Mr ‘C’s is a nursing home in the centre of Torquay. Mr 'C's is a care home in the centre of Torquay. Mr 'C's is a care home in the centre of Torquay. It is registered to provide accommodation and personal care to up to 40 people who may have needs related to dementia. The home also provides nursing care. There is a nurse on duty during the day, and at night one nurse covers three homes owned by this provider.This inspection took place on 16, 17 and 21 November 2016 and was unannounced. During the first two days of the inspection there were 19 people living at the home and on the third day of the inspection there were 18 people living at the home. The home is spread over five floors with the dining room, kitchen and lounges on the ground floor and people’s bedrooms on the first to fourth floors. People with the highest level of nursing care needs had bedrooms on the first floor, where the nurse’s base was situated. People who were more independent, with residential care needs were furthest away, on the fourth floor. At the time of the inspection, there were eight people requiring nursing care and eleven people requiring residential care living at the service. Twelve people needed the help of two care staff to assist with their mobility. Two people were living with dementia type illnesses.
The service was first inspected in August 2014, when we identified the provider was not meeting the regulations in respect of records. We carried out a ratings inspection in August 2015 when the home was rated as Requires Improvement. The provider was not meeting the regulations in respect of ensuring people received safe care and treatment, staffing levels and record keeping. The provider sent us an action plan that confirmed improvements would be completed by December 2015. At this inspection we found sufficient action had not been taken in relation to the concerns identified at the previous inspection. We also identified new areas of concern.
We have found people were not always receiving a safe, effective, caring, responsive or well-led service.
The home 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 registered manager was responsible for two nursing homes owned by the company and had a quality monitoring function for a third home, one day per week. This meant they only spent two days a week at Mr ‘C’s, sometimes split into half days. The lack of a consistent manager presence had impacted on the safety and quality of care and led to people and their relatives losing confidence in the overall management approach.
The layout of the building presented challenges for staffing. There were not always enough staff on duty at all times to ensure people received the care, support and observation they needed. At night there were two care staff on duty to cover the home. A registered nurse covered Mr ‘C’s and two other nursing homes in the group overnight. They were not always present at Mr ‘C’s. Although the registered manager told us they had assessed staffing levels, the consistency of concerns raised indicated people did not always receive assistance at the times they needed it.
Staffing levels meant staff were not always able to provide care in a way that ensured people’s dignity was protected. For example, on the second day of our inspection when we arrived we found one person downstairs walking by the reception area who was naked from the waist down. There were no care staff on the ground floor at this time.
Complaints about some aspects of care were repeatedly raised by people living at the service and their relatives. These included the varying availability of hot water in parts of the home and call bells not being answered in a timely way. Although the service had a system in place for responding to complaints, we found the service had not investigated these concerns sufficiently to fully understand the issues or put them right. For example, we found the call bell system had not been working reliably since the home opened in May 2014. There was no hot water on the second day of our inspection on one floor of the home. Both these issues were resolved by the registered manager. However, they had not been resolved when people had complained. Some people were unhappy with the way their complaints had been responded to they had asked the local care Trust for support.
Risk assessments and care plans were in place for each person. Although risks to people had been identified, the steps to be taken to deals with those risks were not always clear. Care plans did not always give enough detail to staff to be able to manage those risks. Whilst there was a lot of information available within care plans, the important information could be difficult to find. Sometimes care plans used highly medicalised language which was unlikely to be accessible for people, their relatives or care staff and could restrict involvement in planning of care.
Some areas of risk were not identified, assessed or managed. For example, bed rails were widely in use in the home to prevent people falling from bed. There were no risk assessments in place regarding their use. Some bed rails did not have protective soft coverings to reduce the risk of entrapment or injury. There were no specific risk assessments in place regarding risks for people who could not call for help. One person’s care plan said they should be checked every hour, but there was no system for ensuring that they had been checked on regularly, and the rationale for these decisions had not been recorded, as they should be. Where one person was at risk of pressure sores, there were no records to evidence they were repositioned in line with their care plan.
Body maps were used to show where people had broken or sore areas of skin. These were cluttered and unclear and this made it difficult to track the progress of people’s wounds. One person’s body map said they had a grade two pressure sore, but there was no evidence of any guidance for staff regarding treatment of this. Lack of clear recording increased the risk that care may not be provided in a safe way.
Management of topical creams was unsafe. Nurses were signing to say these had been applied. However, nurses were assuming they had been applied by someone else. This placed people at risk of creams not being applied correctly and skin becoming sore and breaking down, or medical conditions not being treated effectively. The registered manager took actions to address this.
The environment was not suitably adapted to meet the needs of some people who were living with dementia. For example, signage was not in place to help people orientate themselves and patterns on the floor coverings on the ground floor were confusing and unsuitable. We have made a recommendation in relation to this to the provider.
Although staff had received training in relation to the Mental Capacity Act (MCA), this learning was not being applied. Capacity assessments were not decision specific or individualised for each person. Capacity assessments and best interest’s decisions were not completed where they should have been. For example, in relation to the use of a lap safety belt or bed rails.
Applications for Deprivation of Liberty Safeguards (DoLS) had not been made for everyone who legally required this safeguard. This meant people’s human rights were not fully protected.
The premises were not free from offensive odours. Odours of urine were noted at different places and different points of the inspection, in some bedrooms and communal areas. We have made a recommendation in relation to this to the provider. Where one person was living with dementia and had difficulty getting to the toilet in time, there was no care plan in relation to managing their continence.
At the last inspection we found that there was a low level of social activity in the home and concerns about people being socially isolated. At this inspection we found improvement had been made in this area. A new activities organiser had been appointed and was working individually with people. There were more organised activities available for those who could take part. However, some people’s choices were restricted because they could not leave their bedrooms.
Staff understood the principle that people should be supported to make their own choices and decisions about their care wherever possible. We heard staff asked people for consent before delivering care and offered people choice to support decision making.
People were supported to maintain their health through good nutrition. People told us they liked the food and were able to make choices about what they had to eat. One person said “The food is alright, no complaints there”. Another said “The food is good and there’s a choice.” Pictures of different meals were available to assist those who had communication difficulties. Every morning the chef spoke with people individually about their food preferences for the day. Some people had specific dietary needs. The chef had been trained to cater for those needs.
People spoke highly of the care they received from staff. Comments included, “The staff have always been very good to me”. Asked if the staff seemed caring, one person said, “Yes, they do. Very kind. I just don’t think there is enough of them. They laugh, joke and are very kind.” Another person said staff were always “Smiley and happy” and there was a good atmosphere in the home. We observed staff caring for people during the inspection. Staff addressed people with their preferred name. We saw that staff were cheerful and positive when talking with people, and treated them with respect. People responded