Archived: Monmouth Court Care Home

Monmouth Court Nursing Home provides care and support to a maximum of 153 older people, some of whom were living with dementia and or had complex nursing needs. People were accommodated across three units, with a fourth unit being closed at the time of our inspection. At the time of our visit there were 58 people living at the service.

At our previous inspection in December 2015 the service was rated as ‘inadequate’ and so placed into special measures. This was because we identified major shortfalls with breaches of regulation regarding the lack of action taken to mitigate the risks to people, insufficient numbers of suitability, qualified and experienced staff available at all times to meet people’s complex health care needs and the monitoring of the safety and quality of care provided to people across all three units at the service. This was linked to a lack of clinical oversight and effective leadership and support from the registered manager and the provider. In response to our findings we asked the registered manager to take urgent action to protect people from harm. We took urgent action by placing conditions on the provider’s registration including the restriction of any new admissions to the service.

At this inspection we found some improvements. However, there was a need for further development of the service. We identified continued shortfalls in relation to people having access to sufficient numbers of, suitably qualified staff at all times to meet their needs and in the training, development and deployment of staff to meet the needs of people living with dementia. There continued to be a high number of nursing staff vacancies which meant there continued to be a high number of agency nurses employed. This impacted on the effectiveness of communication and the consistency of care provided to people to ensure their health, welfare and safety needs were met.

Since our last inspection the registered manager had left and a new manager appointed in August 2016. There is a requirement for this service to have a manager registered with the Care Quality Commission (CQC). The manager told us they had completed their application to register but their application was currently with Bupa’s legal team for review before submission to 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.

People and their relatives were positive about the change in management and responses to any concerns and or complaints they had raised with the provider. There were improved systems in place for continuous quality and safety monitoring of the service including clinical oversight of the service.

The provider had improved systems in place for identifying risks to people’s health, welfare and safety. We found some improvement had been made with systems now in place to ensure the safe management and monitoring of people's nutrition and hydration needs, in particular for people with swallowing difficulties, those at risk of choking and people at risk of insufficient intake of nutrition and hydration. However, risks that had been identified were not always consistently managed.

At our previous inspection we identified major shortfalls in the safe management of people’s medicines. At this inspection we found significant improvement. However further work was needed as we found inconsistencies in the management and recording of people’s prescribed creams and lotions. Staff were not always provided with clear information as to where on the body and how often the creams and lotions should be applied.

The provider had systems in place and staff trained in identifying acts of abuse and what steps to take to reduce the risk of people experiencing abuse. Staff had been provided with procedural guidance in reporting issues of concern such as whistleblowing and safeguarding policies and procedures to follow. However, we found risks to people’s health, welfare and safety were not always effectively managed. There continued to be a high number of nursing staff vacancies. There was not to always sufficient numbers of skilled and experienced staff available to provide consistency of care which met people’s needs.

We observed some very caring interactions between staff and people living at the service. Relatives were positive about the improvements they had observed in the culture of the staff group. Staff were observed in the main to be kind and respectful but care delivery on Harlech unit was often task focused as staff had limited time to spend with people. This included the number of staffing hours allocated to those staff employed to provide social stimulation, including group activities and so staff were not always able to meet the holistic, individual needs of people living with advanced dementia.

We found inconsistencies in the quality of care planning to guide staff in the steps they should take to meet people’s needs. Care plans did not always reflect the current needs of people and contained limited information as to people’s preferred wishes and preferences about how they would like to live their day and support that should be provided to enable them to do this. There was a lack of provision of support to enable people to maintain their hobbies and interests as much as they are able. People were not always protected from the risks of social isolation. There were a high number of people who stayed in bed. It was not always clear within their care plans as to why this was the case.

During this inspection we identified a number of continued breaches of the 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 this report.

The inspection was unannounced and took place over two days, on the 15th and 17th December 2015.

The home had a registered manager in place. 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 requirements in the Health and Social Care Act 2008 and associated regulations about the service is run.

We identified significant shortfalls in the care provided to people across all three units at the home. This was linked to a lack of oversight from the registered manager and provider.

Relatives raised concerns about people’s safety. People were put at risk of harm because care records and assessments did not clearly reflect all current areas of risk and how these should be managed to protect the person from harm. Staff were not proactive in reducing the risks to people and so they were left without appropriate support. For example, when they were anxious or unable to do something independently.

Medicines were not managed and administered in a way which ensured people’s safety and did not reflect best practice in some areas.

The service was not complying with the requirements of the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS). Staff were unable to demonstrate that people were appropriately supported when they were unable to make choices about their lives.

People were not consistently supported to live full and active lives, and to engage in meaningful activity within the service. We saw people who were socially isolated with little or no action taken by staff or the manager to address this.

Care planning for people was generic and not person centred. In addition care planning wasn’t written in a way that helped staff to understand people’s experiences or interests prior to moving to the home. People and their representatives were not involved in the planning of their care, and their views were not reflected in their care records.

People told us and we observed that there were not enough suitably trained and experienced staff available to meet peoples social, emotional and physical needs. Staffing levels were not calculated by the management based on the needs of people using the service.

Staff were not consistently supported to develop their skills within the caring role. There was no system in place to assess staff competency and performance. Supervision of staff was not consistent.

Systems in place to monitor the quality of the service were not effective in identifying shortfalls and areas for improvement. There was not an open culture within the service. Staff told us they felt there was a disconnect between them, the registered manager and provider. People and their representatives said that although they were invited to residents meetings, issues raised in the meetings were not acted on by the manager so improvements were not made.

People told us they knew how to make a complaint but didn't feel they would be listened to. It wasn't clear how complaints were used to improve the service.

Throughout the two inspection visits we identified such serious concerns that we immediately fed these back to the Registered Manager so action could be taken to protect people from harm. In addition, we shared information about the concerns we identified with the local council’s safeguarding team and local commissioners. Following the inspection, we wrote to the provider to request information about how they intended to make the urgent improvements required to protect people from the risk of coming to significant harm. We also took urgent action to stop this home from admitting anyone new by amending their conditions of registration.

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

When we returned to the service on 21 January 2014, to we found improvements had been made. People’s needs were being met and found this was reflected in the care records that we looked at.

We spoke with six people who used the service and one relative of a person. Feedback was positive about the care provided. One person told us, “It is alright here. The staff are lovely and try their best to help you.”

During our inspection we saw that staff interacted with people in a caring, respectful and professional manner.

In the dementia care unit, we found staff had a greater understanding of the individual support and environmental needs to be able to support people living with dementia.

Across the service we found inconsistency in the implementation of, and the recording of people’s care needs. This meant where staff verbally told us of the support they provided to people, it could not always be evidenced by their record keeping. This meant that we could not be assured that people had received the level of support staff said they had given. Especially for the more vulnerable people who were totally reliant on staff for their health and wellbeing. One person told us, “I have settled in now but it took a while to get used to things. The people (carers) are nice which helped, once you do settle in, it is very nice here.”

We found improvements in the staffing levels. Systems were now in place to monitor, and where needed increase staffing levels to match people’s dependency levels. One person told us, “They (staff) come more quickly now if you need them, not waiting around so long now…but it is not perfect.”

People told us that they were generally satisfied with the service they were provided with and the staff treated them well. One person told us, “I am quite comfortable.” Another person said, “Oh yes, I am very happy.” Another person commented that, “They (staff) are all very kind.” A fourth person said, “Nice level of care, I do as much as I can do myself.”

We found there were issues with the staffing levels in the service, and information given in people’s care plans to support people’s dementia related needs. This had an effect on the care and support provided to the people who lived there.

People told us that they liked the food and got on well with the staff who cleaned their bedroom and laundered their clothing. One person remarked that they are, “All lovely people who wash your clothes and people who clean for you, one comes in every day.”

People told us if they had a concern, that they felt comfortable to talk with staff. One person said that they liked residing in the service, “Because I don’t have any worries, if you want anything ask the nurses and they will sort it.”

People told us that staff listened to what they said. One person told us, “Staff are so kind and helpful.” Another person told us, “Staff talk to you… food is very good here.” A third person said, “Staff do listen to me" but felt that staff could, “Take their time when answering call bells.”

One relative said, “I was told this was not a good home, but I am happy with the care my (next of kin) receives, I have had no problems.” Another relative told us that they, “Can visit anytime” and, “I have never found fault.”

The second registered manager named in this report was not in post and not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a Registered Manager on our register at the time.