Green Gables Nursing Home (Downing Green Gables Limited)

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

Systems and processes in place to assess, monitor and improve the service were not always effective. The provider and registered manager had not identified the issues we found in the inspection.

The registered manager and staff team lacked knowledge about safeguarding. People told us they felt safe and had no concerns, but we found there was a potential risk to people if a safeguarding concern arose and staff were unable to respond to it appropriately. We signposted the registered manager to information to develop and update their knowledge. The provider and registered manager gave us assurances staff knowledge on safeguarding would be improved.

There was a lack of oversight of the training and competence staff had in managing medicines. The registered manager gave us assurances systems would be put in place to ensure staff had appropriate training and competence.

There was not a robust system in place to ensure the service always recorded and learnt from incidents.

Recruitment records were not fully completed with all the required information. The provider gave us assurances the information had been sought at the time staff were employed and told us recruitment checks would be fully documented in future.

There was a lack of leadership in the service in ensuring the care provided was in line with up to date best practice guidance. The registered manager informed us they would undertake a review of the service to check they were following up to date best practice in all areas.

The service did not always communicate effectively with outside agencies. Some of the barriers to this communication were related to technology. The provider had put measures in place to improve this.

We received mixed feedback about the staffing levels in the service. Though we did not observe any concerns about staffing during the inspection, the provider agreed to review their staffing levels based on the feedback we had received from staff and people.

We were assured the provider had robust infection control procedures in place, which staff were following, to keep people safe from the risks of COVID-19. The provider assigned additional staff support for people who were required to isolate upon admission to the home, which helped promote their safety and wellbeing. The provider had also effectively followed recent government guidance to develop safe procedures around indoor visits for relatives.

We observed staff supporting people appropriately with moving and handling during the inspection. People had a variety of risk assessments in place and these were reviewed regularly.

The registered manager told us they tried to create an open, approachable culture. People, relatives and staff told us they felt able to approach the management of the service with any concerns.

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

Rating at last inspection

The last rating for this service was good (16 May 2018).

Why we inspected

We undertook this inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns received about safeguarding, moving and handling and staffing levels. A decision was made for us to inspect and examine those risks.

We inspected and found there were concerns with the management of the service, so we widened the scope of the inspection to become a focused inspection which included the key questions of safe and well-led.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Green Gables Nursing Home on our website at www.cqc.org.uk.

Follow up

The provider sent us information indicating how they will make improvements to address the issues we found in the inspection. We will review this at the next inspection. 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.

Green Gables accommodates up to 38 people in one adapted building. There were 31 people at the service at the time of inspection. The accommodation is over three floors, each floor is accessible via stairs or a passenger lift.

The service was rated Requires Improvement at its last inspection in September 2016 and had a breached one regulation in relation to staffing. Following the last inspection, we asked the provider to complete an action plan to show what they would do to meet the breach and improve the key question of Safe to at least Good. At this inspection, we found that the provider had made sustained improvements by increasing staffing levels. There were sufficient staff available to monitor people’s wellbeing and attend to people’s needs without appearing rushed. The service is now rated Good overall.

The registered manager had increased the number of staff on shift during daytime hours. This meant that there was always a member of staff present in communal areas of the home to attend to people’s needs. The deputy manager was prominent in organising and supporting staff to ensure they were effectively meeting people’s needs. People and their relatives told us that improvements had been made to both the level and standard of staffing. This meant that staff were able to quickly respond to people’s requests and spend quality time during the day with them. The provider had systems in place when recruiting new staff to check their character and experience to help ensure they were suitable to work with people.

There was a registered manager in place. 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.

People were supported to maintain good health. The provider had participated in programmes in conjunction with health professionals to promote people’s nutrition and hydration. People told us they were happy with the meals available to them and they received the appropriate support from staff if they required or assistance whilst eating. People had access to healthcare services as required and recommendations from health professionals were incorporated into people’s care plans.

Risks to individual’s health and wellbeing were assessed and monitored. The provider had made improvements after feedback from incidents. In one example, the provider had made changes to how they managed people’s wound care after feedback from professionals highlighted where improvements were needed.

People’s needs were assessed using assessment tools which helped the registered manager determine appropriate care and treatment plans. Care plans were developed in partnership with people, families, social workers and health professionals. Where people required additional healthcare support, the registered manager made the relevant referrals in good time, to ensure that people received effective care.

People’s care plans detailed their preferences around their daily routines and personal care arrangements. Staff were sensitive to these needs and treated people with dignity and respect. People were positive about staff and told us they were caring, humorous and attentive to their needs.

The provider had made considerations about how to provide dignified and empathetic support to people at the end of their lives. People’s wishes about their final care arrangements had been explored, which helped to ensure that the care provided was in line with their preferences.

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.

There were safe systems in place to manage people’s medicines and staff were aware of the support people needed around their medicines for pain or anxiety.

The home was clean and risks associated with the spread of infections were safely managed.

Staff had access to a range of training relevant to their role. Nursing staff were supported to maintain their professional qualifications. Staff received ongoing support in their role through supervisions and observations of their working practice by the deputy manager. The registered manager held regular staff meetings, which helped review staff performance and reinforce good practice.

Staff were aware of their responsibilities in safeguarding people from abuse and harm. The registered manager had reported concerns appropriately to local safeguarding teams and acted upon recommendations to help keep people safe.

There were systems in place to deal appropriately with people’s complaints. Where people had raised concerns, the registered manager thoroughly investigated the issues at hand and provided people with an update from their findings. People and their relatives were positive about how well their concerns were investigated and their perspective considered.

The registered manager used a range of methods to involve people to gain feedback to make improvements. These included questionnaires, comment cards and residents meetings. The registered manager was keen to make improvements and shared feedback with staff where issues needed addressing.

The registered manager had a system of audits and checks which focussed on assessing and maintaining the quality and safety of the service. The provider’s regional manager had oversight of the servicer through a series of reports, visits and observations of staff. The provider also regularly visited the home and had a good insight into the day to day culture of the service.

The provider was developing the environment to make it more accessible for people to use. At the time of inspection, the communal garden area was being redeveloped, which would enable people to easily access the outside space.

The home had a registered manager. A registered manager is a person who has registered with the Care Quality Commission (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.

We identified concerns relating to staffing that may compromise people’s safety. There were insufficient staff deployed to ensure people remained safe at busy times when staff were mainly task driven. Staff often took too long to respond because they were providing support to other people. This meant that there was an increased risk that people’s needs may not be met safely.

Staff were always under pressure and did not have time to sit and talk with people, which left some people feeling lonely and socially isolated. The home did not employ a full time activities coordinator which meant that people were not always supported to follow their interests and take part in stimulating social activities which enhanced their well-being.

Staff generally felt supported by the registered manager and deputy manager but some had become disillusioned in relation to the management response regarding their concerns about staffing levels. Staff did not always feel their views were listened to by the management team.

Most people told us they felt safe because they were supported by staff whom they knew and trusted. People were protected from abuse because staff were trained in safeguarding and understood the actions required to keep people safe.

Potential risks to people's safety had been identified and managed appropriately to mitigate the risk of harm to them. Risk assessments gave staff clear guidance to follow in order to provide the required support to keep people safe and promote their independence.

The provider followed safe recruitment practices. All staff underwent pre- employment checks as part of their recruitment, which were documented in their records. People were safe as they were cared for by staff whose suitability for their role had been assessed by the provider.

People were protected as processes were in place to manage emergencies to ensure people were safe, for example; evacuation plans in the event of a fire or flood and contingency plans to deal with the failure of utilities.

People’s medicines were administered safely by nursing staff who had completed safe management of medicines training and had their competency assessed by the registered manager. People had medicines risk assessments to manage the risks associated with the use of their medicines, including any known allergies or side effects.

Most people and their relatives told us the registered manager and staff provided effective care and support. People told us staff knew their needs and how they wished to be supported. Staff received effective supervision, training and support to enable them to carry out their roles and responsibilities effectively. Staff completed an induction course based on nationally recognised standards and spent time working alongside experienced colleagues. New staff had their competency assessed by the registered manager and nurses before they were allowed to support people unsupervised. Staff had completed the provider’s required training which ensured they understood how to meet people’s support and care needs. The provider had enabled further staff training to meet the specific needs of the people they supported, including diabetes and dementia awareness.

Staff consistently supported people to make as many decisions as possible and always sought their consent before providing any care or support. People who did not have capacity to consent to their care or support had their rights protected under the Mental Capacity Act (MCA) 2005.

People and relatives told us the food was nutritious and appetising. The cook followed nutritional guidance based on people’s preferences and any professional assessments undertaken by dieticians or speech and language therapists to ensure people would receive the support they needed to eat and drink. People were supported to maintain a healthy, balanced diet.

People were supported to stay healthy and were promptly referred to relevant healthcare professionals when required.

People were supported in their day to day care by staff who were kind and gentle. People and relatives consistently told us that staff had developed positive relationships with people over time, which we observed in practice.

Initial assessments were completed before people moved into the home to ensure the provider was able to meet people’s needs. Care documents showed needs and risk assessments were completed and reviewed with the involvement of the person, their relatives or care manager where required.

Staff had completed training in relation to equality and diversity and were able to explain how they ensured people had their different cultural customs and values respected. People were consistently treated with dignity and respect by staff, who spoke with people in a way that was appropriate to meet their needs and ensure their understanding.

All complaints about Green Gables had been managed in accordance with the provider’s complaints procedure. People had access to information on how to make a complaint, which was provided in an accessible format to meet their needs.

We observed the registered manager and deputy manager engage with staff providing highly visible, clear and direct leadership, for example; supporting staff to calm a person whose behaviour which may challenge others had begun to escalate.

The provider had established quality assurance and governance systems which the registered manager operated effectively to drive continuous improvement in the service delivery. Staff embraced the provider’s philosophy and values to provide the best quality care, which they demonstrated in their day to day support of people.

We identified one breach of regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we have taken at the back of the full version of the report.

We observed how staff supported people and looked at documents including care plans and management reports. We considered information from a number of sources to decide on the focus of the inspection. All of the evidence we had gathered under the outcomes we inspected was used to answer the five questions we always ask;

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

This is a summary of what we found.

Is the service caring?

The service is caring. We saw that staff supported people with patience, respect and care. They treated people with dignity and promoted their independence and took a genuine interest in people's well-being. One visitor that we spoke with told us, 'I have always found the staff here to be very caring. Particularly the senior care staff and they're the ones who set the standards aren't they'.

Care plans reflected people's needs and preferences. We saw that in spite of a lack of continuity of staffing, nursing staff and care workers followed guidance to ensure people were supported as they wished.

Is the service responsive?

We found that some processes for monitoring care needs and performance were not providing the managers with important performance information. For example, staff supervision and appraisal and the complaints process. As a result the service was responsive to those matters it became aware of but not always fully in the picture and able to ensure people were supported appropriately.

We saw evidence that the provider had taken prompt remedial action relating to the safety of wheelchairs following an incident. The lack of footplates on existing stock and the impact of this on people using the service had apparently not come to light as a result of the service maintenance regime.

The recent re-introduction of the staff supervision and regular care plan reviews if sustained is seen as a positive development.

Is the service safe?

We found that the general security of the premises and gardens was appropriate and adequate to ensure that people lived in a safe environment. We saw that in general, people using the lounge and dining room were relaxed, and appeared to enjoy the company of staff.

People and visitors told us that they felt safe though one identified some anxiety about a fellow resident as a result of what they considered to be aggressive behaviour.

However, we considered that the safety of the service was compromised by the inadequate numbers of permanent nursing and care staff. We noted that there was an over reliance on agency staff. Over 50% of the care staff shown on the duty rota were not directly employed by the service.

The regularity with which people's needs was assessed was unclear from the care planning this meant that staff could potentially rely on out of date information when providing care.

Is the service effective?

The service is generally effective in the management of peoples health needs. Care plans detailed people's care needs and wishes. There was a monthly review process in place to ensure changes in people's care needs were identified and responded to. However, we noted that a condition affecting one person using the service had not been assessed fully and that guidance to nursing and care staff was incomplete.

People using the service and visitors told us that structured activities had been rare recently and that their access to the community had been limited by lack of staff.

Is the service well led?

The registered manager told us that they operated an 'open door' policy and was

always available to people, relatives and staff to discuss care quality issues. We noted that their profile was high in the service during our inspection.

We consider that the service is not well led at this time because some procedures for monitoring and assessing care quality and service performance have fallen into disuse. We consider that the service has become reactive rather than proactively identifying emerging problems and introducing strategies to manage them.

All the people and relatives we spoke with told us that the care was good and that staff look after people 'Very well'. One relative told us that their family member looked 'Really well' since they moved in.

People said that they felt 'Safe' and relatives we spoke with confirmed this. Staff were able to describe to us what to do if they had concerns about safeguarding.

We found that the service was clean and tidy in all the areas we looked at and staff followed procedures to keep people safe and well. Relatives told us that the service was always 'Spotless.'

We found that there were sufficient staff to meet people's needs. People told us that staff were always available and that they did not have to wait for them if they needed something.

We found that some records were not always easy to read and that there were gaps in recording in respect of some people's food monitoring charts.

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

We concluded that people's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

The home was undergoing major refurbishment. The provider was in the process of adding a further 12 bedrooms; four on each floor. We found that people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises.

We concluded that staff were able, from time to time, to obtain further relevant qualifications. However we found that there were not enough qualified, skilled and experienced staff to meet people's needs.

We concluded that people's complaints were fully investigated and resolved, where possible, to their satisfaction.