Archived: Tordarrach Nursing Home

At our first comprehensive inspection of the service in April 2016 we identified breach of regulations relating to depriving people of their liberty, good governance and staff training. We rated the service ‘Requires improvement’ overall. We carried out a focused inspection in October 2016 and found the provider was meeting the breaches of regulations we had identified previously. We did not change the rating at that inspection and the service remained ‘Requires Improvement’.

At our comprehensive inspection in June 2017 we identified breaches of regulations relating to safe care and treatment, good governance, person-centred care and submitting notifications of significant incidents to CQC. We rated the service ‘Requires Improvement’ overall and ‘Inadequate’ in the key question ‘Is the service well-led?’ We served the provider with warning notices for the breaches relating to safe care and treatment and good governance and told the provider they must be compliant by July 2017. We carried out a focused inspection in October 2017 to check whether the provider was compliant with the warning notice and found they were. We did not change the rating because we needed to see sustained improvement over a greater period of time.

Tordarrach Nursing Home provides nursing care for up to 20 people. People presented with a complex range of needs. Most people were older people, many of whom were living with dementia. There were also two younger adults using the service, one with a mental health condition and the other a regular respite user of the service who had a brain injury. There were 11 people using the service at the time of our inspection.

There was a 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.

During this inspection we found the provider had not maintained systems to reduce risks relating to falls from height and water hygiene. In addition we found the provider had not assessed and managed risks relating to cold temperatures well. We identified two radiators in the communal lounge were broken which made parts of the lounge cold, and the provider was unaware of this. Staff did not always do all they could to mitigate risks relating to a person’s care and we observed a person experienced pain when staff supported them to reposition their legs.

Medicines management was suitable although systems to ensure medicines outside the fridge were stored at safe temperatures were lacking. Our checks of medicines stocks and records indicated people received their medicines as prescribed.

The provider did not always obtain evidence staff had the right to work in the UK and we reported our concerns about one staff member to UK Visas and Immigration. The provider had not always obtained two references for each staff member in accordance with their recruitment policy. There were not always enough staff deployed to support people promptly. People were safeguarded from abuse and improper treatment due to systems in place.

The provider had an improvement plan in place in relation to infection control after an inspection by the clinical commissioning group (CCG) identified concerns. We found most areas of the service were clean although some areas of the dining room such as curtains had food stains.

We found the provider had not fully followed the recommendation we made at our last comprehensive inspection regarding adapting the environment to cater for people with dementia. In addition the provider had not considered best practice in dementia care in other aspects of service delivery. The provider had also not considered best practice in occupying and stimulating people with dementia.

The provider had not ensured Mental Capacity Act (2005) assessments were decision specific in accordance with the Act. This meant the provider may have incorrectly determined people’s capacity in relation to key decisions and so may have prevented people making their own decisions in relation to their care.

We observed people were sat in armchairs with tables in front of them for the whole day which may have deprived them of their liberty unnecessarily. We raised our concerns with the provider who informed us they would review this. Besides this the provider applied for authorisations to deprive people of their liberty appropriately.

Staff received a programme of support although training was lacking in some areas and records relating to staff training were not always clear. Staff attended key training in relation to their role but training in relation to people’s individual needs, such as brain injury and mental health issues, were not provided.

People were not always supported to receive choice of food. The lunchtime meal was shop bought frozen food reheated on the day of our inspection which meant the quality of some meals could be improved. The chef had a good understanding of people’s dietary needs and received updates from staff if people’s needs changed. We observed people received the support they required from staff to eat. People received the necessary support in relation to their day to day health needs.

People did not always receive kind, compassionate, person-centred care. Staff did not engage well with people using the service and some staff required support to improve their communication skills. We observed some interactions which showed staff did not always show empathy in the way they cared for people and did not always ensure people felt they mattered. The provider lacked systems to check staff provided care to people in a compassionate and personal way.

People were not always treated with dignity and respect. Staff exposed parts of people’s bodies in the communal lounge when carrying out tasks such as hoisting and clinical procedures. A screen was not used to maintain people’s dignity. Staff had not always explored and maintained systems to help people express themselves. Information about people was not always stored in a way which ensured confidentiality.

Relatives were able to visit at any time besides mealtimes. We observed some people waited long periods to be served their meals while those around them ate. Relatives told us they were willing to support their family members to eat to reduce the burden on staff and increase the quality of care to people but the provider rejected their requests for this.

People lacked meaningful activities to stimulate and occupy them and staff heavily relied on the TV to entertain people on a day to day basis. This meant the provider had not improved in relation to this since our last comprehensive inspection. People were also not supported to maintain and improve their mobility on a daily basis with people seldom supported to move from their seats.

The provider’s complaints policy remained suitable although the provider told us they had not received any complaints since our last comprehensive inspection so we did not look at complaints in depth.

The provider had poor systems to govern the service and had not sustained improvements we found at previous inspections. The auditing systems in place were not robust as these had been ineffective in alerting the provider to the concerns we identified during our inspection. Staff lacked the leadership and support they required to develop in their roles and the service was poorly managed. There were ineffective systems to observe the care of people who were unable to express themselves verbally to check it was delivered in a responsive, compassionate manner.

Systems to gather feedback and experiences from people using the service could be improved. Systems to gather feedback from relatives and staff were in place.

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.

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.

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.

During this inspection we found breaches relating to safe premises and equipment, consent, person-centred care, dignity and respect and good governance and we are taking enforcement action against the provider. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after a

At our previous comprehensive inspection in June 2017 we identified breaches of regulations relating to safe care and treatment, good governance, person-centred care and submitting notifications of significant incidents to CQC. We served the provider with warning notices for the breaches relating to safe care and treatment and good governance and told the provider they must be compliant by July 2017.

We undertook this focused inspection to check that the provider had followed their plan and to confirm that they now met legal requirements in relation to the two warning notices we served. We did not inspect in relation to the two other breaches of regulations we identified at our previous inspection as we will check these at our next inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tordarrach Nursing Home on our website at www.cqc.org.uk

This inspection took place on 10 October 2017 and was unannounced.

There was a 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.

At this inspection we found the provider had taken sufficient action to become compliant with the warning notice relating to safe care and treatment. The provider had assessed risks relating to the safe care and treatment of people and of the premises and taken action to reduce risks. For example, the provider had contracted an external professional to assess risks relating to water safety and had taken action to reduce the risks of people becoming ill due to water-borne infections. The provider had taken action to reduce risks relating to fire safety, bed rails, falls from windows and burns and scalds.

At this inspection we also found the provider was now compliant with the regulation relating to good governance. The provider had implemented systems to check risks were being identified and managed, which included reviewing risk assessments and the safety of the premises. In addition the provider had introduced systems to review accidents and incidents and complaints to identify patterns and trends. The provider was reviewing care plans and risk assessments for all people using the service and transferring them into a new format to ensure information about people was accurate and clearly recorded.

However, we found the provider had not yet introduced systems to monitor the quality of interactions between staff and people using the service. The registered manager told us they would begin their formal observations of staff as soon as possible. The provider had begun to develop a matrix to track staff training needs, and they sent the completed version to us after the inspection.

At the previous inspection on our comprehensive inspection in April 2016 we identified breach of regulations relating to depriving people of their liberty, good governance and staff training. We rated the service ‘Requires Improvement’ in two of the key questions we asked of services, ‘Is the service effective?’ and ‘Is the service well-led?’. Therefore the service was rated overall as ‘Requires improvement’. We carried out a focused inspection on 12 October 2016 and we found the provider was meeting the breaches of regulations we had identified previously. We however did not change our rating of the service as we needed to see sustained and maintained improvement.

Tordarrach Nursing Home provides nursing care for up to 20 older people, some of whom were living with dementia. There were 13 people using the service at the time of our inspection.

There was a 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 provider did not have appropriate arrangements to ensure risks to people were always managed appropriately with suitable risk management plans put in place, including managing risks relating to falls from height and entrapment and falls relating to bed rails. Some aspects of the premises were not safe. For example checks of a fire door alarm system were not in place and so the provider had not identified the alarm was not working during our inspection. This meant people who required staff supervision in the community to stay safe were at risk of leaving the service and coming to harm without staff being aware.

Medicines management was generally safe and our stock checks indicated people had received their medicines as prescribed. However, staff did not always administer medicines safely to a person and had not assessed the particular risks relating to this sufficiently as part of keeping them safe. In addition protocols for staff to follow when administering ‘as required’ medicines were not always in place which meant staff could not be sure the signs to observe to indicate people required these medicines.

People were not adequately protected against the risks associated with the management of records because the provider did not have appropriate systems in place. Quality assurance procedures were ineffective in assessing, monitoring and improving the service as they had not identified the issues we found during our inspection.

The registered manager did not always submit statutory notifications to CQC about the outcomes and applications made to relevant authorities for authorisations to deprive a person of their liberty as required by law. This meant CQC was not able to monitor the volume and nature of these applications at the service.

The provider did not provide people with a suitable range of regular activities they were interested in to occupy them and we observed people had little to do for much of the day of our inspection.

People knew who to complain to and had confidence any complaints they made would be dealt with appropriately.

Staff received regular support with a suitable programme of induction, training, supervision and appraisal to help them understand and meet people’s needs. Staff felt well supported by the registered manager.

Staff understood how to use the Mental Capacity Act (2005) properly in assessing people’s capacity and in making decisions for them when they lacked capacity. In addition the registered manager applied for authorisations to deprive people of their liberty appropriately as part of keeping them safe.

Systems were in place to safeguard people from abuse and staff understood the signs people may be being abuse and how to report concerns.

There were enough staff deployed to meet people’s needs. Recruitment was safe because the provider carried the required checks before staff worked with people who use the service to ensure they were suitable.

People enjoyed the food they were provided with, and received a choice of food that met their needs. People received the right support in relation to eating and drinking. People received access to the healthcare professionals they required, such as GP, tissue viability nurses and physiotherapists as and when necessary.

Although staff knew the people they supported, they provided care in a task-based way with minimal conversation. People provided mixed feedback regarding how kind and caring staff were. People were not cared for in a person centred way. For example people told us they could not always choose the time they got up in the morning.

We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach relating to Care Quality Commission (Registration) Regulations 2009 during our inspection. We served a warning notice to the provider for breaches of the regulations in relation to good governance and safe care and treatment. In relation to the breaches of regulations in regard to person-centred care and notification of incidents you can see the action we took at the back of the full length version of this report.

Additionally the provider did not monitor key aspects of the service. They had not ensured staff completed certain training relevant to their roles. This could put people at risk of receiving inappropriate or unsafe care.

The provider had also not taken adequate measures when a member of staff had not provided a renewed police check. This meant the provider did not suitable arrangements to assure themselves of the continued suitability of staff employed at the service.

After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of regulations described above.

We undertook a focused inspection on the 12 September 2016 to check they had followed their action plan and to confirm they now met legal requirements. This inspection was unannounced.

This report only covers our findings in relation to these requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Tordarrach Nursing Home on our website at www.cqc.org.uk

Tordarrach Nursing Home is registered to provide accommodation for up to 20 older people who require nursing and personal care.. At the previous inspection we asked the provider to apply to the CQC to register for nursing care because they were not registered to provide this activity. The provider had done this and so they were operating within the legal framework. At the time of our inspection, the home was accommodating 13 older people many of whom were living with dementia.

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

During our focused inspection we found the provider had followed their action plan. Significant training had been undertaken by staff via the local authority, external trainers or e-learning. There was a greater awareness among staff of MCA and DoLS within the home and they had all received refresher training.

The provider had improved governance systems to monitor the care provided to people. There were mechanisms in place to ensure criminal record checks were renewed every three years. The provider completed premises safety checks and now employed an external company to complete future checks in a timely manner.

Whilst the provider had taken sufficient action to meet the legal requirements that were being breached at the last inspection, we have not improved our rating for the service. We need to see consistent improvements over time before we are able to change the rating of this service from ‘requires improvement’.

Tordarrach Nursing Home is registered to provide accommodation for up to 20 older people who require personal care on a daily basis. During the inspection the provider was also providing nursing care to some people. Whilst the provider is registered to provide personal care to people at Tordarrach Nursing Home, it is not registered to provide nursing care. We have asked the provider to apply to the CQC so they can provide nursing care legally to people using the service.

At the time of our inspection, the home was accommodating 13 older people many of whom were living with dementia.

The service has a 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.

We found several issues of concern about the provision of care at Tordarrach Nursing Home. The provider had trained some staff regarding the requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DoLS). The Act helps protects people who are unable to make decisions for themselves. Whilst some staff had an awareness of the Act, they were not always aware of its implications and therefore could be restricting people of their liberty illegally.

The provider did monitor and audit certain aspects of the service. However, there were other areas where this monitoring had not identified shortcomings. For example, the provider did not ensure staff completed certain training designated as mandatory or other training relevant to their roles. They had also not taken adequate measures when a member of staff had not provided a renewed police check. In this way the provider could assure themselves of the continued suitability of a member employed at the service.

We identified three breaches of the Health and Social Care (Regulated Activities) Regulations 2014 during our inspection. You can see what action we told the provider to take at the back of the full version of this report.

We also had concerns that people were not offered a range of social and recreational activities in line with their needs and interests. We have made a recommendation that the provider review the provision of activities in line with guidance from reputable sources in respect of this issue.

People told us they felt safe. Staff we spoke with were knowledgeable about what they needed to do if they suspected someone was at risk of harm. Staffing levels were sufficient to meet people’s needs.

People had their health needs met. This included having access to healthcare professionals when they needed them. People’s nutritional needs were assessed and monitored. They received a variety of meals according to their needs and wishes. People received their medicines as prescribed to them. The home was able to provide end of life care to people, should it become necessary.

Staff knew people well and could tailor their care accordingly. Care was personalised and staff were able to maintain people’s privacy and dignity when providing care. People were encouraged and able to maintain links with their friends and relatives.

People we spoke with were positive about the registered manager who they considered open and approachable. They felt any issues they raised would be taken seriously and acted upon.

Accidents and incidents were recorded and analysed by the registered manager in order to minimise the possibility of re-occurrences. Risk assessments were reviewed regularly so they reflected people’s current needs and care was provided on that basis.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service 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 home environment was clean and tidy. Medicines, foodstuffs and cleaning products were stored safely. Effective systems were in place to ensure the environment was kept clean and hygienic and to reduce the risk of infection. Senior staff assessed potential risks to people's safety, health and welfare and care provided reflected these to ensure the risks were managed. Staff received training in moving and handling people safely and we observed staff using appropriate techniques that ensured people were safely supported. There were arrangements in place to deal with foreseeable emergencies, such as fire and medical emergencies, to safeguard people in these situations. There were enough staff to safely meet the needs of people using the service and appropriate employment checks were undertaken to protect people from the risks of being cared for by unsuitable staff.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made and in how to submit one. This meant people would be safeguarded as required.

Is the service effective?

People told us staff 'ask your permission before they do things' and care plans emphasised the need to seek people's consent before providing care. Staff were aware of when they needed to obtain people's consent and we observed staff checking that people were happy for them to provide care before they did so. This meant people were only receiving the care and support they had agreed to have.

People's care plans were reviewed regularly and any changes to these were updated promptly. This meant staff had up to date, accurate information about the care and support people needed. This included involving other services or professionals where required to ensure that people's care reflected relevant research and guidance.

Is the service caring?

Throughout our visit, we observed staff interacting with people in a kind, respectful and compassionate manner. People told us staff were 'good and understanding' and 'helpful and polite.' We observed, and people told us, that suitable activities were available to ensure people were occupied and their quality of life was maximised. We saw that staff continually worked to ensure that people were comfortable, had enough to eat and drink and received assistance when they needed it.

Is the service responsive?

The service responded to the needs of people who lacked capacity to make informed decisions about their care by ensuring that correct procedures were followed so that decisions were made in their best interests. Information was gathered about people's personal preferences, cultural and religious needs and health needs and responded to these needs by planning care in such a way as to take them into account. The service provided staff with specific training to meet the individual care needs of people who used the service.

Where recurring incidents had identified unmet needs, the service had responded by making appropriate referrals to ensure the unmet needs were addressed and people were kept safe. Extra staff were deployed to respond to any additional needs identified.

We saw that the service responded quickly to any comments or feedback from people who used the service, their relatives and staff. Incidents were appropriately recorded and follow-up actions put in place to keep people safe and prevent reoccurrence.

Is the service well-led?

The service used the views and experiences of people using the service, their relatives and staff to assess and monitor the quality of service provided. The provider had an action plan from a recent audit and we saw that some actions had been completed, demonstrating that the provider continuously worked to improve the quality of the service.

People who used the service, their relatives and staff were aware of how to raise a concern and whom they should approach. They told us the manager was approachable and we saw from rotas that they spent most of their working time at the home, including some time on shift. This meant that the manager was present to observe and monitor the quality of the service and available should people wish to speak to them.

The relative said they, 'could not fault the care.' One person said "it is the greatest home in London', a second person said, it is 'very nice and the staff are helpful and kind', a third person said they liked everyone (staff and people) and the food.

The atmosphere was relaxed on the day of the inspection. We saw people taking part in games including skittles.

People received the care and support that met their needs. We saw that medicines were managed in a safe way. People were protected against the risk of unsafe or unsuitable premises. We found that insufficient checks were made on staff before starting to work at the home. We saw that there was adequate information explaining how people should complain.

We spoke to one relative who was visiting on the day we inspected. They told us they were free to visit whenever they wanted to and they were always warmly welcomed. They told us they were kept informed about any changes to their relative's health.

Staff we spoke with displayed an understanding about the people that they were supporting and treated them with dignity and respect.