Background to this inspection
Updated
8 February 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection took place over three days, the 7, 8 and 12 of December 2016 and was unannounced.
The inspection team was made up of four inspectors, a specialist nurse advisor and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of service. The expert by experience had experience of providing care and support for an older person.
Prior to our inspection we reviewed the previous inspection report to help us plan what areas we were going to focus on during our inspection. We looked at other information we held about the service including statutory notifications. This is information providers are required to send us by law to inform us of significant events.
Some people living at the service were unable to tell us, in detail, about their experiences of how they were cared for and supported because of their complex needs. However, we spoke with 11 people who were able to verbally express their views about the quality of the service they received and six people’s relatives. We also spoke with one visiting healthcare professional.
We observed the care and support provided to people and the interactions between staff and people throughout the three days of our inspection. We also carried out a Short Observational Framework for Inspection (SOFI). SOFI is a tool used to help us assess the care of people who are unable to communicate to us their experience of the care they received.
We looked at records in relation to nine people’s care. We spoke with the manager, the clinical services manager, the deputy manager, and two regional managers. We also spoke with, five nurses, the cook, one activities coordinator and eight members of care and domestic staff.
We looked at records relating to the management of medicines, staff recruitment, staff training and systems for monitoring the quality and safety of the service.
Prior to and during our inspection we spoke with stakeholders such as the local authority and visiting health care professionals.
Updated
8 February 2017
This inspection was unannounced and took place over three days, on the 7, 8 and 12 of December 2016.
Monmouth Court Nursing Home provides care and support to a maximum of 153 older people, some of whom were living with dementia and or had complex nursing needs. People were accommodated across three units, with a fourth unit being closed at the time of our inspection. At the time of our visit there were 58 people living at the service.
At our previous inspection in December 2015 the service was rated as ‘inadequate’ and so placed into special measures. This was because we identified major shortfalls with breaches of regulation regarding the lack of action taken to mitigate the risks to people, insufficient numbers of suitability, qualified and experienced staff available at all times to meet people’s complex health care needs and the monitoring of the safety and quality of care provided to people across all three units at the service. This was linked to a lack of clinical oversight and effective leadership and support from the registered manager and the provider. In response to our findings we asked the registered manager to take urgent action to protect people from harm. We took urgent action by placing conditions on the provider’s registration including the restriction of any new admissions to the service.
At this inspection we found some improvements. However, there was a need for further development of the service. We identified continued shortfalls in relation to people having access to sufficient numbers of, suitably qualified staff at all times to meet their needs and in the training, development and deployment of staff to meet the needs of people living with dementia. There continued to be a high number of nursing staff vacancies which meant there continued to be a high number of agency nurses employed. This impacted on the effectiveness of communication and the consistency of care provided to people to ensure their health, welfare and safety needs were met.
Since our last inspection the registered manager had left and a new manager appointed in August 2016. There is a requirement for this service to have a manager registered with the Care Quality Commission (CQC). The manager told us they had completed their application to register but their application was currently with Bupa’s legal team for review before submission to CQC. 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 and their relatives were positive about the change in management and responses to any concerns and or complaints they had raised with the provider. There were improved systems in place for continuous quality and safety monitoring of the service including clinical oversight of the service.
The provider had improved systems in place for identifying risks to people’s health, welfare and safety. We found some improvement had been made with systems now in place to ensure the safe management and monitoring of people's nutrition and hydration needs, in particular for people with swallowing difficulties, those at risk of choking and people at risk of insufficient intake of nutrition and hydration. However, risks that had been identified were not always consistently managed.
At our previous inspection we identified major shortfalls in the safe management of people’s medicines. At this inspection we found significant improvement. However further work was needed as we found inconsistencies in the management and recording of people’s prescribed creams and lotions. Staff were not always provided with clear information as to where on the body and how often the creams and lotions should be applied.
The provider had systems in place and staff trained in identifying acts of abuse and what steps to take to reduce the risk of people experiencing abuse. Staff had been provided with procedural guidance in reporting issues of concern such as whistleblowing and safeguarding policies and procedures to follow. However, we found risks to people’s health, welfare and safety were not always effectively managed. There continued to be a high number of nursing staff vacancies. There was not to always sufficient numbers of skilled and experienced staff available to provide consistency of care which met people’s needs.
We observed some very caring interactions between staff and people living at the service. Relatives were positive about the improvements they had observed in the culture of the staff group. Staff were observed in the main to be kind and respectful but care delivery on Harlech unit was often task focused as staff had limited time to spend with people. This included the number of staffing hours allocated to those staff employed to provide social stimulation, including group activities and so staff were not always able to meet the holistic, individual needs of people living with advanced dementia.
We found inconsistencies in the quality of care planning to guide staff in the steps they should take to meet people’s needs. Care plans did not always reflect the current needs of people and contained limited information as to people’s preferred wishes and preferences about how they would like to live their day and support that should be provided to enable them to do this. There was a lack of provision of support to enable people to maintain their hobbies and interests as much as they are able. People were not always protected from the risks of social isolation. There were a high number of people who stayed in bed. It was not always clear within their care plans as to why this was the case.
During this inspection we identified a number of continued breaches 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 this report.