Withens Nursing Home

Withens Nursing Home is a residential care home providing personal and nursing care for up to 33 people. It can accommodate older people who have nursing needs and people living with dementia. At the time of the inspection there were 24 people living in the service. The service was arranged over two floors with communal areas on the ground floor. The upper floor was accessible via a lift.

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

People told us they felt safe in the service and liked living there. One person said, “I like it here, everyone is marvellous.” Relatives agreed their loved ones were safe in Withens. Staff received training in safeguarding, and this was up to date. People received safe care and treatment and environmental risks were managed. Medicines were managed safely in line with national guidance.

There were quality monitoring processes in place to monitor the service. There was a manager who was registered with the Care Quality Commission who had left around the same time as our inspection. The provider had already put interim management arrangements in place and a regional management team provided support for the service. Staff had confidence in the management team and found them approachable.

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

The last rating for this service was requires improvement (published 20 October 2020) and there were three 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

We received concerns in relation to safe care and treatment, poor care and needs, including nutritional needs, not being met due to low staffing. As a result, we undertook a focused inspection to review the key questions of safe and well led and a targeted inspection of one area in effective. We also checked that the provider had followed their action plan and to confirm they now met legal requirements.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Withens 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.

The Withens Nursing Home is a nursing home providing personal and nursing care in one adapted building for up to 33 people aged 65 and over. At the time of the inspection there were 18 people at the service. They had a communal lounge and conservatory area with a separate dining room. The service is laid out over two floors, upper floors are accessible via a lift.

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

People told us they felt safe living at the service. However, risks to people’s health and welfare were not always assessed and action had not always been taken to manage risks and keep people safe. Accidents and incidents were recorded, but analysis was not in-depth and lessons had not always been learnt to prevent them happening again.

There were not enough staff to meet people’s needs consistently and keep people safe. People received their medicines when prescribed. However, topical medicines such as creams and medicines requiring refrigeration had not always been stored safely.

There was a manager in post who had started in May 2020 and was in the process of registering with the Care Quality Commission (CQC).

There were systems in place to monitor and check the quality of the service. However, these had not been effective in identifying issues we found on our inspection.

The manager had not always referred safeguarding incidents quickly, and they had not always notified CQC of incidents as required.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The service was working within current infection control guidance and staff were wearing personal protective equipment as required. The service was clean and there were cleaning schedules in place to reduce the risk of infection.

People were asked their opinions on the quality of the service during meetings. Staff meetings were held regularly where staff could raise any concerns they had. The manager had focused on team building, staff told us this had improved, and they now felt more supported.

Staff continued to work with other health professionals to meet people’s health needs and ensured good communication between staff, local hospitals and GP’s .

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

Rating at last inspection

The last rating for this service was Good (published 7 December 2017).

Why we inspected

We undertook this focused inspection in response to concerns about safe care and treatment of people using the service. This report covers our findings in relation to key questions Safe and Well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from Good to Requires Improvement. This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risk management, staffing and notifications at this inspection.

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

Follow up

We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Staff provided personal and nursing care for up to 33 older people. The accommodation spanned two floors and some rooms had on-suite facilities. A lift was available for people to travel between floors. There were 28 people living in the service when we inspected. People had chronic and longer-term health issues associated with ageing or illness requiring nursing care and some people were living with dementia as a secondary diagnosis.

We carried out our last comprehensive inspection of this service on 05 and 06 December 2016. At that inspection breaches of legal requirements of the Health and Social Care Act Regulated Activities Regulations 2014 were found. The breaches related to Regulation 17, Good Governance; Accurate and complete records were not being kept. Regulation 18, Staffing; Staff were not deployed in sufficient numbers. We also made six recommendations. The recommendations related to medicines audits, Deprivation of Liberty Safeguards applications, staff surveys, residents meetings and meeting people’s social needs. You can read the report from our last comprehensive inspection by selecting the 'all reports' link for The Whitens Nursing Home on our website at www.cqc.org.uk

At the time of this inspection the local authority in Kent had been working with the provider on an improvement plan. This improvement plan had been implemented in response to recent concerns about incident and safeguarding management in the service. The action plan and the improvements being made had been shared with CQC by the provider. At this inspection, we found that the provider had brought in a team of senior managers to implement the improvements that were required.

There was not a registered manager employed at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. The provider had employed a manager who had made an application to register with the Care Quality Commission on 21 June 2017, but they had left before the registration process had been completed. However, the provider was in the process of recruiting a new manager. At the time of this inspection the service was being managed by an experienced interim manager.

Staff protected people’s privacy and confidentiality whilst delivering care, but at other times, people could be observed in bed as their doors were open. It was not clear if people had consented to their doors being left open. We have made a recommendation about this.

The risk from infection were minimised by safe systems of work by staff delivering personal care and by a planned and actioned cleaning and maintenance routines. However, two areas in the service requiring maintenance posed a risk to infection control. We have made a recommendation about this.

The provider had a system in place to assess people’s needs and to work out the required staffing levels. Since the last inspection, the provider had been making changes to the way staff were deployed and simplifying recording systems to reduce the amount of time staff spent away from care task, for example completing paperwork. A recently appointed nurse deputy manager was leading on the effective delivery of nursing care.

Space in the service for the storage of confidential information was limited. However, since the last inspection, information that staff needed access to when delivering care was kept in people’s bedrooms and other larger care plans were stored in locked cabinets at the nursing station on the ground floor.

We observed safe care. Staff had received training about protecting people from abuse and showed a good understanding of what their roles and responsibilities were in preventing abuse. Nursing staff understood their professional responsibility to safeguard people. The interim manager responded quickly to safeguarding concerns and shared information with the safeguarding teams.

Incidents and accidents were recorded and checked by the interim manager to see what steps could be taken to prevent these happening again. The risk were assessed and the steps to be taken to minimise them were understood by staff.

Staff received training that related to the needs of the people they were caring for and nurses were supported to develop their professional skills by maintaining their registration with the Nursing and Midwifery Council (NMC).

We observed that staff were welcoming and friendly. Activities were planned to keep people mentally active and to maintain skills or hobbies they were interested in. People and their relatives described that staff were friendly and compassionate. Staff delivered care and support calmly and confidently. People were encouraged to get involved in how their care was planned and delivered. Staff upheld people’s right to choose who was involved in their care and people’s right to do things for themselves was respected.

There were policies in place for the safe administration of medicines. Nursing staff were aware of these policies and had been trained to administer medicines safely.

Nursing staff assessed people’s needs and planned people’s care. They worked closely with other staff to ensure the assessed care was delivered. General and individual risks were assessed, recorded and reviewed. Infection risks were assessed and control protocols were in place and understood by staff to ensure that infections were contained if they occurred.

The provider and interim manager ensured that they had planned for foreseeable emergencies, so that should emergencies happen, people’s care needs would continue to be met. Equipment in the service had been tested and was well maintained.

Decisions people made about their care or medical treatment were dealt with lawfully and fully recorded. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Restrictions imposed on people were only considered after their ability to make individual decisions had been assessed as required under the Mental Capacity Act (2005) Code of Practice. The interim manager understood when an application should be made.

People were supported to eat and drink enough to maintain their health and wellbeing. People had access to good quality foods. The chef prepared foods that were seasonal and used fresh ingredients. People had access to food, snacks and drinks during the day and at night.

People had access to qualified nursing staff who monitored their general health. End of life nursing care was supported by links to the local hospice team. People had regular access to their GP to ensure their health and people’s health and wellbeing was supported by prompt referrals and access to medical care if they became unwell.

Recruitment policies were in place. Safe recruitment practices had been followed before staff started working at the home. This included checking nurse’s professional registration.

Policies were in place so that if people complained they were listened to. The interim manager held regular meetings with people and their relatives and made changes or suggested solutions to issues people raised.

The interim manager of the service, nurses and other senior managers were experienced and provided good leadership. They followed their action plans to improve the quality of care people experienced. This was reflected in the changes they had already made within the service.

An acting manager in post was going through the processes of being registered with the Care Quality Commission. 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 on 17, 20, 23 May 2016, we found eight breaches of the Health and Social Care Act 2008 (Regulated Activities). These breaches were in relation to staffing levels, recruitment practices and training, medicines management, Mental Capacity Act 2005 (MCA) processes, activities, care plans, records and auditing systems. The provider sent us an action plan stating that they would address all of these concerns by November 2016.

At this inspection, we found that the registered provider had not fully addressed the issues relating to staffing levels and of the provision of meaningful activities.

There were not always sufficient staff on duty to meet people’s needs. People, relatives and staff told us that more staff were needed.

Activities were not consistently provided to people who remained in their rooms. The acting manager had identified this and an additional activities coordinator was being recruited. We have made a recommendation about this in our report.

Trained competent staff were safely managing medicines. An accurate audit trail to monitor the administration of medicines was not undertaken. We have made a recommendation about this in our report.

People were protected against abuse and harm. The provider had effective policies and procedures that gave staff guidance on how to report abuse. Staff were trained to identify the different types of abuse and knew who to report to if they had any concerns.

The provider had ensured that the home was well maintained. Up to date safety checks had been carried out on electrical and gas installations. Equipment, such as hoists, were being checked and serviced.

People’s needs had been assessed and detailed care plans had been developed. Care plans had appropriate risk assessments that were specific to people’s needs.

The principles of the Mental Capacity Act 2005 (MCA) were adhered to. People were being assessed appropriately and best interests meetings took place to identify the least restrictive methods of keeping people safe. Staff had training on MCA and had good knowledge.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options were considered as per the Mental Capacity Act 2005.

Spot checks were not being effectively recorded and fully implemented by the acting manager. We have made a recommendation about this in our report.

People were supported to have a healthy and nutritious diet. Staff could identify when people required further support with eating and appropriate referrals were made to health professionals and staff were seen to be following the guidance provided.

People and their relatives told us they were involved in the planning of their care. Records also confirmed people’s involvement. Care plans and risk assessments were being reviewed on a monthly basis by staff and at any time when it was required.

People had freedom of choice at the service. People could decorate their rooms to their own tastes and choose to participate in any activity. Staff respected people’s decisions.

People’s private information was not always kept secure. We found that care plans were left unattended in a communal area and the secure storage unit was, at times, not locked correctly.

The provider had ensured that there were effective processes in place to fully investigate any complaints. Outcomes of the investigations were communicated to relevant people.

The acting manager was approachable and supportive and took an active role in the day-to-day running of the service. Staff were able to discuss concerns with them at any time and were confident these would be addressed appropriately. The acting manager was open, transparent and responded positively to any concerns or suggestions made about the service. The provider produced a yearly survey for people living at the service and their relatives. However, the provider was not producing a staff survey to capture staff views on the service. We have made a recommendation about this in our report.

The Withens Nursing Home is owned by Ranc Care Homes Ltd, a company who own several care homes. The service provides accommodation for up to 33 older people and provides nursing care to people with high needs, including people who are nursed in bed, people living with dementia, and people receiving end of life care. Accommodation is provided over two floors, with a passenger lift providing access between the floors. At the time of the inspection, 29 people lived at the service, all of whom were receiving nursing care.

The service had not had a registered manager since February 2015. There had been two managers since February 2015, both managers had transferred to other services owned by the company. 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 provider had appointed a manager who was present on the first day of the inspection visit and had worked at the service for three months. The manager was in the process of applying to become the registered manager. They were not present on the second and third days of the inspection visit due to the findings on the first day of the inspection visit. The head of quality and care services was in day to day control of the service on the second and third days of the inspection visit.

Nursing staff managed and administered medicines for people. Medicines were not always appropriately managed, administered and recorded.

Staff were recruited using procedures designed to protect people from unsuitable staff. However, robust recruitment checks had not always been carried out.

There was not always sufficient staff on duty to meet people’s needs. Staff had not received all of the training they needed to meet people’s needs and had not received regular support, supervision and appraisal from their manager.

Procedures and guidance in relation to the Mental Capacity Act 2005 (MCA) was in place which included steps that staff should take to comply with legal requirements. The manager failed to act in accordance with the Mental Capacity Act as capacity assessments did not follow the principles of the Mental Capacity Act and deprivation of liberty safeguards applications had not been made to the local authority supervisory body in line with agreed processes to ensure that people were not unlawfully restricted. The service was meeting the requirements of the Deprivation of Liberty Safeguards.

People were not always provided with a diet that met their needs and wishes. Menus did not offer varied choices. Before the inspection visit was completed the menus had been changed and the new menus offered more variety as well as different choices.

Person centred care planning records were not fully completed and showed inconsistencies therefore; people may not have received care and support that met their needs.

At the time of the inspection visit there were no meaningful activities taking place in the service to keep people alert and occupied.

There were risk assessments in place for the environment, and for each person who received care. Assessments did not always identify people’s specific needs, and did not show how risks could be minimised.

The provider and the manager investigated and responded to people’s complaints. People knew how to raise any concerns. We found that concerns had not always been dealt with appropriately and in a timely manner. We have made a recommendation about this.

The provider regularly assessed and monitored the quality of care to ensure standards were met and maintained. However, the manager had not maintained the monitoring of quality of care, and had not followed up on previous action points to improve the quality of care.

Staff supported people in making arrangements to meet their health needs. Nursing staff carried out on-going checks of people’s health needs, and contacted other health and social care professionals for support and advice.

People were protected against the risk of abuse. People told us they felt safe. Staff recognised the signs of abuse or neglect and what to look out for. Both the manager and staff understood their role and responsibilities to report any concerns and were confident in doing so. However, reporting was not always carried out in a timely manner.

Staff interacted well with people, and supported them when they needed it. Staff respected people and we saw several instances of a kindly touch or a joke and conversation when supporting people.

There were systems in place to obtain people’s views about the service. These included formal and informal meetings; questionnaires; and daily contact with the staff.

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

When we inspected the service in August 2014, we found that the provider was non compliant with the regulation 23 of the Health and Social Care Act 2008 because the staff had not received appropriate training, supervision and appraisal. Some staff's feedback indicated they were dissatisfied with previous instability of management as there had been several managers appointed over the past three years and periods of time where no managers were in post.

We requested the provider to submit a remedial action plan in a set time frame to remedy this. The service had provided us with an action plan that demonstrated how they planned to address these issues. During our inspection, we found that this action plan had been implemented and that the issues had been addressed to achieve compliance.

We spoke with the manager and five members of staff and one relative of a person who used the service. We looked at staff training records and at the system in place to support and appraise staff and to gather their feedback.

During this inspection, the inspector focused on answering our five key questions; is the service safe, effective, caring, responsive and well-led?

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

Is the service safe?

We found that people who used the service were protected from the risk of abuse because all care staff were trained in the safeguarding of adults, in the principles of the Mental Capacity Act 2005 and in the Deprivation of Liberty Safeguards (DoLS).

Members of staff we spoke with were able to demonstrate their knowledge and were positive about their responsibilities. One member of staff said, "We are trained to protect the people we care for".

Is the service effective?

We found that the staff had received the training they required to meet the needs of people who used the service and that additional training was available and scheduled. This was to make sure that staff were knowledgeable about people's individual conditions and individual needs.

Is the service caring?

We found that people who used the service were supported by kind and attentive staff. A relative of a person who used the service told us, "The staff appear to be knowledgeable and we trust them to care for our family member well".

Is the service responsive?

One member of staff told us, "Training has taken off in a big way, and now that it is built-in in our hours, cover is no longer a problem, it is great". The manager had implemented a permanent system to collect staff's feedback and analysed the findings every week to identify and address any staff's dissatisfaction.

Is the service well-led?

The new manager had driven improvements in the service. This included an open door policy, an effective communication system and comprehensive maintenance of staff's records such as training, supervision, appraisals and relevant audits. All the staff we spoke with confirmed the manager was approachable and receptive to ideas or suggestions. Four members of staff told us, "We are now much better organised, and staff are valued more", "We get good support from the manager, it is good to have a manager who intends to stay", "I am encouraged to go for a higher diploma and it is really nice to feel valued like this", and "This manager is really good, she properly listens to us".

During this inspection, we considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer our five key questions; 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. The summary describes what we observed, the records we looked at and what people using the service and the staff told us. If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

CQC monitors the operation of Deprivation of Liberty Safeguards (DoLS) which applies to residential care homes. We spoke with the manager and they demonstrated their knowledge of the procedures to follow if an application needed to be made to deprive a person of their liberty. We found that no person who lived in the home were deprived of their liberty at the time of our inspection. All care staff had been trained in the safeguarding of vulnerable adults. However not all care staff had been trained in the principles of the Mental capacity Act (2005 (MCA) and in first aid. We found that risk assessments with clear action plans were in place to ensure people remained safe. Emergencies measures were in place and the people who lived in the home had personal evacuation plans.

Is the service effective?

People and their relatives told us they were satisfied with the quality of care that had been delivered. A relative of a person who used the service said, "All the staff are extremely kind and professional, they understand what needs to be done". We saw that the delivery of care was in line with people's care plans and assessed needs. Care plans, risk assessments and handovers reflected people's current needs. Changes in care plans were effectively communicated to staff.

Is the service caring?

We found that the people who lived at the home were supported by kind and attentive staff. We observed staff interacting with people who used the service and noted how staff provided encouragement, reassurance and practical help. Requests for assistance were responded to promptly. We saw that staff showed kindness and patience when they supported people at mealtimes or during activities. A relative of a person who used the service told us, "The staff are really very nice and efficient". Two people who lived in the service said, 'People are nice to me' and 'The staff are very kind and polite'.

Is the service responsive?

People's needs had been assessed before they moved into the service and their support plans were reviewed regularly to reflect any change in their needs. We saw that people's records included their life history, wishes and preferences and desired outcomes to be achieved. People were able to choose what they preferred to eat. The chef met with people on a daily basis to ask what they would like to eat. Requests that were made during residents meetings or expressed in satisfaction surveys were followed through and responsive action was taken. We found that some members of staff had expressed dissatisfaction about their working conditions and felt they were not listened to. We found that additional training for staff was not sufficient to address specific needs of people who used the service. The service had failed to provide regular and consistent one to one supervision and appraisals to the staff.

Is the service well-led?

The manager had been in their post for three months. They operated a system of quality assurance and completed audits to identify how to improve the service. Additionally, an operations manager carried out compliance checks and developed improvement plans. When audits identified the need for an improvement, this was implemented. People and their relatives or representatives and staff were consulted about how the service was run. Annual survey questionnaires were provided and their results were analysed. A member of staff told us, "The new manager is approachable and we have hope that they will stay and continue to improve the home'. Another member of staff said, 'We have had too many changes of management and we need some stability. The staff morale is low but we like the new manager'.

We spoke with three people who used the service and two representatives who used the service. Comments included 'I am well looked after' and 'I have recently been involved in reviewing my relatives care plan and it meets their needs. We are really happy with the care my relative is getting'. We found that the provider had reviewed the care plans for all the people using the service with input from the person using the service and their representative and care staff. We found that staff had received refresher training and there was a plan in place for staff to receive supervision and appraisals to ensure they maintained the relevant competencies to carry out their job role.

We found that the provider had developed a more robust system to monitor the quality of the service provided. We found that the provider had reviewed personal information held on people using the service and staff and these were now up to date and accurate.

We spoke with seven representatives of people who used the service and two people who used the service. Comments included, 'I am happy with the care that my relative receives, the staff do their best', 'The staff are kind to my relative' and 'I have asked that my relative be socialised more and for them to be more actively stimulated, but they don't seem to be able to do this. I think this is because there are not enough staff'. People also told us that although they were aware of a care plan being in place for themselves or their relative, they did not remember seeing their care plan. We spoke with staff who told us that they liked working in the home. Comments included, 'We have a good team here' and 'It would be good to have some direction from the nurses and the manager'.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. Our observations showed that people who used the service did not always get the care and support that they needed.