This inspection was carried out on the 28 and 29 July 2016 and was unannounced.
Thornton Manor nursing home is a private home that is set in its own grounds and located close to the rural village of Thornton –Le-Moors between Ellesmere Port and Chester. The service is based over two floors and is registered to provide nursing and personal care for up to forty seven people. At the time of our inspection there were forty four people living at the service.
There was a registered manager in post at the service since 2011. A registered manager is a person who has registered with the 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.
At the last inspection on 5 January 2016 we found that a number of improvements were needed at the service. These were in relation to the failure to assess and mitigate risks to people, poor management of infection control and cleanliness, a failure to ensure that people were always treated with dignity and respect and failing to ensure records were personalised. Following our inspection the registered provider wrote to us and informed us they would meet all the relevant legal requirements by the end of May 2016.
We also issued the registered provider and registered manager with a warning notice as records did not accurately reflect the care and support people required and quality assurance systems were not robust. We instructed both parties to meet all relevant legal requirements by 13 May 2016.
During our inspection we found that the registered provider had not demonstrated full compliance with the Health and Social care Act 2008 (regulated activities) 2014. We found that improvements had not been sustained and the registered provider was not meeting legal requirements. We identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. CQC are now considering the appropriate regulatory response to the concerns we found. We will publish the actions we have taken at a later date.
People told us that they felt safe living at the service. Staff had an understanding of different types of abuse, how to safeguard people from abuse and how and who to report concerns too. However, areas we had previously raised relating to poor practice, institutional and restrictive practices had not been identified or addressed at the service. During our visit we asked a senior staff member to raise areas of concern we found to the local authority safeguarding team.
The service was not clean. Several areas across the building, including bathrooms were dirty. Equipment, fixtures and fittings were rusty, dirty or in need of repair, replacement or deep cleaning. Carpets and flooring in several areas of the home had an unpleasant smell or required replacing due to wear, tear and damage. Coats worn to access the kitchen for infection control reasons were dirty and stained. The management of infection control was poor.
Sufficient checks were not made on pressure relieving equipment. Sixteen people used pressure relieving mattresses and we found that the settings for seven people were incorrect. One pressure mattress was unplugged from the power and this had not been identified by staff. Care plans did not evidence the correct pressure levels required for individuals. People were at an increased risk of developing pressure ulcers.
Risks to people’s health and safety were not always identified. Where people had experienced significant weight loss or refused treatment for the management of diabetes staff had failed to access support and advice from relevant health professionals to minimise any further risks. Care plans failed to identify the specific equipment people required to support them with their mobility.
People received their medication as prescribed. People’s medication administration records (MAR) had been appropriately signed when medication was given. Medication was stored in a safe and secure way. However, care plans for PRN (as required) medication were not in place for staff guidance. This meant that staff would not know when to give people their PRN medication, or at what dosage. This placed people at risk of having their medicine administered incorrectly.
Staff showed a basic understanding of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The registered provider did not have a policy and procedure in place with regards to the MCA. Staff practice showed that consent was sought from people prior to care and support being provided. Care plans did not reflect how people’s consent; ability to make specific decisions and decisions made in their best interests was considered. DoLS applications we reviewed completed by the registered manager had not considered the use of bedrails as a restrictive practice.
The mealtime experience varied across both floors. People who lived on the first floor were not able to sit at a dining room table to have their meal. The registered provider has confirmed that an additional dining room space has been introduced since we visited. Staff approach varied across the service. We found that staff on the first floor were task orientated in their approach and cultural practices and routines had been developed.
The service is advertised as a dementia specialist service. We found that the environment was not dementia friendly and no adaptions had been made to aid and support people who are living with dementia.
Records were not personalised and did not reflect people’s individual preferences about how they would like their care and support to be provided. The registered provider had introduced supplementary records (day charts) which were used to record food and fluid intake and repositioning. We found that charts were not completed effectively by staff. There were gaps of up to 15 hours where no food, fluid or repositioning had been recorded. Information relating to what people had eaten and drank was not completed in detail to accurately reflect what they had consumed. This meant that the registered provider was not able to safely protect people from the risks of dehydration, inadequate nutrition and the development of pressure areas.
The quality assurance system in place was not effective and did not monitor the quality of care and facilities provided to people who used the service. We found continued issues as part of our inspection relating to the management of infection control and the overall condition of the environment. Audits completed by the registered manager had not identified or addressed concerns relating to the environment. Accidents and incidents were recorded on a monthly analysis, however there were no actions recorded to identify that the registered manager had considered risks, patterns or changes required to people’s care needs. There were no actions identified to keep people safe from harm. Independent quality checks were not completed by the registered provider.
The registered provider had failed to display the CQC report and ratings following our previous inspection at the service and on their website. These are required to be made available for public viewing by the registered provider.
People and their family members told us that they knew how to raise a complaint and felt confident that the staff and management would act upon them immediately. The registered provider had a complaints policy and procedure in place and records showed that complaints had been dealt with appropriately.
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.