All inspections: Harecombe Manor Nursing Home

This inspection took place on 7 and 9 September 2015. It was unannounced. There were 36 people living at Harecombe Manor Nursing Home when we inspected. People cared for were all older people who needed nursing care and were living with a range of care and treatment needs, including stroke, heart conditions, breathing difficulties, diabetes and arthritis. Many people needed support with all of their personal care, eating and drinking and mobility needs. Some of the people were also living with dementia. The registered manager reported they provided end of life care at times. No one was receiving end of life care when we inspected.

Harecombe Manor Nursing Home is a large manor house which has been extended. People’s bedrooms were provided over two floors, with a passenger lift in-between. There were a sitting and dining room on the ground floor, with an additional sitting room on the lower ground floor. Support facilities such as the laundry and training room were also provided on the lower ground floor. There was a wheelchair accessible terrace overlooking the extensive garden areas. Harecombe Manor Nursing Home was close to the middle of Crowborough. The provider for the service was Mr and Mrs Ollivier.

Harecombe Manor Nursing Home had a long standing 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.

Harecombe Manor Nursing Home was last inspected on 2 and 4 December 2014. They were rated as inadequate at that inspection. The Care Quality Commission (CQC) issued a Warning Notice after the inspection in respect of assessing and monitoring of the quality of the services. The provider sent us an action plan which detailed when different areas would be addressed. This stated all matters would be addressed by 31 May 2015.

We found the provider had not met the Warning Notice or addressed most of their action plan by their due dates.

As at the last inspection, systems to regularly assess and monitor the quality of the service were not effective and failed to identify and manage certain risks to the health, welfare and safety of people. This included ensuring they had met the areas they needed to address identified in the previous report and ensuring they followed their own policies and procedures.

As at the last inspection we continued to find people did not have a full assessment of all their needs carried out and did not have their care planned and delivered in such as way so as to meet their individual needs. This included systems for prevention of pressure damage and risk of injury to people from falls. As at the last inspection, people were not supported with engagement by the provision of meaningful recreational activities, which met their preferences.

People were still not protected against the risks associated with unsafe management of medicines. This was particularly in relation to ‘as required’ (PRN) medication and appropriate support for people who wanted to take their medicines independently.

People were still not protected from the risks of inadequate nutrition and hydration. People who needed assistance did not receive the support they needed to drink sufficient amounts. Records relating to amount of diet people ate were not adequate to show people had received the nutrition they needed.

The provider continued not to have suitable arrangements for ensuring the consent of people. This was particularly where people remained in bed all the time. Relevant referrals had not been made to external bodies to ensure people were not deprived of their liberties. Referrals had also not been made to relevant professionals to develop such people’s care plans.

At this inspection both people and staff told us about lack of staff availability, particularly a slow response time to call bells. People also did not have support from staff for extended periods of time when they were in the sitting room, because of staff availability. The provider had not done an analysis, such as a dependency assessment or assessment of response times when call bells were used, to assess if the number of staff on duty were enough to meet people’s needs.

We received mixed comments from people about how they raised issues and were consulted about the service they received. Several people told us about issues which had concerned them. Records of matters raised formally were documented but informal issues, such as those raised with us during the inspection were not documented, so the provider was not made aware of them to ensure they took relevant action.

The provider had taken action in some areas. At the last inspection, we identified systems to assess the risk of infection were not effective and appropriate standards of cleanliness and hygiene were not maintained. At this inspection, the provider had ensured this had been addressed and all areas were clean and necessary equipment to reduce risk of infection was available.

At the last inspection, we identified issues relating to a range of areas, including ensuring safe bed rails. This had been addressed and all bed rails were being safely used in accordance with guidelines. New hoists to support people with their mobility had also been provided. Action was being taken to ensure the safety of windows and of fire doors.

At the last inspection, we identified recruitment procedures were not satisfactory. The one member of staff employed since the last inspection had relevant documents on their file to demonstrate their suitability to work with people.

The provider had developed a training plan and staff had been trained in relevant areas such as fire safety. Plans were in place to ensure staff were trained in other key areas such as the Mental Capacity Act 2005. Staff showed an awareness of actions they needed to take to ensure people were safeguarded from risk of abuse. Systems for supporting staff by supervising them in their roles had commenced.

Staff supported people in a caring way, including during medicines rounds. People said they could choose, for example what clothes they wore. Staff, including an agency care worker, knew the individual needs of the people they were caring for. Visitors said they could come and go as they wanted to.

People spoke positively about the meals. The lunchtime meal was given to people in attractive surroundings and the meal smelt appetising.

Staff said they could raise issues with the management of the home. They reported positively on the philosophy of care to ensure people “Came first.”

You can see what action we told the provider to take at the back of the full version of the report.

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.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.

CQC are taking enforcement action to ensure that Mr and Mrs Ollivier provide safe and effective care.

This inspection took place on 2 and 4 December 2014 and was unannounced.

Harecombe Manor Nursing Home is a registered home which provides both residential and nursing care mainly to people over the age of 65. Long term, respite, palliative and end of life care services are available. People we met with had complex needs, some of which related to a risk of pressure ulceration and living with dementia or diabetes. The home is registered to accommodate a maximum of 51 people. At the time of our inspection there were 37 people living there. The service is laid out over three floors and has a large garden area at the rear.

There was a registered manager in post at the time of our inspection. 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 our last inspection in July 2014 we found the provider had failed to implement a quality assurance system and there was no formal mechanism to seek feedback from people about the standard of care and treatment provided. We took enforcement action to ensure necessary improvements were made.

At our last inspection we also found that staff were not fully supported to deliver care and treatment to people safely and to an appropriate standard. There was a lack of regular training, supervision and team meetings. We told the provider they must take action to improve.

At this inspection, although some improvements had been made, we identified a number of areas of practice which potentially placed people at risk of receiving inappropriate care and support. Risks had not been identified through auditing or quality assurance. We have taken enforcement action in relation to this. You can see what action we told the provider to take at the back of the full version of this report.

Inconsistencies relating to medication had not been identified. Some prescribed medicines, such as skin creams were not being administered in a consistent manner. There were no recent audits of medication. We observed staff administering medicines safely. They made sure people had taken their medicines before signing medication records.

Appropriate action had not always been taken to protect people who needed support with eating and drinking from risk associated with a lack of food and fluids. We observed a main meal and saw people were given sufficient amounts to eat and drink. People told us they liked the food and individual food preferences were taken into account.

Inconsistent infection control procedures meant there was a risk of cross infection from equipment that was not properly cleaned. There were no recent audits of cleanliness and infection control. The environment was undergoing some refurbishment. There was a plan in place to make further improvements. Communal areas and people’s rooms were visibly clean.

People told us they felt their health and care needs were met. However, risks relating to people’s complex needs were not always managed effectively. Care plans and risk assessments were not always clear about how to manage these risks. There were some areas of good practice. A GP was complimentary about nursing standards. There were not enough social activities. People were not able to go into the community when they wanted.

The provider was not fulfilling the requirements of the Mental Capacity Act 2005 (MCA). Where people lacked capacity to make decisions for themselves, correct procedures were not being followed. The manager reported they were aware of the requirements of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). They reported there was no one at the service who required a DoLS safeguard to be in place. DoLS are safeguards put in place to protect people where their freedom of movement is restricted.

Staff told us they felt supported in their roles by the manager. A training and supervision programme was in place. However, further training was needed to support staff in treating people with complex health needs. Staff were trained in safeguarding and were confident about what they should do if they had any concerns or suspected someone was at risk of abuse.

The provider did not have all the required information to show safe recruitment practices were followed. However as the majority of staff had worked at the service for considerably longer than a year and agency staff were kept to a minimum, this had a lower significance than in a service with a high turnover of staff.

Following feedback by the inspectors on the first day of the inspection the manager had taken action and discussed the issues with staff in order to make some immediate improvements. The manager was open and receptive to the concerns raised.

Since the last inspection the manager had updated policies and procedures and introduced a new quality assurance system which was ongoing. People were being asked for their views about how the service was run.

Friends and relatives were able to visit people whenever they wanted and were made welcome by staff. We saw a number of visitors come and go during the inspection and they were greeted warmly by the manager. People were able to raise concerns and felt communication was good. The manager took account of complaints and responded appropriately to issues raised by people or their relatives. The feedback we received about the manager was positive. People told us the home was well led. There was a clear philosophy of care at the service which was understood by staff.

There were a sufficient number of suitable staff to meet people’s needs. We observed staff treating people with respect and taking the time to chat with them while carrying out care and support. People told us they were looked after by staff who were caring and kind. People said they felt safe at the service.

We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we told the provider to take at the back of the full version of this report.

This inspection was carried out by one inspector. During the inspection we spoke with the manager, five members of staff, five people who used the service and two visitors.

We answered our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led? Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We found that all areas of the home were maintained to an appropriate standard. There were systems in place to reduce the risk of cross infections. Staff had access to personal protective equipment, such as gloves and aprons. We saw that these was used when required. People were cared for in a clean and hygienic environment.

There were up to date risk assessments in place for people that used the service which explained the risks and how these were to be minimised. This meant that the provider took steps to ensure that people's safety and welfare was maintained.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. While no applications have needed to be submitted, proper policies and procedures were in place. Relevant staff understand when an application should be made, and how to submit one. There was guidance on DoLS displayed on the office wall.

Is the service effective?

It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. We found that not all of the required training had been provided to staff and was not always kept up to date. Staff did not have regular supervision with a manager which meant that there was no formal opportunity to discuss practice in a confidential meeting. Team meetings were not taking place regularly which meant that staff did not have an opportunity to meet together to discuss ideas and any issues. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service caring?

People were supported by committed and caring staff. We observed that people appeared comfortable in the home and familiar with the staff that worked there. We saw that staff members spoke directly with people and supported them at an appropriate pace. People told us that they were happy at the service and were treated with respect. One person said "Staff are respectful and courteous" and another commented "I am very content".

Is the service responsive?

People's needs were continually assessed. Records confirmed people's preferences, interests, goals and diverse needs had been recorded and support had been provided in accordance with people's wishes. People's needs were reviewed each month to make sure that any changes were identified and appropriate support provided.

Is the service well-led?

At our last inspection in September 2013 we found that the provider did not have an effective system to in place that regularly assessed and monitored the quality of service that people received. We told the provider to take action to make improvements.

At this inspection we found that a quality assurance system had not been implemented and that there was no formal system to seek feedback from people who used the service. This meant the provider could not get an informed view in relation to the standard of care and treatment provided. The provider had not made the required improvements identified at our last inspection. We have taken enforcement action in relation to this and the provider must tell us how they plan to improve.

During this unannounced inspection we spent seven hours at the home and spoke individually with twelve of the people who lived there. We also joined people in the dining room for their lunchtime meal and observed the way they were served and supported at this time. Those people who were well enough to talk with us said that they liked living at Harecombe Manor and described good quality care. All the people we spoke with told us that staff were "Kind" to them and that they were "Treated with respect." We were repeatedly told by people that they had "No complaints at all" and that they were "Well looked after."

We found documentary evidence that each person had a plan of care which provided detailed records about their needs and the care that had been provided. This meant that people had received appropriate care. We saw that the home had clear systems in place to monitor people's health to ensure they maintained healthy skin and weight. When people had become unwell, there was evidence that the home had liaised promptly with other professionals to ensure that they received the right medicines and equipment to make them as comfortable as possible.

We interviewed four staff including the manager and found them all to be caring and knowledgeable as they discussed the needs of the people who lived at the home. Staff told us that they had the right skills and equipment to do their jobs and said that they were well supported by the manager.

We found that the home had clear plans to continually improve the services at Harecombe Manor. Although people told us that they felt able to voice their views about the home, there were no formal systems for regularly obtaining and evaluating their feedback.

We spoke privately with eight people who used the service and others who were sitting in communal areas. Everyone we spoke with said that they were well looked after at Harecombe Manor and were as happy as they could be away from their own home. People told us that staff were "Friendly", "Marvellous" and "Kind" and that they usually responded promptly to their calls for help.

We saw that the home maintained records of the care that they provided to people. We did however also identify some examples where staff had not followed the correct guidelines for supporting people and had recorded incomplete information. Staff spoken with were clear about their roles and demonstrated a willingness to improve in these areas. We found that records were kept securely with a system in place that enabled staff to access the information they needed to deliver care.

We saw evidence that staff had received regular training in key areas such as safeguarding, manual handling, infection control and food hygiene. Nursing staff had been supported to maintain their registration. This meant that people were supported by people who were competent to care for them.

People told us what it was like to live at Harecombe Manor and described how they were treated by staff and their involvement in making choices about their care. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people living in care homes are treated with dignity and respect and whether their nutritional needs are met.

The inspection team was led by a CQC inspector joined by an 'expert by experience' (people who have experience of using services and who can provide that perspective) and a practising professional.

During the day, out of the 35 people accommodated at the home, we spoke with nine people, six in communal areas and three in bedrooms. People said that they were well looked after and their needs were met.

People said that they made decisions about where they wanted to spend their time. They said that they had a varied menu choice and were happy with the food served.

There were several complaints about response times to the call bell. Two people complained that they had to wait for an hour for a staff member to see to them.

People told us that they had been involved in the decision to move to the home and some people said they had been able to have a look around before they moved in. Everyone we spoke with said they were happy with the service they were receiving and comments they made included;

'I'd recommend this place to other people'

'I'd rather be at home, but I am as happy as I can be here'

People told us that they chose when to get up and go to bed and how they spent their time. People said that the staff always told them what was happening and involved them in their care. Everyone we spoke with felt their decisions were respected by the staff and that they were treated with respect and kindness.

People told us that they received the support that they needed and that they were happy with the standard of the care. Comments included 'I'm very happy with the care', 'I'd rather be at home of course, but it is very comfortable here and they are very obliging' and 'It's a good home, I am happy with the care'.

People told us that they could see a doctor or other health professional quickly when they needed to and one person said 'The staff are always very quick to deal with any health problems you might have'. People were happy with the support they received for their personal care and told us that they were encouraged to continue to do as much as possible for themselves. They said they could have a bath or a shower as often as they wanted to.

The people that use the service told us that there were some social activities provided in the home including bingo twice a week and quizzes. They said they could choose whether they wanted to be involved or not. One person said 'There are things like bingo that go on in the upstairs lounge, but I like to watch TV so I spend most of my time in here [the downstairs lounge]'. Some people said they did not think there were enough activities going on and one person commented 'Not much going on, they do bingo, but not much else'. Others were satisfied with the range of activities in the home. Everyone we spoke with said that they could choose which of the two lounges they preferred to use and that one of them was used for the activities, whilst the other was quieter and usually had the TV on. People told us that they had the opportunity to go on outings during the warmer months. One person said 'We had a recent outing to Hastings, that was a really good day'.

Everyone we spoke with told us they were happy with the meals provided and that they had a choice of what they ate and drank. People told us that they could choose to have something different if they did not like the two options that were on the menu for that day. Comments about the meals included;

'Ever since I've been here the food has been perfect'

'The food is pretty good'

'There is always a choice of meals, except when there is a roast'

Relatives of people using the service told us that they felt assured that their relative was safe in the home. They said that the manager and nurses always contacted them quickly to discuss any concerns. People that use the service told us that they felt safe living in the home. We asked people that needed to use a hoist, or other equipment, to move around whether they felt safe and secure when the staff helped them with this. They told us that they did. One person said 'I always feel safe when the staff are helping me to get into the bath or use a hoist'.

People told us they were happy with their bedrooms and the facilities available. Everyone we spoke with said they had a bathroom either in their room or nearby. One person said 'You can bring your own things for your room if you like'.

People using the service told us that they liked the staff that supported them and felt safe in their care. They said that they were usually supported by staff that they knew, but occasionally agency staff were used to cover staff sickness. Comments included

'The staff here know how I like things done and I can always tell them if I want something done differently, they don't mind'

'Sometimes they need to use agency staff and then the care you get is not quite how you want it and you have to tell them how you want it done.'

People using the service told us that the manager was approachable and responded quickly to any problems or concerns they had. One person said 'When I needed to make a complaint it was sorted out very quickly, there was no problem'. Another person commented 'I have never had any problems with the quality of the service here, but if I did I would talk to the matron straight away. They are often asking me if everything is ok'

Relatives and people using the service said the manager was approachable and was always around if they needed to talk to her about anything.

These older reports are from our old approaches to inspection, including those from before CQC was created.

Archived: Harecombe Manor Nursing Home

All Inspections

7 and 9 September 2015

During a routine inspection

2 and 4 December 2014

During an inspection looking at part of the service

10 June 2014

During an inspection looking at part of the service

14 August 2013

During a routine inspection

5 December 2012

During an inspection looking at part of the service

8 May 2012

During a themed inspection looking at Dignity and Nutrition

5 September 2011

During a routine inspection

Reports under our old system of regulation