Chestnut Lodge Nursing Home

Chestnut Lodge Nursing Home is a residential care home providing personal and nursing care to up to 17 people. At the time of our inspection there were 13 people using the service.

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

The home did not ensure appropriate checks were conducted prior to agency staff being deployed to support people. Choking risks had not been managed safely. Introduction of thickener had not always involved the advice from the Speech & Language Therapy Team (SALT) this placed people at risk of harm. Fire drills had not been conducted in line with the provider’s policy. The issues identified during the inspection had not been recognised or identified by the provider or registered manager. This meant the provider’s quality assurances were ineffective.

Permanent staff were recruited safely. Staffing levels were calculated using a dependency tool which looked at the needs of each person. Staff received supervisions and had the opportunity to speak out.

The provider had a system to investigate and record safeguarding incidents. Staff had completed safeguarding training.

Information gathered accidents and incidents was analysed to identify trends or patterns with actions put in place to minimise risk of further incidents.

The home was clean and tidy. Staff had completed training in infection control and followed protocols to reduce the risk of infection.

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 registered manager promoted an open culture. The provider and registered manager understood their duty of candour. The home had developed strong partnerships with health and social care professionals to ensure people received joined up care.

People told us they were happy living at the home. People told us staff were kind and caring and response to their needs.

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.

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 good (published 20 February 2018).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We undertook a focused inspection to review the key questions of safe and well-led only. 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 to requires improvement. This is based on the findings at this inspection.

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

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, and the assessing and monitoring of the quality and safety of the home.

Please see the action we have told the provider to take at the end of this report.

We last inspected the service in January 2017 and at that time identified breaches in four of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The breaches were related to person centred care, need for consent, staff training and good governance.

We took action by serving warning notices in relation to two of the breaches and requiring the provider to send us an action plan stating how they would achieve compliance in respect of the others. During this inspection we found there had been improvements made in line with the terms of the warning notices and the provider’s action plan. As a consequence of these improvements the service was no longer in breach of the regulations detailed above.

Chestnut Lodge Nursing Home is a ‘care home’. 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.

Chestnut Lodge Nursing Home accommodates up to 17 people in one adapted building. At the time of this inspection there were 15 people using the service.

The service has a large communal lounge a separate dining area and a small conservatory on the ground floor and a smaller lounge area on the first floor with a table and space to dine in. There is a stair lift connecting the ground and first floor.

The service had a registered manager in place. 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.

Improvements had been made to medicine records. There was guidance in place for the use of ‘as required’ medicines and there were no unexplained gaps in people’s medicine administration records (MAR). Medicines, including controlled drugs, were stored safely, administered appropriately and disposed of correctly.

Staff who administered medicines had a competency assessment every 12 months to ensure they were correctly following procedure. Nurses had their PIN number checked to ensure their registration was current. The PIN is a unique identifier enabling employers to check the registration status of nurses with the Nursing and Midwifery Council (NMC).

Safe recruitment procedures were in place and appropriate pre-employment checks were undertaken.

Some people felt there was not always enough staff on duty and some of the staff agreed this was the case. People’s dependency levels were calculated but not used to determine the number of staff. We have made a recommendation about this.

Care records contained detailed risk assessments. People had individual personal emergency evacuation plans in place. Accidents and incidents were recorded and analysed to look for patterns or trends. Regular maintenance checks and repairs were carried out and all areas of the service were clean and tidy.

Improvements had been made in respect of staff training. The majority of staff were up to date with training and additional training courses linked to the needs of the people using the service had been completed by staff. Some training was still not included on the matrix.

Requests for DoLS authorisations were being submitted appropriately and improvements had been made in the recording of best interest decisions. However, we identified that further improvements were needed in relation to recording of mental capacity assessments.

Staff felt well supported and received regular supervision sessions and annual appraisals.

People were supported to maintain their health and wellbeing and had access to health professionals when needed.

People were happy with the food they received. The cook knew people’s individual dietary requirements and provided fortified food for people who required extra calories. The mealtime experience was relaxed and staff provided the necessary level of support. People’s weights were monitored regularly and expert advice sought from dieticians if there was any cause for concern.

People and their relatives were happy with the way care was delivered and happy with the staff approach. Staff interacted positively with people who used the service and had a good knowledge of the people they cared for. Relatives were made to feel welcome and were involved in the care planning process.

Staff provided care in a way that protected people’s privacy and dignity and promoted independence. Advocacy support from external agencies was available should anyone require it.

Improvements had been made to care plans which now contained more information to help staff support people in a personalised way. People were receiving care that was tailored to their individual needs.

The environment felt homely and people had personal items in the living room as well as their bedrooms. The provider had employed a part-time activity co-ordinator who organised a variety of activities including visits from external entertainers and also spent time with people on a one to one basis.

There was a complaints procedure in place and people knew how to make a complaint if necessary.

People had end of life care plans in place and all staff had undertaken training in end of life care.

Equality and Diversity was part of the provider’s mandatory training requirements and people were cared for without discrimination and in a way that respected their differences.

At our last inspection we found that records were not always complete or accurate and effective audit systems were not in place. Improvements had been made however, some records still had information missing. Action had begun to rectify the issues we highlighted but sustained improvement in record keeping is needed.

The system of audits had improved and these were taking place regularly. Staff meetings took place every two months and staff felt able to discuss any issues with the registered manager or the deputy manager.

An annual satisfaction survey was completed by people using the service and relatives. An action plan was produced in response to the feedback received.

The service had close links with healthcare professionals who gave positive feedback regarding the knowledge and cooperation of management and staff.

Chestnut Lodge Nursing Home offers accommodation for up to 17 people with a physical or learning disability. There are two communal lounges and a dining area as well as a small conservatory on the ground floor and a small lounge on the first floor. There are sixteen bedrooms one of which is to be shared by two people. The home is situated in Norton and is close to local amenities with good local transportation links.

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

The service was previously inspected in November 2015 and was not meeting two of the regulations we inspected. These related to staff training and good governance. We took action by requiring the registered provider to send us action plans telling us how they would improve this. When we returned for this inspection we found the issues identified had not been addressed.

The majority of staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). They demonstrated an understanding of how to support people who may lack capacity to make their own decisions.

Eight people living at the service had a DoLS in place. These were monitored by the registered manager to ensure they remained up to date. There was no evidence of best interest decisions being undertaken or documented. The registered manager did not undertake capacity assessments but applied for DoLS authorisations for those people they believed may lack capacity.

There were systems and processes in place to protect people from the risk of harm. Staff had received safeguarding training and were aware of the action they should take if they suspected abuse was taking place. Staff were aware of whistle blowing procedures and all said they felt confident to report any concerns.

People’s medicine records were not always complete or accurate making it difficult to check people were receiving their medicines as prescribed. Staff had received medicines training but had not had their competency checked in line with the registered provider’s policy.

There were not sufficient numbers of staff on duty taking into consideration the complex needs of people and the layout of the service. Although people’s care needs were being met there was not time to engage people in activities or ensure accurate records were kept. We have made a recommendation about this.

Recruitment and selection procedures included some appropriate checks prior to staff starting work. These checks included obtaining references from previous employers and disclosure and barring service checks to ensure that staff were safe to work with vulnerable people. However we saw that nurse’s registration to practice was not always checked prior to employment.

We saw that environmental risk assessments had been carried out. Safety checks and certificates were in place for items that had been serviced and checked such as fire equipment, gas and electrical safety. There was a contingency plan in place but it did not contain up to date information or cover a variety of emergency situations.

Not all staff had received mandatory training and the registered manager was unable to provide sufficient evidence that all staff had the skills and knowledge to provide support to the people they cared for.

Staff received supervision but staff meetings were not held on a regular basis.

The records we viewed showed us that people had appropriate access to health care professionals such as occupational therapists and dieticians and the service was visited regularly by a GP.

We saw that people were provided with a choice of healthy food and drinks to help ensure their nutritional needs were met. People had provided feedback on menus during residents meetings but we did not see evidence of regular involvement in menu planning. Kitchen staff were knowledgeable about people’s special dietary requirements and accommodated changes to the menu if people requested it.

People were happy with the care they received and told us that staff encouraged independence and respected their privacy and dignity.

Care plans covered all aspects of care but were not written in a person-centred way. There was no timetable of activities, either for the service as a whole or individuals and there was no evidence that individual preferences with regard to meaningful activities were met.

The registered manager was undertaking some audits of the service but these were not done regularly and did not pick up on the issues we found. People’s views were sought via an annual survey but there was no evidence the information was used to improve the service.

The registered provider did not take an active role in the governance of the service and the registered manager did not have sufficient time to undertake all the tasks necessary as part of their role.

We identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered provider to take at the back of the full version of the report.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people. We saw that staff had a good knowledge and understanding of the people who lived at the home. One person commented, 'Oh they (the staff) are just lovely, really they are'. A relative said, 'It makes me happy knowing that he is happy here, honestly I don't think that I could ask for more'.

Is the service responsive to people's needs?

People's care and treatment needs had been assessed and care plans put in place that detailed the care and treatment that people needed. These records provided guidance to staff on what care and support was needed. People had access to activities that were important to them and had been supported to maintain relationships with their friends and family.

During the inspection we spoke with a district nurse who was visiting the home. They told us that staff were good at responding to people's changing needs and that they were not afraid to approach them for advice where needed.

We saw that following our previous inspection the service had responded to our concerns and had taken appropriate action to ensure that improvements were made in respect of the safety and suitability of the premises.

Is the service safe?

Care plans and risk assessments were in place and were current and up to date. Care records detailed the support people required and encouraged people to be independent where possible. People we spoke with during the inspection told us that they felt safe. One person said, "It is nice living here, knowing that they will help me and that I am safe".

We saw that nutritional screening was carried out for people who used the service. This meant that people received timely and appropriate intervention if they lost weight to help maintain their welfare and safety.

The premises were suitable, safe and clean. The premises were well maintained and integral elements of the premises were serviced regularly to ensure the safety of people who lived at the home and others who worked there or visited.

We saw that there was a consistent group of staff employed and deployed within the service. The registered manager oversaw the staff rota. They took people's needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people's needs were always met safely and effectively.

Is the service effective?

People we spoke with told us that they were very happy with the service. People told us that the staff were, "Lovely" and that, "Nothing seems too much trouble for them". Relatives we spoke with said, "I have complete peace of mind, I know that he is in the best place and getting the best care".

We observed throughout the day that people appeared to be happy. There was a lot of laughter, joking and smiles between staff and the people who lived at the home.

Is the service well led?

The service had a quality assurance system, we found that where they identified shortfalls these were addressed promptly. As a result the quality of the service was continuingly improving.

We saw that the service proactively gathered the views of the people who used the service. We saw that their feedback was acknowledged and that action was taken in response to this feedback. This helped to ensure that people received a good quality service at all times. Relatives we spoke with told us that the management team had an open door policy. They said, "Any concerns, anything at all and I would not hesitate to raise them, they are very approachable".

We were able to observe the experiences of people who used the service. We saw that staff treated people with dignity and respect. We saw that people had their needs assessed and that care plans were in place.

People's health, safety and welfare were protected when more than one provider was involved in their care and treatment, or when they moved between different services.

We saw that people lived in a homely environment that promoted their wellbeing, however people who used the service, staff and visitors were not protected against the risks of an unsafe premise.

We saw that the service had appropriate equipment. We saw that regular checks and servicing of equipment was undertaken to ensure that it was safe.

We found there was an effective complaints system in place at the home.

We found that before people received any care or treatment staff asked for their consent and acted in accordance with their, or their families wishes. We found that people who lived at Chestnut Lodge Nursing Home experienced care, treatment and support that met their individual needs and protected their rights.

We saw that the home retained and maintained accurate and appropriate records which protected people who used the service from the risks of unsafe or inappropriate care and treatment.

One relative we spoke with told us, "The staff are very good, they are all familiar with her needs and she is familiar with each of them and this is really important."

One person who used the service told us, "It is top notch here it really is great, I have stayed in a few homes and this one is just wonderful."