour nursing and/or personal care. The home is split into four units known as ‘houses’ for people with different levels of need, including people who are living with dementia. The home is located in Ingol, close to the city of Preston and is accessible by road and public transport. Ample car parking is available at the home. There were 61 people who lived there at the time of our inspection.

The home did not have a registered manager in post. The last registered manager had left in 18 months ago. During our last inspection an interim manager was providing cover and was in the process of applying to be registered to become the registered manager. However during this inspection we were informed that they were leaving the service and an interim manager had not been identified. The regional support manager was providing managerial cover supported by a team of ‘service recovery' managers. 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.

Before this inspection we had received some concerning information in relation to medicines management, the management of risks to people such as wound care and the management of safeguarding concerns in the service. We looked into these areas during the inspection.

The overall rating for this service is ‘Requires improvement’. The service has previously been placed in special measures and there will be no change to this situation following the outcomes from this inspection.

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.

People who lived at Greenfield Care Home told us that they felt safe in the home and that there was sufficient staff available to help them when they needed this. People who lived at the home and their visitors spoke highly of the care staff and told us they were happy with the care and treatment.

There had been an improvement in the quality of care and treatment across the four different units. This included the care records, care staff responses to people’s needs, adequate numbers of staff and referrals to other professionals.

We observed staff communicating with people in a kind and respectful way. People told us staff respected their privacy and dignity and encouraged them to be independent.

Since our last inspection in December 2016 the provider had made improvements in relation to ensuring that there was the right mix of skills and competencies of staff on duty each day. In majority of the times they had ensured that a qualified nurse was in charge of the nursing units.

Training records indicated that all staff had received training in fire safety awareness and nurses had been provided with relevant training to meet the clinical needs of people in their care. Staff had also received training in safeguarding and knew the appropriate action to take if they believed someone was at risk of abuse. They were aware of the procedures for reporting bad practice or ‘whistle blowing' within the organisation. However the internal safeguarding processes and procedures in the service were not robust.

People told us and we observed there had been an improvement in staff’s response to people’s needs. The level of staffing on the days of the inspection was sufficient to ensure that the current number of people living in the home had their needs met in a timely manner. The numbers of staff on shift during the day and night were seen to be consistent. Systems were in place for the recruitment of staff and to make sure the relevant checks were carried out before employment.

Since the last inspection the provider had been responsive and proactive in improving the systems used in the recording of information about people’s needs and the planning of their care.

We looked at the risk assessments in place for people and these included risk assessments for skin and pressure area care, falls, moving and handling, mobility and nutrition and for the management of a different conditions or specific medication. However we found shortfalls in other areas of risk management, including wound care, and a failure to provide staff that were first aid trained on units that had people with high risk of choking.

We found some improvements had been made in relation to medicines management. Audits had been carried out and medicines had been stored safely. There was significant number of medicines related incidents since the last inspection in December 2016. People did not always get the medicines they were prescribed for. We found continuing concerns regarding the safe management of people’s medicines.

Measures had been taken to reduce the risks associated with fire. Infection control measures were in place and standards of hygiene had been maintained. The premises and equipment had been maintained and serviced in line with regulations and manufacturer’s recommendations.

Improvements had been made in relation to seeking consent. The service had taken appropriate action where people lacked the capacity to make decisions about their care and needed to be deprived of their liberty to keep them safe.

People using the service had access to healthcare professionals as required to meet their needs. However this was not always timely. There were systems in place to assess people’s health care needs on admission to the service to ensure the home was able to meet their assessed needs.

Improvements had been made across the service to ensure care plans were accurate and written in a person centred manner.

The provider had sought people’s opinions on the quality of care and treatment being provided.

People received adequate food and drinks throughout the day ensuring their nutritional needs were met. We saw that a range of organised activities were being made available to people. Staff had been actively involved in supporting people with activities that had been arranged. We noted that the environment within two units of the home had been developed to make it as enabling an environment as possible for people living with dementia.

Management and governance systems in the home had improved however they remained unstable. Further improvements were required to ensure stability in leadership and governance. The service had no registered manager and had not had one for 18 months. There had been five different managers since June 2015. Two house managers who had been recruited at the time of our last inspection had left the home. One unit did not have a manager. A service recovery team had been assisting with leadership and to help improve the service.

We noted an improvement in the systems designed to assess, monitor and improve the service. However, the number of shortfalls we found indicated the quality assurance and auditing proces

Greenfield Residential and Nursing Home is a purpose built care home, registered to accommodate up to 112 people, with varying needs, who require 24 hour nursing and/or personal care. The home is split into four units known as ‘houses’ for people with different levels of need, including people who are living with dementia. The home is located in Ingol, close to the city of Preston and is accessible by road and public transport. Ample car parking is available at the home. There were 80 people living there at the time of our inspection.

The home did have a registered manager in post however they had not worked at the home for some time. An interim manager was providing cover and in the process of applying to be registered to become the registered manager. They were not present during inspection and the clinical service manager was present and providing management cover. The previous registered manager had left but had not yet applied to cancel their registration. 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.

At the last inspection on 15 and 16 March 2016 we found the provider was in breach of legal requirements of the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014, in respect of the need to seek consent when providing care and treatment. We issued a warning notice and asked the provider to be compliant with the regulation by June 2016. At this inspection, we found continued failures with this regulation which demonstrated that the provider was still not compliant.

Before this inspection we had received some concerning information in relation to medicines management, inadequate levels of care staff and nurses, inadequate training for nurses to provide specific clinical duties and poor care records. We looked into these areas during the inspection.

We found the service to be in breach of nine regulations under the Health and Social Care Act, 2008 (Regulated Activities) Regulations 2014. The breaches were in relation to, person centred care, seeking consent, safe care and treatment, failure to manage people’s medicines effectively, failure to deploy sufficient numbers of suitably qualified, competent persons to deliver care, failure to ensure staff received appropriate support, training, professional development, supervision and appraisal, good governance, failure to manage complaints effectively and failure to undertake robust employment checks and failure to notify Care Quality Commission of significant events that affected the smooth running of the service. You can see what action we have told the provider to take at the back of the full version of the report

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 representations and appeals have been concluded.

There was a variance in the quality and consistency of care and treatment between the five different units. We found people living in the two residential units received satisfactory standards of care. This included leadership; the response to people’s needs and care records. However, the quality of care and treatment in the three nursing care units was inconsistent and did not always meet the fundamental standards of care people should expect. A lack of consistent, adequate numbers of suitably skilled staff had impacted on the quality of care and treatment and had impacted on one of the residential units which had been providing adequate levels of care.

The provider had not ensured there was the right mix of skills and competencies of staff on duty each day or the minimum number of staff. A single nurse had been left in charge of three nursing units in some instances which meant there had been only one nurse to look after 46 people requiring nursing care. One unit did not have care staff during night. We asked for care staff to be provided for this unit every night and the provider acted immediately.

We were informed that the provider was undertaking on-going recruitment of care staff and nurses to ensure the service was fully staffed.

During the inspection we observed staff responding to people’s needs in a timely manner and there were always staff available for people when they asked for assistance, however, staff, people, relatives and visitors informed us this did not happen routinely and that people had to wait longer to receive support from care staff.

Safe recruitment practices were not always followed to help ensure only suitable people worked in the home. Not all staff had provided full employment histories and there was a lack of suitable references from previous employers.

We saw risk assessments in people’s care files, the quality and accuracy varied between residential units and nursing units. Risks assessments in the two residential units had been completed and reviewed adequately when people’s needs changed. However, in the nursing units people’s risk assessments were not always completed nor were they accurate, reviewed or updated when people’s needs changed. Staff did not monitor people’s risks appropriately. We found similar inconsistencies with care plans.

We found staff did not always follow relevant recognised guidance in relation to skin care and pressure sore management. People were left at significant risk of developing skin sores as they had been left in bed for long periods of time.

Risk assessments for bed rails had been completed and reviewed regularly. Where necessary these have been replaced.

Staff had received training in safeguarding adults. They showed awareness of signs of abuse and what actions to take. There was a record of safeguarding incidents which showed how they had been investigated and analysed for trends and patterns. However, lessons learnt were not always put into action and recommendations from safeguarding incidents had not been acted on.

People’s medicines had not been managed safely. Guidance for safe management of medicines had not been followed which included secure storage of medicines, excessive amounts of waste medicines and lack of robust recording for creams. Medicine were not always given on time and medicine rounds took longer to complete in nursing units, which had an impact on people who took medicines that required regular timing for pain management.

People were not effectively protected in the event of a fire. Building fire risk assessments were in place; however, personal emergency evacuation plans (PEEPS) that we found in people’s care files did not provide sufficient guidance to enable safe evacuation of people in case of emergency.

Infection control measures were in place and standards of hygiene had been maintained. The premises and equipment had been maintained and serviced in line with regulations and manufacturer’s recommendations.

The provider had not met the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). They had failed to fully comply with a warning notice which was issued by the Care Quality Commission in June 2016.

We found people’s care plans had not been written in line with the Mental Capacity Act, 2005 (MCA). Mental capacity assessments had been completed appropriately for people who lived in the residential houses or units. However, mental capacity assessment we found in the three nursing units were generic and not decision specific. People who could not communicate their decisions had not been supported through best interest processes.

We identified people who required DoLS authorisations who had not been considered for authorisation. The provider was undertaking work to improve staff’s knowledge and practice in relation to mental capacity and supporting people to make decisions about their care and treatment.

There was shortfall in mandatory staff training for nurses to enable them to undertake key clinical tasks to ensure people’s needs were adequately met. All nu

At our last inspection, we found the provider was in breach or legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, in respect of staffing, safe care and treatment, meeting nutritional and hydration needs, person centred care, need for consent and good governance. At this inspection, we found improvements had been made in each area.

However, we found the service was in breach of legal requirements relating to the need for consent. This was because the provider could not demonstrate that care and treatment was only provided with the consent of the relevant person. In addition, where a person was unable to give such consent because they lacked capacity to do so, the provider had not acted in accordance with the Mental Capacity Act 2005. You can see what action we have told the provider to take at the back of the full report.

Greenfield Residential and Nursing Home is a purpose built care home, registered to accommodate up to 112 people, with varying needs, who require 24 hour nursing and/or personal care. There were 96 people living there at the time of our inspection. The home is split into four 'houses' for people with different levels of need, including people who are living with dementia. The home is located in Ingol, close to the city of Preston and is accessible by road and public transport. Ample car parking is available at the home.

The home did not have a registered manager in post. Management cover was being provided by a relief home manager whilst a suitable candidate was being recruited. The previous registered manager had left but had not yet applied to de-register. 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 were an adequate number of staff deployed in each of the four houses to meet the needs of people who lived there safely. We observed staff responded to people's needs in a timely fashion and there were always staff available for people to call on if they required assistance. Robust recruitment processes were followed to ensure only suitable candidates worked with people who lived at the home. The home assessed people's needs appropriately to ensure they could be met fully and safely.

Checks were carried out to make sure the environment was clean and tidy. However, we found some areas of the home required more attention to detail. The relief home manager had already identified this as an area for improvement and took swift action to remedy this.

People's medicines were managed safely with the exception of stock such as creams and eye preparations, which had a limited shelf life. We have made a recommendation about this.

We found improvements had been made with regard to staff skills, experience, training, supervision and support. People we spoke with told us that staff knew what they were doing and had the necessary knowledge and skills to meet their needs effectively. Staff told us and records we looked at confirmed that improvements had been made with regard to staff supervision and support. Staff explained that the team was now more stable and that they received regular, worthwhile supervision.

The service ensured people received sufficient nutrition and hydration which met their needs. People were supported to eat and drink as required. People's health was monitored routinely and they were supported to access external healthcare services if they needed them. The home was operated from purpose built premises, which assisted in the environment being suitable for it's purpose.

People's involvement, or the involvement of other relevant persons in reviews of care was not always recorded in detail. We have made a recommendation about this.

The service did not routinely involve advocates in cases where people lacked capacity to make decisions and did not have someone else to speak for them with regard to their care and treatment. We have made a recommendation about this.

People were cared for by a consistent staff team who had developed positive and caring relationships with them. We found improvements with staffing levels and staff deployment had resulted in a positive impact on the experience of people who used the service. Throughout our inspection we witnessed kind and compassionate interactions between people who lived at the home and staff. There were no restrictions on visiting times.

During this inspection, we found the care delivered to people was more centred around the person; staff were driven less by tasks and more by providing care to people. Prior to anyone being admitted to the home, a thorough pre-admission assessment was carried out to assess people's level of need, to ensure the service could meet their needs fully. The assessments were wide ranging and covered all aspects of care.

We found assessments of people's needs and written plans of care were, in the main, reviewed regularly, in line with timescales prescribed by the provider. However, we did find some cases where reviews had not taken place as planned, which meant people's plans of care may not have been sufficient to address their current level of need.

The service employed three activity coordinators. Activities included trips out into the community, visits from entertainers and singers, board games, crafts, baking and one on one time for people who preferred not to involve themselves in group activities. The provider had implemented a suitable complaints policy and procedure. Feedback about people's experiences of care and treatment were sought in a variety of ways.

Systems designed to assess, monitor and improve the service were being operated effectively. The service had a written plan of improvements to improve the experience of people who lived at the home. However, we found audit tools that were used in each 'house' were not used consistently, as directed by the home's policies and procedures.

Improvements had been made with regard to the leadership and management at the home, which had resulted in an improved caring culture. Staff we spoke with knew what was expected of them and told us they were generally supported to fulfil their role. The service had implemented a wide range of policies and procedures which provided staff with clear information about current legislation and good practice guidelines.

Is the service safe? People were protected against the risks associated with medicines. This was because we found no errors in the recording of medicines administered to people who lived at the home. On the day of our visit we saw staffing levels were sufficient to provide a good level of care and keep people safe. However, people told us this was not always the case. Policies and procedures were in place around the Mental Capacity Act and safeguarding. Staff had a good understanding of these to keep people safe and protect their human rights.

Is the service effective? Staff had access to ongoing training to meet the individual and diverse needs of the people they supported. However, great efforts needed to be put into place to ensure staff received appropriate supervision. People were assessed to identify the risks associated with poor nutrition and hydration and spoke highly about the quality and choice of food. The management and staff at the home worked well with other agencies and services to make sure people's health needs were managed.

Is the service caring? People were supported to express their views and wishes about all aspects of life in the home. On the whole, we saw that staff treated people with patience and compassion and respected their rights to privacy and dignity. However, we did observe an event when a staff member could have dealt with a person's distress in a better way. The registered manager was made aware of this, and measures were put into place to ensure staff dealt with these types of events in a more effective manner.

Is the service responsive? Records showed people and their family members had been involved in making decisions about what was important to them. People's care needs were kept under review and staff responded quickly when people's needs changed. However some aspects of the service were not responsive to people's needs. There wasn't an established programme of activities.

Is the service well-led? There were systems to monitor identify, assess and manage risks to the health, safety and welfare of the people who lived at the home. Appropriate measures needed to be put into place to ensure that the risks associated with the deployment of staff were managed effectively.

People had care plans that promoted a person centred approach to their care. Staff were attentive to peoples request for assistance. They spoke respectfully and attended to personal care needs as required.

Staff knew how to care for people at risk of falling, developing pressure ulcers or may not eat enough.

Activities were very good and age appropriate with good social value such as 'The Gentleman's club' and the Ladies club'.

Visiting arrangements were very good.

People told us they were satisfied with the catering arrangements. 'I like everything really. All the food is nice, I have no complaints'. 'We get a good choice. The staff know what I like. I forget sometimes what I order but that doesn't matter'.

Equipment people used was kept in good working order.

People who use the service benefit from staff that had been subject to the necessary character checks to ensure they were fit, trustworthy, qualified and physically and mentally fit to do their job.

The provider had an effective system to regularly assess and monitor the quality of service that people received.

Medicines were safely administered. We observed part of the morning medicines round on Elm. We saw that support was offered to people who need help when taking their medicines. Water was offered and care was taken to complete the medicines records immediately after administration, helping to ensure their accuracy

Both people were generally happy with nurses and carers handling their medication but one person told us that although they hadn't mentioned it before, they 'would prefer (their) medicines after, rather than during (their) lunch, as it 'put them off' their meal.

We found appropriate arrangements were in place for confirming people's current medicines on admission to the home. However, we saw one example where special individual instructions for medicines administration had not been uplifted to one person medicines record. This increases the risk that they may not receive the support they need to take their medicines safely.