Archived: Manor Barn Nursing Home

Manor Barn Nursing Home is a residential care home providing personal and nursing care for up to 31 older people with various support needs, including physical and sensory impairment. At the time of our inspection, 25 people were in residence. The home consists of one adapted building. There are a range of communal areas, including a garden for people to enjoy.

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

People spoke highly of the care they received and from our observations it was clear they enjoyed a good rapport and close relationship with the staff supporting them.

Since our last visit, there had been improvements in managing risks to people and equipment, ensuring people’s choices were respected and in the provision of one to one activity. Staff were well informed about risks to people's health or wellbeing and knew how to deliver their care safely. Staffing levels met people's needs. The home was clean, and staff had been trained in infection prevention and control. Lessons were learned if things went wrong.

We identified an issue with topical creams, but this was quickly addressed and a new audit was put in place to ensure creams were dated on opening and remained in date.

Care was personalised to meet people's needs. Strong relationships were formed between staff and people due to the continuity of staffing and the very caring approach of staff members. Care plans provided detailed information and guidance for staff on people's care and support needs, their likes and dislikes, and how they wished to receive personal care. People were encouraged to be involved in decisions relating to their care and were treated with dignity and respect.

Staff felt supported and had confidence their views and opinions were valued. They had regular training, supervisions and an annual appraisal. People were enthusiastic about the food and were able to make suggestions for the menu. Snacks and drinks were readily available throughout the day. People had access to a range of healthcare professionals and support. Premises were suitable and comfortable and met people's needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People's communication needs were identified and planned for. People expressed confidence they could raise any issues or concerns with any member of staff or the management team and these would be addressed.

Staff were skilled in supporting people at the end of their lives. They took time to understand the person’s wishes and worked to facilitate these. Relatives spoke highly of the care their loved ones had received.

There was strong and effective leadership and everyone we spoke with said they would recommend the home. The service was well organised and had a range of systems in place to ensure its smooth operation and to support good communication.

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

Rating at last inspection

The last rating for this service was Requires Improvement (published 17 February 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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

At this inspection we found the service to be Requires Improvement overall. 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:

At the last inspection in December 2017, we found three breaches of Regulation. We made requirements for these to be addressed and the provider sent us an action plan to show what they would do to improve people’s safety. At this inspection, we confirmed the provider had taken sufficient action to address the previous breaches of Regulation.

Risk assessments were completed for people and gave guidance about people’s care needs but the guidance was not always followed. For example, skin integrity plans or pressure care plans guided staff on people’s care needs but there were inconsistencies in the pressure care for some people.

The provider did not consistently check risks in the home environment, for example we found broken furniture in communal areas but people had not been harmed and when we told staff about this they took immediate action to remove the broken furniture.

Bruises and marks were not consistently recorded by staff and the provider did not monitor or have oversight. We raised this to the deputy manager and training and compliance manager and they immediately took steps to develop and implement a bruises and marks care plan. We recommended that the provider continues to trial a bruises and marks care plan and to start recording and overseeing where people have bruises and marks.

People were not always supported by their preferred gender of staff, for example during personal care. People gave us mixed responses about this. We recommended that the registered manager ensures that where people have made a preference that this is consistently respected through staff rota’s.

People had access to a structured activities programme. Some people were cared for in bed, due to this they were at risk of social isolation. The provider had made efforts to increase opportunities to have visits from an activities coordinator once to twice a week to people’s rooms. During the inspection we saw activities staff visiting people in their rooms but this continued to be an area of improvement.

People were supported by a consistent staff group. Recruitment processes were robust and safe. Staff told us they felt supported and management told us they felt supported by the provider.

People told us staff were kind. Relatives told us staff were caring and compassionate. Provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

Staff were trained to meet people’s needs. People were protected from abuse and staff knew how to keep people safe in an emergency such as a fire.

Care plans were comprehensive, up to date and covered all assessed risks and needs for people. People and appropriate relatives were involved in planning their care.

People’s medicines were well managed and given according to people’s preference. People were supported to access health and social care professionals to maintain their health and wellbeing.

Rating at last inspection: Requires Improvement; The last report was published on 31 January 2018

Why we inspected: This was a planned comprehensive inspection that was scheduled to take place in line with Care Quality Commission (CQC) scheduling guidelines for adult social care services.

Follow up: We will review the service in line with our methodology for ‘Requires Improvement’ services. If any concerning information is received we may inspect sooner.

We carried out the previous comprehensive inspection on 29 November 2016. The overall rating was requires improvement. We issued requirement notices in relation to the mental capacity act and the maintenance of records. Following the inspection, the provider sent us an action plan, telling us how they would make improvements and that the legal requirements would be completed by 31 March 2017. During this inspection, we found some improvements had been made but had continued concerns related to the mental capacity act, management of “as required” medicines and record keeping.

There was a new registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The new manager had been registered with the Commission in September 2017.

People and their relatives told us staff were caring and kind. People told us they liked living at the service, were happy and would recommend the service to their friends. Staff demonstrated kindness and compassion for people through their conversations and interactions. People told us their privacy and dignity was promoted and they were actively involved in making choices and decisions about how they wanted to live their lives. People were protected from abuse because staff understood what action to take if they were concerned someone was being abused or mistreated. Relatives confirmed they felt their loved ones were safe.

People received care which was responsive to their needs. People and their relatives were encouraged to be part of the care planning process and to attend or contribute to care reviews where possible. This helped to ensure the care being provided met people’s individual needs and preferences. Support plans were personalised and guided staff to help people in the way they liked.

Risks associated with people’s care and living environment were effectively managed to ensure people’s freedom was promoted. People were supported by consistent staff to help meet their needs in the way they preferred. People’s independence was encouraged and staff helped people feel valued by engaging them in everyday tasks where they were able, for example laying the table and tidying their rooms if they wished. The registered manager and provider wanted to ensure the right staff were employed, so recruitment practices were safe and ensured that checks had been undertaken.

People’s medicines were mostly well managed. However, at the previous inspection in November 2016, it was noted that people did not have individual protocols in place in relation to ‘When required’ medication (also called ‘PRN’ drugs). These are medicines prescribed by GPs when a person has a short term or intermittent condition. These medications are not given as a regular daily dose or at specific times (e.g. during medication rounds) but given at the request of the person in accordance with their GP’s instructions. “PRN” medicines. Although PRN protocols were in place, these required greater detail. For example, some people were prescribed pain relief but there was not clear guidance in place on how individual pain should be assessed if people were unable to communicate, there was no guidance in place if the dose of the medicine was variable and the medicine sheets did not always record the time the medicine was given which was important when medicines required a certain time gap or had a maximum dose within a 24 hour period. The PRN protocols similarly needed further detail if a person was prescribed sedative medicine to enable consistent care.

People received care from staff who had undertaken training to be able to meet their unique needs. People’s human rights were protected because the registered manager and staff had an understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. However, we found the systems in place to record people’s capacity and decisions made in relation to care and treatment required further improvement.

People’s nutritional needs were met because staff followed people’s support plans to make sure people were eating and drinking enough and potential risks were known. However, where people’s food and fluid were being monitored records in place at the time of the inspection did not accurately reflect the care people received. People were supported to access health care professionals to maintain their health and wellbeing.

Policies and procedures across the service were being developed to ensure information was given to people in accessible formats when required. People were treated equally and fairly. Staff adapted their communication methods dependent upon people’s needs, for example using simple questions and information for people with cognitive difficulties and information about the service was available in larger print for those people with visual impairments.

The service was led by the registered manager, provider and supported by a dedicated team of nurses and care staff. The quality assurance systems in place had not identified the areas of concern during the inspection. Following the inspection feedback changes were made to these processes to help assess the ongoing quality of the service. Complaints and incidents were learned from to ensure improvement. The registered manager and provider promoted the ethos of honesty and admitted when things had gone wrong. The service kept abreast of changes to maintain quality care.

We found three breaches of Regulations. You can see what action we told the provider to take at the back of the full version of the report.

Manor Barn Nursing Home provides accommodation for up to 31 older people, some of whom are living with dementia and who need support with their nursing and personal care needs. On the day of our inspection there were 25 people living at the home. The home is a large property, spread over two floors, situated in Fishbourne, Chichester. There is a communal lounge, a dining room and a well maintained garden.

The management team consisted of a registered manager and a deputy manager. 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 were asked their consent before being assisted and there were measures in place to ensure that people’s relatives had been involved in decisions about people’s care needs. However, practice and the lack of records confirmed that there was a lack of understanding in relation to the practical application of mental capacity assessments (MCA) and the deprivation of liberty safeguards (DoLS). Mental capacity assessments that had been completed were not decision specific and deemed a person not to have capacity simply due to the fact that they were living with dementia. Decisions for some people had been made by someone who was legally unable to make those decisions and best interest decisions had not always involved the relevant people. There was a potential lack of DoLS applications made and a DoLS authorisation that had been granted had not been renewed. The lack of understanding and practical implementation of the MCA and DoLS were areas of concern.

People had access to activities on certain days and records showed that people had enjoyed visits from external entertainers. However, observations showed that some people spent their day with very little stimulation or interaction from staff, other than when being supported with their basic care needs. Quality assurance audits were in place to ensure the delivery of good quality care, however, not all systems and processes were audited. For example, the auditing of care plans did not take place and the registered manager had not recognised that a DoLS authorisation had expired. Records were not always consistently maintained and showed that the recording of moving and positioning as well as food and fluid charts had not always been completed in their entirety. Guidelines for staff to follow in relation to ‘as and when required’ medicines had been devised but not implemented and therefore staff were not provided with sufficient information to enable them to know when to administer ‘as and when required’ medicines and as a result people may not have had access to medicines when they needed them or they may have been administered inconsistently.

People were protected from harm and abuse. There were sufficient levels of appropriately skilled and experienced staff who had undertaken the necessary training to enable them to recognise concerns and respond appropriately. People were able to take risks in accordance with risk assessments that had been devised and implemented. People told us that they felt safe. People received their medicines from registered nurses; they had these on time and according to their preferences. There were safe systems in place for the storage, administration and disposal of medicines. One person told us, “I get forgetful so they give my tablets to me”. Another person told us, “They do it all. They do my blood sugar twice a day”. Infection prevention and control was maintained, the environment was clean and people told us that they were happy with the cleanliness of the home. A comment within a recent quality assurance questionnaire stated, ‘It is always clean, I appreciate that’. Another comment stated, ‘The level of cleaning and hygiene maintained is exemplary’.

People were cared for by staff that were kind and caring, they were involved in their care and able to make their thoughts, preferences and concerns known. People’s health needs were assessed and met by registered nurses who made referrals to external healthcare professionals when required. There were person-centred care plans in place that provided staff with information about people’s needs, these were reviewed regularly and provided staff with guidance as to how to support people according to their preferences. People’s privacy and dignity was respected and maintained, observations showed staff knocking on people’s doors before entering. People had a positive dining experience and told us that they were happy with the quantity, quality and choice of food. One person told us, “It’s pretty good and I’m quite fussy. The quality of the meat is very good. You can choose the food and if there is something you don’t like or you fancy something that isn’t on the menu, they’ll do it for you”.

People were supported to stay at the home until the end of their lives, there were suitable plans in place to ensure people could express their wishes and preferences with regard to their end of life care. A relative told us that they were happy with the care their loved one had received before they passed away, they told us, “The standard of care here has been superb, it has been brilliant as well as the support they have given us, the family”.

The registered manager welcomed and encouraged feedback. People, relatives and staff were complimentary about the leadership and management of the home. The registered manager had developed an open culture and had an approachable nature. One person told us, “The management here is pretty good, you can talk to them and they come and see you”. A relative told us, “I feel I can talk to the manager and nursing staff and they are positive and helpful”.

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

Is the service safe?

People told us that they felt safe. Safeguarding and whistleblowing procedures were robust and staff understood how to safeguard the people they supported.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the provider to maintain safe care. The provider had robust policies and procedures in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. At the time of inspection, no-one was subject to Deprivation of Liberty Safeguards.

Is the service effective?

People's health and care needs were assessed with them and they or their representatives were involved in the compilation of their care plans. People said that they had been involved in the process and that care plans reflected their current needs.

Visitors confirmed they were able to see people in private and that visiting times were flexible.

Is the service caring?

We spoke with five people who live at the home. We asked them for their experience about the staff that supported them. Feedback from people was positive, for example one person said, "I don't have anything negative to say. I enjoy living here". Another told us, "It's like a home from home. I can't fault it".

People who live at the home and their families were asked to complete a satisfaction survey by the provider. These were used to help improve the service in the future.

People's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

The home worked well with other agencies and services to make sure people received care in a coherent way.

People knew how to make a complaint if they were unhappy. Complaints were dealt with in a timely and satisfactory manner.

People engaged in a range of activities both in the home and in the wider community.

Is the service well-led?

The service operated a quality assurance system which identified and addressed shortcomings. As a result, a good quality of the service was maintained.

The staff we spoke with were clear about their roles and responsibilities. They had a good understanding of the needs of the people they were caring for and were properly trained and supported to carry out their duties.

We spoke with five members of staff and the manager. Staff told us that they enjoyed working in the home. One said, 'This is the best home I've ever worked at, the residents are looked after as if they were our own family'. Another told us, 'It's a good team' and said, 'We are able to have fun with the residents as well as doing our jobs correctly'.

We also spoke with three relatives and two friends of people who lived at the home. They were all complimentary about the home and staff. One said, 'I'm very happy with the place, I think they do great jobs'. Another told us, 'The staff are very good, they meet X's (their relative's) needs'.

We found that the home was clean and bright and that people looked well cared for. People were offered choices about the care that they received and were provided with a good range of food and drink. Staff were welcoming and we saw that they supported people in a timely manner with kindness and respect. Everyone that we spoke with told us that they could approach the staff and manager if they were unhappy or had ideas to discuss.

We looked at the care records of three people who lived there. We found evidence that they had been involved in making decisions about their care. We also saw that care had been planned and delivered in line with people's individual needs and preferences.

We spoke with three members of staff who worked at the home. They said they liked working there and felt well supported and trained in their roles. We observed that they were kind and considerate in their interactions with the people who lived there.

When we looked around the home we saw that it was relaxed and friendly. We saw that there was a range of activities that people could get involved in.

The people we spoke with said they were confident they could approach staff with any complaints and that they would be resolved. One person said, "I feel I am listened to and that things will be addressed".