Archived: The Leonard Pulham Nursing Home

The Leonard Pulham Nursing home providing personal and nursing care to 34 older people. At the time of the inspection 30 people were residing in the service. The service is purpose built over two floors. People share facilities such as the lounge and dining areas.

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

People told us they felt safe living in the service. Improvements had been made to the how the service assessed and monitored risks related to care and the environment. Staff recruitment systems minimised the possibility of employees providing unsafe care to people. Medicines were safely stored and administered by trained staff. Systems were in place to ensure the service was safe.

People’s needs were assessed, and the environment was clean and well maintained. People were supported to enjoy their meals and their nutrition and hydration was monitored to enable people to remain healthy.

Staff were supported through training, supervision and appraisals as well as team meetings and daily staff meetings. Supervision wasn’t provided as regularly as the provider had wished, but this was being addressed by the recruitment of additional senior staff.

Staff were “Kind and caring.” Most people were happy to spend time with staff and interactions we observed were overall positive, meaningful, and respectful. We did observe one incident where a person who was unwell did not have their needs met in a timely way, but this was not the norm. This was because in addition to this incident people were not always offered a choice of what time they went to bed and got up in the morning.

Some people, relatives and staff told us there were not enough staff. The registered manager disputed this. We could find no evidence to support the concern apart from our observation that staff were very busy throughout the time we spent in the service. The registered manager agreed to explore people’s concerns more thoroughly.

People’s cultural, religious and dietary needs were acknowledged and where possible met. People’s preferences and dislikes were documented, however, more detail about people’s personal histories would assist staff to have a more holistic understanding of people.

The service supported people with communication and was compliant with the Accessible Information Standards. Accidents and incidents were clearly recorded, and investigations were undertaken to ensure the risk of repetition was minimised.

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.

The new management in the service had implemented audits to check the quality of the service, these had been completed and actions had been taken to improve the provision of care and support.

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

Rating at last inspection and update

The last rating for this service was requires improvement (28 January 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last inspection.

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

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.

We previously inspected the service on the 27, 28 and 29 September 2017. The service was rated requires improvement. At the last inspection we found breaches of the Regulations of the Health and Social Care Act 2008. We found there was a danger of people not receiving the right support. Records relating to people’s support, level of risk and medicines were not accurate and were not always updated when changes occurred. The registered persons had failed to be open and transparent when serious injuries had occurred. At the last inspection we found the service to be in breach of The Care Quality Commission (Registration) Regulations 2009. The registered persons had failed to notify the Care Quality Commission (CQC) about important events they legally required to do so.

We asked the provider to complete an action plan to show what they would do and by when to improve the key questions, Safe and Well-Led to at least good. At this inspection we found ongoing concerns about records relating to people’s care and support and ongoing lack of notifying CQC about events.

The Leonard Pulham Nursing home is a ‘care home’ which provides nursing support. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home can accommodate up to 34 people. At the time of our inspection 31 older adults lived at the home.

The service did not have 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 registered manager had left the service in September 2018. The provider had been proactive in recruiting and a new manager was due to commence employment in January 2019.

At the last inspection we made a recommendation to the service, to ensure staff followed the core principles of the Mental Capacity Act 2005 (MCA). At this inspection we found people were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible; the policies and systems in the service did not support this practice. People can only be deprived of their liberty to receive care and treatment with appropriate legal authority. In care homes, this is usually through MCA application procedures called the Deprivation of Liberty Safeguards (DoLS). People who did not have capacity to agree to restrictive practice for instance, the use of bed rails, had not been referred to the local authority for a DoLS assessment.

At the last inspection we made a recommendation about the management of medicines. At this inspection we found improvements had been made. The service was working with a member of the Clinical Commissioning Group (CCG) pharmacy team. We received feedback from the CCG that improvements had been made in the management of medicines.

We found there were not enough staff to provide person-centred care. People told us “The problem is when you want to use the toilet and it takes too long to be attended to. Sometimes you ring the bell and you have to wait for too long to have someone to assist you” and “When I want to use the toilet, I ring the buzzer and it takes time for me to get someone; it takes 15 to 30 minutes.” We discussed our concerns with the deputy manager who told us “I know we are short staffed.”

People were not always protected from avoidable harm. We found environmental risks were not always identified. We found hot pipes were exposed and radiator covers were loose. We highlighted this to the provider. The maintenance staff quickly responded to our concerns. We have made a recommendation about this in the report.

At this inspection we found there was a lack of understanding about the requirements of the regulations. We have made a recommendation about this in the report.

There was a lack of signage in the home, which could present as confusing for people living with memory loss or dementia. We have made a recommendation about this in the report.

People told us they were happy living at the home, they had developed good relationships with staff. Comments from people included “I am very happy here. The care I receive is really good,” “The girls; they are all very good, I can’t complain” and “Staff are respectful, they ask me what I want, if I refuse, they take note of it.”

People had access to a wide range of meaningful activities and had opportunities to go into the local community.

People were supported to maintain their health and any changes to a person’s medical condition were responded to quickly.

People told us they were treated with dignity and respect. Relatives told us they always felt welcome in the home.

This is the second consecutive time the service has been rated Requires Improvement. You can see what action we told the provider to take at the back of the full version of the report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

We previously inspected the service on 24 & 26 November 2014. The service was meeting the requirements of the regulations at that time.

The Leonard Pulham Nursing Home is a care home with nursing for older adults. It is registered to provide accommodation for 34 people. At the time of our inspection 34 people lived at the home. The home is located within a rural location within the Chiltern Hills. Accommodation is over two floors.

The service did not have 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. A new manager was in post and had submitted an application to the Commission to be the registered manager. The manager had a wealth of experience and skills in health and social care.

People described the home to us as warm, welcoming and friendly. Comments included, “I only have high praise of the nursing home. I think they are doing a great job,” “The staff are always cheerful, friendly and helpful.”

People had developed positive working relationship with staff. We observed a number of positive interactions between staff and people who lived at the home. One person described staff as “I think they’re absolutely lovely.”

We found mixed practices around the management of medicine. People told us they received their medicine on time and we observed staff were professional and confident in the administration of medicines. However improvements were required in the training of staff, stock control and record management relating to medicines. We have made a recommendation in the report about this.

We found there was mixed practice around ensuring people were treated in line with legislation. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. Staff were able to tell us how they supported people to make decisions about their care. However care plans and records relating to people’s mental capacity did not always follow best practice. We have made a recommendation about this in the report.

We found a number of records relating to the care and treatment of people were not always accurate or contained enough detail to provide staff with sufficient guidance on how to support people. There was a reliance on verbal handover meetings. Staff did not always have time to read care plans.

One person had fallen which resulted in a fractured arm. The service had not notified CQC of this and it was legally required to do so. We discussed this with the manager and they were unaware they should have informed us of this. There is a requirement for services to be open and transparent when things go wrong. We call this duty of candour (DOC). There are clear responsibilities on registered services. We checked if the requirements had been met. At the time of our inspection the manager told us they were not aware of a DOC policy. After the inspection we received confirmation from the provider a policy was in place. However the policy had not been followed for one event which met the DOC threshold.

People were supported by staff with the right skills and experience; there was a programme of induction, training and on-going support for staff. The provider recognised some of the required pre-employment checks needed to be in place for all new staff appointed.

People were supported to maintain a healthy diet. The home had been complemented by the local authority for their work to support people with their nutritional and hydration needs. The manager had written an article for the local authority quality team newsletter.

People received a personalised service by staff who were aware of their likes, preferences and dislikes.

People were supported to undertake meaningful activities. People had access and opportunity to take part in group and individual sessions with dedicated activity staff.

The manager had made a number of improvements to the service since in post. They had introduced systems to seek feedback from people, relatives and staff on what improvements could be made. The manager was open to support from external agencies and worked well with them to improve the quality of life for people who lived at the home. One social care professional described the manager as “[name of manager] is really keen to receive any support that we can offer. She is extremely committed to deliver the best care possible… as well as reflecting her commitment to delivering the best possible care.”

We found breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We found one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of this report.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read our full report.

Is the service caring? During our previous inspection on 18 and 19 February 2014 the service was found to be caring. This was not reviewed during this inspection.

Is the service responsive? During our previous inspection on 18 and 19 February 2014 the service was found to be responsive. This was not reviewed during this inspection.

Is the service safe? During our previous inspection on 18 and 19 February 2014 the service was found to be safe. This was not reviewed during this inspection.

Is the service effective? We have judged the service was not effective. This is because the provider had not supported all staff through the use of annual appraisals and the provision of mandatory training. A training plan for all staff to complete mandatory training started on the day of our inspection 1 July 2014 and would be completed in November 2014.

We found on this inspection amendments needed to be made to the system used for recording staff training to enable the provider to identify gaps in training and to take appropriate action.

We found on this visit improvements had been made to the supervision offered to staff. We found records showed supervision was carried out frequently for all nursing and care staff.

We have asked the provider to tell us how they will make improvements in relation to the training matrix to ensure they can identify the training needs of staff. What actions they will be taking to ensure all staff receive all the mandatory training and annual appraisals.

Is the service well led? We judged the service to be well led. This was because staff told us they had been impressed with the new head of care and nursing. One staff member told us they felt they 'Very much led by example, and they had got the confidence of everyone in the building, the team is beginning to gel.' Another staff member told us the head of care and nursing treated each staff member as an individual and as a result the team had improved. This helped to ensure that people received a good quality service.

Two more people told us 'There is always someone to look after you' and, 'On the whole I receive very good care'.the staff are generally very nice people.' We observed how staff interacted with people in a positive and caring way.

During our previous inspection 3 July 2013 we were concerned that risk assessments were not detailed and health information was missing. During this inspection we read the care files for three people. Detailed risk assessments were in place to protect people from harm. Care documents were regularly reviewed and updated.

We spoke with seven staff. We looked at the training and supervision records for nine staff. We found that the provider was not providing support and supervision to staff in line with the provider's policy.

During our previous inspection we had concerns with the provider's inability to respond appropriately to allegations of abuse. During this inspection we were told they had received training and were now able to demonstrate to us how to respond appropriately.

We looked at records such as policies and procedures; we found these had been reviewed recently. The provider may wish to note the policies needed additional information to ensure they were fit for the purpose of the home.

People's cultural and religious beliefs were respected though people were not always given a choice. For example, everyone had their breakfast in their room. The provider told us this was their choice; a staff member told us it wasn't their choice. We found no documentation to show people had been given a choice.

We found the documentation in the home was lacking information in some areas. Risk assessments weren't detailed and health information was missing. We found no records to show how people's mental capacity had been assessed. We found the records for administration of medicines were not always accurate. There was no guidance for staff when administering 'only when needed' medicines.

We were told by staff and people who used the service the home was short of staff, although no one felt the shortage was impacting on their care. We were aware the provider was actively recruiting.

We found some staff had not received frequent formal supervision. We saw some policy documents hadn't been reviewed recently and the multi-agency safeguarding vulnerable adults procedure was not available. The nominated individual was not able to describe appropriately how to respond to allegations of abuse.

We saw that people experienced safe and effective care based on detailed care plans that encouraged independence. There were risk assessments that met individual needs and provided guidance to staff to minimise potential risks. We saw that good nutritional care was provided in a way that met people's needs and preferences.

People using the service were protected from abuse as they were supported by staff who had appropriate knowledge and training on safeguarding adults. People we spoke to told us if they had any concerns they would report them to the manager or senior person on duty.

Staff we spoke to and records we reviewed demonstrated that there were the appropriate number of staff on duty at the right times to meet people's needs. Staff were appropriately inducted and supported and received ongoing training and supervision which provided them with the skills and knowledge to meet changing needs.

The provider had effective systems in place to monitor and assess the quality of the service. The provider regularly collected the views of families and they were very positive about the service. There was good evidence that the service made changes as a result of assessing quality.