Whitstable Nursing Home

Whitstable Nursing Home is a residential care home providing personal and nursing care to up to 34 people in one large adapted building. The service provides support to older people who require nursing care who may be living with dementia. At the time of our inspection there were 22 people living at the service.

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

People told us they felt safe living at the service. However, potential risks to people’s health and welfare had been assessed but there was not always detailed guidance for staff to mitigate the risks. Staff had not maintained accurate records about people’s care and support. There was a risk people had not received the care required to keep them safe and well.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not always support this practice. Staff had not always recorded how and why decisions had been made to support people in a way that may have been restrictive.

Checks and audits had been completed to assess the quality of the service. These had not always been effective in identifying shortfalls such as the shortfalls found at this inspection. When shortfalls had been identified action had been taken to rectify them. This included supporting staff to highlight incidents as quickly as possible and improving the system of reporting concerns to the local safeguarding authority.

People were supported by staff who had been recruited safely and received training and supervision to develop their skills. There were enough staff to meet people’s needs, any gaps were filled by regular agency staff.

Medicines were managed safely by nursing staff, people received their medicines as prescribed. People were referred to healthcare professionals when their needs changed, and staff followed the guidance given.

People and staff were asked their opinions on the service and for their suggestions. Improvements had been made to the activities programme and the menu as a result of suggestions by people.

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 14 March 2019).

Why we inspected

We received concerns in relation to the management of people’s nursing care needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Whitstable Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to record keeping, risk management, decision making and governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

¿ People were supported to stay safe when they met their friends and/or family members. Large Perspex screens were used during visits to maintain social distancing. Alternative entrances to the home had been put in place, to ensure essential visitors were able to maintain social distancing and to reduce foot flow. At the time of the inspection there were no visitors to the service due to an outbreak of Covid-19.

¿ Stocks of the right standard of personal protective equipment (PPE) were well maintained and staff used and disposed of it correctly. Guidance on the use of PPE and current IPC procedures were clearly visible across the service and available in picture format.

¿ People and staff members had an individual risk assessments so that care and support could be tailored to everyones individual requirement.

¿ Staff supported external professionals such as doctors and clinical specialists to complete assessments remotely to reduce the number of people coming into the home. The registered manager told us that this worked well to ensure that people were having any changes assessed so that steps could be taken to meet these needs.

¿ The service had an admissions protocol covering admissions from different locations. People moving into the service from a hospital were required to have a negative COVID-19 test prior to discharge. New people moving into the service had a 14 day period of isolation in their room, minimising the risk of infection spread to other people.

Further information is in the detailed findings below.

Whitstable Nursing Home provides nursing and personal care for 35 older people and for people living with dementia. At the time of our inspection 26 people lived in the service.

Rating at last inspection: ‘Requires Improvement’ (report published February 2017)

Why we inspected: This was a planned inspection based on the rating at the last inspection. At our last inspection we found that there were two breaches of regulations. This was because there were shortfalls in the planning, delivery, monitoring and evaluation of the nursing care provided for people with specific healthcare conditions. There were also shortfalls in the completion of quality checks to ensure that people consistently received safe care and treatment. At the present inspection we found that improvements had been made to address the breaches of the regulations to ensure that nursing care was delivered in line with national guidance. We found that in each domain the service now met the characteristics of Good. The overall rating of the service is, ‘Good’.

What life is like for people using this service:

People were safeguarded from situations in which they may be at risk of experiencing abuse.

Risks to people's safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected.

Medicines were managed safely.

There were enough nurses and care staff to provide people with the care they needed.

Background checks had been completed before new care staff had been appointed. Suitable provision had been made to prevent and control infection

Lessons had been learned when things had gone wrong.

Care was delivered in line with national guidance and nurses and care staff had the knowledge and skills they needed to promote positive outcomes for people.

People were supported to eat and drink enough to have a balanced diet.

Suitable arrangements had been made to ensure that people received coordinated care when they used or moved between different services and they had been helped to access healthcare services.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. The service was compliant with the Mental Capacity Act 2005.

Some of the accommodation was not well maintained. However, there were plans to put the defects right.

People were treated with kindness, respect and compassion.

People were supported to express their views about things that were important to them.

People received personalised care that promoted their independence.

The registered manager, nurses and care staff recognised the importance of promoting equality and diversity.

Complaints were promptly resolved to improve the quality of care.

People were supported at the end of their life to have a comfortable, dignified and pain-free death.

People who lived in the service, their relatives, nurses and care staff were actively engaged in developing the service.

There were systems and procedures to enable the service to learn, improve and assure its sustainability.

The registered manager was actively working in partnership with other agencies to support the development of joined-up care.

More information is in the detailed findings below.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit in line with our re-inspection programme. If any concerning information is received we may inspect sooner.

Whitstable Nursing Home is a care home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the car provided, and both were looked at during this inspection.

Whitstable Nursing Home is registered to accommodate care and support for up to 34 people. At the time of the inspection there were 23 people at the service.

At the previous inspection in October 2016 three breaches of regulation were found. The provider had failed to ensure that care plans reflected people’s assessed needs and preferences, failed to maintain accurate care records for each person and failed to ensure that complete information about people’s previous employment had been investigated. Following the inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Responsive and Well Led to at least good. At this inspection improvements had been made and the legal requirements of one of the previous breaches had been met. However, a new breach was identified and there was a continued breach.

The provider had failed to ensure that care plans reflected people’s assessed needs and preferences, failed to maintain accurate care records for each person and failed to ensure that complete information about people’s previous employment had been investigated. At this inspection improvements had been made and the legal requirements of the previous breaches had been met. However, a new breach was identified.

The service had a registered manager in post. A registered manager is a person who is registered with CQC to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care act 2008 and associated Regulations, about how the service is run.

Potential risks to people’s health and welfare had not been consistently assessed and there was not detailed guidance for staff to follow to mitigate the risks to people.

Checks and audits had been completed on the environment, equipment and all areas of the service. The audits had not identified the shortfalls in the risk assessments to keep people safe. In all other audits when shortfalls had been identified, an action plan was put in place and signed off when the action had been completed.

The registered manager met with people before they came to live at the service to ensure staff would be able to meet their needs. The assessment covered all aspects of their physical, mental health and equality needs. People’s needs were assessed using best practice guidelines and formed the basis of the person’s care plan. Each care plan contained information about the person’s life, likes and preferences. The care plans contained details about how the person liked to be supported.

People had been asked about their end of life wishes and these had been recorded to ensure people’s wishes were respected. Staff had received training appropriate to their role, including end of life care. Staff received one to one supervision and appraisal to discuss their role and their training needs. There were sufficient staff on duty to meet people’s needs, staff were recruited safely. People’s medicines were managed safely and people received their medicines when they needed them.

Staff monitored people’s health and people were referred to specialist healthcare professionals when required. Staff supported people to be involved in discussions about their care. People had access to professionals including opticians, chiropodists and dentists when needed to support people to stay as healthy as possible. Staff worked with health and social care professionals to ensure people received the support they needed. People were supported to eat and drink to maintain a balanced diet.

People were protected from abuse and discrimination. Staff knew how to recognise signs of abuse and knew that they should challenge colleagues if people were being discriminated against. Staff knew how to report concerns and felt confident they would be dealt with appropriately. Accidents and incidents had been recorded and analysed, action had been taken to reduce the risk of them happening again.

The building had been adapted to meet people’s needs. People were protected from the risk of infection, staff wore protective clothing when required and kept the building and equipment clean.

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

Some people knew how to complain, the complaints procedure would benefit from being written in a way that would be more meaningful to people living with dementia. Any complaints received had been investigated and action taken to prevent the incident from happening again. People were encouraged to provide feedback about the quality of the service and any suggestions they may have. These were acted upon by the registered manager and people told us any concerns had been acted on immediately.

People were treated with dignity and respect. Staff had developed caring relationships with people and their relatives. Staff encouraged people to be as independent as possible. People’s confidentiality and privacy was promoted by staff. People had access to a variety of activities. The service had links and were involved in the local community.

There was an open and transparent culture within the service. People and relatives knew the registered manager well and told us that they were approachable. Staff told us they felt supported by the registered manager. People and staff attended regular meetings to discuss the service and to give their views and suggestions. The provider asked people for their views regularly on themes of the service throughout the year. Staff survey had been completed and the response from staff had been positive.

The registered manager attended local forums to keep up to date with best practice. Staff understood their roles and responsibilities.

Services that provide health and social care to people are required to inform CQC of important events that happen in the service. This meant we could check that appropriate action had been taken. The manager was aware that they needed to inform CQC of important events in a timely manner.

At this inspection two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. You can see what action we have asked the provider to take at the end of the report.

Whitstable Nursing Home provides nursing care and accommodation for up to 34 older people, some of whom may also be living with dementia. The service is an adapted detached building situated near to the seafront of Whitstable. The accommodation is provided on two floors, the upper floor is accessed by three staircases and one passenger lift. There are 20 single and seven shared rooms, three with en-suite facilities. There are two separate lounges and a dining area available for people to use. On the day of the inspection, there were 21 people living in the service.

The service did not have a registered manager in post at the time of our visit, although they had appointed a new manager and told us that they would be applying to 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.

Whitstable Nursing Home was last inspected on 11 and 12 April 2016. They were rated as inadequate overall at that inspection and placed into Special Measures. The provider sent us information and updates about actions taken to make improvements following our inspection. At this inspection we found that significant improvements had been made in most areas. In others, however, there were still some improvements required.

People were not fully protected by robust recruitment processes. The employment history of new staff was not explored thoroughly. At this inspection we found that processes had improved significantly but required further improvement.

Care plans had been developed since our last inspection and most contained personalised guidance to ensure that people received care and support that met their needs. However, some plans required more detail to be added to ensure that all people received the most appropriate care and support that detailed preferences and wishes. Audits to check detail in care plans had not been effective in identifying these shortfalls.

There were enough staff deployed to meet people's needs and they had received supervision to help them carry out their roles effectively. Staff were caring and responsive to people's needs and interactions between staff and people were warm and respectful. Most staff that had received appropriate training. This had improved significantly since the previous inspection; however some staff had not completed all of the necessary training. This is an on-going area for improvement.

People's safety had been protected through cleanliness and robust maintenance of the premises. Fire safety checks had been routinely undertaken and equipment had been serviced regularly.

Medicines were well managed. Registered nurses followed correct and appropriate procedures in the storage and administration of medicines.

Meal times were a sociable event and people told us they were offered choices and enjoyed their meals. Risks of malnutrition or dehydration had been adequately addressed. There was varied programme of activities on offer, with a range of group and individual activities offered to ensure people’s needs were met.

There were opportunities for people and others involved in the service to provide feedback, and the provider had acted on feedback received to improve and personalise the service and support that people received. Effective quality assurance systems had been implanted and were used to identify shortfalls or areas for improvement.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. Staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some people had been assessed as lacking mental capacity to make complex decisions about their care and welfare. The acting manager had made DoLS applications, so people were not deprived of their liberty unnecessarily.

As this service is no longer rated as inadequate, it will be taken out of special measures. Although we acknowledge that this is an improving service, there are still areas which need to be addressed to ensure people's health, safety and well-being is protected. We identified a number of continued breaches of Regulations. We will continue to monitor Whitstable Nursing Home to check that improvements continue and are sustained.

We found a number of 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 this report.

Whitstable Nursing Home provides nursing care and accommodation for up to 34 older people, some of whom may also be living with dementia. The service is an adapted detached building situated near to the seafront of Whitstable. The accommodation is provided on two floors, with most bedrooms on the ground floor, the upper floor is accessed by three staircases and one passenger lift. There are 20 single and seven shared rooms, three with en-suite facilities. There are two separate lounges and an open dining area available for people to use. On the day of the inspection, there were 25 people living in the service.

The service is run by 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.

At the previous inspection the provider could not demonstrate that there were always sufficient numbers of suitably, qualified, skilled and experienced staff employed to meet people’s assessed needs. Although staffing levels had increased since that time people’s needs continued not to be met by sufficient numbers of suitably, qualified, skilled and experienced staff during this inspection.

There were insufficient staff on duty to demonstrate compassionate person centred care practices.

In between meals people were left for long periods without activity or conversation. Although people’s personal care needs were met staff carried out their duties in a methodical task-led approach spending no time conversing with people except when assisting with personal care.

People were not fully protected by robust recruitment processes. The employment history of new staff was not explored thoroughly. Processes in place to protect people from abuse were not robust, because staff had not received up to date training, which helped them understand abuse and how to keep people safe. Staff did not receive the necessary training, supervision and support in order to provide the knowledge and skills to care for people.

Choices of food were supplied, but people were not supported to eat and drink in a way that supported their independence. Staff were not effectively monitoring people under observation for dehydration.

People’s care, treatment and support needs were assessed before they moved to the service and a plan of care developed to guide staff on how to effectively support people’s individual needs.

Plans of care were not personalised to ensure that people received the most appropriate and safest care and treatment, which took into account their needs, preferences and choices.

Information in the care plans were not kept up to date. Reviews of people’s care did not contain evidence of the involvement of people in their care and treatment.

There were limited opportunities for people and others involved in the service to provide feedback, and the provider had not acted on feedback received to improve services. Quality assurance systems were either out of date, absent or had not been used as indicators of where the service needed to improve.

The Care Quality Commission is required by law to monitor the operation of the Deprivation of Liberty Safeguards. Staff showed that they understood their responsibilities under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). Some people had been assessed as lacking mental capacity to make complex decisions about their care and welfare. The registered manager had consulted the local authority with regards to making DoLS applications, so people were not deprived of their liberty unnecessarily.

Medicines were stored and administered safely to people by registered nurses in accordance with current legislation.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. 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.

We considered our inspection findings to answer questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

This is a summary of what we found. This summary is based on our observations during the inspection, discussions with people using the service, staff supporting people, relatives and the manager:

Is the service safe?

We saw that although people were protected against the risk of abuse, there was a lack of continuity of care when responding to people's behaviour that may be challenging.

We looked at the management of staffing levels, and found that the home had suitable numbers of staff on duty, although we noted that sometimes staff were not always deployed effectively.

People's care needs were met and staff understood the support people needed with regard to their personal care.

Is the service effective?

Records were maintained for different aspects of people's care and support. They were generally well maintained although food and fluid charts did not always accurately record people's intake to ensure that individual needs were fully monitored.

Staff had received training and supervision appropriate to their role. Further training had been planned in order to meet the individual needs of the people who lived in the home.

We found that the home provided a suitable variety of food to meet people's nutritional needs and to provide them with sufficient choice.

People were supported appropriately with their healthcare needs.

Is the service caring?

People and their relatives were encouraged to make their views known about their care and support.

People made positive comments about the staff. We observed that overall staff treated people with kindness and respected their privacy and dignity. We noted, however, that when one person had a telephone conversation they were not given the opportunity have their conversation in private. Some parts of the care plans were not always written in a respectful manner.

Is the service responsive?

Some of the aspects of the service were not responsive. For example we found that a complaint had not been dealt with in accordance with the providers' procedures.

The home had not been proactive in accessing support with regard to one person who may have been subject to Deprivation of Liberty procedures.

The home had recognised that there was a lack of meaningful activities and the activities coordinator was in the process of gathering information about people likes and dislikes.

Staff were clear about their roles and responsibilities.

Following our visit we met with the provider to discuss our findings. The provider understood their responsibilities in relation to ensuring people received a service that met their needs.

Is the service well-led?

There were some systems in the home that did not monitor risk effectively. There was a lack of effective systems to monitor behaviours and incidents to reduce the likelihood of reoccurrence.

Staff told us that they felt supported by the manager.

The manager took an active role in the home.

People's privacy and dignity was respected. We saw that staff knocked on doors before entering and called people by their preferred names. Staff now engaged more and spoke with people as they passed them. What people could do for themselves was recorded and this maintained people's independence.

Any form of restraint was now risk assessed and agreed to. For example, the use of bed rails to prevent people from falling out of bed. People's private possessions were safeguarded in that inventories were completed and lockable storage provided.

Staffing levels had been reviewed and were now sufficient to meet people's needs. This meant that staff were visible and present in communal areas and so able to respond to people's needs. One person told us 'I like it here. The staff are very helpful and kind.'

Visiting professionals from the local authority told us that the service had improved. Their monitoring visits had found that people using the service appeared happy with the service and that the home was clean and smelled fresh. A relative reported that they were happy with the care and that they had noticed some improvements in the last few months.

Since our last inspection the provider had sent us an action plan showing how they intended to improve the service and achieve compliance. The provider had sent us updates about the action being taken to improve the service.

A new manager had been recruited and started work at the home 1 July 2013. The manager had started to audit care plans and risk assessment and had made referrals for extra support for people where needed. Care plans were now complete and up to date so gave staff guidance about how people preferred to be supported. Care plans and risk assessments had been reviewed and updated where needed and had been reorganised with a content list and dividers added to make them more organised.

We found that the home was cleaner and smelled fresher. Visiting professionals told us that they had noticed the smell was better and the home was cleaner. There were now more cleaning staff on duty covering every day of the week and a head of housekeeping had been employed to oversee the cleaning staff. Staff had had training about infection control and the infection control policy had been updated so it was in line with current legislation. Systems were now in place to detect, prevent and control infections.

Community access and activities were not being provided. There was no activity person and people told us that they were bored.

Peoples' needs were assessed but care and treatment was not always planned and delivered in line with their individual care plan. Some care plans had not been completed when a need or a risk was evident. This meant that staff had no guidance to follow about how to support people's needs and reduce potential risks.

Forms of restraint were used that had not been assessed and that people had not consented to. People were at risk of unsafe, outdated moving and handling procedures. There were not sufficient skilled staff to meet people's needs.

People told us that items of their personal property had gone missing. People who were at risk of falls did not always have a care plan or risk assessment to show how to reduce this risk. Some people were suffering injuries from falls; however the accident reports were not analysed to see if a pattern or trend emerged to show if the risk could be reduced.

The home did not smell fresh and was not clean and hygienic.