Chollacott House Nursing Home

Chollacott House Nursing Home (hereafter referred to as Chollacott House) is a residential home that provides personal and nursing care for older people. Chollacott House accommodates 42 people in one adapted building. At the time of the inspection 29 people lived at the service.

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

People’s care records were not always reflective of their care or health needs. We found aspects of people’s care experience could be improved further. For example, some people were not treated in a manner that always promoted their dignity. Furthermore, people’s social care needs were not being attended to and there were prolonged periods of time where people did not receive meaningful engagement with staff.

People were supported by staff who understood how to recognise and escalate safeguarding concerns. There were adequate numbers of staff to support people with their care and health needs. Staff had been recruited safely and received an induction and supervision. Staff followed good hygiene practices.

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.

Staff understood their roles and responsibilities. Quality assurance systems were not always effectively used to monitor and drive improvement. The service had partnerships with other agencies such as health and social care professionals to meet people’s needs.

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 26 September 2017).

Why we inspected

The inspection was prompted in part due to concerns received about the quality of the service provided to people. As a result, we undertook a focused inspection to review the key questions of safe, caring, responsive and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

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

We have found evidence that the provider needs to make improvements. Please see the safe, caring, responsive and well led sections of this full report.

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 Chollacott House Nursing Home on our website at www.cqc.org.uk.

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 breaches of regulation in respect of person -centred care and good governance at this inspection.

We have also made three recommendations in relation to manging risk, medicines and respecting people’s dignity and privacy at this inspection.

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.

Chollacott House is a nursing home which provides nursing and personal care for a maximum of 42 people, many of whom have complex nursing needs. This includes people who have had a stroke, or who have long term medical conditions such as diabetes and dementia. The home also provides care for people convalescing or needing a short period of respite as well as people needing end of life care. Drake unit, part of Chollacott House and based on the first floor, has nine beds and provides care for people with neurological conditions such as Huntington's disease, Muscular Dystrophy, Motor Neurone Disease and head/brain injuries. 35 people were living at the service at the time of this inspection. The provider is Stonehaven (Healthcare) Ltd, and there are eight homes in the group.

The last comprehensive inspection took place on 7, 13 and 18 April 2016. At that time we found four breaches of regulations and the service was rated as ‘requires improvement.’ Concerns found related to safe care and treatment (including the management of medicines); dignity and respect; consent and quality monitoring systems. We took enforcement action in relation to the quality monitoring breach, by serving a warning notice on the provider and registered manager. This required the provider to make urgent improvements in this area by 30 September 2016. This was because the provider's quality monitoring systems were not effective. The provider submitted an action plan to show when and how improvements were to be achieved.

On 16 November and 23 November 2016 an unannounced follow up inspection was undertaken. The focus of this inspection was to follow up whether the service had met the warning notice and check on the safety of people living in the service. We found improvements had been made in relation to consent; cleanliness and infection and the management of medicines. However, two ongoing breaches of regulations were identified at this inspection relating to safe care and treatment and quality monitoring systems. We took enforcement action by issuing a condition of registration. This meant the provider had to send the Care Quality Commission (CQC) monthly reports on the actions that have been taken to ensure people were safe and appropriate care and support was provided. We also met with the provider to discuss our concerns.

Monthly reports were received by the CQC, which demonstrated action had been taken to reduce the risk of unsafe care and treatment. At this inspection we found improvements had been made and maintained since the last inspection.

The service has a registered manager. 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.

Quality assurance checks and audits carried out by the provider; registered manager and senior staff were in place and had been completed at regular intervals to monitor the safety and quality of the service. This was an improvement since our last inspection in November 2016, and had resulted in better outcomes for people using the service. Feedback from people using the service, those acting on their behalf, professionals and staff was positive about the management of the service.

People were positive about their experience of living at Chollacott. They said they felt safe and liked the staff. Relatives also spoke highly of the staff and the care provided to their family member. They had no concerns or complaints about the service. Health and social care professionals had no concerns and felt people were well cared for.

There were sufficient staff to keep people safe and their needs were met in a timely manner. The registered manager and staff were aware of their responsibility to report any abusive or unsafe practice. The recruitment processes were robust and pre-employment checks were carried out to ensure staff were of good character and were suitable to work at the service. Staff understood their roles and responsibilities in keeping people safe and protecting them from harm.

Risk assessments were in place, which identified risks relating to people’s health and wellbeing along with the measures needed to minimise the risk. Medicines were managed safely and people were receiving their medicines in line with the prescriber’s instructions.

Staff had undertaken training to ensure they had the skills and knowledge needed to carry out their roles. Staff said they were well supported by the registered manager and senor staff and received supervision meetings to discuss and monitor their performance.

People’s rights were protected because the staff acted in accordance with the Mental Capacity Act 2005.

People had access to a range of health care professionals to help maintain their health. People enjoyed their meals. A varied diet was provided for people, which took into account their dietary needs and preferences so their health was promoted and choices could be respected.

Staff were kind and caring. Staff knew people well and there were positive relationships between people and all members of the staff team. People were treated with dignity and respect and staff were mindful to protect people’s privacy.

Care plans were detailed and person-centred. The care plans we reviewed were all up to date and contained a good degree of information about the person, including their personal history, medical conditions and preferences.

There was a programme of activities. These were varied and people said they enjoyed the activities provided. There had been trips out, as well as activities within the service.

The inspection was to follow up if the required improvements had been made following our last inspection on 7, 13 and 18 April 2016 when we identified four breaches of regulations, related to quality monitoring, safe care and treatment, dignity and respect and consent. We took enforcement action in relation to the quality monitoring breach, by serving a warning notice on the provider and registered manager. This required the provider to make urgent improvements in this area by 30 September 2016. This was because the provider’s quality monitoring systems were not effective, because they did not do all that was reasonably practicable to identify and mitigate risks for people. We issued requirements for the other three breaches of regulations. Previously the Care Quality Commission had identified breaches of regulations at an inspection in January 2015, two of which still had not been addressed in full at the April 2016 inspection.

Prior to this inspection, some concerns from relatives were raised with the Care Quality Commission, about people at the home falling and injuring themselves. We also received anonymous concerns about staffing levels, leading to poor care and about staff not reading or following care plans. We contacted the service to seek additional information about these concerns and spoke with the local authority, who investigated a relative’s complaint and were satisfied with the assurances received.

The week before the inspection, the service notified us about a person who had fallen and injured themselves, and needed hospitalisation. During the inspection, we received a notification about another person who had developed a pressure ulcer. This focused inspection was to follow up whether the service had met the warning notice and check on the safety of people living in the home. This report only covers our findings in relation to these topics. You can read the report from the last comprehensive inspection by selecting the 'all reports' link for Chollacott House Nursing Home on our website at www.cqc.org.uk

The service has a registered manager. 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.

Since the inspection in April 2016 we have received an action plan from the provider which outlined the improvements being made. The service has also worked in partnership with the local authority quality assurance and improvement team to improve their systems and processes.

Risk assessments and care plans were inconsistent in that some lacked sufficient detail on measures needed to reduce risks, for example in relation to nutrition/hydration and pressure ulcer risks.

People were at increased risk because daily records of food/fluid intake for people were poorly completed. Daily records for nine people showed they were at increased risk of malnutrition and dehydration. There were no records of any action taken in response to inadequate fluid intake or gaps in records about whether people had been given their meals. However, our observations showed people in their rooms and in communal areas were supported to eat and drink regularly. On several occasions, we saw staff offering people snacks and supplement drinks in between meals. Kitchen records confirmed some people were having food supplements, and there was a record confirming each person’s meals were sent from the kitchen each day. This suggested daily records could not be relied on as an accurate record of what people had actually eaten and drank.

People were not being fully protected from the risks of acquiring pressure sores. Care staff checked the pressure relieving equipment each day, although no records of these checks were kept. When we asked care staff what checks were needed, their responses showed many staff did not know what checks were needed. We identified two people’s pressure relieving mattresses were not at the recommended setting for the person’s weight, which increased their risk of skin damage.

People were not fully protected because the quality monitoring systems in place were not fully effective. This was because this inspection highlighted new risks for people relating to poor records of food/fluid intake, a lack effective checks of pressure relieving equipment and some gaps in care plans. These findings demonstrated the systems in place to assess and monitor the quality of the service provided were still not fully effective. This was because they were not identifying, and minimising some risks relating to the health, welfare and safety of people using the service. Further improvements in quality monitoring were still needed.

We followed up concerns raised with the Care Quality Commission about whether staffing levels at the home were adequate to meet people’s needs and keep them safe. Most people and relatives said they thought staffing levels were sufficient to keep them safe. Most people said they could get up and go to bed at a time of their choosing, although one person said they would have liked to have got up earlier that morning. People’s personal care needs were met, they could have a wash, shower or bath. Where people needed two staff to care for them, they were always available, which staff confirmed. Staff were busy in the morning but worked in a methodical and organised way and at a time and pace to suit each person. Staff responded promptly to call bells, usually within five minutes. Any gaps in staffing were met by existing staff working extra shifts and by the use of regular agency staff. Some discussions were underway about whether night staffing levels needed to be increased.

External professionals generally reported confidence in the service and said staff worked well with them. The registered manager, deputy manager and clinical lead were working with the local authority quality assurance and improvement team to improve their systems and processes, and a further visit was planned to monitor progress.

Significant improvements had also been made in cleanliness and infection control. People were cared for in a clean, hygienic environment and there were no unpleasant odours in the home.

People received their medicines safely and on time and significant improvements had been made in the safety of medicines management.

People were protected from potential abuse and avoidable harm. Staff had received safeguarding adults training and knew how to report concerns internally and to external agencies. Robust recruitment checks were completed to ensure fit and proper staff were employed.

Two ongoing breaches of regulations were identified at this inspection. We will carry out a further inspection within the next six months to check the remaining requirements have been met. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Chollacott House is a family run business. The nursing home provides nursing and personal care to a maximum of 42 people, many of whom have complex needs. Some live within the Drake Unit which accommodates people with neurological conditions. There were 35 older people resident at the beginning of the inspection.

The service is required to have a registered manager. 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. Chollacott House had a registered manager.

The service monitoring had not always led to a safe, quality service for people because the monitoring had not always identified where improvement was needed.

Medicine management had improved but some risks still remained, such as not always recording whether any allergies existed. Further improvements were made during the inspection visits.

The home was superficially clean but some equipment in regular use was stained and dirty and increased risk from cross contamination.

Personal care needs were not always met, such as two people’s finger nails being broken and dirty, which upset a person and a family member.

Some people’s clothing left them at risk, such as a broken shoe strap which could lead to a fall.

There was a programme of upgrading the premises but some environmental risks had not been identified and were not being dealt with within a quicker timescale. Some were addressed during the visit.

Some people’s legal rights were not upheld in line with the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards, such as not assessing a person’s capacity to make an important decision. People who were able to provide informed consent had that consent sought before they received care or treatment.

Staff expressed concern and kindness for people but this was not always translated to a kind and caring service where people could feel valued, such as finding out why a person was distressed.

Staffing arrangements took into account people’s assessed needs and were under regular review.

People’s dietary needs were understood and monitored. Most comments about the food were positive and there was a varied menu which was adapted to meet individual preferences.

People were protected through safe recruitment practice, staff training and supervision. Staff spoke very highly of the training they received.

People’s views were sought through regular resident and family meetings, care plan reviews and a yearly survey of opinion. Their views had been taken into account by the provider.

People had a variety of activities available to them including the use of the minibus for outings, arts and crafts, exercise and a newly developed garden area. One staff member said of the activities worker, “She makes every day special for people”.

People’s needs were assessed and planned with theirs, or their family's, involvement. Care plans related to either the personal care or health care needs of the person so the plan was clear for care and nursing staff to follow.

People felt able to take issues to the registered manager who investigated and followed through on any complaints. People and staff spoke highly of the registered and deputy managers.

We found four breaches in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3). You can see what action we asked the provider to take at the back of this report.

Consent to treatment was sought and people were involved in planning their care. Restrictions on people's movements were agreed with family, professionals and in their best intrerst.

Standards of care and treatment were well monitored and delivered. Staff were kind, interested in people's needs and friendly.

People were happy with the food which was varied and in sufficient quantities. Specialist feeding regimes and concerns about diet were handled appropriately. One person, who had soft boiled egg for breakfast, said, "They do try to do what I want."

The home handled medicines in a safe and professional way, which ensured people received the correct medicine when required.

Contact with the registered manager, meetings and surveys gave people the opportunity to comment about the home. Where requests had been made, the home had endeavoured to meet those requests, one example being more fish on the menu.

Safety was managed within the home and there were regular audits of the service provided. Where any complaints had been made they were diligently investigated although two people told us that initially they had not been "invited".