Archived: Nada Residential and Nursing Home

Following a serious safeguarding incident a focused inspection, looking at the safe and well led key questions, was carried out in March 2017. The service was rated as inadequate in both of these key questions.

After both inspections the provider sent us action plans detailing how they were going to make improvements to meet the Health and Social Care Act regulations. This inspection was carried out to check what improvements had been implemented since these inspections.

We found that whilst improvements had been made in some areas, for example staff training, the security of the building and monitoring people when they accessed the local community to help ensure they were safe, no improvements had been made in other areas. We found continued breaches in five Regulations with regard to fire safety checks, medicines management, the environment, the lack of service specific staff training for the needs of the people living at the service, staff supervisions, lack of activities for people living at the home and a lack of quality assurance systems used to improve the service provided by the home. We also found four new breaches with regard to the planning and provision of care and support to one person nearing the end of their life, staff not having the time or knowledge to provide 1:1 support around people’s anxieties and drug or alcohol use and for the registered manager retrospectively completing records for checks on the fire safety equipment. We are currently considering our options in relation to enforcement and will update the section at the back of the full version of this report once any enforcement has concluded.

We have also made a recommendation that Personal Emergency Evacuation Plans (PEEPS) should be kept in an easily accessible file that the staff can pick up in the event of an emergency so that the information in the PEEPS would be available for the emergency services.

Nada is a privately owned care home that is situated in the Cheetham Hill area of North Manchester close to a variety of local shops and other community services. The home is registered to provide nursing care and accommodation for up to 28 people who may have a combination of mental health and personal care needs. At the time of our inspection there were 20 people living at the home.

The provider was also the registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 day to day management of the home was delegated to the deputy manager and clinical lead. However the clinical lead was the designated nurse on duty when working and so did not have time as supernumerary to the rota to complete their other tasks.

At the time of our inspection in December 2016 the deputy manager had been off work, returning shortly after our inspection. At this inspection we were told the deputy manager worked five days each week. The registered manager was available to be contacted if required but did not regularly attend the home.

The service had tried to reduce the amount of smoking that took place within the building. Staff had completed on line and taught courses in fire awareness. The fire safety checks log book had been completed each week by the registered manager up until May 2017. A note then stated a member of staff would complete the checks. None had been completed since this date and neither the registered manager nor deputy manager had checked to ensure this delegated task had been done. The registered manager had also retrospectively made entries in the fire log book for the period 7 September to 12 December which were seen to not have been completed at our inspection in December 2016.

Staff told us they had completed a range of training courses since our inspection in December 2016. More training was planned. However the service supported people with a history of drug and alcohol abuse and mental health issues. Some staff had received training in these areas in 2013, but they had not completed refresher training and so the training was not current. Additionally staff who had joined the service since 2013 had not received any training in these areas so did not have an insight into the needs of the people who used the service. Records showed care staff did not have supervisions, although some nurses and domestic staff had.

No action had been taken to improve the activities provided at the service. People told us an entertainer occasionally visited the home. The care staff member whose role was to organise activities had left the service and no one had taken over this role.

The environment required re-decorating and upgrading. We saw one bedroom with a broken radiator cover and walls with different shades of paint on them. Walls were marked and scuffed. A few pieces of furniture had been purchased since our last inspection. One room had a strong odour, due to the person’s incontinence, which affected the surrounding corridor and bedrooms. No referrals had been made for specialist continence services. Staff cleaned the room as best they could but the odour persisted.

Care plans and risk assessments were in place and had been written for people accessing the community independently. However an end of life care plan for one person had not been written for three weeks after their discharge from hospital on palliative care. The care plan was written after a safeguarding had been raised by a social worker. The person had been found to be dirty and they did not have a pressure relieving mattress in place. During our inspection the person was seen to be comfortable, clean and with a suitable mattress.

Care plans did not contain sufficient detailed guidance about what support the care staff needed to provide and what people were able to do for themselves. One to one sessions identified in people’s care plans to reduce people’s anxiety or to discuss their alcohol consumption did not take place.

Medicine Administration Records (MARs) were seen to be fully completed. Protocols for any ‘as required’ medicines had improved. They included how the person would communicate, either verbally or non-verbally that they needed the ‘as required’ medicine to be administered. However we noted one person’s Fybogel medicine had run out and had not been re-ordered for six days, meaning this person did not receive their prescribed medicines for this period. A code had been entered on the MAR stating the Fybogel had been offered but not administered, which was not possible as it was out of stock.

Since our focused inspection keypads had been fitted to the external doors. Staff knew when people were leaving the building. A record was made of where they were going and when they were due to return to the home. Staff and people we spoke with liked this system as it made them feel safer.

Staff had a clear understanding of who had capacity to access the community on their own and who required staff to support them. Contingency plans were in place in case a person did not return at the agreed time. Care plans were in place where staff held cigarettes or property on behalf of people living at the service.

The registered manager and deputy manager did not have a robust quality assurance system in place. Only three care plans had been audited since our inspection in December 2016, no spot checks on the environment had been completed, records such as the fire log book and deep clean records had not been checked.

Residents meetings were held and surveys conducted but it was not clear what action had been taken as a result of these. One person said they did not feel able to make a complaint about the service as they would be told to leave.

Incidents and accidents were recorded and reviewed by the deputy manager. People received support with their nutritional needs.

Staff files showed a system of recruitment was in place; however this had not been followed in one instance as only one reference had been obtained.

The overall rating for this service remains ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration

This incident is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of absconsion, particularly for those people who lacked the mental capacity to access the community independently. This inspection examined these risks.

Nada is a privately owned care home that is situated in the Cheetham Hill area of North Manchester close to a variety of local shops and other community services. The home is registered to provide nursing care and accommodation for up to 28 people who may have a combination of mental health and personal care needs.

The provider was also the registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 Registered Manager gave the inspector a list of 13 people living at the service where DoLS applications had been made. Two of these had been authorised by the local authority, with the remaining 11 applications waiting for the local authority to complete their mental capacity assessments. We saw one person who required one to one staff support did not have a DoLS application in their care file.

Of the 13 people with DoLS applications in place, six people were assessed as being able to access the local community independently if they informed the staff where they were going and when they would return to the home. However people had been able to open the front door and fire exit themselves. Staff were not always able to respond to the single buzzer that sounded when the doors were opened as they were supporting other people. Keypads were being fitted at the time of the inspection to prevent this from happening in the future; however this had taken two weeks to arrange after the serious incident. The registered Manager told us this was the earliest that the keypads could be fitted.

Care plans and risk assessments were not always in place for people accessing the community on their own. There were no contingency plans in place if people did not return at the agreed time.

Systems were not in place for staff to record who had left the home and what time they were due to return. This meant staff may not always be aware of who had gone out and that they had to check that they had returned as agreed. Thirty minute observations had been introduced to monitor the whereabouts of each person who lived at the service. This would alert staff within 30 minutes of people had left the building without informing staff.

There was no evidence that people had been shown the safest routes to go to the local shops, for example using pelican crossings to cross main roads.

The staff we spoke with were aware of who was able to access the community and that they had to agree when they would return. However there was no overview of who was able to go out on their own and who required staff members to support them when they went out. This meant new staff or agency staff members may not know they had to agree what time people were due to return with them and so may not inform other staff or the nurse in charge that they had gone out or not returned.

Since the serious incident staff told us they supported people to cross the main road.

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

Nada is a privately owned care home that is situated in the Cheetham Hill area of North Manchester close to a variety of local shops and other community services. The home is registered to provide nursing care and accommodation for up to 28 people who may have a combination of mental health and personal care needs. At the time of our inspection there were 24 people living at the home.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 day to day management of the home was delegated to the deputy manager. However the deputy manager was not available during our inspection. We were told they had been off work for several weeks and it was not known when they would be returning to work. Following the inspection we have been informed the deputy manager had returned to work shortly after our inspection.

At the last inspection in November 2015 we identified six breaches of the Health and Social Care Act 2008 and one breach of the CQC (Registration) Regulations 2009. The service provided CQC with an action plan detailing how they would make improvements to meet the regulations.

During this inspection we found improvements had not been made and there were continued breaches in the regulations with regard to managing the risk of fire, medicines management, following the principles of the Mental Capacity Act (MCA), staff training, the environment, the provision of activities and good governance. There was also a new breach with regard to the staffing levels within the home. We have also made a recommendation about the home having a written business continuity plan for staff to follow in the case of an emergency.

People said they felt physically safe living at Nada, however three people reported they were worried that their money and cash card would be stolen by another person living at the home. Staff encouraged people to give them their money and cash card to keep them safe. However we saw one person asking for their cash card and not being given it as the staff on duty could not access where it had been stored by a colleague who was not working that day.

People smoked within the home. They were encouraged to smoke in a dedicated smoking room or outside, however people continued to smoke in their bedrooms or bathrooms. Smoking risk assessments were in place where appropriate. Staff training on fire awareness was not up to date, the fire alarm and fire doors had not been checked since September 2016.

People received their medicines as prescribed. However guidelines for when people needed ‘as required’ medicines were not in place for everyone and those that were did not always specify how the person would inform staff, either verbally or non-verbally, that they needed an as required medicine to be administered. Care staff applied some creams and added thickeners to people’s fluids to reduce the risk of choking. The nurses signed the medicines administration record even though they had not personally administered these items.

A person had moved to live at Nada in August 2016 who required one to one staff support during the day. The staffing had not been increased at this time. This meant there were insufficient staff on duty during the day to meet everyone’s needs. The registered manager arranged for an additional staff member to be on duty on the days of our inspection. This shows they were aware of the need for one more member of the care staff to be on duty.

Some improvements had been made in following the principles of the MCA. Deprivation of Liberty Safeguards (DoLs) had been applied for where appropriate. However consent or best interest decisions were not in place where the home held people’s cigarettes and money for them. A capacity and best interest form had been completed for one person but we did not see this in place for other people living at the home.

We found not all staff training was up to date. This included fire training, moving and handling, challenging behaviour and continence care.

The environment at the home needed re-decorating and upgrading. The maintenance person had left the service three months prior to our inspection. Maintenance tasks were being completed by a member of the care staff, who was provided time on the rota to complete them.

There were no activities provided at the home. One member of staff had been identified to arrange activities; however they did not have any time set aside for them to do this.

With the deputy manager not being in work at the time of our inspection the registered manager could not find all the information we requested, for example the incident forms that were reviewed by the deputy manager. Other information was not easily found. The deputy manager had been the only person able to access the home’s computer system. The clinical lead was given the passwords during our inspection to access the system. Therefore any information held on the computer had not been updated since the deputy manager had been off work and the registered manager did not have a full oversight of the home.

We found management audits were not in place to monitor and improve the service. We saw a care plan audit had been completed once for one person. The registered manager and clinical lead were unaware of any other audits that had been completed. After the inspection we were told five care plan audits had been completed in total. At the time of our inspection there were 24 people living at Nada. A nurse audited the medicine administration records (MAR) each month to check all entries had been signed and the quantities of tablets received and administered corresponded. However the (MAR) audit did not cover the ‘as required’ medicines guidelines as we found some ‘as required’ medicines still did not have clear guidelines in place.

Care plans and risk assessments were in place. These gave detailed guidance for staff in how to support people. Care plans were reviewed each month and updated when people’s needs changed.

Staff were safely recruited and relevant checks were made. We saw examples of staff treating people with dignity and respect and responding to people’s needs in a kind and caring way.

People had access to relevant health care professionals, although four people said they needed to see a dentist. People’s nutritional needs were met. However 40% of people said the food was cold. We saw snacks being offered during the day. The clinical lead said snacks were offered each day. However a relative informed us after the inspection that snacks were not given regularly.

A complaints policy was in place. However we were aware of a complaint made on behalf of one person that had not been recorded. The complaint itself had been dealt with by the home.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to 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 so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, their relatives, the staff who supported them and from looking at records.

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

Is the service safe?

People were treated with respect and dignity by the staff. People told us they felt safe.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. This reduced the risks to people and helped the service to continually improve.

The home had proper policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards although no applications had needed to be submitted. Relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people would be safeguarded as required.

Recruitment practice was safe and thorough. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

There was an advocacy service available if people needed it, this meant that when required people could access additional support.

People's health and care needs were assessed with them, and they were involved in writing their plans of care. Specialist dietary, mobility and equipment needs had been identified in care plans where required.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

People's preferences, interests, goals and diverse needs had been recorded and care and support had been provided in accordance with people's wishes.

Is the service responsive?

People completed a range of activities in and outside the service regularly.

People knew how to make a complaint if they were unhappy.

Is the service well-led?

The service worked well with other agencies and services to make sure people received their care in a joined up way.

The service had a quality assurance system. As a result the quality of the service was continuingly improving.

Staff told us they were clear about their roles and responsibilities. This helped to ensure that people received a good quality service at all times.

Some of the people who lived at the home had limited communication due to memory impairment and because of this we could not directly obtain their views about their care and treatment. In light of this we also spoke with staff and observed people who lived at the home.

We found that since our last inspection the registered provider had taken action to ensure that people's dignity, privacy and independence was upheld.

We found that staff had updated their training in safeguarding adults and the registered provider now regularly notified us of significant events that impacted upon the day to day management of the home. This meant that people who lived at Nada Residential and Nursing Home were better protected from abuse.

We found that the registered provider had taken action to ensure that staff were fully trained and supported to meet peoples care needs.

People told us they were happy living at Nada Residential and Nursing Home. One person told us: 'They're looking after me. I like it here, I like the staff.'

Of the provider one person said; 'He's a good man'.

We found that since our last visit every person's care plan and risk assessment documentation had been reviewed and care records provided good detail about how people's care needs were to be met.

We found that staff had attended training in continence care and staff told us they had a better understanding of how to meet people's care needs.

We saw that risk assessments were in place on people's care records, for example, falls risks, risk of chocking and smoking in bedrooms. This meant that as far as it was possible people were being supported and enabled to live their life in a way they preferred.

We found that the provider was now managing and monitoring people's consumption of alcohol and this no longer affected other people who lived at the home. We found that the provider had developed a number of systems to assess and monitor the quality of care provided and these included monitoring all accidents and incidents that occurred.

Other people told us they were happy and they liked living at the home. One person told us; 'Staff look after you, it's alright living here'.

We found that people could still not lock their bedroom doors and secure their belongings and we found that some people were at risk of not receiving the care they needed because their needs were not reassessed and planned for.

We had concerns that people were not fully protected from poor care and treatment. Recent incidents highlighted gaps in the home's arrangements to prevent and alert safeguarding events.

We found that a plan of redecoration at the home had begun and a number of bedrooms had been painted and these provided an adequate standard of accommodation.

We found that some staff needed to up date their training and formal supervision arrangements for staff needed to be improved.

There were insufficient checks made of the quality, effectiveness and outcomes of service delivery. There were gaps in monitoring and learning from the experience of people who used its services.

We saw that other more able people who lived at the home preferred to spend time in their bedrooms or went out for the day and so we were unable to gain feedback from these people on this occasion.

Some people did comment on the service they received in response to direct questions such as; 'Are you happy living at Nada Residential and Nursing Home'? The replies we received ranged from 'Yes', 'I like it a lot - it's marvellous' and 'No, I've lived here too long'.

One relative told us 'The care is good' and 'The staff are good'.

They said 'I feel safe in the knowledge that my (relative) is being well cared for'.

We spoke to a friend and advocate for one person living at the home. They told us their friend was 'Very well supported' by staff. They told us that staff made every attempt to engage their friend in purposeful activity, including support when shopping.