The Care Quality Commission
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Archived: Lymewood Nursing Home

Overall: Inadequate read more about inspection ratings

Woodhouse, Uplyme, Lyme Regis, Devon, DT7 3XA

Provided and run by:
Lymewood Care Limited

All Inspections

8 September 2015

During an inspection looking at part of the service

We previously carried out an unannounced comprehensive inspection of this service on 29 Jul, 6, 10 and 26 August 2015. At this inspection we took enforcement action in relation to four breaches of regulations by serving four warning notices and made requirements for four other breaches.

At the time of this inspection on 8 September 2015, the timescales for the provider to meet the timescales set in the warning notices had not passed, nor had the period of time for the provider to respond to the warning notices or the draft inspection report of 29 July, 6, 10 and 26 August 2015.

This inspection was carried out because we were concerned about the staffing situation at the home. In addition, we had received information of concern that people who were at risk of choking were not receiving safe care to prevent this known risk. The team inspected the service against one of the five questions we ask about services: is the service safe?

This report only covers our findings in relation to this. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for (Lymewood Nursing Home) on our website at www.cqc.org.uk

Lymewood Nursing Home is registered to provide accommodation for up to 37 adults who require nursing or personal care. The home offers its service to people who have dementia or mental health needs. At the time of this inspection there were 30 people living at the home.

The service does not have a registered manager in post. The current manager had been in post for six weeks but has resigned and is due to leave in October 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.

As a result of the previous inspection, and the number of concerns about the service, a whole home safeguarding process continues. This is through multidisciplinary safeguarding strategy meetings which include representatives from Dorset and Devon health and social care agencies. The service is being monitored daily through a combination of visits by social services staff, the safeguarding nurses, the community nursing and local mental health team. Reviews of the people’s care are being carried out to check if the home is able to meet their needs. Placements to the service remain suspended by health and social care commissioners. The provider voluntarily agreed not to admit anyone new to the home.

Concerns remain regarding the staffing arrangements at the home. This was because some staff had left and because of the high reliance on agency staff. There were still some gaps in the rota where staff had not yet been found to cover upcoming shifts. We asked the provider to provide further assurances that the staff rota was completed and up to date. Staff on duty were kind, caring and considerate to people they were providing care but some staff had a more in depth knowledge and understanding of people’s needs than others.

There remains a risk of people not getting their care in a timely way because of the numbers of staff on duty at times. On the day we visited three people had received their breakfast late and two people had to ask for lunch on two occasions before it was provided. Because of the lack of continuity of a stable permanent staff group, there remains the risk that people’s current needs were not always known or identified in a proactive way.

We followed up concerns raised with us about ten people with possible swallowing/choking risks. This was to check whether the food and drink offered to those people was of the appropriate consistency. Also, to check whether staff had the knowledge they needed to safely care for those people.

Of the ten people we looked at, four people had known swallowing/choking risks. Each of those four people had a swallowing assessment completed by a speech and language therapist (SALT). Their care plans included instructions for staff about any dietary modifications needed and about positioning the person safely for eating and drinking. We observed three people having lunch in their rooms; each person was assisted to eat/drink by care staff. All three people were given food of the appropriate consistency as recommended by their SALT assessment. Each person was appropriately in an upright position and staff gave the person time to swallow each mouthful of food/drink before offering more food. Two people’s drinks were thickened to an appropriate consistency in accordance with their care plan.

An experienced care worker was supervising an agency care staff to assist one person with their lunch whilst they assisted a second person. However, an agency staff assisting a third person with a choking/swallowing risk was unaware of this risk. The staff handover sheet in use included information about people’s dietary modifications but it did not include any information about choking risks. A fourth person with a choking risk was refusing to accept the dietary modification recommended by the SALT and remained at risk. However, the person’s mental capacity assessment showed they had capacity to weigh up the risks and benefits of this decision.

Kitchen staff had the appropriate information about people with choking risks being on pureed diets and knew how to prepare foods of the appropriate consistency. Three people had recently been identified as having possible swallowing/choking risks and urgent SALT assessments had been arranged. However, those people did not currently have any dietary modifications. We encouraged the provider and manager to seek further advice about managing those people safely whilst awaiting a SALT assessment.

The remaining three people we looked at did not have choking risks but were on modified diets due to other reasons, such as not being able to chew. However, communication between staff about which people had swallowing difficulties/choking risks was not always effective, which meant some staff did not receive the information they needed to safely care for each person.

We looked at fluid and food charts of four people. These were being completed most of the time, but there were some gaps in the records. This meant we were not sure whether these were recording omissions or whether those people had not received some meals/drinks. This could put people at increased risk of malnutrition or dehydration.

The overall rating for this service is ‘Inadequate’ and the service remains 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.

Since this inspection the provider voluntarily decided to close the home and the remaining people moved out on the 25 September 2015.

29 July & 6,10 & 26 August 2015

During a routine inspection

Lymewood Nursing Home is registered to provide accommodation for up to 37 adults who require nursing or personal care. The home offers its service to people who have dementia or mental health needs. At the time of this inspection there were 30 people living at the home.

We last inspected the service on 20 September 2013 and found no breaches in the regulations we looked at.

Prior to the inspection we received a number of concerns relating to the management of the service; staffing levels; the standard of person care; moving and handling practice and infection control issues. As a result of the concerns we brought the planned inspection forward. We carried out an inspection on 29 July,6 and 10 August 2015. We received further concerns relating to care issues after this date and carried out a further inspection in the evening of 26 August 2015.

The service did not have a registered manager in post. The long serving manager had cancelled their registration with CQC effective as of May 2015, although they continued to work at the service as the deputy 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.

A new manager had been appointed and had been working at the service for less than two weeks at the time of this inspection.

Some people, their relatives and visiting health and social care professionals said they were happy with the service overall. However, we found significant concerns about how the service was being managed. Improvements were needed in several areas where the provider was not meeting the requirements of Regulations.

Management and staff in the service had not recognised safeguarding issues and had not made referrals to the appropriate agencies, such as the local authority safeguarding teams, when this was needed. This had left people at risk and had not protected them from harm. As a result of the outcome of the inspection, and a number of concerns received about the service we made a safeguarding alert to Devon County Council (DCC). We also prompted the new manager to alert the safeguarding team to recent past events. These concerns are being investigated under the safeguarding protocols of the local authority. The service will be monitored through a combination of visits by social services staff, the safeguarding nurse, the community nurse team, the local mental health team, as well as multidisciplinary safeguarding strategy meetings. In the meantime placements to the service have been suspended by the health and social care commissioners.

People’s health, safety and welfare were put at risk because there were not always sufficient numbers of suitably qualified, skilled and experienced staff on duty at all times. Communal areas were not adequately supervised to protect people from harm and people experienced delays in receiving the care and support they required at times.

As a result of findings relating to unsafe staffing levels and other concerns, the registered provider agreed to voluntarily suspend admissions for people who privately fund their care until additional staff had been recruited.

The service was not safe because people were not always protected against the risks associated with medicines. The provider did not have appropriate arrangements in place to manage all aspects of medicines safely.

People’s health and welfare was not always protected because risks, particularly those associated with certain behaviour, were not well managed.

Care plans did not reflect the preference of people using the service. Care plans are a tool used to inform and direct staff about people's health and social care needs. Lack of detailed and accurate care plans meant care and support may not be given consistently.

The care planned and delivered was not personalised to reflect people's likes, dislikes and preferences. People’s dietary preferences were not always met as they were not taken into account when planning the menu. There was a risk that the task orientated approach to care may impact on people's individual preferences and wishes.

There was a lack of stimulation for people using the service. An activities co-ordinator was employed for 20 hours per week; however staff had little time for social interactions. Activities were offered five afternoons a week but they did not always take into account individual interests and preferences or consider individual’s abilities.

Although we saw instances of caring interactions between staff and people using the service, we saw occasions where people were not respected and did not have their dignity maintained. We observed that staff at times did not speak to people or offer reassurance when they were providing support. Staff did not always have the skills or knowledge to support people effectively.

The quality monitoring systems at the home were not effective, which meant some risks were not being identified or responded to appropriately. The provider had failed to recognise the number of issues identified during this inspection. This meant that learning did not take place relating to incidents and concerns raised. Staff said concerns about staffing levels were not being adequately responded to. The service had not always informed the Commission about notifiable incidents in line with the Health and Social Care Act 2008.

People were at risk because accurate records were not consistently maintained. There were gaps in people’s food charts, bowel, and repositioning and personal care charts. We could not be assured that people’s care needs were being met.

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.

There were eight breaches of regulation. You can see what action we told the provider to take at the back of the full version of the report.

20 September 2013

During a routine inspection

Most of the people using the service were unable to talk directly to us so we carried out observation and spoke to relatives and staff for evidence about how standards were being met. The home catered for older people with needs relating to dementia, some of whom were highly dependent. We found that staff had an understanding of people's needs and that they were trained and supported in relation to their responsibilities. One relative told us ' I selected here for my mother as I was very impressed with empathy shown to people in this condition and to us as the family'.

We saw that people overwhelmingly were comfortable and relaxed and that there was positive and frequent interaction between people who used the service and between staff and people.The environment was well laid out in the way it allowed people to have the supervision and support they needed in the least restrictive way. Staff were working on how they could offer choice to people in day to day decisions as much as possible.

We found up to date care plans for people alongside daily logs and risk assessments. The staff tried to provide a person centred approach and respond to each individual according to their level of need. There was an open atmosphere for regular contact with relatives and professionals to determine people' best interests where appropriate. The manager and staff were aware of the need to work within a safeguarding framework and we found that the service provided was safe.

18, 19 February 2013

During a routine inspection

We spoke with a person who used the service who told us 'The staff are nice' and said 'They (the staff) will sit and talk to me.' One person's relative said 'The staff are very caring', and when asked about the level of care their relative received said 'Nobody could look after them better.'

People's needs were assessed and daily care was delivered in line with their needs. Where people lacked mental capacity to make decisions about their care and treatment, we saw that people's relatives or representatives were involved.

We saw the home was clean and hygienic with a suitable system to monitor cleanliness.

Staff were supported by the provider through regular training and were encouraged in their professional development.

The home had suitable systems to monitor the quality of the service provided.

13 December 2011

During an inspection in response to concerns

This inspection was carried out to follow up information we received through multidisciplinary safeguarding processes. There were 30 people living at the home on the day we made an unannounced visit. This visit, which lasted 10.5 hours, was carried out by a Compliance Inspector with a Pharmacist Inspector, who looked at the home's medication systems. The registered manager and deputy manager made themselves available throughout the inspection.

Many people living at the home were not able to comment directly on the service itself because of their memory problems. We have used a formal observation method during our visit to help us understand their experiences. This involved observing people in the main lounge, for an hour and a half. We observed their mood state, how they engaged in activities, and interacted with staff members, other people, and the environment. This helped us to make judgments about how people occupied themselves during the day, and the skills of the staff who supported them.

When we looked around the home on our arrival, we heard staff talking in a kindly way to people as they assisted them, explaining what they were about to do. For example, involving people as they used equipment to move them, and people were being offered choices for their breakfast.

Care records showed that people's faith needs had been identified, and support had been given to meet these with consideration for other needs the person had. Where music or a radio was playing in individuals' bedrooms, their care records included that they liked the type of music or programme that we heard. One person we spoke with told us they were happy with the way they received their medicines, and that there were no problems with this. We saw that people received individual support at mealtimes or with drinks between meals if they needed assistance or prompting.

During our time in the lounge, we noted that staff interacted more with some people than with others. Communication was generally positive or task orientated when staff did engage with people, although there were other occasions that indicated communication skills of some staff could be improved. For example, someone was asked loudly by staff if they 'wanted the loo', though others were approached more discretely. We observed that some individuals were not given the opportunity or encouragement to move from their chairs for over three hours.

People and their advocates had opportunities to be involved in making decisions about their care and the life of the home. Records showed that relevant people had been involved in 'best interest' decision-making, on behalf of people who had been assessed as lacking the capacity to make important decisions about their care and treatment. Annual questionnaires were sent to individuals or their advocates, seeking their views on aspects of the service. Feedback was given that included the service's response to issues raised with any intended action. 'Support Group meetings' were held for people's relatives or advocates where aspects of life at the home were discussed. Action had been taken in response to attendees' comments. For example, regarding an entertainment that was not received well.

The service also had systems in place to identify, assess and manage risks to individuals at the home, such as in relation to risks of falling, pressure sores, and nutritional assessments. These risk assessments informed care plans for people's care and treatment, promoting their welfare and wellbeing. General risks were less well managed. For example, we observed that some staff practice created a possible cross-infection risk, which had not been picked up through general staff supervision.