Longton Nursing and Residential Home

People’s experience of using this service:

At the last inspection the provider was in breach of multiple regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found the provider had made improvements and was no longer in breach of regulations.

The service was safe and people were supported to fulfil their abilities and expectations.

The registered manager had improved quality assurance systems. Care records had been improved and reflected people’s needs and preferences.

The provider had made some improvements in relation to seeking people’s consent. However, we made a recommendation about further improvement needed around the assessment of a person’s capacity before seeking consent from others and before someone is deprived of their liberty.

Individual risks to people and the environment had been identified and measures put in place to manage them and minimise the risk of avoidable harm occurring. Staff demonstrated a good understanding of their roles and responsibilities for keeping people safe from harm.

We identified people's bedrails were not always at a suitable height to keep them safe. The registered manager acted immediately on our concerns. They actioned remedial work, risk assessment and ordered bedrail height extenders as recommended by the Health and Safety Executive guidance on the safe use of bedrails.

Medicines were managed safely by trained staff who ensured people received medicines at the right time.

Staffing levels had been increased in the morning since the last inspection and staff told us they felt suitably staffed to be able to provide safe and effective care. People told us staffing levels were sufficient.

People received person-centred care and we observed staff interacted with people in a kind and compassionate way. Staff understood the needs of the people they supported and had formed trusting relationships.

We received mixed feedback from people about the quality of food provided for them. The registered manager was aware of people’s feedback and had made arrangements for a change in food provider which was due to commence in April 2019.

The registered manager was highly regarded by staff, service users and visitors. People told us they could approach the registered manager if they had any concerns and concerns were responded to.

People received person-centred end of life care and staff were trained in advanced care planning and clinical aspects of caring for someone at the end of life.

Staff received training and development to enable them to provide care in a safe and effective way.

Rating at last inspection: Requires improvement (19 September 2018).

Why we inspected: This was a scheduled inspection based on the service's previous rating and to review action taken against served warning notices for regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Follow up: We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Further inspections will be planned for future dates.

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

Longton Nursing and Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Longton Nursing and Residential Home is registered to provide care for 58 people. Accommodation is provided on two floors and people have access to communal spaces and garden areas. At the time of the inspection, there were 56 people accommodated in the home.

The service was managed by 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.

At the last inspection carried out on 14 November 2016, the service was rated as good. At this inspection, the rating had deteriorated to ‘Requires improvement’. We found six breaches of the current regulations in respect to the management of medicines, the management of risks, staffing levels, staff training, person-centred care and the governance arrangements. You can see what action we told the provider to take at the back of the full version of the report in relation to the management of medicines, staffing levels, staff training and person-centred care. We are considering what action we will take in relation to the management of risks and the governance arrangements. Full information about the CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Safeguarding adults’ procedures were in place and staff spoken with understood how to safeguard people from abuse. However, staff were not clear on the reporting processes outside the home. Two people raised concerns about the approach taken by a few staff. We referred their concerns to the local authority under safeguarding adults’ procedures. Whilst there were arrangements in place to assess risks to people’s health and safety, the assessments had not always been updated in line with people’s current needs. We also found that no risk assessments had been carried out for one person who had lived in the home for approximately two weeks. Environmental checks had been carried out and servicing certificates were in date. However, there were no records of room checks seen, which included checks on bedrails since June 2018.

There were appropriate arrangements in place for the recruitment of new staff. All care staff and some people and their relatives raised concerns about the level of staffing in the home. The staff told us they felt rushed and had insufficient time to meet people’s needs. For instance, staff told us that people requiring assistance had not received a mid-morning drink on the second day of the inspection. People told us they had to wait for long periods for assistance and this impacted on their welfare.

Medicines were not always handled safely and we found shortfalls in the records.

There were arrangements in place for staff training, however, according to the staff training matrix, the staff had not completed all the training the provider deemed mandatory for their role. At the time of the visit, new staff did not complete the Care Certificate, as part of their induction. We also noted that whilst staff received supervision, this was not always at two-month intervals in line with the schedule. We were informed a new training officer had been appointed and they planned to develop the training and provide staff with more supervision.

The staff understood the main purpose of the Mental Capacity Act and Deprivation of Liberty Safeguard applications had been submitted to the local supervisory body, as appropriate. We saw best interest meetings had been held where it was assessed a person was unable to make a decision. However, we noted that relatives had signed one person’s personal preference form. Whilst the registered manager told us the person completed the form with their relatives, we saw no evidence of their involvement, despite them having capacity to express their own preferences.

There were arrangements in place for servicing equipment. However, staff told us there was insufficient equipment to meet people’s needs. They explained there was only one shower cradle and this could only be used once a day, to allow it to dry out. This meant people requiring this equipment may not be able to have regular showers. Further to this, there was no effective monitoring or records made when people had a bath or a shower and people told us they did not always had a regular bath or shower.

People were complimentary about the food provided. Food and fluid charts were maintained as necessary, however, there was no evidence seen to indicate the amounts had been totalled and evaluated and there was no guidance seen for staff on people’s recommended level of intake. People had access to healthcare services, as appropriate.

We saw caring interactions between the staff and people living in the home during the inspection. However, people spoken with were not familiar with their care plan and there was limited evidence seen to indicate people had been involved in planning their care. This is important so staff are aware of people’s choices and preferences.

Apart from one person, all people had an individual care plan. However, the plans looked at had not always been updated in line with changing needs.

People had access to a complaints procedure and records were made of complaints received in the home. However, three people told us they were reluctant to raise concerns. The people were assured by the operations manager and the managing director told us action would be taken to ensure people felt safe.

There were systems in place to monitor and improve the quality of the service, which included seeking feedback from people, relatives and staff. However, we found a number of shortfalls during the inspection. The registered manager, the operations director and managing director gave assurances that improvements would be made to the service and people’s concerns would be investigated and addressed.

At the time of inspection there was a manager who was 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.

We last inspected Longton Nursing and Residential Home on the 06 May 2015. We identified several breaches of regulation. We found medicines were not managed safely, people’s privacy and dignity was not consistently protected and care records contained basic information only and did not cover all assessed needs or how people wished their care and support to be delivered. In addition we found systems for assessing and monitoring the quality of service provided were not always effective and confidential records were not retained securely. In relation to consent, we found written consent had not been obtained. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Longton Nursing and Residential Home on our website at www.cqc.org.uk.

At the last inspection on the 06 May 2015 we asked the registered provider to take action to make improvements. We were provided with an action plan which detailed how the registered provider intended to ensure improvements were made.

We undertook this inspection to check they had followed their plan and to confirm they were now meeting legal requirements.

During this inspection carried out on the 14 and 21 November 2016 we found improvements had been made. We saw people were supported with compassion and empathy and staff were gentle and kind. Care records reviewed contained sufficient information to enable staff to deliver care and support which met peoples’ needs and wishes. When not in use, we found care records were stored securely to prevent access from unauthorised persons. We reviewed a sample of quality audits. We found checks were in place to monitor quality of the service and any areas of improvement were identified and actioned. We saw documentation which evidenced people and their families were involved and asked to give consent when decisions needed to be made.

There were systems in place to ensure people who lived at the home were protected from the risk of harm and abuse. Staff we spoke with knew the action to take if they had any safeguarding concerns. They told us they would report concerns to ensure people were protected from harm. Prior to the inspection we received information of concern regarding moving and handling techniques at the home. We discussed these with the registered manager and registered provider who took substantive action to ensure people’s safety was maintained. Following the inspection we were informed that investigations had been carried out by Lancashire safeguarding authorities and no action was required.

People who lived at Longton Nursing and Residential Home and their relatives told us they felt the home was well managed and the registered manager was approachable.

There were a range of audits in place to ensure any improvements were identified. These included checks on the environment, medicines, care records and accidents and incidents.

We saw risk assessments were undertaken to manage individual risks. Written documentation was available to inform staff of the support people needed to maintain their safety. We also found care records contained individual health assessments and care plans contained information on the care and support people needed to maintain their wellbeing. Staff were knowledgeable of peoples’ assessed needs and the help and support people required. People who received care and support and their relatives told us they were happy with the care provision from Longton Nursing and Residential Home.

There were arrangements in place to ensure people received their medicines safely. However we saw some poor practice took place. For example we saw the medicines trolley was left unlocked when staff moved away from it. We have made a recommendation regarding this.

Recruitment checks were carried out prior to a staff member starting work at the home. Staff received training to enable them to give care that met peoples’ needs.

We discussed staffing with people who lived at the home, the registered manager and relatives. People told us they considered there were sufficient staff available to meet people’s needs and they received help quickly. During the inspection we observed people being supported promptly.

People told us they considered staff to be caring. Comments we received included, ““The staff here are lovely.” And, “Staff are dedicated and compassionate.”

There were a range of activities available for people to participate in if they wished to do so. People told us they enjoyed the activities provided. One person said, “I take part in what I like. Staff remind me what’s on, or I look at the board to remind myself.”

People were supported to eat and drink sufficient to meet their needs. People we spoke with complimented the meal provision at Longton Nursing and Residential Home. We were told, “I think the food’s excellent.” And, “I love the meals here.”

There was a complaints policy, which was understood by staff and was available to people who received care and support. People told us they were confident any complaints would be addressed.

We arrived at Longton Nursing Home at 9pm, just as the day staff were going off duty and the night staff were arriving for work. A verbal handover took place, so that a summary of recent events could be passed to the oncoming shift.

We established that there were 57 people who lived at the home and a complement of five staff members on the night of our inspection. The staff team included two qualified nurses, although one was working as a care assistant during this particular shift. We were told everyone with the exception of three people required two staff members to assist them with personal hygiene and mobilisation during the night.

During the course of the inspection we gathered evidence against the outcomes we inspected, to help 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 is based on our observations during the inspection, speaking with those who used the service as well as care staff and from looking at records. We visited the home at night time and therefore some people were already in bed. However, we were able to speak with four people, who were enjoying a hot drink and biscuits in the lounge.

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

Is the service safe?

People told us they were happy to be at the home and felt safe living there. One person said, "They (the staff) are kind and they are very thoughtful." Another commented, "They are always very, very busy."

All staff we spoke with told us that staffing numbers did not alter in accordance with the dependency levels of those who lived at the home.

The day following our inspection the manager provided us with a copy of the dependency scores for each person during January and February. She told us she reviewed these every month, in accordance with a dependency rating scale, a copy of which she also provided. However, there was no evidence to show how the numbers of staff were calculated from the results of the tools used. We spoke with the manager who said she worked the staffing levels out in accordance with how many people needed nursing care and how many were assessed as requiring residential care, but there was no structured format in place. She said there were 13 staff on duty during the morning, 10 in the afternoon and 5 at night.

Records showed that there usually five members of staff on night duty and this figure did not seem to vary from week to week. We spoke with the manager the day following our inspection who told us there were five staff members allocated on night duty and this was sufficient for the number and dependency levels of those who lived at the home. She told us people's needs had been fairly stable for some weeks.

We noted call bells were answered reasonably quickly and care files showed how often people wished to be checked during the night.

We were told not to use the small passenger lift, as it was 'unsafe'. We were told people who lived at the home did not use it. This maintenance issue needs to be addressed, so that the particular lift is safe for use and therefore people's safety is protected.

Is the service effective?

We arrived at the home at 9pm, just as staff were changing shift. We noted a verbal handover took place. This enabled the night staff to be fully aware of the current situation in relation to individual needs and to be updated with any changes that had taken place since they were last on duty.

Is the service caring?

We toured the premises and found the atmosphere to be calm and relaxed.

The temperature in the lounge was cool. One very frail person was sitting in a reclining chair. She was inappropriately dressed with bare arms. She told us she was cold. One staff member responded by saying to us, 'She is always cold'.

Staff made several remarks to us when referring to those who lived at the home, which were undignified and derogatory. For example one person was referred to as a 'feeder' and others collectively were referred to as 'feeders'. Another person was referred to as a 'wanderer' One member of staff said, "We put the little ones in bed first." This sort of language is unacceptable. It does not promote people's dignity or demonstrate a caring approach.

Is the service responsive?

When we arrived at the home we found some people had already retired to bed, but we were told this was their choice.

Written instructions for staff were on the notice board in the office, which identified people who were to be assisted out of bed, washed and dressed before the day staff arrived for duty at 8am. This list also identified which day of the week individuals were to be assisted with a shower or bed bath. This practice was not person centred or responsive to people's individual needs and wishes.

We looked at the care records of eight people who lived at the home. We found the time people liked to go to bed or when they preferred to get up in the morning was rarely documented. However, one plan of care was more person centred than others we saw, although the information provided about personal care preferences did not coincide with instructions given to staff.

We were told everyone was in bed by 11pm, except for one person, who alerted staff when she wished to be assisted to get into bed around 1am. This was recorded in her care file.

Most records we saw were very vague about certain areas of need. Specific details had not been recorded within the individual plans of care. This did not promote person centred care planning.

Is the service well led?

We were told the manager did not have the authority to organise agency staff, but she had to seek approval from the provider. This arrangement did not allow the manager full control of the staff rotas or autonomy to manage the service within her responsibilities. We were told the provider recently refused to allow the manager to request agency cover for staff sickness on night duty, which left the shift short staffed and this was confirmed by the staff rota we saw. However, the duty rotas did show agency staff were occasionally used at night time to cover staff shortages. No-one from the management team attended the home that night to assist with the additional workload.

We were told spot checks were never conducted at night to determine if night staff were performing well or if there were any specific issues relating to night work.

We were told that staff meetings were held, but that staff did not feel they would be listened to if they raised the issue of staffing levels at night.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with those using the service, their relatives, support staff and the manager and from looking at records. Some of those using the service were unable to communicate with us verbally. However, we were able to speak with eight people living at the home and four relatives, who all gave us positive responses to the questions we asked. If you want to see the evidence supporting our summary please read our full report.

Is the service safe?

People we spoke with told us they felt safe living at Longton Nursing and Residential Home and felt their needs were being consistently met by a kind and caring staff team. Systems were in place to help managers and the staff to learn from untoward incidents, such as safeguarding concerns, accidents and emergency situations. This helped the service to continually improve.

The home had proper procedures in place in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards. Applications were made, as were needed. This helped to ensure people were not being unnecessarily deprived of their liberty. People (or their relatives) were involved in making decisions about the care and support provided.

At the time of our visit to this location, we toured the premises and found the environment to be fit for purpose. It was safe, clean and hygienic. Equipment was well maintained and serviced regularly. Therefore, people were not put at unnecessary risk.

Recruitment practices adopted by the home were robust, with all necessary checks being conducted before people were employed. This helped to ensure people appointed were fit to work with this vulnerable client group.

Is the service effective?

There was an advocacy service available if people needed it. This meant that when required people could access additional external support. The health and personal care needs of those using the service had been assessed, with a range of people involved in their care and support.

Systems were in place to ensure the service was effectively assessed, so the quality of service provided could be consistently monitored. A broad range of training modules were provided for staff, with regular mandatory updates. This helped to ensure the staff team delivered effective care and support for those living at the home.

People's needs were taken into account with the layout of the service enabling people to move around freely and safely. Visitors confirmed they were able to see people in private and visiting times were flexible.

Is the service caring?

We asked those living at the home about the staff team. Feedback from them was very positive. They said staff were considerate and compassionate towards them and helped them to meet their needs. When speaking with staff it was clear they genuinely cared for those they supported and were observed speaking with people in a respectful and friendly manner.

People's preferences and interests had been recorded and care and support had been provided in accordance with people's wishes. One person commented, "It is excellent here." Another told us, "There is nothing wrong with this place. Everything is champion."

Is the service responsive?

Some activities were provided within the home and some people were able to access the local community with varying degrees of help. Occasional trips out were arranged to local places of interest.

Staff were seen to be responding to people well by anticipating their needs appropriately. The service worked well with other agencies to make sure people received care and support in a consistent way.

Evidence was available to show the home responded well to any suggestions for improvement and appropriate action was taken to rectify any shortfalls identified.

At the time of our visit to this location there were enough staff on duty, who were appropriately qualified, trained and experienced to meet the changing needs of those living at the home. The manager gave a good example of situations where the number of staff had been increased in order to provide the care and support needed by certain individuals.

Systems were in place, so that complaints could be managed appropriately. This helped to ensure people were fully aware of the procedure to follow, should they be unhappy about something at the home.

Is the service well-led?

The service had a quality assurance system in place and records showed that identified problems and opportunities to change things for the better were addressed promptly. As a result, the quality of service provided was continuously monitored.

Staff spoken with had a good understanding of their roles. They were confident in reporting any concerns and they felt well supported by the managers of the service. People living at Longton Nursing and Residential Home and their relatives completed annual satisfaction surveys. Where shortfalls or concerns were raised these were taken on board and dealt with appropriately.

Monitoring had now been implemented and through the clinical audit tool the information gathered had been collated to enable the provider to appropriately assess risks to people who lived in the home.

Records were kept of when people needing pressure relief had been moved and turned. Records were always signed by two staff showing care had been delivered appropriately and as required, based on people's needs.

We ate lunch with people living in the home and found the food to be of a good standard. We asked people about the quality of the food and were told it was generally very good. One person said, 'I get a good breakfast and there is plenty of choice, I can always get something I like at most meals.'

We were told staff were all very nice but not always around when you needed them. One person said, 'If I ring my buzzer, they come, it can just sometimes take a while.' We were told this by a number of people. We asked people how this affected them and one person told us, 'I have just learnt more patience.'

The home did not have a comprehensive Quality Monitoring or Quality Assurance system in place. Some audits had been undertaken but effective action planning that led to improvement had not been completed. Where risks were identified they were not always appropriately assessed and managed.

People living in the home that we spoke with said they felt safe and had confidence in the staff. One said, 'I don't like the hoist, but I know staff need it to move me and they always make me feel comfortable and safe.' Another said, 'The staff are fantastic, always have a smile on their face and up for a joke.'

We were told the home was always clean and tidy. One person said, 'My (relative) came home for the weekend and they shampooed the carpet whilst the room was empty.' Another said, 'The home is big enough for me to get round in my chair, the design has been well thought through.'

We ate in the dining room and found there to be sufficient staff to support those that required support. However there were times during the day when lounges with large numbers of people in them were left unsupervised.

Monitoring had been implemented but the information gathered had not been collated to enable the provider to appropriately assess risks to people living in the home.