Archived: The Limes Nursing Home

We met with eleven people who used the service and observed their experiences of care to support our inspection. We spoke with the registered manager, ten care and nursing staff, two relatives and reviewed six care plans. The home was separated into two parts, The Limes, which supported people needing nursing and residential care, and, The Pines, which supported people living with dementia.

We considered our inspection findings to answer questions we always ask:-

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

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

Is the service safe?

People were cared for in an environment which was not clean and hygienic. There was a risk of cross contamination because sluice rooms were not locked and clinical waste was not stored securely. In the Pines medicines were not stored securely and spillages, faecal matter and spilled food was not cleaned up properly. This also put people at risk of infection and contamination.

We found the environment in The Pines was not suitable to meet the needs of people living with dementia. The environment was oppressive and there were no aids or adaptations in place to help support, and promote the independence of people living with dementia .

People in The Limes told us they liked the staff and felt safe and comfortable. They told us they liked their rooms and staff came as soon as they could if they were needed.

Clinical risk assessments were in place, the registered manager had suitable arrangements to safeguard people from foreseeable emergencies and some staff had received appropriate training to understand how to safeguard the people they supported.

We were made aware eight staff members had left in the previous fifteen months and the manager told us the new staff had not yet been trained. Some staff had received induction though not all. This meant people living at the home were at risk of receiving care and support from staff who had not had appropriate training.

At the time of the inspection, there were no people at the home subject to a Deprivation of Liberty Safeguard although we were made aware people had been in the past. What we were told meant the manager understood the process which must be followed and the reasons why an application was needed.

We found safeguarding concerns had been reported and accidents and incidents were logged.

There were no audits available for us to see to make sure the building was maintained or whether procedures were followed.

Is the service effective?

Five of the people we spoke with who resided in The Limes told us they were happy with the care they received although they said there was not much to do. Three people we spoke with in The Pines told us they "were bored". We noted all of the people who lived at the home in receipt of nursing care had a named nurse. There was no keyworker system in place for people in residential care or for people living with dementia, although this was something the manager told us they were looking to introduce.

We found overall people in need of nursing care received good care and support from suitably qualified and trained staff but people living with dementia did not. We discussed this with the manager who told us this was because staff had not had the relevant training in dementia care. They told us they would source some dementia training but did not specify when.

We saw in some areas of the home people were able to make decisions about where they wanted to sit although this was not consistent in different areas of the home. We also saw some people had a choice of where they ate meals, although not all.

We found people's care records were not accessed by care staff so there was a risk people's care needs would not be met. The manager told us this was because the notes in the care plans were clinical notes which were for the qualified nursing staff. The manager told us they were looking at improving in this area and trying to ensure care staff became more involved in the care planning.

We were informed a working group had been established in June to look at care staff involvement and a proposal had been made to for care staff to prepare the life history of people living at the home. We were unable to check the progress of this during our inspection but the manager said this would be completed 30th June 2014. We will check to ensure this has been done.

Is the service caring?

Observations during the visit showed some staff supported people well and some staff did not. We found the ethos of the home was on the quality of care provided for people requiring nursing care and whilst we recognise the importance of this we noted the staff approach was task focused with not much time available to sit and talk, or respond to, individuals living at the home.

During the day we saw some positive interactions taking place in The Limes and some staff responding in a kind manner to people who lived in this area of the home. However, we observed people living with dementia experienced poor care in relation to their dementia care needs. There was no clear strategy to support people living with dementia.

Is the service responsive?

When a person who lived at the home needed other professional input, we saw the staff had ensured this happened. There were statements of intent held on file to identify the persons wishes for end of life care.

Information within the care plans we looked at did not give staff an insight into the interests, likes and dislikes and areas of importance to the people in their care. This meant staff had no insight into the people they were supporting, particularly those living with dementia, which would enable them to better support their needs.

Meetings did not take place with staff to discuss the running of the service and to ensure the service was responsive in meeting the changing needs of people who lived at the home.

People who lived at the home did not have meetings with staff to discuss their views and opinions about the care and support they received. This meant that people were not involved in communications or able to influence the running of the home.

Is the service well-led?

The owner of the home was also the registered manager. There was not a clear management structure in place identifying roles and responsibilities of staff working at the home or how the manager was supported to run the service.

We were unable to see any audits carried out by the registered manager because none had been done recently. Staff did not receive regular supervision. The manager told us they were looking to improve in these areas although did not specify when. We found there were good systems in place which were not being utilised effectively due to the lack of clarity about roles and responsibilities and management support to facilitate them.

One relative told us they would feel able to speak with the manager if there were any concerns. Staff told us they felt the manager was approachable.

At the last inspection we found that the care records contained limited information about people's life histories, their personal likes and dislikes and preferences. We were told that this part of the care records had since been developed.

At the last inspection we found that improvements needed to be made to the communication systems with visiting health care professionals. The provider told us that the communication systems had improved and information was being handed over effectively. This was confirmed by a visiting health care professional we spoke with during the visit. The visiting health care professional told us they had no concerns about the way people were looked after and described the nursing staff as 'very good'.

We spoke with a number of people's relatives about the care provided. They were happy with the way their relative was being looked after. They said the staff appeared to be patient and kind and they had no concerns about their relative's safety. Most people felt the staffing levels were good although one person felt the staffing levels in the evening were a little too low.

People told us that generally they were happy with the care they received. They said that staff were nice but seemed to be very busy. One person said: 'It's alright but you have to fit around staff, they're very busy.' Another person told us that generally everything was ok but wasn't happy with the laundry. They said, 'I haven't seen these trousers in weeks, I think they've been doing the rounds.'

Relatives of three people who used the service told us they were happy with the care their relative received. One person said: 'I think my relative is being looked after very well. Most staff seem to be very kind and attentive.' Another person told us: 'We're very happy. Staff seem to be nice and capable. They have had more new staff recently but I don't think it has caused a problem'.

There were a range of care plans and risk assessments in place for each person. Overall they contained sufficient information to enable staff to provide appropriate care and support although we found care plans contained limited person centred information about the person's likes, dislikes and preferences. We spoke with some of the healthcare professionals who supported people living at the home. They reported that generally they were happy with the standard of care provided, although some concerns were raised about the way people's continence was assessed and managed and that some people experienced cuts and bruises that were not always reported straight away.

We observed staff providing care and support to people. We saw that two members of staff assisted people when they required hoisting which was in line with people's care plans. However, two health care professionals involved with the service raised some concern about this issue.

The manager told us he had not been informed of any abuse allegations. None of the staff we spoke with had any concerns about the care practices of their colleagues or the safety and welfare of any of the people who used the service. Health care professionals involved in the service told us they had never witnessed staff treating people badly. We spoke with a number of people who used the service. They had no concerns to raise about the way they were looked after. One person described the staff as 'lovely'. Another said 'The staff are very good'.

There were no rules imposed on people or any institutional practices observed. Staff were trained to protect people and recruitment practices were safe in ensuring people employed were of proven good character.

People knew the complaints procedure. Comments made included 'We all grumble from time to time. That's to be expected. Staff can't be everywhere at the same time. Some people think they can. If there was anything serious enough I would definitely say'. And 'It depends on what it is and the circumstances but I've never had to complain about anything whilst living here'.