Norlands Nursing Home

Norlands Nursing Home is a care home providing personal or nursing care to for up to 21 older people, people living with dementia, people with a learning or physical disability and people with mental health needs. At the time of inspection, there were 17 people living at the home. There were 3 single rooms and nine shared rooms at the home.

People’s experience of using this service and what we found

People felt safe living at the home. Improvements had been made to the management of medicines and the registered manager had oversight of the safe management of medicines. People had appropriate risk assessments in place and staff were aware of strategies to manage risk. Staff were aware of what action to take following any safeguarding concerns. Staff told us they felt confident to report any concerns and that they would be acted upon.

People were assessed to ensure their needs could be met while living at the home. People were very complimentary of the meals and we observed staff to be attentive and patience with people who required help with eating and drinking. People with alternative dietary needs were catered for. Staff were inducted into their job role and received regular training. The home worked in line with the Mental Capacity Act 2005.

People felt well cared for and there were kind interactions between people and the staff team. The staff could describe the most appropriate way to care for people and were aware of peoples likes and dislikes. People told us the staff were responsive.

Care plans were person centred and the addition of a one-page profile gave detailed information to staff. Care plans were regularly reviewed and a relative told us they had been involved in formulating the plans. Activities were varied, and we observed people joining in throughout our visit. The home had not received any complaints since the last inspection. People told us they knew who to complain to and felt they could make a complaint if they needed to. People could be supported to remain at the home, if that was their choice, at the end of their life.

The registered manager and the provider were actively involved in the running of the home. Staff felt supported by both and were very complimentary about the management of the home. Improvements to audits across the home gave the registered manager a clear oversight and allowed them to make improvements where needed. Both the registered manager and the provider were aware of their responsibilities of their registration.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 23 July 2018) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Norlands Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Norlands Nursing Home is registered with CQC to accommodate a maximum of 21 older people, including those living with dementia. At the time of this inspection the home was full.

At this inspection we found two breaches of regulations concerning safe care and treatment and good governance. We have also made three recommendations relating to the mental capacity act, person-centred care, and equality, diversity and human rights. You can see what action we have asked the service to take at the back of the full report.

We looked at how medicines were managed and found a variety of issues. For example, on the front of each Medication Administration Record (MAR), there was no place to record if a person had any allergies. This placed people at an increased risk of receiving a medicine that they were allergic to. We also found arrangements for administering ‘as and when required’ medicines was ineffective and not response to people’s needs.

We looked at how the service assessed and mitigated risks. We found that not all people who used the service had individual risk assessments completed and that where a risk assessment had been completed, information was recorded in a variety of different places. For example, some risks were noted and addressed in care plans under the heading of ‘safety’ however these were not easily identifiable or clearly presented, others on a separate risk assessment page.

We looked at the use of thickeners in people’s drinks and how special diets were managed for those deemed a high risk of choking. We found the information recorded in people’s care plans was contradictory and did not reflect the most recent swallowing assessment completed by a Speech and Language Therapist (SaLT). As a result of this, we asked the service to complete an immediate review of each person deemed to be at risk of choking. We also raised safeguarding alerts with the local authority.

Norlands Nursing Home benefited from a low staff turnover and all members of staff were on permanent contracts. The service did not use an external staffing agency and short falls in shifts were covered by existing permanent staff. Recruitment procedures remained safe and effective.

Care staff understood how to help people make choices on a day to day basis and how to support them in making decisions. However, information recorded in care plans relating to the mental capacity was not decision specific and we found a blanket approach had been taken in respect of recording if a person was deemed to lack capacity.

We asked the registered provider to provide us with overarching records relating to the management of Deprivation of Liberty Safeguards (DOLS) made to the local authority and found these were not sufficiently robust to ensure oversight was maintained. For example, there was no DOLS matrix or tracker in place that would help the service to record key dates relating to the DOLS process.

People received care and support from staff who knew them well and who had the skills and training to meet their needs. Staff told us they continued to receive lots of opportunities for training and professional development.

We observed the mealtime experience and saw that people benefited from freshly prepared, home cooked food and were offered choice from a varied menu. At breakfast people could choose from a cooked option, cereal, toast or fresh fruit. At lunch time people were offered a choice of two options for both the main and desert. At tea time a selection of sandwiches was provided with a further desert option.

The daily menu was displayed on a white board in the dining room but no pictorial menus were made available This type of menu can help people who are living with dementia to communicate their personal preferences at mealtimes.

Norlands Nursing Home benefited from attractive landscaped gardens and an outside space that was accessible for wheelchair users and people with limited mobility. Weather permitting, visiting relatives were encouraged and supported to spend time with their loved ones outside in the fresh air.

Throughout our inspection we observed lots of instances of warm and caring interactions between staff and people living at the home. Without exception, people described the home as a very caring place to live.

People living at Norlands Nursing Home were diverse and multi-cultural. Through talking to staff, we were satisfied the ethos and culture at the home was non-discriminatory and the rights of people from certain groups would be respected.

Everyone was allocated a keyworker and their role was to get to know the person particularly well and to ensure their day-to-day needs were met.Throughout our inspection, it was clear that staff at Norlands Nursing Home knew people well and their basic care needs were being met.

However, care and support planning documentation was not reflective of this.

Documentation for recording day to day care and support was disorganised and spread across multiple systems. The majority of care files contained historical information that was not always reflective of a person's needs and this made eliciting the current picture difficult. We also found care and support records to be task and nursing orientated and did not take sufficient account of people's likes, dislikes, personal preferences and who was important to them.

People living at Norlands Nursing Home could choose to participate in a range of traditional activities. For example, sing-a-longs with a visiting entertainer, board games, dominos and bingo sessions. People were also supported to access the local community through visits to the local shops, cafes and the market.

In reviewing arrangements for good governance, we looked at systems for audit, quality assurance and questioning of practice and found records to be disorganised and not sufficiently detailed enough to provide assurance that oversight was being maintained. In particular, we found no regular overarching analysis was completed in order to identify trends or contributory factors.

We spoke at length with the registered manager to ascertain their understanding of the legal responsibilities associated with being a registered manager. In particular, the fundamental standards of quality of safety. Through these discussions, and from the evidence gathered during the inspection, it was apparent the registered manager had not kept pace with changes to legislation and they were not in a position to fulfil the role of registered manager effectively.

Norlands nursing home provides accommodation and nursing care and is registered for 21 older people including those living with dementia. The accommodation is over two floors. On the day of the inspection 20 people were receiving care services from the provider. The home had an experienced registered manager who had been in post for several years. 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 this inspection we found that people who used this service were not always safe. The care staff knew how to identify if a person may be at risk of harm and the action to take if they had concerns about a person’s safety. However issues regarding the recording of medication could place people at risk.

The care staff knew the people they were supporting and the choices they had made about their care and their lives. People who used the service, and those who were important to them, were included in planning and agreeing to the care provided.

The decisions people made were respected. People were supported to maintain their independence and control over their lives. People received care from a team of staff who they knew and who knew them.

People were treated with kindness and respect. One person who used the service told us, "It's such a homely place, the owner and staff are lovely."

The registered manager used safe recruitment systems to ensure that new staff were only employed if they were suitable to work with vulnerable people The staff employed by the service were aware of their responsibility to protect people from harm or abuse. They told us they would be confident reporting any concerns to a senior person in the service or to the local authority or CQC.

There were sufficient staff, with appropriate experience, training and skills to meet people’s needs. Staff were well supported through a system of induction, training, supervision, appraisal and professional development.

There was a positive culture within the service. This was demonstrated by the attitudes of staff when we spoke with them and their approach to supporting people to maintain their independence.

The service was well-led. There was a formal quality assurance process in place. This meant that aspects of the service were formally monitored to ensure good care was provided and planned improvements were implemented in a timely manner. We found that the audits carried out did not always identify discrepancies and areas for improvement in relation to records. There were good systems in place for care staff or others to raise any concerns with the registered manager.

We considered our inspection findings to answer questions we always ask:-

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found.

Is the service safe?

We saw that people had received an assessment of their need before moving into the home to ensure that staff were able to safely meet the person's care and treatment requirements.

People were cared for in an environment that was clean and hygienic and met their needs. The home had additional security measures in place to protect people.

At the time of the inspection, there was no person who lived at the home subject to Deprivation of Liberty Safeguards. Staff had received training, so they knew how to safeguard people at risk of abuse and we saw best interest decisions had been made to protect people from harm.

One relative told us that they thought their relative was safe living at the home. They said, 'I can go on holiday with no worries and know they are being looked after properly.'

The provider had emergency procedures in place to keep people safe from harm, including fire evacuation procedures. We also found that the building was in good order and safe for people to live in.

The provider had effective recruitment procedures in place, including appropriate checks on staff before they began working at the home.

Is the service effective?

People who lived at the home had a named key worker which meant that there was better coordination of the person's needs.

People living at the home and their relatives, told us that they were happy with the care that was delivered and their needs were met. Staff had received adequate training to meet the needs of the people who lived at the home.

When we spoke to one relative, they told us that the service was very good and had helped to improve their relative's health issues since they came to live there. This showed evidence of an effective service.

Is the service caring?

We asked two relatives if they had any concerns about the care provided by the home and they told us that were happy with the care provided.

Observations during the visit showed staff being attentive to the people they were supporting. We found good interactions taking place and people were comfortable and relaxed with the staff supporting them.

The home held regular meetings for the people who lived at the home to share their views. Yearly surveys were also completed to further collect the views of the people living at the home.

People who lived at the home were escorted to hospital if the need arose, which meant that people were supported by a familiar face.

Is the service responsive?

We could see from care records, that when a person's needs changed appropriate actions were taken to ensure that needs were met, including for example; arranging for people to see a GP.

Activities were organised around what people liked to do, for example; going on holiday when they wanted to.

We saw staff quickly responding to requests from people who wanted help with personal care and other activities.

Relatives told us staff contacted them to update them on any changes to the health of their relative or any other information that they may need to know about.

Is the service well-led?

There was a registered manager in post at the home. The home also had regular visits from the owner who provided additional assistance to people who lived at the home.

We found a good staff team in place; staff had very good knowledge of the home and what care the service provided to people living there.

Three relatives told us that they were kept regularly updated by the staff team if any changes occurred. One relative told us, 'It's always got a homely atmosphere when you visit and staff go out of their way to make you welcome'.

All of the people who lived at the home and their relatives that we spoke with, knew who to contact if they had a problem.

People's care needs were assessed before they decided to move to the home.

Care plans were detailed and person centred. People had a range of risk assessments in relation to their care needs and identified risks. This enabled people to remain as independent as possible within the limitations of their care needs.

People received their medication as prescribed.

Staff were trained and supported to do their job.

There were good quality assurance arrangements in place which ensured good outcomes in terms of the care and treatment people received.

People told us they were happy with the care they received. One person who lived at the home told us 'This is the best care home I've ever lived in and it's the cleanest'.

Another person told us 'Food is good, there's always plenty to eat and you get a good variety'.

We found the home was sufficiently staffed and that nursing and care staff enjoyed their work and were committed to ensuring the best possible outcomes for people living at the home. One member of staff said 'we [care staff and nursing staff] have the pleasure of looking after these people [people living at the home]'.

One person living at the home said 'My health isn't good and I need my medication and they [staff] are good I always get my medication'.

We spoke with relatives of a person living at the home. They told us 'staff are very attentive, they are always coming around offering drinks and food to the residents. It's really good, the care is good'.