Archived: The Gables Nursing Home

The provider is registered to provide accommodation for up to 26 older people living with or without dementia in the home over two floors. There were 11 people using the service at the time of our inspection. The home provides nursing care for older people.

At our last inspection on 20 and 21 September 2016, we served warning notices on the provider in the areas of medicines and good governance. We also asked the provider to take action to make improvements in the areas of person-centred care, safe care and treatment, safeguarding service users from abuse and improper treatment, premises and equipment, and staffing. We received an action plan setting out when the provider would be compliant with the regulations. At this inspection we found that the concerns in the areas of safeguarding service users from abuse and improper treatment and premises and equipment had been fully addressed. However, while improvements had been made, more work was required in all other areas.

The registered manager was no longer working at the home. They had left in September 2016 and a new manager was in place. The new manager had started the process to be registered with the CQC at the time of our inspection. They were available during the inspection. 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.

Staff did not always safely manage identified risks to people. Sufficient numbers of staff were not always on duty to meet people’s needs. The management of medicines required improvement.

Staff knew how to keep people safe and understood their responsibilities to protect people from the risk of abuse. Staff were recruited through safe recruitment processes. Safe infection control practices were followed.

People were not effectively supported by staff to have sufficient to eat and drink. Staff received appropriate induction and training but supervision and appraisal required improvement.

People’s rights were protected under the Mental Capacity Act 2005. External professionals were involved in people’s care as appropriate. People’s needs were met by the adaptation, design and decoration of the service.

Most staff were kind and permanent staff knew people well. People and their relatives were involved in decisions about their care. Advocacy information was made available to people. People received care that respected their privacy and dignity and promoted their independence.

People did not always receive personalised care that was responsive to their needs. Activities required improvement. Care plans required improvement to ensure that they contained sufficient information to guide staff to provide personalised care for people. A complaints process was in place and staff knew how to respond to complaints.

The provider was not fully meeting their regulatory requirements. Some systems were in place to monitor and improve the quality of the service provided, however, they were not fully effective. People and their relatives were involved or had opportunities to be involved in the development of the service.

We found one 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 this report.

Accommodation for up to 26 people is provided in the home on two floors. There were 12 people using the service at the time of our inspection. The home provides nursing care for older people.

At the previous inspection on 25 and 26 April 2016, we asked the provider to take action to make improvements to the areas of notifications, person-centred care, need for consent, safe care and treatment, safeguarding, meeting nutritional and hydration needs, premises and equipment, good governance and staffing. At this inspection we found that the concerns in the areas of notifications and meeting nutritional and hydration needs had been fully addressed. However, while some improvements had been made, more work was required in all other areas.

At the previous inspection the overall rating for this service was ‘Inadequate’ and the service was placed in ‘special measures’. At this inspection the overall rating for this service is ‘Requires Improvement’ and the service is no longer in special measures.

A registered manager was in post and was present on the first day of the inspection but not on the second day. 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.

Staff knew how to identify potential signs of abuse; however, restraint was being carried out by staff and they had not received sufficient training or guidance to do this. Staff did not always safely manage identified risks to people. Sufficient numbers of staff were on duty to meet people’s needs during our inspection, however, systems were not robust to ensure that sufficient staff were on duty at all times.

Safe infection control and medicines practices were not always followed. The most recent staff member had been recruited through safe recruitment practices; however, records were not available to provide assurance that all recent staff had been recruited safely.

Staff did not receive appropriate training, supervision and an appraisal. People’s rights were not always protected under the Mental Capacity Act 2005. People’s needs were not fully met by the adaptation, design and decoration of the service.

People received sufficient amounts to eat and drink and external professionals were generally involved in people’s care as appropriate.

Staff were kind but did not always respect people’s privacy. People and their relatives were not fully involved in decisions about their care. Advocacy information was made available to people.

People did not always receive personalised care that was responsive to their needs. Activities required improvement. Care records did not always contain information to support staff to meet people’s individual needs. A complaints process was in place and staff knew how to respond to complaints.

There were systems in place to monitor and improve the quality of the service provided, however, they were not effective. People and their relatives were not involved nor had opportunities to be involved in the development of the service. However, the provider and registered manager were generally meeting their regulatory requirements.

We found 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.

Accommodation for up to 26 people is provided in the home on two floors. There were 17 people using the service at the time of our inspection. The home provides nursing care for older people.

At the previous inspection on 14 and 15 April 2015, we asked the provider to take action to make improvements to the areas of person-centred care, dignity and respect, need for consent, safe care and treatment, good governance and staffing. At this inspection we found that improvements had not been made and more work was required in all areas.

A registered manager was in post and was present during the inspection. 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.

Staff did not always safely manage identified risks to people. The premises were not always managed to keep people safe. Sufficient numbers of staff were not always on duty to meet people’s needs. Safe infection control and medicines practices were not always followed. Staff knew how to identify potential signs of abuse; however, restraint was being carried out by staff and they had not received sufficient training or guidance to do this. Staff were recruited through safe recruitment practices.

Staff did not receive appropriate training, supervision and appraisal. People’s rights were not always protected under the Mental Capacity Act 2005. People did not always receive sufficient amounts to drink. External professionals were not always promptly involved in people’s care as appropriate. People’s needs were not fully met by the adaptation, design and decoration of the service.

Staff were mostly kind but did not always treat people with dignity. People and their relatives were not fully involved in decisions about their care. Advocacy information was made available to people.

People did not always receive personalised care that was responsive to their needs. Activities required improvement. Care records did not always contain information to support staff to meet people’s individual needs. A complaints process was in place and staff knew how to respond to complaints.

There were systems in place to monitor and improve the quality of the service provided, however, they were not effective. People and their relatives were not involved nor had opportunities to be involved in the development of the service. The provider and registered manager were not meeting their regulatory requirements.

We found 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.

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.

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.

During the inspection we gathered information to answer five key questions; is the service safe, effective, caring, responsive and well-led? Below is a summary of what we found. The summary describes what we observed, the records we looked at and what people who used the service, their relatives and the staff told us.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

People who used the service told us they felt safe. One person said, '[Staff] They're very safety conscious.' Relatives we spoke with also told us they felt their family members were safe.

Staff told us they had read the safeguarding policy and would report any concerns. The manager told us that staff had attended safeguarding training since our inspection in April 2014.

We found that effective staff recruitment and selection processes were in place.

We used our SOFI (Short Observational Framework for Inspection) tool during the inspection. The SOFI tool allows us to spend time watching what is going on in a service and helps us to record how people spend their time, the type of support they get and whether they have positive experiences. We conducted a SOFI observation for 40 minutes, observing the care in the small and larger lounges during the morning. We saw people received appropriate and safe support.

We looked at the care records for three people who used the service. We saw care plans about different needs. A care plan is a document that should identify a person's needs and how staff can meet those needs. These mostly contained detailed information and were centred around people's individual needs. However, we found that staff were not always completing charts at the required frequency to record changes of position to protect people's skin.

We asked the provider to tell us what they would do to meet the requirements of the law in relation to records.

People who used the service told us they felt that the care home was well maintained. One person said, 'The [maintenance staff member] who does the work is fantastic.'

People also told us they felt that the care home was kept clean. However, we found some concerns regarding cleanliness and infection control. We saw, for example, that the grouting behind the sink in a downstairs bathroom had deteriorated. We saw that some items that included bedside protectors were not clean.

We asked the provider to tell us what they would do to meet the requirements of the law in relation to cleanliness and infection control.

Is the service effective?

People who used the service told us they felt staff were good at their jobs. One person said staff were, 'Very professional.' A person told us they received the support they needed and said, 'The care, you couldn't want better.'

Staff generally had a good understanding of the needs of people who we discussed with them. They told us they received training and supervision.

Is the service caring?

People who used the service told us staff were caring. One person said staff were, 'Very, very caring.' They also told us staff treated them with dignity and respect.

Relatives told us staff were caring and friendly. One relative said, 'They [staff] seem to be very caring.'

We saw staff communicated warmly with people as they supported them and staff were caring and kind.

Is the service responsive?

Staff told us they would involve other agencies when required. We saw some information in the care records that showed that the service had involved other agencies. However, the provider may find it useful to note that we saw that an external health professional had completed a care plan for one person that stated that behaviour charts should be observed. We saw that a care plan produced by the care home also stated that staff should document the person's behaviour on behaviour charts. However, we saw no behaviour charts in place.

Is the service well-led?

People who used the service and staff told us they felt the service was well-led. One person said, 'You've got a very good person in charge."

Staff told us they felt they could contribute their views on the service and a staff meeting had recently taken place. They also told us they felt the care home was well-led.

However, we found that the systems in place to regularly assess and to manage risks relating to the health, welfare and safety of people who used the service were not always effective. We found, for example, that concerns we identified regarding records and cleanliness and infection control had not been identified and addressed by the quality monitoring systems. We also found that the provider had not taken some actions they told us they would take following our inspection in April 2014. They told us that Mental Capacity Act 2005 assessments would be completed when required. However, we found two people did not have capacity assessments in their care records when these were appropriate.

Is the service safe?

Safeguarding procedures were in place and staff told us they would report safeguarding concerns. However, one staff member told us they had not read the safeguarding policy. We also found some gaps regarding safeguarding training for staff.

The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. A DoLS policy was in place. The registered manager knew when an application should be made, and how to submit one. However, other staff we spoke with did not have an understanding of DoLS.

People using the service who provided feedback told us they felt the building was kept clean. However, we found that some items were not clean. This meant they had not been cleaned effectively.

We saw some actions had taken place since our previous inspection to make improvements regarding the premises. However, we found some concerns. We saw, for example, some walls in bedrooms had areas where paint was missing. We also saw cracks on a bedroom wall and a small number of ceilings with water damage due to leaks.

We found some care records and some other records regarding staff and the management of the service were not accurate and fit for purpose. We found some care records were not always kept securely.

Is the service effective?

People using the service told us they received good care and they received the care they needed. One person said, 'They're [staff are] very good.' Relatives also told us their family members received good care.

However, we saw a person using the service was at risk of developing pressure ulcers. We saw staff had not always acted in accordance with the person's identified needs regarding pressure area care.

We found staff received supervision and appraisals. Staff had also received some training since our previous inspection. However, we found some gaps in training.

Is the service caring?

People using the service and relatives told us staff were kind and caring. A relative said, 'Everyone is very kind and very nice.'

We also saw staff were caring when supporting people and staff communicated in a respectful and very kind way. However, we saw one example where staff did not act in a way that respected the dignity of a person.

Is the service responsive?

Staff had a good understanding of people's care and support needs and they knew people well.

We found people's needs were assessed and care plans and risk assessments were regularly reviewed. However, we found a care plan was missing for one person. We also found gaps regarding Mental Capacity Act 2005 assessments.

Is the service well-led?

People using the service told us they would speak with the registered manager if they had concerns and they felt they would be listened to. One person said, '[The registered manager] is very good.' However, a person told us they had not met with the registered manager to discuss their views on the service.

Relatives told us they felt the service was good. One relative said, 'We think it's good.' They also told us they felt they would be listened to if they raised concerns.

However, we found that no group meetings for relatives or surveys had taken place since our previous inspection to gather feedback from relatives on the service.

Staff told us they felt the service was well run and they felt listened to by the registered manager. However, a staff meeting had not taken place since September 2013 to enable staff to provide feedback in a formal group meeting.

We saw that some audits had taken place to monitor the service. However, we found no recorded care record audits since we inspected the service in July 2013. We found some concerns with all of the outcomes we inspected during our visits in April 2014, which meant risks had not always been identified and addressed.

Relatives we spoke with told us their family members received good care that met their needs. One relative said, 'It's pretty outstanding actually and pretty consistent amongst the carers.'

During our visits we saw positive interactions between staff and people using the service. We spent 30 minutes in the lounge at lunchtime. We saw staff asked people about their preferences, were caring and provided support to people when needed.

We also gathered information from a representative for the provider, the area manager and care staff. The Registered Manager was absent during our visits.

We found that people using the service were not fully protected against the risks of unsafe or unsuitable premises.

People using the service and relatives who we spoke with told us they felt there were enough staff to meet their needs. One relative said, 'Oh yes. I'm pretty sure that's so.'

We found gaps in staff training, supervision and appraisal.

We also found that the provider did not have an effective system to regularly assess and monitor the quality of service that people received. We found that records were not always kept securely and were not always fit for purpose.

They told us they were well cared for. However, one person told us they sometimes had to wait for staff when they needed assistance. Two people told us they would prefer more activities. They told us they felt safe.

We spoke with two relatives. They told us their relatives were well cared for. One relative told us there were enough staff. Another relative said, 'Sometimes at night it can be a bit tight.' We found that the current management arrangements were not working effectively.

We found that care records we looked at were often not person-centred and did not include enough information about people's needs and preferences.

A relative told us the lounge needed decorating. We found that some items on the premises were not stored appropriately.

People using the service who we spoke with told us they felt staff were well trained. However, we found that staff did not always receive appropriate training, supervision and appraisal.

We found that the provider did not have an effective system to regularly assess and monitor the quality of service that people received and records were not always fit for purpose and stored securely.