Archived: Higham House Nursing Home

At the last inspection in March 2018 we rated the service overall ‘Inadequate,’ in breach of the regulations and placed in special measures. Services in special measures are kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, we inspect the service again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

Following the last inspection, we met with the provider to stress the high-level concerns we had about the service. We asked the provider what they would do, and by when to improve the key questions, ‘Safe, Effective, Caring, Responsive and Well-Led’ to at least good. The areas identified for improvement included, fire safety, building upkeep and maintenance, infection controls, cleanliness, analysing and reporting accidents, incidents, reporting safeguarding concerns, providing person centred care, respecting privacy, record keeping and governance of the service.

This is the seventh inspection of Higham House Nursing Home where the provider has failed to maintain compliance with the legal requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Higham House 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.

Higham House Nursing Home accommodates up to 30 older people in one adapted building. At the time of this inspection, 17 people are using the service.

A registered manager was in post. 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.

The registered manager did not always respond to requests from the Local Safeguarding Authority to carry out investigations into safeguarding concerns brought to their attention. They also did not always follow local safeguarding protocols, by reporting potential safeguarding incidents to the relevant authorities.

Medicines were managed appropriately, and people received sufficient support to take their medicines as prescribed and when required. However, medicines stocks and records were not always stored away securely.

People did not always receive person centred care, most notably at mealtimes. Staff were not being deployed to allow them to provide sufficient support to people who need assistance with eating and drinking at mealtimes. The mealtime experience needed improvement to make it a more enjoyable and social time for people.

People were treated with respect and compassion, although privacy was not always respected. There was a lack of meaningful activities, as the activity provision at the service was minimal.

Systems were not in place to plan and review staff training in a timely way to ensure staff received training that is appropriate to their respective roles and responsibilities.

Statutory notifications were not always submitted to the CQC. Failure to consistently notify CQC of events and safeguarding incidents means we cannot check the provider has taken appropriate action to ensure people's safety and welfare.

The provider did not have sufficient processes in place to assess, monitor, learn from and continually improve the quality of the service. Records relating to the management and oversight of the service were disorganised, which impacts on the ability to effectively oversee the day to day running of the service. Systems were in place to seek feedback from people using the service and relatives, however feedback received was not always been used to drive continuous improvement of the service.

People’s general health and wellbeing was monitored, and information was shared with all involved in people's care. When concerns about changes in people’s health and wellbeing were noticed staff took the appropriate action to refer people to the relevant healthcare professionals, for advice and support.

Sufficient action had been taken to improve fire safety, the building upkeep, maintenance, infection controls, and cleanliness of the service.

Staff recruitment records were made available for inspection and the records seen evidenced that appropriate recruitment checks are carried out prior to staff taking up employment. Ancillary staffing arrangements had been improved to allowing for routine deep cleaning to take place.

People spoke positively about the staff that support them and relatives felt staff always made them feel welcome. People and their representatives had opportunities to contribute to the planning of their care and support. People's needs and preferences were set out in their care plans. People's care and support needs were regularly reviewed and updated to ensure information was current to their changing needs.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

The laundry system had been reviewed and improved to ensure people’s clothing and bedding was laundered appropriately.

At this inspection, we found the provider in breach of the legal requirements. You can see what action we told the provider to take with regards to the breaches at the back of the full version of the report.

At the last comprehensive inspection on 1 March 2017 the service was rated ‘Requires Improvement’ and was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations, 9 Person centred care, 11 Need for consent, 12 Safe care and treatment, 13 Safeguarding service users from abuse and improper treatment, 17 Good Governance and 18 Staffing.

Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the key questions under safe, effective and well led, to at least good.

On the 3 May 2017, we carried out a focused inspection that was unannounced. The service was inspected against four of the five questions we ask about services: is the service safe, effective, responsive and well-led. No risks, concerns or significant improvements were identified in the remaining key question: is the service caring through our on-going monitoring or during our inspection activity so we did not inspect this area.

The inspection on 3 May 2017 found that sufficient improvements had been made to meet the breaches in the regulations. The ratings from the previous comprehensive inspection for the key questions inspected were included in calculating the overall rating in the inspection. The rating remained ‘Requires Improvement’ as we needed to see consistent good practice over time.

At this inspection, we found the good practice improvements found at the last inspection, had not been sustained.

Higham House Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Higham House Nursing Home accommodates up to 30 older people in one adapted building. At the time of this inspection, twenty six people were using the service.

A registered manager was in post. 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.

The provider had not put in place all that was reasonably practicable to maintain the building upkeep, to ensure the premises were safe to use for their intended purpose and used in a safe way.

The provider had not replaced worn and damaged furniture as required to keep the premises and equipment appropriately maintained,

Monitoring systems were not effective to demonstrate accidents and incidents were appropriately analysed to identify hazards, trends or themes, to mitigate the risks of further accidents and incidents.

The provider had not followed local safeguarding protocols. Records did not evidence safeguarding concerns were reported to the relevant authorities. The provider had not taken the necessary action to investigate safeguarding concerns within the timeframe set by the safeguarding authority.

The provider had not always taken timely action to make sure people were protected from the risk of infections, namely the risks of being exposed to Legionella bacteria.

The legal obligation to submit statutory notifications to the Care Quality Commission (CQC) of events and incidents involving people at the service had not been met. Failure to notify CQC of events and safeguarding incidents meant we could not check the provider had taken appropriate action to ensure people's safety and welfare.

Records were not available to demonstrate that feedback received from people using the service and relatives was used to drive continuous improvement at the service.

Staff recruitment records were locked in a cabinet and not made available for inspection. The provider had not taken timely action to have a new lock fitted to the filing cabinet storing the staff files.

People were treated with respect and compassion, although people's privacy and dignity was not always maintained. There was a lack of meaningful activities, as the activity provision at the service was minimal. There was a lack of care and attention to detail when laundering people’s clothing and bedding. The laundry systems needed improving to ensure bedding and clothing did not leave the laundry un-ironed and creased.

The staff arrangement did not fully support people’s social and emotional needs to be met. Ancillary staffing arrangements, only allowing for basic cleaning to take place, leaving very little time for deep cleaning to take place.

Staff had received training to ensure people’s needs were met; this also included training in end of life care.

Medicines were managed appropriately and people received sufficient support to take their medicines as prescribed and when required.

People spoke positively about the staff that supported them and relatives felt staff always made them feel welcome. People and their representatives had opportunities to contribute to the planning of their care and support. People’s needs and preferences were set out in their care plans. People’s care and support needs were regularly reviewed and updated to ensure information was current to their changing needs.

People were encouraged to eat and drink enough to meet their needs, but the mealtime experience could be improved to make it a more enjoyable and social time for people. Staff monitored and recorded their observations about people’s general health and wellbeing and shared this information with all involved in people’s care. When they had concerns about people, they took appropriate action so that medical care and attention could be sought promptly from the relevant healthcare professionals.

At this inspection, we found the provider in breach of the legal requirements. You can see what action we told the provider to take with regard to this breach at the back of the full version of the report.

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.

We previously carried out an unannounced comprehensive inspection of this service on 1 March 2017 and identified six breaches of legal requirements.

We found that accidents and incidents had not always been reviewed appropriately to determine whether they should be raised as a potential safeguarding. This meant that not all incidents had been referred to the local authority for further investigation and that appropriate action was not always taken to keep people safe from abuse or neglect.

Risk assessments were not always reflective of people's current needs and did not always contain sufficient information to guide staff.

There was not always sufficient staff on duty, with the correct skill mix, to support people with their needs. Staff were only able to meet people's basic care needs but did not have the time to provide them with any meaningful support during peak times because of their deployment within the service.

Staff supervisions were not completed on a regular basis which meant that staff did not always have a record of formal discussions which took place. All staff said they felt well supported by the registered manager, who accepted that they needed to review the supervision system in place to bring this in line with the provider policy.

Although there were systems in place in respect of the Mental Capacity Act 2005 (MCA) these were not always used appropriately to ensure that decision specific assessments were completed for people.

Care plans did not always provide staff with sufficient guidance to meet people's specific needs and wishes and were often not user-friendly. Some aspects of the care plans had not consistently been reviewed and there was not always evidence to show that people or their families had been involved in reviewing them.

Quality monitoring systems and processes had not always been used as effectively as they could be to ensure that action was taken to make improvements when required. Audits failed to highlight key areas of the service in which improvements were required. There was a lack of management and oversight systems in place, which meant the registered manager and provider, were unable to monitor, assess and drive improvements at the service.

Following the inspection the provider sent us an action plan detailing the improvements they were going to make, and stating that improvements would be achieved by 1 May 2017.

This report only covers our findings in relation to the outstanding breaches of regulation. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Higham House Nursing Home’ on our website at www.cqc.org.uk.

This inspection took place on 3 May 2017 and was unannounced.

During this inspection, we found there was more robust oversight of accident and incident records. The registered manager now reviewed them to ensure they were reported as a potential safeguarding matter if appropriate.

We reviewed people’s risk assessments and care plans to ensure they had been updated in accordance with any changes in their care needs, or general condition. Guidance for staff was more robust and detailed which aided them to better complete the risk assessments. We found that steps had been taken to review care records and associated risk assessments on a monthly basis so they remained reflective of people’s care and support needs.

Staff numbers and staff deployment within the service had been reviewed to ensure that numbers were sufficient to keep people safe and enable them to have their needs met in a timely manner.

Action had been taken to review people's mental capacity, in line with the Mental Capacity Act 2005 (MCA) and where appropriate, we found that decision specific mental capacity assessments had been completed, utilising appropriate professionals to ensure a robust decision making process had taken place. We also found that staff had worked to document people's consent to care and treatment.

Quality assurance processes had been reviewed and we found that the registered manager now had more oversight of the areas where there had been previous breaches of regulation. They now had an action plan by which they would review each area to ensure they remained current and reflective of the situation within the service.

While improvements had been made we have not revised the rating for the four key questions inspected; to improve the rating to ‘Good’ would require a longer term track record of consistent good practice. We will review our rating for safe, caring, effective, responsive and well-led at the next comprehensive inspection.

We previously carried out an unannounced focused inspection of this service on 11 November 2016 and identified one breach of legal requirements. We found that areas of the service were not always clean and free from the risks associated with infection control. There were not effective cleaning schedules or logs in place to ensure cleaning was carried out as required.

We asked the provider to take action in response to our concerns around these areas by 15 December 2016 and issued the provider with a warning notice for this breach. On 6 January 2017, we carried out a focused inspection to see whether the provider had followed their improvement plan and confirmed that they were now meeting legal requirements. During this inspection we returned to undertake a comprehensive inspection of the service and to ensure that standards had still been maintained in respect of infection control and cleanliness.

This inspection took place on 1 March 2017and was unannounced.

We found that accidents and incidents had not always been reviewed appropriately to determine whether they should be raised as a potential safeguarding. This meant that not all incidents had been referred to the local authority for further investigation and that appropriate action was not always taken to keep people safe from abuse or neglect. Potential service user on service user safeguarding incidents had not always been reported to the relevant external agencies.

Risk assessments were not always reflective of people's current needs and did not always contain sufficient information to guide staff. The risk assessment process was however due to be evaluated as part of a review of all care plans.

There was not always sufficient staff on duty, with the correct skill mix, to support people with their needs. Staff were only able to meet people's basic care needs but did not have the time to provide them with any meaningful support during peak times because of their deployment within the service.

Staff supervisions were not completed on a regular basis which meant that staff did not always have a record of formal discussions which took place. All staff said they felt well supported by the registered manager, who accepted that they needed to review the supervision system in place to bring this in line with the provider policy.

Although there were systems in place in respect of the Mental Capacity Act 2005 (MCA) these were not always used appropriately to ensure that decision specific assessments were completed for people.

Care plans did not always provide staff with sufficient guidance to meet people's specific needs and wishes and were often not user-friendly. We found that some aspects of the care plans had not consistently been reviewed and there was not always evidence to show that people or their families had been involved in reviewing them. As a result they were not always reflective of people's current needs and requirements.

Quality monitoring systems and processes had not always been used as effectively as they could be to ensure that action was taken to make improvements when required. Satisfaction surveys had been completed but there had been no attempt to analyse or have oversight of the outcome of these in order to drive future improvement. Audits were carried out however; they failed to highlight key areas of the service in which improvements were required. There was a lack of management and oversight systems in place, which meant the registered manager and provider, were unable to monitor, assess and drive improvements at the service.

People were not able to comment on whether they felt safe but their demeanour was generally relaxed in the presence of staff. Staff had received training although we received mixed responses in their feedback as to the action they would take in the event of a possible safeguarding incident.

Robust recruitment checks were completed to establish that staff were safe to work with people before they commenced employment. Systems and processes in place ensured that the administration, storage, disposal and handling of medicines were suitable for the people who lived at the service.

During this inspection, we found that improvements had been made to the systems in place within the service, to ensure that appropriate standards of cleanliness and hygiene had been maintained. Staff had reviewed their practice in respect of cleaning, and had worked hard to ensure this was now more thorough.

Staff were supported through a system of induction and on-going training, based on the needs of the people who lived at the service. They also benefitted from additional informal support with free access to the registered manager which enabled them to discuss any concerns and training and development needs.

People were able to make choices about the food and drink they had, and staff gave support when required to enable people to access a balanced diet. There was access to drinks and snacks throughout the day. We found that people were supported to access a variety of health professional when required, including opticians and doctors, to make sure they received appropriate healthcare to meet their needs.

Staff members treated people with kindness and compassion. They worked to develop positive relationships with the people they cared for and treated them with dignity and respect. Visitors were welcomed to the service and staff members spent time getting to know them and working alongside them to ensure people's needs were met.

There was a positive culture at the service. Staff were motivated to perform their roles and felt well supported by the registered manager. They were able to talk to the registered manager about any concerns they had and seek guidance and support.

We identified that the provider was not meeting regulatory requirements and was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We carried out an unannounced focused inspection of this service on 11 November 2016 and identified one breaches of legal requirements. We issued the provider with a warning notice for this breach. On 6 January 2017, we carried out a focused inspection to see whether the provider had followed their improvement plan and to confirm that they were now meeting legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Higham House on our website at www.cqc.org.uk.

During the inspection on 11 November 2016, we found that areas of the service were not always clean and free from the risks associated with infection control. There were not effective cleaning schedules or logs in place to ensure cleaning was carried out as required. We asked the provider to take action in response to our concerns around these areas by 15 December 2016. During this inspection we returned to see if the service had made the improvements we asked for and we found that the provider was now meeting these regulations.

The service had a 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.

Improvements had been made to the systems in place for assessing and managing infection control and standards of cleanliness. The provider had introduced improved systems for managing the cleanliness of the service. Additional cleaning staff had been recruited and robust cleaning logs and checklists were in place, to help guide staff and to demonstrate which areas of the service had been cleaned and when.

Higham House provides residential care for up to 30 older people and people with dementia care needs. On the day of our visit, they were providing care and support to 26 people.

The service had a registered manager in post. 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.

During this inspection, we found that cleaning within the service was not always carried out to a good standard. People were not protected from the risks of infection as there were ineffective cleaning processes in place. We found that there were no effective systems in place to manage and monitor the prevention and control of infection or to ensure that the premises and equipment was safe and cleaned to an appropriate standard. Areas within the home remained significantly unclean and posed a risk of cross infection to people and staff.

We also found that the registered person had not protected people against the risk of an unsafe and inadequately maintained environment. There was a lack of appropriate signage and decoration for the people living at the service. We found there was a lack of appropriate signage for communal areas, including toilets and bathrooms to make them recognisable for people using the service. This meant that the service did not always provide a supportive environment for people with dementia care needs.

There were adequate numbers of staff on duty to support people safely, although their deployment did not always mean that staff could attend to people in a timely manner.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

We found that people's individual needs had been appropriately assessed before they were admitted to Higham House. After admission to the home, we saw that needs were regularly reassessed to ensure people received the safe care they required. This meant that staff had appropriate guidance to follow so as to minimise potential risks to people's safety and welfare.

People told us they felt safe with the staff supporting them. One person said, 'I like the girls, I really do. They are all nice.' A relative told us, 'I can have a laugh with the staff, it's great. They really do care for everybody.'

We found that staff were aware of the different types of abuse and what action to take if they suspected abuse had taken place. Systems were in place to ensure that lessons were learnt from safeguarding investigations. The home worked in accordance with its safeguarding policy and liaised with the local authority when required. This reduced the risk to people and helped the service to safeguard people.

There were suitable arrangements in place to respond to emergencies. The manager and other appropriately qualified staff were available 'on call' to support staff to manage an emergency situation safely and in a timely way.

We found that the equipment in place used to support people with their care needs, was appropriately maintained and serviced. Safety equipment, such as the fire alarm, extinguishers and call bells, were regularly tested and kept in good working order. This meant that people were cared for in a safe and maintained environment.

Is the service effective?

When we spoke with four staff and found that they had received the training and support they needed to do their job effectively. We observed staff engaging with people in a positive manner and when we spoke with staff, we established that they had a good working knowledge of people's preferences. They were able to advise us about the support people needed, and how they delivered their care. We found that this information was reflected in each person's care plan which demonstrated that people's needs were effectively met.

Some of the people at Higham House had complex needs and often required support to make safe decisions. Where people's ability to choose had been impacted upon by dementia, we found that the records contained appropriate information about their care needs and abilities. This meant that staff were guided to support people to express themselves and make their feelings and wishes known.

We found that people's needs had been assessed before the home provided them with the required care. On the day of our inspection, a new person had been admitted and we heard staff asking about likes and dislikes and engaging with family members as to how to manage challenging behaviour. People were involved in the planning and development of their care plan which they had been asked to sign.

Staff spoken with said that they had been provided with appropriate training and the records we saw supported this. We found that supervision and appraisal, for staff had been regular and were told that both the manager and deputy manager had an 'open door' policy so that anything could be discussed. This demonstrated that people were cared for by staff that were supported to deliver care and treatment safely and to an appropriate standard.

Is the service caring?

The staff presented as very friendly and helpful. We heard staff encourage people to be independent and provide them with timely assistance whenever required. One person told us, 'They are always there if I need help.' A relative said, 'I am always greeted like a member of the family, all the staff know me and take time to speak to me.' This demonstrated that people and the relatives felt supported and respected by the staff that were caring for them.

Is the service responsive to people's needs?

We saw that there was sufficient staff on duty to meet people's needs. This was also confirmed by the three staff, two visitors, and four people we spoke with. A relative told us, 'People never seem to have to wait for help; there is always enough staff about to help.' During the course of our inspection, we heard that call bells were responded to in a timely manner.

The three staff we spoke with had a good understanding of how to support people in a way that respected each person as an individual, each with their own needs and wishes.

Where people had specific dietary requirements we found that the home was responsive to these, and ensured that people received a nutritious dietary intake, with a variety of options.

The people we spoke with said that they knew how to make a complaint or raise a concern, although they had never had to. We found that the provider maintained a record of complaints and compliments but that there had been no complaint received for some time. People and staff told us that if they had an issue it was dealt with swiftly because they had the freedom to speak with senior staff.

Is the service well-led?

The staff we spoke with said the manager was very approachable, and always there to help them. We were also told that the deputy manager was flexible in their approach and willing to offer support. Staff said, 'We are a close team and all know how each other works. We help each other.' One relative said, 'I would be more than happy to go straight to the manager if I had a worry, but I never have had to.'

We found that the home had effective quality assurance processes in place and these had been embedded into the staff's routine. We found that staff meetings had been taking place as required and that there was a philosophy of effective communication between all staff, which helped to ensure people's needs were well met and responded to safely.

During our visit we found that staff were respectful and caring in their approach when talking with the people who lived in the home. We saw the manager had maintained good links with other health agencies and relevant organisations.

We spoke to the manager, deputy manager, staff, people who lived in the home and their family members. Staff told us they enjoyed their work and felt supported in their learning and development. One member of staff told us, 'I enjoy it very much.'

Family members we spoke to told us, 'I would recommend it to anyone." And, "The managers door is always open, you can talk to her any time."

We also looked at how information and records were managed. Overall, we found information was up-to-date and stored securely. On two staff we looked at some personal information required to be updated, however we saw that the manager addressed these matters immediately they were pointed out to her .