Archived: Garston Manor Nursing Home

On 25 February 2016, a multi-agency safeguarding meeting was held. As part of that a plan was agreed with the provider, health and social care professionals, to protect people’s safety and wellbeing. This included health professionals visiting the home every day as part of a support and protection role. The local authority quality improvement team are working with the home to help support improvement. We shared our concerns with the providers and with the safeguarding and commissioning teams during the inspection.

Garston Manor Nursing Home is registered to provide nursing care and support to 26 people who are living with dementia, mental health needs, and/or physical disability. The service 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.

People were not safe and were placed at risk of harm and abuse. Where abuse was suspected, the provider had not taken appropriate action to protect people, in line with their safeguarding policy. Where safeguarding incidents had taken place, the provider had not notified the local authority safeguarding team or asked for support or advice.

Risks to people’s physical health were not identified and managed. The management of diabetes, choking, skin and pressure area care, and moving and handling was unsafe. Poor monitoring and management of people’s eating and drinking put some people at risk. Care plans were not clear and up-to-date, which meant staff did not have information on how to meet people’s needs. This meant people were at risk of receiving inconsistent care and not receiving the care and support they needed.

People were seen by GPs who visited the service regularly. However staff did not always make referrals to other healthcare professionals to ensure people’s care and treatment remained safe. Since the safeguarding process started in the service, all relevant healthcare professionals have been involved. Records relating to the administration of medicines were not always clear.

None of the people living in the home had capacity to make their own decisions in relation to their care. Care files contained capacity assessments. There was some evidence the service had thought about people’s needs and relatives had been involved in making best interest decisions. However, some assessments were basic. Where staff were keeping one person in bed, no assessment or decision had been made in relation to this, to ensure it was in the person’s best interests.

People did not always benefit from staff who showed kindness, respect, and compassion. There was a lack of consistency in the caring approach of staff. People were not always at the centre of the care they received because staff focused on the task, rather than the individuals. When people became anxious and distressed, some staff did not respond appropriately to reduce the person’s anxiety. Most of the time during the day people were asleep, looking around the lounge, or walking around. There was little attempt to engage any of the people with any form of activity or conversation. At other times, we saw some caring and pleasant interactions from staff but these were limited to when care was carried out.

By the third and fourth days of our inspection, the provider had increased staffing levels. We observed staff had time to meet people’s basic care needs but not to spend time with people. The provider did not have a system for determining how many care staff were needed in relation to the number of people who lived in the home and their dependency needs. This meant people were at risk of not having their needs met.

People were at risk of receiving care from unsuitable staff as recruitment processes were not robust. Staff had not been given appropriate training to ensure they had the skills and knowledge to meet people’s needs effectively. Our observations of poor practice showed staff were not provided with suitable supervision or monitoring to ensure they met people’s needs effectively.

The environment was not suitably adapted for people with dementia. The deputy manager said he had assessed the environment using a recognised dementia care assessment tool last year. However, we saw there had been little improvement since our inspection in July 2015. 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. People were not protected from the prevention and control of infection. The service did not maintain and follow good practice policies in line with current national guidance on infection control. Equipment including hoists and lifts had been regularly serviced.

The provider had a quality assurance system in place. However, this system was not effective as it had not identified the risks and issues we found during our inspection.

We saw some good practice. Although people, due to their dementia, were not able to tell us how they felt about staff or living at the home. We observed people responding positively to some staff. People’s relatives told us they were happy with the care. Comments included “very happy – they feed her and keep her clean”;“ They are good at everything here” and “I am thoroughly happy”. The service sought feedback from people, their relatives and visiting professionals. The results of the survey sent out in January 2016 showed there was a high level of satisfaction.

During the inspection, we identified a number of concerns about the care, safety and welfare of people who lived at Garston Manor Nursing Home. We found ten breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We have shared our concerns with commissioners, the safeguarding team, and the local authority food and safety team. People's care needs are currently being reviewed by the local authority commissioners.

We are taking further action in relation to this provider and will report on this when it is completed. 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.

• Services placed in special measures will be inspected again within six months.

• The service will be kept under review and if needed could be escalated to urgent enforcement action.

As part of this inspection we spoke with two relatives and seven staff. The nurse on duty was the person in charge on the day of our inspection. We reviewed records relating to the management of the service which included three care plans, daily care records, medication records, staff rotas, and quality assurance records. We contacted the Registered Manager and requested further information after the inspection. This was because we were unable to access all of the information we needed during our visit.

Below is a summary of what we found. The summary describes what relatives and the staff told us, what we observed and the records we looked at.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Care was not always planned and delivered in line with people's assessed needs. During the morning of our inspection one person moved into the home. We spoke with staff who told us they didn't have any information about the person's needs. Following the inspection the Registered Manager told us the care plan had been received by the service but was overlooked by staff on the day of our visit. This meant the person may have been at risk of unsafe or inappropriate care.

The management of medicines did not protect people against the risks of unsafe administration of medicines. We watched some medicines being given to people at lunchtime, and we saw that they were given in a safe way. However, medication records were not always completed. This meant there was no clear audit trail that showed people had safely received their medicines at the time they needed them.

There were not always enough staff on duty to meet people's needs. The provider had identified a minimum number of staff needed on each shift. Staffing levels had regularly dropped below this number. This meant the service had not ensured there were sufficient staff who had time to care for and engage with people.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. We saw that the service had a DoLS policy in place. The Registered Manager had completed DoLS training. However, they did not know when an application should be made, and how to submit one. This meant people were being unlawfully deprived of their liberty.

Is the service effective?

People's care and treatment was planned and delivered in line with their individual care plan. We found that the care plans were detailed. For example, they showed us the care and support people needed, what they could do themselves, and when they might need encouragement. However, one of the care plans we looked at did not reflect the person's current needs. For example, the care plan stated the person ate independently. We observed staff assisted the person with their meal. Staff we spoke with told us the person now needed assistance with eating. This told us the care plan had not been updated to reflect the person's changed needs.

Is the service caring?

People we spoke with were positive about the home and the staff. Comments included 'They've been absolutely marvellous', 'The staff are very good', and 'The staff rang me when my relative was not well'. We observed that staff were patient when assisting people with their mobility, food, and medication. We found staff were kind and attentive whilst supporting people. This showed that staff were professional and respectful to people living in the home.

Is the service responsive?

Records showed that health professionals such as GPs, occupational therapists, and moving and handling advisors were contacted when the service had concerns about people's health.

Is the service well-led?

Staff told us they were clear about their roles and responsibilities. Staff we spoke with told us they felt well supported and had regular discussions with the Registered Manager. Several relatives told us they were asked about the quality of the service. People told us that their comments were listened to and acted upon. One person told us 'I can't complain about it'.

During this inspection, we identified shortfalls relating to care and welfare, safeguarding, management of medicines, and staffing. The provider's quality assurance systems had not picked up these issues. This told us there was not an effective quality assurance system in place.

On the day of our inspection, 22 people were living in the home. As part of the inspection, we spoke with seven people who lived in the home, four relatives and four staff. People who lived in the home had dementia and when we spoke with them they were not always able to tell us about their experiences.

During our inspection visit we observed that interactions between people who lived in the home and staff were good and showed staff respected people. We asked relatives about the quality of the care provided at the home. They commented " X has settled and feels comfortable', 'the staff are very good at letting us know what's happening' and 'if X needs something, the staff are there'. Care plans contained enough information for staff to follow so they knew how to meet people's needs.

We saw that medication was stored securely. We saw that the medication systems in use meant people had their medicines at the time they needed them and in a safe way.

We observed there were enough experienced care workers on duty who knew the needs of the people who lived in the home.

The provider was developing the quality assurance systems to ensure they effectively monitored the quality of the service. The provider had identified the areas they needed to improve and was starting work on an action plan.

During our visit we observed that some interactions were good and showed staff respected people at the home, whilst other interactions were less respectful. Relatives were asked about the quality of the care provided at the home. They commented 'they're happy and well looked after' and 'staff are very kind'. However, one relative told us they had received very little feedback on one person's health. Care plans contained enough information for staff to follow so they knew how to meet people's needs.

Medication procedures had been recently improved following concerns which had been raised. However, we found some medicines were being given without the correct guidance being in place.

Recruitment procedures were incomplete. For example, one member of staff had recently started to work at the home before essential checks had been undertaken. Whilst there were enough staff on duty, care workers who had been recently employed had not received the training they needed to support them to carry out their roles.

Quality assurance was assessed and monitored. However, concerns identified had not been put right by the service through the use of their monitoring systems.