Lowfield House Nursing Home

Lowfield House Nursing Home is a residential care home providing personal and nursing care to 18 people, with complex needs relating to a learning disability, at the time of the inspection. The service can support up to 21 people. The home accommodates people in one adapted building. The service has been developed and designed in line with the principles and values that underpin Registering the Right Support and other best practice guidance. This ensures that people who use the service can live as full a life as possible and achieve the best possible outcomes. The principles reflect the need for people with learning disabilities and/or autism to live meaningful lives that include control, choice, and independence. People using the service receive planned and co-ordinated person-centred support that is appropriate and inclusive for them.

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

People were safeguarded from abuse by appropriate systems and processes. Risks to people were assessed and people’s independence was promoted. Staff numbers were assessed according to people’s needs. Medicines were administered safely by trained and competent staff. Infection control procedures were evident. Processes were in place to analyse and learn when things go wrong.

People’s needs and choices were assessed to support good outcomes for people. Staff appeared knowledgeable and were provided with training. People were supported to eat and drink and maintain a balanced diet. Staff shared information with colleagues and professionals to facilitate the best support for people. People had regular and appropriate access to health professionals. The service had considered people’s needs when adapting and decorating the home. Consent to care was sought. 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 views were sought wherever possible and considered within their care plans. People’s privacy and dignity were respected.

Care plans were individual and personalised to the needs and preferences of people. Comments, complaints and compliments were used to improve the quality of care. People’s end of life wishes were sought and people were supported in their end of life, where applicable.

There was a clear vision for the home and an open culture. There was a governance framework in place which covers all aspects of the service and the care delivered. People, relatives and staff were engaged in the running of the home. There was evidence of continuous improvement by analysing trends, themes and by sharing best practice. The home worked in partnership with the community.

The service applied the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence. The outcomes for people using the service reflected the principles and values of Registering the Right Support by promoting choice and control, independence and inclusion. People's support focused on them having as many opportunities as possible for them to gain new skills and become more independent.

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 good (published 27 April 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.

The service had a registered 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.

The last comprehensive inspection of the service was completed in May 2016. At that time the service was non-compliant with regulations pertaining to delivering safe care and treatment, supporting staff, deploying suitable numbers of staff and operating effective governance systems. The service was rated as Inadequate. We undertook a focused inspection in September 2016 and found that the registered provider had taken action and achieved compliance with the aforementioned regulations. We saw improvements had been made, however, we could not rate the service higher than requires improvement because to do so requires consistent and sustained improvement over time.

People who used the service were protected from abuse by staff who had completed safeguarding training and knew what action to take to keep people safe. There were systems and processes in place to protect people from the risk of harm. Known risks were recorded and steps had been taken to reduce the possibility of their occurrence. People were supported by suitable numbers of staff who had been recruited safely. Relevant checks had been undertaken to ensure prospective staff had not been barred from working with vulnerable people. Medicines were ordered, stored and administered safely. People received their medicines as prescribed.

People were supported to make their choices in their daily lives. The principles of the Mental Capacity Act 2005 (MCA) were followed when people lacked capacity to make informed decisions themselves. The registered manager had a clear understanding of their responsibilities in relation to Deprivation of Liberty Safeguards (DoLS) and had made applications as required.

People were supported by staff who had completed relevant training to equip them with the skills and abilities to support people effectively. Staff told us and records confirmed they received effective levels of support and appraisals. People were encouraged to maintain a healthy lifestyle and eat a balanced diet of their choosing. People had choices at each meal and their dietary needs were catered for. People’s holistic healthcare needs were met by a range of healthcare professionals. We saw that advice and guidance was clearly recorded and implemented in to people’s care plans.

We observed staffs’ approach was kind and caring. It was clear staff were aware of people’s care needs and preferences for how this was to be delivered. Staff treated people with dignity and respect throughout the inspection and encouraged people to maintain their independence. Staff gave people the time to express themselves and engaged with them in a supportive and inclusive way. The registered manager told us they encouraged people’s families and friends to visit the service and that there was no restriction placed on visiting times.

People or their appointed representatives were involved with the initial and on-going planning of their care. Care plans had been created to ensure staff were aware of the care and support people required as well as their preferences for how it should be delivered. People were encouraged to maintain relationships with important people in their lives and to take part in a range of activities both inside and outside of the service. The registered provider had a complaints policy that had been produced in an easy to read format which ensured it was accessible to the people who used the service. Although the service had received very few complaints the registered manager confirmed they would be investigated in line with the registered provider’s policy and used to develop the service whenever possible.

People who used the service and staff contributed to the development and management of the service. People were asked to provide feedback about the care they received and the service as a whole. The registered manager understood their responsibilities to inform the CQC when specific incidents occurred within the service. Staff told us the registered manager was supportive and approachable. We saw that regional directors visited regularly and provided feedback to improve the day to day management of the service. The registered provider operated governance systems to monitor the quality of the service and we saw that when shortfalls were identified action was taken to improve the care and support people received. However, we found that the internal audits did not always ensure people’s care plans reflected their needs or were updated when required.

This service did have a registered manager in place at the time of our inspection However, we were informed during the inspection of their intention to de-register and step down from their role. 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 the 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 provider’s quality assurance systems were not effective. They failed to highlight the areas of the service that required improvement and were not used to ensure action was taken to rectify known issues in suitable timescales that were proportionate to the risk. In April 2016 a regional director visited the service and produced a work session record which highlighted a large number of areas that required improvements to be made which had not been identified by the registered provider’s quality assurance systems.

Infection prevention and control practices within the service were not safe and did not follow best practice guidance. Soiled linen was stored in communal toilets. Areas of the service had become permeable and could no longer be cleaned effectively. We found a foot operated bin in a communal bathroom and a bath hoist that had developed rust and a communal toilet that did not have liquid soap or paper towels. This increased the possibility of cross contamination and put the people who used the service at risk.

Staff did not receive appropriate levels of individual supervision on a one to one basis or annual appraisals in line with the registered provider’s policies and procedures. Staff told us they did not feel supported in their roles and we saw that opportunities for their personal development were missed. Not all staff had completed training in relation to supporting people with learning difficulties.

Staff were not deployed in suitable numbers to meet the needs of the people who used the service. Staffing levels had an impact on people’s meal time experiences and the infection control practices within the service. When people were taken on social activities the staffing levels in the service were inadequate as only two care staff were left to support up to 17 people with high needs.

We observed the caring and supportive relationships developed between staff and the people who used the service and noted that people were treated with dignity and respect. However, we found that actions taken by the management of the service failed to ensure people’s dignity was promoted. We saw that in two people’s rooms chains and locks were attached their wardrobes, the registered manager told us that they were no longer required and should have been removed but were overlooked. Action was taken to address our concerns during the inspection.

Each person had a range of care plans in place to meet their individual needs. People, their relatives or appointed people were invited to contribute to the initial and on-going development of their care.

Staff had completed a range of training including care planning, dignity in care, fire safety, infection control, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, safeguarding and health and safety.

People were supported to eat and drink sufficient amounts to meet their needs. Specific dietary requirements were catered for and when concerns with people’s food and fluid intake were highlighted relevant professionals were contacted for their advice and guidance.

The registered provider’s complaints policy was available in an appropriate format to ensure it was accessible to the people who used the service. We saw that the policy was displayed within the service and any complaints that were received were responded to appropriately.

The Care Quality Commission had been informed of accidents, incidents and other notifiable events as required.

People were protected from abuse and avoidable harm by staff who understood their responsibility to report any concerns they became aware of.

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

This inspection was unannounced and undertaken on 16 September 2016. We had previously inspected the service on 13 and 16 May 2016; it was rated as Requires Improvement overall and we issued two requirement notices for breaches in regulations for infection control practices and staffing. We also issued a warning notice for the breach in regulation for governance. The acting manager and two of the organisation’s regional directors sent an action plan in response to the breaches we identified stating what measures the registered provider was going to take in order to address the issues. This inspection visit was to check the action taken in respect of infection control practices, that staffing levels were sufficient to meet the needs of people who used the service and that the registered provider had improved its governance of the service. The findings of this inspection have not changed the service’s overall rating; however it did improve the rating of the specific question ‘Is the service Well Led’ from ‘Inadequate’ to ‘Requires Improvement’.

The service is required to have a registered 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. The service did not have a registered manager at the time of this inspection and an acting manager had been appointed and was present throughout this inspection. They told us they had submitted an application to the CQC to become the registered manager for the service.

We found improvements had been made to the infection control practices throughout the service. We found new laundry bins, pedal bins, a bath seat and liquid soap and paper towel dispensers at the service. New cleaning schedules for daily, weekly and monthly tasks had been put in place and systems of monthly checks on infection control were completed which helped the acting manager to monitor the standards of hygiene in the service and identify any shortfalls.

The staffing levels had been reviewed and increased by one care staff every morning shift and one care staff every afternoon shift. We found there was sufficient staff on each shift to meet people’s individual needs and support them safely. The acting manager was at the service for 21 hours each week and during their absence there was a deputy manager at the service for 42 hours each week.

We found improvements had been made with staff support, supervisions and appraisals. The acting manager told us they were planning to complete five supervisions and one appraisal yearly with each member of staff. Staff told us they felt supported by the acting manager and they were now receiving individual supervisions where they could discuss their personal development.

During this inspection we found improvements had been made to ensure the effectiveness of the quality assurance systems at the service. Staffing levels, infection control practices and staff supervisions and support were all checked regularly and any shortfalls were identified and actioned.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, and the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service is safe. People felt safe because their rights and dignity were respected by the staff. People told us they felt safe. Members of staff understood their roles in safeguarding people from abuse. Members of staff understood the service's policy on the Mental Capacity Act 2005.

The service had risk management processes in place and staff supported people to take positive risks to promote their independence.

Recruitment processes were safe and thorough. People were supported by staff that had been checked with the Disclosure and Barring Service and whose references had been checked before they started work.

Processes and training was in place to ensure people received their medication safely.

Is the service is effective?

The service is effective. Where possible, people were involved in the assessment of their needs and care plans reflected their choices and preferences. Staff supported people to be as independent as possible.

People's identified needs were monitored regularly and effectively.

Is the service caring?

The service is caring. We observed people were cared for by staff who showed patience and encouragement.

Staff knew the people they cared for and understood their preferences and personal histories.

Policies and procedures were in place to ensure staff understood how to respect people's privacy and dignity.

People's families were encouraged to make their views known about their care and treatment and these views were respected.

Is the service responsive?

The service is responsive. Members of staff actively listened and acted on people's views and decisions. People were given the information at the time they needed it. People's capacity to make their own decisions was considered under the Mental Capacity Act 2005.

Concerns and complaints were encouraged. People were made aware of how to complain.

Is the service well led?

The service is well led. There were effective systems in place to continually review safeguarding concerns and people's levels of care.

The registered manager had systems in place to monitor and assess the quality of the service provided to people. Where gaps or shortcomings had been identified the registered manager took swift action to address the issues.

Members of staff were clear about their roles and responsibilities. Staff were motivated, well trained, supported, and open. They acted in caring way. The registered manager understood their responsibilities.

The service worked well with other agencies and external services to ensure people who used the service received care in a joined up way.

What people who used the service, and those that matter to them, said about the care and support they received:

Due to the complex needs of the people who used the service we were unable to gain some people's views. We therefore used a number of different methods to help us understand their experiences. This included observing how staff supported people, speaking with staff and checking records. People who used the service were only able to communicate with us in a limited way. When we asked people if they likes living in the home and felt safe, one person said, 'Yes' and another nodded their head.

Prior to this inspection we received concerns from North Lincolnshire Council about the quality of the care plans, practice relating to medicine administration and the cleanliness of the environment. We looked at elements of these concerns during this inspection.

We found that everyone had a care plan which had had been developed over a number of years and the care files contained a lot of information due to this. We had some difficulty identifying which information was part of the person's current care requirements.

We also saw that care plans had not been consistently reviewed to make sure they reflected people's needs. We observed that staff had a good knowledge of peoples needs and preferences.

The provider had appropriate arrangements in place to manage medicines although some of these required review.

We saw staff reported maintenance issues and that these were usually addressed in a timely manner. There were ongoing works to improve the facilities in the home.

We found mal-odours were present in a small number of bedrooms and heavily stained mattresses had not always been changed. Processes to minimise cross infection in the laundry had not been maintained.

We saw that when staff helped people they spoke calmly and provided clear information about choices and alternatives available. They were sensitive to people's needs and provided reassurance and guidance when needed.

We saw that people's capacity to make informed decisions and provide consent was assessed and arrangements put in place to protect them when they found this difficult. We saw that staff had access to information about how best to meet people's needs.

Although the home was clean and tidy and there were no mal-odours we saw that the environment was in need of redecoration.

We found there were enough appropriately trained staff on duty to meet people's needs and people could make complaints and these were acted on.

People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. One person who used the service told us that people were involved in the running of the home through weekly meetings.

We found that people may not always experience care, treatment and support that met their needs and protected their rights as there were not always enough staff deployed to meet people's needs in a timely manner on a morning shift.

We found that people's needs were assessed and care and treatment was planned. We found that care plans had been evaluated and updated as needs had changed. One person told us "They look after me well, they keep a check on my diabetes and blood sugars and I go to the chiropodist frequently."

We found that people who used the service were protected from the risk of abuse because the provider had taken reasonable steps to ensure that the possibility of abuse would be identified and reported appropriately. Staff displayed knowledge of the procedures, how to recognise abuse and where to refer allegations of abuse. People who used the service told us they felt safe.

We found that there were appropriate staff recruitment procedures in place.