Archived: Rowan Garth Care Home

Rowan Garth Care Home is a large care service in Liverpool which comprises of five separate units, set within extensive grounds, the service can accommodate up to 150 people. Each of the five units are single-storey and can accommodate up to 30 people. The service supports people with a range of care needs from nursing and end of life care, to short term respite care and residential care. Rowan Garth is situated in a suburb of Liverpool, close to transport links. Clover unit closed on 30 September 2016 so only 4 units were occupied at the time of the inspection. The units provide residential, nursing, dementia residential and dementia nursing care. The provider is BUPA Care homes (CFH) Limited.

During the inspection, there were 112 people living in the home.

During the last inspection on 11, 12 and 13 April 2016, we found the provider was not meeting legal requirements in relation to safe care and treatment and good governance and we issued warning notices in these areas. The provider was also not meeting legal requirements in relation to protecting people from abuse and improper treatment and we issued a requirement notice regarding this. During this comprehensive inspection we checked to see whether improvements had been made in these areas and to ensure legal requirements were being met.

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.

At our previous inspections of Rowan Garth in September 2015 and April 2016 we had concerns about the way medicines were managed throughout the home. After our last inspection in April 2016, we issued a warning notice telling the provider that improvements must be made by May 2016 as they were in breach of legal requirements. We found during this inspection however, that medicines continued not to be managed safely and legal requirements were still not being met.

Staff had completed risk assessments to assess and monitor people’s health and safety. We found however, that not all identified risks were managed safely.

We looked at how the home was staffed. Most staff told us there were usually enough staff on duty to meet people’s needs, but people living in the home had mixed views on staffing levels and relatives felt there were not always enough staff on duty. Our observations showed us there were not always enough staff on duty to meet people’s needs in a timely way as we observed people having to wait significant periods of time to receive support they had requested. The registered manager told us they completed an assessment of people's needs to help determine how many staff were required to ensure people's needs could be met and that this assessment was reviewed regularly. The registered manager told us that based on the number of staff the tool suggested were necessary, the home was overstaffed.

Most people we spoke with told us they felt safe living in Rowan Garth and relatives agreed. All staff we spoke with told us they had completed safeguarding training and knew how to report any issues. We found that appropriate safeguarding referrals had been made. Accidents were reported and actioned appropriately. Records showed that most safe recruitment practices were followed.

Arrangements were in place for checking the environment to ensure it was safe. Internal checks were completed and external contractors were utilised to ensure equipment remained safe.

During our last inspection we found that DoLS applications were not always submitted when required and people were being deprived of their liberty unlawfully. During this inspection we found that although improvements had been made and most applications had been made appropriately, not all restrictions had been identified and acted upon.

When people were unable to provide consent, most care records showed that mental capacity assessments were completed and decisions made in people’s best interest through consultation with the relevant people in line with the MCA.

We looked at ongoing support provided to staff and found that although staff told us they felt well supported, supervisions and appraisals were not always provided regularly to help support staff in their roles. Staff underwent a period of induction and completed training that the provider considered mandatory as part of the induction process and on an on-going basis.

People living in the home were supported by the staff and external health care professionals to maintain their health and wellbeing.

Feedback regarding meals was positive. There were choices available to people and specific dietary needs were catered for.

The registered manager had taken steps some within the units for people living with dementia, towards the environment being appropriate to assist people with orientation and safety, such as memorabilia displayed along the corridor walls and pictorial signs.

People living at the home told us staff were kind and caring and relatives we spoke with agreed. We observed a number of interactions between staff and people living in the home that were warm and caring. We found however, that people were not always treated with dignity and respect and their privacy was not always maintained. We observed one person wearing items of clothing that did not belong to them and on occasion, people had to wait significant periods of time to receive support.

We observed relatives visiting throughout both days of the inspection. The registered manager told us there were no restrictions in visiting and people we spoke with agreed.

The level of detail within plans was inconsistent. Care files showed that not all identified needs were reflected within people's plans of care, plans sometimes lacked detail as to how to manage identified needs and planned care was not always recorded as provided in a timely way. There was limited information regarding people’s background, lifestyle and preferences in relation to their care and support. This meant that it would be difficult to provide person centred care based on people’s preferences.

Due to the recent closure of one of the units within the home, there had been some staff changes within the units and not all staff knew the people they were supporting.

The care files we viewed contained a pre admission assessment; this ensured the service was aware of people’s needs and that they could be met effectively from admission.

We found that there were a limited number of activities available to people and relatives we spoke with agreed.

Relatives we spoke with told us they were kept informed of any changes to their loved one’s health and wellbeing. Feedback was sought through the use of quality assurance surveys and resident committee meetings. Resident and relative meetings were advertised regularly but often nobody attended as relatives told us they were able to raise issues at any time. People we spoke with told us they knew how to raise concerns and relatives agreed.

In April 2016 we found that the quality monitoring systems in place were not always effective and that they had not highlighted the concerns identified during the inspection and we issued a warning notice. During this most recent inspection, we found that sufficient improvements had not been made and the provider was still not meeting legal requirements.

We observed a range of completed audits; however they did not highlight all of the issues we identified during this inspection, such as the significant risks regarding medicines management. When areas for improvement were identified, actions were not always taken or maintained to ensure adequate improvements were made. There was inconsistency in the quality and safety of care between the units within the home. There were more significant concerns identified on the units that provided nursing care.

Staff and relatives we spoke with told us the registered manager was, “Approachable.” Staff told us they enjoyed their job and felt able to share their views. Other staff however, were not always satisfied with how the home was managed.

Staff were aware of the home’s whistle blowing policy and told us they would not hesitate to raise any issue they had.

The registered manager had notified the Care Quality Commission (CQC) of events and incidents that occurred in the home in accordance with our statutory requirements.

The home has been rated as ‘inadequate’ overall and will therefore, be placed in special measures. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve; they will be kept under review and inspected again within six months.

• Provide a framework within which we use our enforcement powers in response to inadequate

care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• If we do not take immediate enforcement action, special measures provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action.

We are considering our regulatory response.

We asked the provider to take action to address these concerns.

After the comprehensive inspection, the provider wrote to us to tell us what they would do to meet legal requirements in relation to the breaches. We undertook an unannounced focused inspection on 11, 12 and 13 April 2016 to check that they had they now met legal requirements. This report only covers our findings in relation to these specific areas / breaches of regulations. They cover four of the domains we normally inspect; 'Safe', ‘Effective’, ‘Responsive’ and ' Well led'. The domain ‘Caring’ was not assessed at this inspection.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Rowan Garth Care Home' on our website at www.cqc.org.uk.

Rowan Garth Nursing Home is a large facility located in the north of Liverpool. The provider is BUPA Care homes (CFH) Limited. The location provides accommodation for up to 150 people across 5 separate units set within extensive grounds. Each of the units is single-storey and can accommodate 30 people. The service supports people with a range of care needs from nursing to end of life care. The units within the home are as follows;

Heather Unit (Dementia and Nursing Care)

Moss Unit (Dementia and Residential Care)

Oak Unit (Nursing Care)

Beech Unit (Residential Care)

Clover Unit (Intermediate Care)

The service is registered to provide nursing and personal care, diagnostic and screening procedures and treatment of disease, disorder or injury for older people.

A registered manager was 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.

We found the breach in the safe management of medicines had not been met. Medicines were not always stored and administered safely in accordance with current guidance and best practice.

The concerns we identified are being followed up and we will report on any action when it is complete.

We found the breach regarding how the service was quality assured and monitored had not been met. The quality assurance systems at the home had failed to identify a number of significant issues and generate improvements in safety and quality.

The concerns we identified are being followed up and we will report on any action when it is complete.

During the course of this inspection we saw evidence that the home had not operated in accordance with the principles of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). Some applications to deprive people of their liberty had not been submitted as required.

The staffing levels reported and observed were appropriate to meet people’s needs safely. We saw evidence that staff were deployed flexibly across each of the units to meet people's care needs.

Improvements had been made to the safety of the physical environment. Regular checks were made on equipment and premises and actions had been undertaken to maintain people’s safety. Improvements had been made to the security of each unit. For example, additional keypad locks had been installed and other means of entry/exit had been made more secure.

Care records were completed and showed evidence of regular review. Care plans and records in relation to pressure area care showed clear evidence of improvement. Pressure area care was safely managed in conjunction with input from community healthcare professionals.

Changes had been made to cleaning practices which had reduced the risks associated with cross-infection and the incidence of strong odours in each of the units.

Concerns and complaints were recorded and responded to within the timescales specified in the relevant policy. Each of the people that we spoke with was able to explain what they would do if they needed to complain about the home.

People had access to a range of social activities which were promoted in each of the units.

People told us that they enjoyed the food and drink available at the home and were supported to eat by staff where required.

You can see what action we told the provider to take at the back of the full version of this report.

' 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. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, and the staff supporting them and from looking at records.

We inspected all five units across the home. We visited late evening and during the day. We looked at care records for 14 people and spoke with 15 people who used the service and two of their relatives. We also spoke with two visiting health care professionals.

Is the service safe?

People told us that they felt safe living at the home and they knew who to tell if they were unhappy with anything. We found that appropriate referrals had been made following an allegation of abuse and that they were dealt with correctly.

People told us they felt safe and well cared for. They enjoyed living at Rowan Garth and found the staff team supportive.

Systems were in place to make sure that managers and staff learnt from events such as accidents and incidents and complaints and concerns. This reduced the risks to people and helped the service to continually improve.

The home had supporting policies and information around mental capacity and consent to support people who may not be able to make decisions about their care or treatment. The manager showed an understanding of the Mental Capacity Act 2005 which is the legislative framework for the decision making process regarding people who may lack mental capacity. Previous reviews had included assessments of whether people were being deprived of their liberty. The home was therefore able to show they had acted appropriately in ensuring the person's rights were maintained and that an appropriate assessment had taken place.

We reviewed records which showed that recruitment practice was safe and thorough. Policies and procedures were in place to make sure that unsafe practice was identified and people were protected.

Is the service effective?

People's health and care needs were assessed, with appropriate referrals being made to external professionals who could assess and support the care of people in the home. Care needs had been identified in care plans and these had been reviewed. We looked at a selection of 14 care files which were selected at random. We found that the care plans reflected the current needs of the individual.

Visitors confirmed that they were able to see their relatives at any time as visiting times were flexible. People we spoke with told us that staff kept them informed and they felt they were up to date with any changes to their relatives care.

We found that there was sufficient staff on duty to provide people with the care and support they needed. Most people we spoke with told us that the staffing level were satisfactory.

Is the service caring?

During our inspection we observed people who lived in the home being cared for, and supported by, staff members who were patient and helpful. One person we spoke to said, "It's lovely here.' Another person commented; "We are very happy with everything, when we leave [relative] here, we know she is ok."

In discussion with us staff members were knowledgeable about the needs and wishes of all people living at Rowan Garth and were able to tell us about the how they ensured that care and support was delivered in a way that ensured that individual needs were met.

Is the service responsive?

People's needs had been assessed before they moved into Rowan Garth. Records confirmed that people's preferences, interests, aspirations and diverse needs had been recorded and care and support had been provided that aimed to meet their wishes.

People had access to some activities and had been supported to maintain relationships outside of the service.

Is the service well-led?

We reviewed the systems that were in place for assessing and monitoring the quality of the service provided at Rowan Garth. These included regular checks on aspects of the service and seeking the views of people who lived at the home and their relatives.

The service was managed in a way that tried to ensured people's health, safety and welfare were protected and the interests of the people who lived at the home were central to the way the service was run and managed.

People told us they had made decisions about their care and treatment and they told us they had received the right care and support.

Each person had a care plan with up to date information about the care and support they needed and people told us that they were happy with the care they received. One person told us, 'Nothing is a trouble, anything I want they do'.

People told us that they felt safe living at the home and they knew who to tell if they were unhappy with anything. We found that appropriate referrals had been made following an allegation of abuse and that they were dealt with correctly.

We found the home to be clean and regular checks had been carried out to ensure the required standards of cleanliness and infection control.

People told us they had received their medication on time and we found that appropriate arrangements were in place to manage medicines.

We found that there was sufficient staff on duty to provide people with the care and support they needed. Most people told us that the staffing level were satisfactory.