Archived: Finch Manor Nursing Home

We carried out an inspection of Finch Manor Nursing Home on 30, 31 October and 6 November 2017. The first day of the inspection was unannounced.

Finch Manor 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. The home is registered to provide accommodation with support for personal or nursing care for up to 89 adults. At the time of the inspection 65 people lived at the home.

The home had 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 last inspected the service in May 2017. During this visit we identified significant breaches of the Health and Social Care Act Regulations with regards Regulations 9,10,11,12,14,16,17, 18 and 19. These breaches were assessed by CQC as serious as they placed people who lived at the home at risk of significant harm. The home was rated inadequate and placed in special measures.

Following the last inspection, we met with the provider and the manager to discuss our concerns. We asked the provider to complete an urgent action plan to show what they would do and by when to improve the service and make it compliant with the Health and Social Care Act regulations. During this visit we found insufficient improvements had been made and that the provider had failed to adhere to the urgent action plans that they had submitted to The Commission. This meant that they failed to take appropriate and timely action to mitigate the risks to people’s health, safety and welfare identified at the May 2017 inspection.

We looked at the care files belonging to 14 people. We found their needs and risks were not properly assessed or managed. Some people had new risk management and care plans in place but they still failed to provide sufficient information on how to meet people’s needs and keep them safe. Records relating to people’s day to day care did not show they received the care and support they needed for example, some people had not received sufficient nutrition and hydration and little action had been taken to address this. Some people had not been repositioned in accordance with risk management advice and some people’s health monitoring had not been undertaken to identify and respond to changes in their physical well-being. Some pressure mattress settings remained unsafe and posed a risk to people’s skin integrity.

New capacity assessments were in place for some people but not others and we found that some people’s capacity was still not properly assessed in accordance with Mental Capacity Act 2005. Some people did not have capacity assessments in place for covert medication or bed rails and some capacity assessments had already been filled in before an assessment had taken place, There were best interest information in people’s care files where decisions on people’s behalf had been taken but sometimes these lacked detail of the discussions that had taken place. One person had conditions attached to their deprivation of liberty safeguard authorisation but despite this we found that the manager and staff had not ensured these conditions were compiled with. This meant that there was a risk that the DoLS was unlawful.

Some improvements had been made with regards to the management of medication for example, stock levels of people’s medications were correct and records indicated that most people had received the medication they needed. The improvements made however were insufficient. Concerns were still identified with regards to the use of thickening agents in the drinks of people who had swallowing difficulties, some medication records were not completed properly and ‘as and when’ required medication plans lacked adequate detail. Some people had their medication administered covertly and we saw that some people had adequate guidance from the pharmacist on how to administer this medication safely, whereas other people did not. This placed people at risk of avoidable harm.

People’s nutritional needs were not always clearly identified or properly managed. Kitchen staff lacked up to date and accurate information on people’s special dietary requirements and some people did not receive the diet they need to keep them well.

Staff were recruited safely but some recruitment decisions made were not properly documented. Staffing levels were not always safe and some of the people and relatives we spoke with raised concerns about this during our visit. Some improvements in staff training had been made and the nursing staff had undertaken the provider’s mandatory training programme. Records showed the supervision of staff was still inconsistent and insufficient. The manager also failed to produce any records to show that staff had received an appraisal of their skills and abilities. This meant they could not be assured that staff had the competency or the support they needed to provide good care.

Parts of the premises were in need of repair or were not suitable for use. The environment in which people lived was not dementia friendly and did not support people who lived with dementia to remain as independent as possible for as long as possible. The provider’s fire safety arrangements were not safe and after our inspection we referred the home to Merseyside Fire Authority. This resulted in the provider being issued a enforcement notice.

Care staff were observed to be kind and patient in their interactions with people but tended to focus more on the completion of tasks. Some care staff demonstrated that they had a good knowledge of the different ways people used to communicate their needs but we saw that this information had not always been used to design or plan people’s care so that all staff were aware of them. The language used in one person’s care plan was also disrespectful. Nursing staff, the registered manager and the nominated individual were not a visible presence in the home and we found that the manager and nursing staff failed to have oversight of people’s care.

People’s privacy and dignity was compromised by the fact that some communal bathroom doors did not fit their door frames. This meant it was possible to see people using the bathroom from the outside. In addition records showed that people’s access to regular baths or showers was limited. This placed their personal hygiene, dignity and skin integrity at risk.

People’s previous complaints about the food on offer at the home had still not been adequately addressed as some people continued to voice similar concerns at this inspection. People’s feedback as to how the manager responded to complaints was mixed.

There were no effective systems or processes in place to ensure that the service provided was safe, effective, caring, responsive or well led. Audits were undertaken but they were ineffective in identifying the issues found during the inspection, most of which were of a serious nature. The manager and provider had failed to take proactive and timely action to the concerns identified at the last inspection. The overall rating for this provider remains 'Inadequate'. This means that it will remain in 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service will 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 we will move to close the service by adopting our proposal to vary the provider's registration to remove this location from the providers registration.

After our visit, we referred our continued concerns to the Local Authority and Clinical Commissioning Group. An urgent meeting was held to discuss the service and the action that needed to be taken to mitigate risks to people’s health, safety and welfare.

The home had 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 our last inspection of the service in November 2016, we identified breaches with regards to Regulation 12 and Regulation 18 of the Health and Social Care Act 2008 (Regulation Activities) Regulations 2014. This breaches related to medication management and safe staffing levels. At this inspection we found no improvements had been made. We found breaches of Regulations 12 and 18 again in addition to breaches of Regulations 9, 10, 11, 14, 16, 17, and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were assessed by CQC as serious as they placed people who lived at the home at risk harm.

We looked at the care files belonging to nine people. We found their needs and risks were not properly assessed, planned for or managed. There was insufficient information on how to meet people’s needs and to provide their care in the way they preferred. Risk assessments were inadequate and did not provide staff with sufficient guidance on how to manage people’s risks and keep people safe. People’s nursing needs were not adequately described or monitored by nursing staff and people’s day to day care did not show they received the care and support they needed from nursing and care staff.

People’s capacity was not properly assessed in accordance with Mental Capacity Act 2005 and their care files lacked evidence of their involvement in the assessment process. It was unclear how these assessments were undertaken as there were no best interest records on file and no evidence that any least restrictive options were explored. Some people had a deprivation of liberty safeguard (DoLS) in place but the documentation in respect of this was poor and did not show that proper legal process had been followed.

Medicines were not safely managed, administered or disposed of. Records showed that people frequently missed their prescribed medication and sometimes had a delay in receiving the medication they needed from the pharmacy. This placed people’s health at significant risk and meant that people may unnecessarily suffer the symptoms their medication was prescribed to relieve. We found that staff lacked sufficient knowledge of the medications and supplements people needed and we observed medication being administered in an unsafe way. The registered manager and home manager acknowledged that they were aware that management of medication was unsafe but had taken no effective action to address this.

People’s nutritional needs were not always met in accordance with medical advice. People’s nutritional care plans lacked information about people’s special dietary requirements and staff lacked sufficient knowledge of people’s dietary needs in order to mitigate the risk of malnutrition. During our visit, the majority of feedback from the people and relatives we spoke with about the food on offer was positive but when we checked the provider’s complaints records, we saw that several complaints about the quality and quantity of the food had been made to the registered manager over the last 12 months.

Staffing levels were insufficient to meet people’s needs and the staff employed were not always recruited in safe way. Staff were not supported appropriately in their job role or supervised effectively in their day to day jobs. Nursing staff had also not completed the provider’s mandatory training programme which meant that there was a risk that their skills and knowledge was not up to date. During our discussions with staff, the registered manager and the home manager they failed to demonstrate that they had sufficient knowledge of people’s needs and risks in order to provide safe, effective and responsive care.

The provider’s fire and emergency procedures required improvement to ensure people could be safely evacuated, parts of the premises and its equipment were not safe or suitable for purpose and there was a lack of suitable systems in place to mitigate the risk of Legionella.

Care staff were observed to be kind and patient in their interactions with people but the majority of their time was spent on completing tasks. In some units care staff had minimal social interaction with people who lived there. Nursing staff, the registered manager and the home manager were not a visible presence in the home and it was unclear what role nursing staff played in the delivery of people’s care.

There was a complaints policy in place but people’s complaints were not always effectively addressed. This was because records showed that the same concerns came up repeatedly in the delivery of people’s care.

There were no effective systems or processes in place to ensure that the service provided was safe, effective, caring, responsive or well led. Audits were undertaken but they were ineffective in identifying the issues found during the inspection, most of which were of a serious nature. Where concerns with the delivery of care had been identified, appropriate action had not always been taken by either the registered manager or home manager to ensure they were addressed to protect people from harm. The provider did not play an active role in the service and had not undertaken any effective checks on the service to ensure it was safe and satisfactory.

After our visit, we asked the registered manager and provider for an urgent action plan on how they were going to ensure immediate and significant improvements were made. An improvement action plan was submitted and is in progress. We also met with the registered manager and the provider alongside the local authority and the NHS clinical commissioning group’s medicines team. Both the local authority and the clinical commissioning group’s medicines team are now also supporting the service to make the required improvements in order to protect people from risk.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

The service will 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 we will move to close the service by adopting our proposal to vary the provider's registration to remove this location from the providers registration.

At the last inspection on 20 May 2013 the service was meeting the requirements of the regulations that were inspected at that time.

Finch Manor Nursing Home is a purpose built, single storey service situated in the Dovecot area of Liverpool, close to transport routes. The service provides care and support in five separate areas of the home. People are accommodated in areas of the home depending on their individual needs. Four of the areas provide care and support for people who are living with dementia.

There was 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.

We found recruitment procedures were safe with appropriate checks undertaken before new staff members commenced their employment. Staff spoken with and records seen confirmed a structured induction training was in place.

The provider had ensured training was available for staff and staff we spoke with were knowledgeable about how to provide care and support to people. However, we found some staff had not received training in important subjects such as safeguarding, infection control, moving and handling, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). This was in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found medicines procedures at the home were not always safe. Staff responsible for the administration of medicines had received training to ensure they had the competency and skills required. Medicines were safely kept in four out of the five areas with appropriate arrangements for storing in place. However, in one area of the home, we saw staff left the medicines trolley unlocked and unattended. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We found staffing levels were sufficient to provide the care and support people needed in four areas of the home. However, in one area, we found staff appeared to be task oriented and rushed, which meant they did not get time to spend with people, other than when delivering care. Activities in two areas of the home were limited due to staffing levels. This was in breach of Regulation 18 of the health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In all but one area of the home, people we spoke with told us they were supported to express their views and wishes about all aspects of life in the home. However, in one area of the home, people told us they had not been asked for their views of the care and support they received. We have made a recommendation about this.

Staff spoken with and records seen confirmed training had been provided to enable them to support people who lived with dementia. We found staff were knowledgeable about the support needs of people in their care.

We found the registered manager had systems in place to record safeguarding concerns, accidents and incidents and take necessary action as required. Staff we spoke with had received safeguarding training and understood their responsibilities to report unsafe care or abusive practices.

The registered manager understood the requirements of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). This meant they were working within the law to support people who may lack capacity to make their own decisions.

The environment was maintained, clean and hygienic when we visited. However, the outside areas at the home required regular maintenance to make them suitable for people to use.

We found equipment used by staff to support people had been maintained and serviced to ensure they were safe for use.

People who were able told us they were happy with the variety and choice of meals available to them. We saw regular snacks and drinks were provided between meals to ensure people received adequate nutrition and hydration.

Provision for activities was good in three areas of the home. In the other two areas, people told us they were bored and ‘had nothing to do’. We raised this with the registered manager who had already identified this as an area for improvement.

The service had a complaints procedure which was made available to people on their admission to the home. People we spoke with told us they were confident their complaints would be addressed.

Care plans were organised and had identified the care and support people required. We found they were informative about care people had received. They had been kept under review and updated when necessary to reflect people’s changing needs.

We found people had access to healthcare professionals and their healthcare needs were met.

The registered manager used a variety of methods to assess and monitor the quality of the service. These included satisfaction surveys and care reviews. We found people were satisfied with the service they received.

Finch Manor care home provided people who use the service and their families with sufficient and appropriate information about their support and treatment to enable them to make informed decisions about their care. People's needs were assessed and, where appropriate, people were consulted and involved in the planning of their care.

People told us about the quality and choice of food and drink available at Finch Manor. They told us that they were satisfied about the choice and quality of meals and that food and drink was readily available to them. People told us, 'There's always a choice of food and it's always served hot."

On our previous inspection we had concerns over the management and recording of safeguarding incidents. We found during this inspection improvements had been made relating to the recording and reporting of safeguarding incidents.

People's individual needs were being met by staff with the relevant skills, knowledge and experience.

Each of the people using the service had a care plan. The care plans we looked at were up to date and contained relevant information about the needs of the person. We found that where a need had been identified in a person's care plan then this was reflected in practice. We saw no evidence that people had been consulted with about their care plan or that they were in agreement with it.

People told us that they had felt safe living at Finch Manor and we found that staff were aware of how to identify and report potential safeguarding adult's occurrences. However we found that records for protecting people were not sufficiently robust.