Horton Cross Nursing Home

Horton Cross Nursing Home is a care home registered to provide care and accommodation for up to 47 people. The home specialises in the care of older people. At the time of the inspection there were 37 people living at the service.

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

During the inspection several concerns were identified and shared with the provider. The provider did not have effective oversight of the care provided and the running of the service. Repeated breaches of the regulation linked to safe care and treatment and good governance indicate lessons were not being learnt by the provider. This meant they also failed to implement improvements at the service in a timely manner.

People did not always receive safe care and treatment. Risks and care needs were not always identified and actions to lessen risks not taken.

People did not always have their clinical needs met effectively. Instructions from health professionals was not always followed leaving people at risk of further health complications.

People did not always receive care that was personalised to their individual needs. The provider had not always ensured staff on duty were sufficiently qualified, competent, skilled, and experienced. This impacted on the quality of care delivered to people.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests. The practice and systems in the service did not support this practice. We have made a recommendation as care plans for people living with dementia did not always contain records of best interest decisions in relation to where and how people spent their time. We observed several people spent all day or long periods in bed or in their room. However, records did not contain information about how these decisions were made.

The provider took the concerns found during the inspection seriously and will work alongside CQC and other agencies to address the issues. The provider developed an action plan following the inspection to address the shortfalls found.

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 20 October 2022).

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 the provider remained in breach of regulations.

At our last inspection we recommendations the provider monitor the storage temperatures for all medicines and make improvements were required to the environment, including access to bathing and showering facilities. We found action had been taken to address the recommendations.

Why we inspected

The inspection was prompted in part due to concerns received about how people's needs were being managed. A decision was made for us to inspect and examine those risks.

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 COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

Enforcement and Recommendations

We have identified breaches in relation to safe care and treatment, staffing deployment, person centred care, and governance.

We have taken enforcement action requiring the provider to ensure the robust and effective management and governance of the service.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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

Quality assurance processes to oversee the safety and quality of the service had failed to identify the concerns we found at this inspection.

We identified shortfalls in managing risks related to the environment and the safe delivery of care and treatment. People's care records were not always accurate, and some required updating to ensure information about risks to people were known. Not all staff had been recruited in a safe way. Important information was missing from recruitment files.

Infection control procedures were not robust. Some areas of the premises were not clean. For example, the communal dining area and lounge. This had improved by the second day of the inspection.

There were sufficient staff on duty to meet people’s needs. However, we have recommended the provider review the staffing arrangements at night.

Medicines were generally safely managed. However, we have made a recommendation the provider monitor the storage temperatures for all medicines.

Improvements were required to the environment, including access to bathing and showering facilities. The provider had a programme of refurbishment in place. We have recommended the provider seek advice and guidance on environmental adaptations for people living with dementia.

On the whole people enjoyed the food served. However, some people would benefit from an improved dining experience, especially those who remained in bed.

Some routines were not person centred. We have recommended daily routines are reviewed to ensure person-centred care and support is consistently delivered to people living at the service.

People said they felt safe at Horton Cross Nursing Home mainly because they were confident in the care and support provided by staff. One person explained, “We find it safe here. Staff are one reason; they are good”. Relatives confirmed they had no concerns in relation to safeguarding. We observed people appeared relaxed and comfortable with the staff who supported them.

Staff had been supported to develop the skills they needed to meet people's day to day needs. Comments from staff included, “We are well supported by the registered manager and team”.

People had access to external health and social care professionals to ensure their health care needs were addressed. Feedback from health professionals was positive. They described a service that ensured referrals were timely; any recommendations were acted on and staff had a good knowledge of people’s needs. One professional said, “Communication is excellent with the service”.

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

Throughout the inspection, the registered manager and provider displayed a candid and transparent approach. They spoke openly about challenges and shared the plans they had in place to address them. They responded to our feedback and were making improvements to the service following the inspection.

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 (published 31 August 2018).

Why we inspected

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 Covid-19 and other infection outbreaks effectively.

We received concerns in relation to risk management following a safeguarding investigation. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified three breaches of regulation in relation to safe care and treatment, staff recruitment and good governance.

We have made recommendations in relation to staffing levels at night; the storage of some medicines; daily routines and aspects of the environment.

You can see what action we have asked the provider to take at the end of this full report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Horton Cross Nursing home is a care home registered to provide care and accommodation for up to 47 people. The home specialises in the care of older people. At the time of the inspection there were 41 people living at the home.

At our last inspection, in March 2016, we rated the service good. At this inspection we found the evidence continued to support the rating of good and there was no evidence or information from our inspection and ongoing monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

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At this inspection we found the service remained Good.

Why the service is rated Good.

People lived in a home where staff morale was good which created a happy and relaxed atmosphere. One person told us, “Staff are always happy and chatty.”

People received safe care and support from adequate numbers of staff who had the skills and experience to meet their needs.

Staff were kind and caring and treated people with respect and dignity. One person said, “If I had to sum up the staff I would say, very caring and loving.”

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.

People’s health was monitored by trained nurses and they had access to other healthcare professionals to meet their individual needs. People received their medicines safely.

People’s nutritional needs were assessed and met. People received the support they required to eat their meals and were happy with the food provided. One person told us, “I’m a fussy eater but they are brilliant. If I don’t want what’s on the menu they make me something different.”

People were treated as individuals and staff supported people to make choices about their day to day lives. Staff knew people well and provided care that was personalised to their wishes and needs.

The home was well led by a stable management team. The management team kept up to date with good practice to make sure people’s care was provided in accordance with best practice guidelines and current legislation.

There were effective quality assurance systems which monitored standards of care and addressed any shortfalls in the service.

Further information is in the detailed findings below.

The last inspection of the service was carried out on 2 April 2014. No concerns were identified with the care being provided to people at that inspection.

Horton Cross Nursing Home provides accommodation with nursing care for up to 47 people. The home provides a service for older people. Accommodation is arranged over two floors and all bedrooms are for single occupancy. The home is staffed 24 hours a day and a registered nurse is on duty at all times.

There was 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.

From the management down; staff were committed to making sure people were safe, happy and received the care and support they needed and wanted. Staff were very kind, caring and patient when they interacted and assisted people. People spoke highly of the staff team. One person said “All the staff are so very kind. That’s from the top down.” Another person said “I cannot speak highly enough of the staff. Nothing is too much trouble and they are all so kind to me.” A visitor told us “I can’t praise them [the staff] enough. They are so kind and welcoming.”

People received care and support which was adjusted to meet their changing needs. People had access to appropriate healthcare professionals to make sure they received effective treatment when required. People received their medicines when they needed them and medicines were stored securely. Medicines were managed and administered by registered nurses whose skills and knowledge were regularly monitored.

People were supported to have enough to eat and drink. People were positive about the quality, quantity and choice of food available. One person told us “The food here is very good and there is plenty of it.” Another person said “The food is excellent and they know what you like.”

Risks to people were minimised because there were effective procedures in place to identify and manage risks. These included reducing the risk of falls, assisting people to mobilise and reducing risks to people who were at high risk of malnutrition and pressure damage to their skin. A plan of care had been developed to minimise risks and these were understood and followed by staff. Staff recruitment procedures minimised risks to people because potential staff were thoroughly checked to make sure they were suitable to work with vulnerable people. Staff had received training and knew how to recognise and report abuse. All were confident that any concerns reported would be fully investigated and action would be taken to make sure people were safe.

The registered manager made sure staff skills and knowledge were up to date and that they were competent to care for the people who lived at the home. This was achieved through regular supervisions, observation of their practice and on-going training. People were very complementary about the staff who supported them and felt they had the skills required to effectively care for them. One person said “All the staff are really good. They know what they are doing and I have great confidence in all of them.”

People told us they were never made to do something they did not want to do. One person said “I get up when I want and go to bed when I want. It’s very relaxed here.” During the afternoon we heard staff asking one person if they would like to go to their room as they appeared sleepy. The person indicated they would and they were assisted to do so.

People were provided with opportunities for social stimulation and they were supported to maintain contact with their friends and family. People told us they could see their visitors whenever they wished and that they were always made to feel welcome.

People and their visitors knew how to make a complaint. Everyone we spoke with said they felt confident any concerns would be addressed.

' 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 safe?

We found the service to be safe because they had a range of policies and procedures in place to protect the people who lived in the home.

There were risk assessments in place regarding mobility, nutrition and skin care. Where someone had been assessed as being at high risk of pressure damage appropriate equipment such as pressure relieving mattresses and cushions were in place. The manager told us there were never any problems obtaining specialised equipment to meet people's assessed needs.

The Care Quality Commission (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 had been trained to understand when an application should be made and how to submit one. This meant that staff knew how to ensure people's rights were respected.

We saw that staff had received training about safeguarding adults from abuse and those spoken with demonstrated a good understanding about what constituted abuse and how to report any concerns. Staff confirmed they would not hesitate in reporting concerns if they had any. They also told us they felt confident that any concerns would be responded to and appropriately investigated.

There were sufficient numbers of suitably qualified, skilled and experienced staff on duty to meet the needs of the people who lived at the home.

Is the service effective?

We found the service to be effective because people's care treatment and support achieved good outcomes. We also found that people's rights and choices were respected by staff.

The majority of people required staff assistance to mobilise. Throughout our visit we heard staff checking people were happy with where they were sitting. We observed staff assisting people to their bedrooms where requested. The people we spoke with told us that staff respected their wishes. Comments included 'They don't do anything without checking with me first. They are very good' and 'the staff keep me informed and make sure I can have my say.'

Is the service caring?

People told us the service was caring. The people we spoke with were positive about the care and support provided by the home. Comments included 'I am very satisfied with everything. They do a good job' and 'It's nice to be able to have a laugh and joke with the staff.'

People told us they felt safe and well cared for and all commented on the kindness of the staff. Throughout our visit we observed staff interactions with people to be kind and respectful and people appeared very comfortable in the presence of staff.

Is the service responsive?

The service was responsive to people's needs. We saw that people's health care needs were monitored and responded to appropriately. Information about people's health needs and contact with health and social care professionals had been recorded. We were informed that the service received good support from health and social care professionals and there were no problems obtaining their input for people when required. The people we spoke with made the following comments 'I am diabetic and the nurses make sure I get regular visits from the chiropodist' and 'I haven't needed the doctor yet but I am confident they would sort something if I was poorly.'

Staff were able to respond appropriately to people's needs because they had up to date guidance on how to support each individual. We read the care plans of four people who lived at the home. These contained assessments of need and outlined how needs would be met. The assessments were regularly reviewed to ensure they reflected people's up to date needs and preferences.

Is the service well led?

The service was well led because there were systems in place which monitored the quality of the service provided. The service was proactive in seeking the views of the people who lived at the home and their representatives. We saw that the service responded to any comments or suggestions made.

The service was managed by a person who had been registered by the Commission. The registered manager, who is a registered nurse, regularly provided 'hands-on' care. This meant they remained up to date with the needs and preferences of the people who lived at the home. The people we spoke with were positive about the manager. They told us the manager was "approachable" and was "always ready to listen." The staff we spoke with told us they received the training and support they needed. They told us the manager responded to training requests and that they found her "very approachable."

We found procedures were in place to minimise any risks to the people who lived at the home. Regular internal audits had been carried out which monitored the on-going health and safety of people. Internal audits included checks on the home's fire systems, environment, care planning and the management of people's medicines.

Some people were able to tell us that staff sought their consent about the care and treatment they received. One person told us that they had recently had a flu jab. They told us that this had been explained to them and they had been given the option not to have one.

People's human rights were not always protected because the home did not follow the principles of the Mental Capacity Act 2005 or Deprivation of Liberty safeguards.

The people we spoke with, including four visitors, were positive about the care and support provided by the home. Comments included 'they really saved my life. I moved here after eight months in hospital. I have improved so much since being here. I feel better than ever' and 'I cannot fault the care here. They are all so kind and caring.'

The home's health and safety procedures minimised risks to the people who lived at the home. We saw that people had been provided with equipment in line with their assessed needs.

People using the service were provided with opportunities to express a view on the quality of the service they received. Quality assurance procedures helped to reduce risks to people who lived at the home.

We spoke with two visitors who told us that the home kept them 'well informed' about the well being of their relative. One visitor told us that they had been involved in the development and review of their relative's care plan. People spoken with were also aware that they had a plan of care and we saw that people had been involved in the review of their care.

We asked people if they were able to make choices about how and where they spent their day. They told us 'I can come to my room when ever I want to. There are no strict rules' and 'They know that I like to go to bed early and get up early. That's always been my routine.'

The home had policies and procedures for recognising and reporting abuse and whistle blowing for staff. All staff spoken with were aware of issues of abuse and knew how to report any worries or concerns. All said they felt confident that any reports would be fully investigated to ensure that people were protected.