All inspections: Thelwall Grange Nursing Home

This unannounced comprehensive inspection took place over several days; 22 October, 28 November and 2 December 2015 and 12 and 28 January 2016 as part of our on-going enforcement activity. As part of this process the registered provider completed an on-going action plan that was continually updated. As a consequence of this it was decided to keep the inspection process open and to undertake visits over a period of time to assess the actions taken.

We had previously completed an unannounced comprehensive inspection of this service on 3 July 2015, 3 September 2015, and 12 September 2105 and found the provider was failing to meet legal requirements.

This inspection was carried out to check that the registered provider was now meeting the legal requirements. We found that they had not made sufficient improvements in relation to person-centred care, need for consent, safe care and treatment, premises and equipment, supporting staff, fit and proper persons employed and good governance and remained in breach of these regulations.

The contracts monitoring team from Warrington Borough Council (WBC) and Warrington CCG are monitoring the home. This is the council’s usual practice that is designed to ensure any improvements are sustained. The CQC are continuing to work with the council.

Thelwall Grange is registered to provide accommodation for up to 43 older people with personal or nursing care needs. Respite care is also offered. The home is situated within its own grounds in a rural location and has access to local amenities. There were 26 people living in the home at the time of our inspection.

One of the conditions of registration for the home was that it must have a registered manager. The service had not had a registered manager in post since September 2015. 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 voluntarily agreed not to accept admissions at the home following our last visit. The home has also been under an embargo [not allowed to admit new residents] from the Warrington Borough Council since our last visit in August and September 2105. Workers from Warrington Borough Council and the Warrington Care Commissioning Group with particular input from Warrington's care homes and contract monitoring teams have been supporting the home throughout this process to assist the provider to improve the quality of care given to people living at the home.

Care plans we looked at during the five days of the inspection did not contain up to date information

We found that the recording of checks on people and the recording of food and drinks given to people in their bedrooms were inaccurate and could not be relied on to effectively monitor how people’s care needs were being met.

We found that issues raised at the last inspection in September 2015 with regard to safety of hot radiators and hot water temperatures had not been fully addressed. Some radiators were still hot to the touch and had no covers in place. Some water temperatures were too hot, leaving people at risk of scalding.

Risk assessments were not updated to ensure that people were kept safe.

References were not always in place to ensure people were suitable to support people living at the home.

Staff lacked knowledge and understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), and were unaware of which people living in the home were subject to DoLS so that they could support them with any restrictions in place. Care files looked at for people with DoLS in place with recommendations had not been updated to ensure that the recommendations were being carried out.

We had concerns about the skill mix and the level of experience of staff. There was no clinical lead at the service. There was also only one qualified nurse employed directly by the registered provider and there was no evidence of clinical supervision for this person so that they could be supported. Clinical supervision has been promoted as a method of ensuring safe and accountable practice in nursing.

There were no staff undertaking the Care Certificate. The Care Certificate is an identified set of standards that health and social care workers adhere to in their daily working life. Induction and training for staff did not fully equip them to provide a good standard of care to people using the service.

The environment had not been updated to ensure people living with dementia could move around the home independently. Whilst the home appeared visually cleaner, there was a strong malodour on a number of days that we visited.

Some improvements had been made however issues found at this inspection had not been identified in the monitoring system in place.

The registered provider had developed a new governance system to assess quality and monitor risk. Whilst some parts of this and the concept behind it was good, it was not fully functioning. This meant that issues were not picked up on and addressed in a timely way.

Notifications to CQC had not always been sent in a timely manner.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

We carried out an inspection on 23 July 2015 in response to information received from a whistle blower and Warrington Borough Council. During this visit we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We completed a further visit on 3 September to gather more information as a comprehensive inspection was required. A further visit was made on 12 September 2015. You can see what action we told the provider to take at the back of the full version of this report.

Thelwall Grange is registered to provide accommodation for up to 43 older people with personal or nursing care needs. Respite care is also offered. The home is situated within its own grounds in a rural location and has access to local amenities. There were 27 people living in the home at the time of our inspection..

Thelwall Grange has a registered manager. However, the registered manager advised us that he was working mainly at another home within the provider company and was intending to apply to deregister as the manager for Thelwall Grange. 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 that a new manager had been appointed at the home and the current registered manager was supporting the new manager for some days each week. However, by the third day of our inspection we found that the new manager had left the home.

Sufficient numbers of staff were not provided to ensure that the home was cleaned to a high standard and that this standard was maintained. There were insufficient staff deployed in the afternoon and evening to ensure that the kitchen was fully staffed and the staff deployed in the laundry was on an ad hoc basis so clean clothes and linen could not be always available.

The standard of bed-linen at the home was poor and this needed replacing.

The hot water in the home in some areas was too hot and could cause scalding and harm. There were no hot water warning signs available. Water temperatures were not checked on a regular basis.

Radiators were excessively hot, measuring 67 degrees, and two people who were living with dementia were sat next to them. These radiators and others in the home had no radiator guards in place to protect people and when asked for risk assessments none were shown to the inspectors on any of the visits to the home.

There was no heating or hot water in the conservatory wing of the home.

Risk assessments were requested for a fire escape in a persons bedroom, however, these were not shown to the inspectors.

Risk assessments and care plans were not in place for someone on respite stay in the home. We found that care was not always provided in a way that met people’s individual needs.

Equipment was stored in the under stair foot well. This was a fire hazard. A cupboard marked “danger lift machinery ” was not kept locked.

We found that these concerns had not been rectified on the second day of our inspection

People who were at risk of losing weight could not be weighed as the scales were out of order. This issue was found at the visit on 23 July and at our subsequent visits on 4 and 12 September 2105 there were no working scales at the home.

Since our inspection the provider has confirmed that they have addressed some of the more urgent areas of concern.

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 or cancel the provider’s registration.

We have been receiving action plans from the provider since our inspection.

We carried out an inspection of Thelwall Grange Nursing Home on the 05 March 2015. The visit was unannounced.

We last inspected Thelwall Grange Nursing Home on 15 July 2013 and found the service was meeting all but one of the requirements of the current legislation in the outcomes assessed. We found that the provider was not meeting the requirements in relation to the safety and suitability of premises and we asked them to take action to address this. Following this the provider sent us an action plan telling us about the improvements they intended to make. During this inspection we looked at whether or not those improvements had been made. We found that the communal areas of the home and some bedrooms had been redecorated. The laundry area had been improved.

Thelwall Grange is registered to provide accommodation for up to 43 older people with personal or nursing care needs. Respite care is also offered. The home is situated within its own grounds in a rural location and has access to local amenities. There were 31 people living in the home on the day of our visit.

The home 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.

CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards (DoLS). We found the location to be meeting the requirements of DoLS. People using this service and their representatives were involved in decisions about how their care and support would be provided. The registered manager and staff understood their responsibilities in promoting people's choice and decision-making under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We saw information that best interest meetings had taken place where people lacked capacity to make decisions for themselves.

People told us they were cared for very well and they felt safe. They said they had never had any concerns about how they or other people were treated. Routines were seen to be flexible to accommodate people’s varying needs such as times of rising and having breakfast.

People were cared for by staff that had been recruited safely and were trained to support them in their duties. We found there were sufficient numbers of suitable staff to attend to people’s needs and keep them safe and we observed calls for assistance were responded to in a timely way. People told us there was enough staff and they were attended to quite quickly most of the time.

Care plans and risk assessments were in place for each person. People’s health needs were monitored and staff worked well with other professionals such as GP’s to ensure their needs were met.

People had their medicines when they needed it. Medicines were managed safely. We found accurate records and appropriate processes were in place for the ordering, receipt, storage, administration and disposal of medicines.

The home was warm, clean and hygienic. Cleaning schedules were followed and staff were provided with essential protective clothing. People told us they were satisfied with their bedrooms and living arrangements and had their privacy respected by all staff.

From our observations we found staff were respectful to people, attentive to their needs and treated people with kindness in their day to day care. Activities were varied and people had good community involvement. Staff were seen to treat people with respect and preserve their dignity at all times.

People were provided with a nutritionally balanced diet. All of the people we spoke with said that the food served in the home was very good.

People told us they were confident to raise any issue of concern and that it would be taken seriously. There were opportunities for people to give feedback about the service in quality assurance surveys. Recent surveys showed overall excellent satisfaction with the service.

People told us the management of the service was good. Staff, relatives and people using the service told us they had confidence in the registered manager.

There were informal and formal systems to assess and monitor the quality of the service which would help identify any improvements needed.

People living at Thelwall Grange were positive about the service and support provided by staff. They told us they were given various choices regarding how they wanted to be supported. Their comments included:

"The staff work damn hard and are lovely, they are very respectful to us, even the agency staff" and "We always get something we ask for."

Staff tried to organise activities on an ad hoc basis as they had to share their activities organiser and activity hours with other services within the company. People living at Thelwall Grange told us they wanted to know what activities would be provided and advised of some activities such as bingo that they wanted to be reinstated.

We noted various areas throughout the building that needed attention and repair. Identified risks and repairs highlighted a weakness in the management of health and safety of the service and could potentially put people's safety at risk.

Prior to our visit we contacted Warrington contracts and monitoring team to seek information and updates regarding their checks on the service. They advised that improvements had been mad. They had just one action plan remaining, for the service to show improvements in the managing of staff competencies to enable them to do their job effectively.

We spoke with five people who used the service. All the people spoken with told us they were happy living in the home and that the staff were helpful. One person commented, "I'm getting well looked after'.

We reviewed the care files of three people who used the service and found evidence that there were procedures in place to ensure their consent was gained in relation to the care provided for them.

We saw that care plans clearly identified the needs of the person and included some information on how they wished their care to be delivered.

People spoken with told us they received appropriate support with their medication. We found evidence that there were effective systems in place for the safe administration of medicines.

We found that staff had received training in the use of equipment within the home. We saw there were some risk assessments in place to ensure that people were protected when equipment was being used.

We spoke with three members of staff who told us they felt well supported and confident in carrying out their responsibilities. We saw evidence that staff were appropriately qualified and provided with training relevant to their role.

We found that there were systems in place to monitor the quality of the service being provided.

This review took place because we had identified some issues at another service owned by the provider and we wanted to make sure there were not similar concerns at this service.

People told us that they are able to 'Have their say' about how the home is run at the residents meetings.

People told us that they are able to make choices on how to spend their day, meals and activities.

People we spoke with provided positive comments regarding the staff.

People we spoke with provided positive comments on the food provided.

People told us that they felt safe.

People told us the staff are very approachable.

We spoke to a number of people during our visit to Thelwall Grange all of whom said that they were happy with the care being provided.

A number of residents who lived at the home were on the day of our visit taking part in a bingo session which they enjoyed. One person who had played said afterwards that she enjoyed 'just getting together with the others and the company'. Other activities that took place were dominoes, arts and crafts and card games.

The residents made items to sell which helped to fund outings to the garden centre, shopping trips and restaurants. They were very proud of what they made and took delight in showing them to us. They also told us that they enjoyed the outings.

People were happy with food and we were told that they were asked what they wanted. Residents meetings had recently been started and two had taken place when the menus had been discussed. One person told us that they found the meetings useful as they were able to make suggestions for improvements.

Two residents had been appointed to represent the residents as a whole. The two residents had recently been involved in interviewing the new manager.

The staff that we spoke with felt that the residents were well looked after, that there were enough staff and that the food was good. They also told us that they had training and support from managers to help them carry out their duties and care for the people who used the service.

We spoke with the dietician from Warrington NHS who was visiting the home at the time of our visit. They told us that they were pleased with the cooperation they had received from the managers in implementing healthy eating.

After our visit we spoke with the Clinical Nurse Educator from Warrington PCT who told us that they were impressed with the care that was being provided to a resident who was extremely ill.

People told us they knew they had care plans but did not want to read them. Some people said staff were aware of their needs. Others said they had not been asked and not all staff knew the care they needed. One person said this made them feel anxious.

People said they were able to get up and go to bed when they wanted and routines were flexible. However, one person told us she had been made to move rooms, which she was unhappy about as the room she was moved to was not suitable for her. She had complained and had eventually moved back to her original room but had had to wait.

People told us there was "nothing going on" in the home. Social activities and events were very limited. One person said "The Activities Organiser has gone. I do nothing. I go to sleep which I don't want to do as it's a waste of life. The place needs a thorough shake up, no one else is doing anything at all".

Most people said they were happy with the food provided at the home.

People said there were not enough staff. Comments included "There are not enough staff, we could definitely do with more. We need company, need the staff to be able to sit and chat but we never get this" and "Staff are OK but there are not enough of them. I ring my buzzer if I am given it , someone speaks to me then turns it off and doesn't come. They always say we will be there in a minute. You can hear everything from other rooms. Staff are always saying they will come. They need more".

We were told that there had been no recent resident meetings and no one had been asked to give their views about the service.

Archived: Thelwall Grange Nursing Home

All Inspections

22 October, 28 November, 2 December 2105 12 and 28 January 2016

During a routine inspection

23 July 2015, 3 September 2015,12 September 2105

During a routine inspection

05 March 2015

During a routine inspection

15 July 2013

During a routine inspection

11 January 2013

During a routine inspection

15 December 2011

During an inspection in response to concerns

12 May 2011

During an inspection looking at part of the service

6 January 2011

During a routine inspection