Archived: The Cottage Nursing Home Limited

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

Although the arrangements for assessing risk, safety monitoring and management within the service had improved since the last inspection, a number of fire safety risks had been identified in the environment and some works were required to be carried out.

Infection control measures had been increased since Covid-19 and the CQC had signposted the manager towards updated guidance for Personal Protective Equipment (PPE) in Care Homes for their staff.

Risk assessments were in place to support people to receive safe care.

People who used the service told us they felt safe. They told us staff treated them well and they knew who the manager was.

Safeguarding investigations were completed as required and appropriate action was taken when staff had not met expectations.

Relatives felt that communication could have been better during Covid-19. Professional agencies confirmed the management team had worked alongside them during Covid-19 and kept them informed.

The provider had quality monitoring systems in place which reviewed incidents and looked for patterns of behaviour. This was helpful to identify trends, or key times when people may need additional support.

The management team were striving to improve the culture within the service and took an open and transparent approach when incidents occurred. The management team were eager to learn and share good practice and this helped people remain safe. Systems were in place to audit the care provided and to seek feedback from people involved with the service.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 9 September 2019).

At this inspection we found improvements had been made and the provider was no longer in breach of regulation, however the overall rating remains the same.

Why we inspected

We carried out an announced comprehensive inspection of this service on 1 August 2019. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions, Safe and Well-led, which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed.

This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Cottage Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

At the time of the last inspection, 39 people were living at the home. Earlier in the year the provider made a business decision to stop providing nursing care for a period. This meant some people needed to move from the home. The change caused unrest with people living at the home and some people felt uncertain about the security of their placement there. The service had provided reassurance to people that nursing care would continue to be provided.

Changes in management since the previous inspection, had impacted on the leadership within the home and on the overall monitoring of the service. Quality assurance systems and processes to monitor performance required improvements. The provider had not always responded without delay to issues identified, to maintain a safe environment.

People told us they felt safe. Staff had been safely recruited and knew how to recognise abuse and keep people safe from harm. People received their medicines as prescribed. Staff had a good knowledge of infection control procedures.

People knew the current manager by name. The manager had identified improvements required and had a plan in place to action these. The service sought feedback from people about their care experience to ensure any issues were addressed.

People received care from staff that were kind, caring and compassionate. People and staff had built positive relationships together and enjoyed spending time together. People’s diversity was respected and embraced. Staff were respectful and open to people of all faiths and beliefs. People’s privacy and dignity was respected.

An activities programme was being developed. People told us activities had improved. Complaints had not always been managed to people’s satisfaction. However, the new manager was responsive to concerns raised and people felt confident they would be addressed. People were supported by staff that knew their hobbies and interests and their end of life preferences and wishes had been considered.

Staff had received training to meet people’s individual care needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive ways possible; the policies and systems in the service supported this practice. People were supported to eat and drink enough and to attend healthcare appointments when needed.

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 requires improvement (published 02 August 2018). The service remains rated requires improvement.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

At this inspection, we have identified a breach of regulation in relation to the systems and processes to monitor the service.

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

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The Cottage Nursing home limited is located in a residential area in Northamptonshire and is registered to provide accommodation and personal care to people who may or may not have nursing care needs. They provide care for older people who may also be living with dementia and can accommodate up to 53 people at the service. When we visited there were 39 people living at the service.

At the last inspection in July 2017, the service was rated Good. At this inspection on 17 July 2018 we found the service had deteriorated to requires improvement.

There was not a registered manager in post. There was an acting manager in post, and the provider had recruited a new manager who would be going through the registration process once their employment commenced. 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.

Risk assessments were in place to manage potential risks within people’s lives, but they were not always implemented or followed by staff.

People did not always receive the support they needed to go to the toilet. There was a lack of moving and handling equipment including hoists, which meant that people had to wait long periods of time before getting the support they required.

People were not always engaged with and spent long periods of time un-occupied.

Quality audits in place were not always effective, and issues found were not always followed up on promptly.

Staff had a good understanding of abuse and the safeguarding procedures that should be followed to report abuse and incidents of concern.

The staff recruitment procedures ensured that appropriate pre-employment checks were carried out to ensure only suitable staff worked at the service. Adequate staffing levels were in place. Staffing support matched the level of assessed needs within the service during our inspection.

Staff induction training and on-going training was provided to ensure they had the skills, knowledge and support they needed to perform their roles. Specialist training was provided to make sure that people’s needs were met and they were supported effectively.

Staff were well supported by the acting manager and senior team, and had one to one supervisions. The staff we spoke with were all positive about the senior staff and management in place, and were happy with the support they received.

People's consent was gained before any care was provided. 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

Staff treated people with kindness, dignity and respect and spent time getting to know them and their specific needs and wishes. Care plans reflected people’s likes and dislikes, and staff spoke with people in a friendly manner.

People were involved in their own care planning and could contribute to the way in which they were supported. People and their family were involved in reviewing their care and making any necessary changes.

A process was in place which ensured people could raise any complaints or concerns. Concerns were acted upon promptly and lessons were learned through positive communication.

The Cottage Nursing Home Limited is registered to provide accommodation and care for up to 53 older people, ranging from frail elderly to people living with dementia. On the day of our visit, there were 35 people using this service.

There was no registered manager in post during our inspection; however the service had a new manager who was in the process of registering with the Care Quality Commission (CQC). A registered manager is a person who has registered with the CQC 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 monitoring systems and processes were in place but required time to become embedded in staff practice to demonstrate how effective they were at identifying and improving the care and welfare of people using the service.

People felt safe. Staff had been provided with training to enable them to recognise signs and symptoms of abuse and they knew how to report any concerns. People had risk assessments in place to enable them to maintain their independence and keep them safe. Adequate staff with the appropriate skill mix were available to support people with their needs. Effective recruitment procedures were in place to ensure suitable staff were employed to work with people using the service.

Systems were in place to ensure that medicines were managed safely. This ensured that people received their medicines at the prescribed times.

Staff received appropriate training, supervision and support to enable them to carry out their roles and responsibilities effectively. People’s consent to care and treatment was sought in line with the principles of the Mental Capacity Act (MCA) 2005 legislation.

People were able to make choices about the food and drink they had and to maintain a healthy and balanced diet. If required, staff supported people to access a variety of health professionals including the dentist, optician, chiropodist, dietician and the speech and language therapist.

Staff provided care and support in a meaningful manner; and knew about people’s preferences and personal histories. People’s views were listened to and they were actively encouraged to be involved in their care and support whenever possible. Staff ensured that people’s privacy and dignity was upheld. Any information about people was respected and treated confidentially.

People’s needs were assessed before coming to live at the service and the care plans reflected how their needs were to be met. Records showed that people and their relatives were involved in the assessment process and review of their care. There was a complaints procedure in place to enable people to raise complaints.

The service was led by a manager who was new in post, and received additional support from the clinical lead. Although the manager was new to the service we found that there was an open and transparent culture, which was used to good effect in supporting people and staff to express their views about the delivery of care.

This was the fourth comprehensive inspection carried out at The Cottage Nursing Home.

Following our previous comprehensive inspection, on 17 and 18 May 2016 we gave this location an overall rating of 'inadequate', and placed them into special measures.

During our previous inspection we found there were no clear systems in place to log safeguarding referrals, or to ensure follow up action was carried out. We also found that people using the service were at risk of harm from some people who displayed behaviours that could challenge the service.

This was a breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found that risk assessments in place to protect and promote people's safety needed to be strengthened to ensure risks were managed effectively to keep people safe. There were inconsistencies with the recording and administration of medicines. Records were not always fully completed and we found that people did not always receive their medicines as prescribed.

This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In addition we found that people were not always protected against the risks associated with unsafe or unsuitable premises. Some areas of the service had not been maintained to a safe standard and repairs had not been carried out in a timely manner. This meant that areas of risk that may be hazardous to people's safety and health had not always been identified and rectified as soon as possible.

This was in breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found that there was no formal staff induction programme in place and there were gaps in staff training that failed to support them to develop their skills and knowledge.

This was in breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During our previous inspection we also found that people were not always treated with compassion, kindness, dignity and respect. People did not always receive care that was responsive to their needs or focused on them as individuals. In addition we found that people were not enabled to participate in sufficient, meaningful activities that met their needs and reflected their preferences.

This was in breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

In addition we found that people were not always treated with dignity and respect and some staff were not always respectful of people's right to confidentiality.

This was in breach of Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We also found that the culture at the service was not person centred, but task focused. Quality assurance, health and safety checks and feedback from people had not been undertaken consistently and had not therefore effectively checked the care and welfare of people using the service.

This was in breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations2014.

The provider submitted an action plan to tell us how they would meet these regulations and the timescale they intended to have met them by. We carried out this inspection on 29 September 2016 to see if the provider had made the necessary improvements to meet the breaches of regulation, and to review whether the service should remain in special measures. We found that the provider had implemented systems which had improved the provision of service. The regulations were met and, as such, the service is no longer in special measures.

The Cottage Nursing Home Limited is registered to provide accommodation and care for up to 53 older people, ranging from physical disabilities to people living with dementia. On the day of our visit, there were 33 people using this service.

The service did not have a registered manager in place, however; a manager had been appointed and they were in the process of registering with the Care Quality Commission (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.

During this inspection, we found that people felt safe at the service and were cared for by staff that were trained in safeguarding principles. Staff had received training in safeguarding and were knowledgeable about abuse. Staff we spoke with were prepared to raise any concerns they had. Systems in place to assess and manage risks had been improved. Risk assessments were detailed and updated on a regular basis, to ensure they were accurate. Staffing levels were sufficient to meet people’s needs and the provider had carried out recruitment to improve continuity of care. Systems for the storage, administration of medication had been improved to ensure that this could be done safely and there had also been significant improvements to the infection control practices at the service.

Staff training had improved and we saw that staff members had received training and refresher updates, to ensure that their skills were up-to-date. Staff also received support from the manager, including supervision and appraisal meetings. People's consent to their care was sought, and systems for the implementation of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards had been developed. People had access to sufficient food and drink and were supported to see healthcare professionals when necessary.

People were treated with kindness and compassion by staff; and had established positive and caring relationships with them. People were able to express their views and to be involved in making decisions in relation to their care and support needs. Staff ensured people’s privacy and dignity was promoted.

People received care that was responsive to their needs. Their needs were assessed prior to them receiving a service. This ensured the care provided would be appropriate and able to fully meet their needs. Improvements had been made to the care planning process and we saw that care plans were detailed and comprehensive. They were updated on a regular basis or when there was a change to people’s care needs. The service had a complaints procedure to enable people to raise a complaint if the need arose.

Improvements had been made to the leadership and management of the service. Staff were positive about the improvements and changes made at the service which inspired them to deliver a quality service. In addition improvements had been made to the quality assurance systems, which had been completed and were being used to good effect and to continuously improve on the quality of the care provided.

We could not improve the overall rating for this service from inadequate to good because to do so requires consistent good practice over time. We will check this during our next planned comprehensive inspection.

This was the third comprehensive inspection carried out at The Cottage Nursing Home.

The Cottage Nursing Home Limited is registered to provide accommodation and care for up to 53 older people, ranging from frail elderly to people living with dementia. On the day of our visit, there were 36 people using this service.

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. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their 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.

The service did not have a registered manager. At the time of our inspection there was an operations manager in post who visited the service four days a week. They had been in post for eight weeks. In addition, the clinical lead for the service was acting as manager until one was recruited. 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 that people were not always supported to remain safe in the service. A small number of people displayed behaviours that could challenge the service and this had an impact on other people living there. We found there was no clear system in place to log referrals, or to ensure follow up action was carried out. Risk assessments in place to protect and promote people’s safety needed to be strengthened to ensure risks were managed effectively to keep people safe. We found that not all the risk assessments we looked at detailed the control measures or actions to be taken to address the identified risk. This meant that risks were not always managed in such a way as to keep people safe.

People had not been protected against the risks associated with unsafe or unsuitable premises. Some areas of the service had not been maintained to a safe standard and repairs had not been carried out in a timely manner. People had Personal Emergency Evacuation Plans (PEEP) in place but they did not provide staff with sufficient and appropriate guidance to follow, to safely support people to move to a place of safety if there was a fire. The fire risk assessment had an action plan to make it more robust; however we were unable to find any evidence that the actions had been addressed. This meant that areas of risk that may be hazardous to people’s safety and

health had not always been identified and rectified as soon as possible.

Recruitment procedures needed to be strengthened to ensure only suitable staff were employed by the service. We observed that some employment checks for a small number of staff had not been obtained. There were sufficient numbers of staff available to meet people’s fundamental care needs, but not always in a timely manner. In addition we found there were insufficient staff to meet people’s emotional and social care needs consistently. This was having an impact on the quality of care received by people and meant that not all their needs could be met.

Inconsistencies found with the recording and administration of medicines showed that people’s medicines were not always managed safely.

People did not always receive care, which is based on best practice, from staff that have the knowledge and skills to carry out their roles and responsibilities. We observed some unsafe moving and handling procedures and we found there was a lack of dementia awareness/knowledge amongst the staff. Training records demonstrated that not all staff were up to date with essential training.

Although we found systems in place to ensure people who lacked mental capacity were supported to make their own decisions, in accordance with the principles of the MCA, these were not always effectively managed. Records did not make it clear what decisions each person had the ability to consent to and what areas they did not. We observed that staff did not consistently gain consent from people before supporting them and people were not generally offered choices. This meant that people were not always given the option to make their own decisions about their day to day care.

People were not always offered the choice of meals available and in instances we observed rushed meal times. Staff support to help people eat their meals was not always carried out with sensitivity.

There were inconsistencies among the staff team in relation to how people were supported. Some staff showed kindness and compassion. A small group of staff showed indifference with poor interactions. We also found that staff did not always promote people’s privacy and dignity, and confidential information was not always stored securely. This meant that staff did not always have due to regard to people’s right to dignity, privacy and confidentiality.

People did not always receive care that was responsive to their needs or focused on them as individuals. We observed occasions where people’s needs were not met and some people’s care did not always match what was recorded in their care plans. We found that decisions about people’s routines were not always in line with their preferences and many people’s daily routines were not person centred but task-led by the staff. This placed people at risk of unsafe and inappropriate care and treatment. Records showed that people and their relatives were not involved in the care planning and review process. This meant that changes to people's care and treatment were not consistently reviewed and updated with the involvement of people to whose care they related and their family members.

We found that people were not enabled to participate in sufficient, meaningful activities that met their needs and reflected their preferences. There was a lack of staff interventions and stimulation for people which resulted in boredom and some people became challenging in behaviour, which then impacted upon other people living in the service. This meant that people were not supported to follow their interests and take part in meaningful social activities.

We found the culture at the service was not person centred, but task focused. There was little in the way of a person centred culture evident in either the environment or the work ethic of the staff. We found that staff were aware of their responsibilities in relation to assisting people with their basic physical care needs; however we found there was little awareness of the needs of people living with dementia. Quality assurance, health and safety checks and feedback from people had not been undertaken consistently and did not therefore effectively check the care and welfare of people using the service. This meant that systems in place were not effective or robust enough to ensure that risks relating to the health, safety and welfare of people using the service were responded to.

Records demonstrated that decisions had been made in people's best interests where they lacked capacity; to ensure they received the right care and support to maintain their health and wellbeing. We found that DoLS were in place for those people who needed them.

We found that people were provided with nutritious, healthy meals and drinks were in plentiful supply throughout the day. Records demonstrated that people had timely access to relevant healthcare professionals to meet their specific health care needs. This meant people were supported to see a healthcare professional if they needed to.

Complaints/concerns had not previously been responded to in a timely manner; however we found that the operations manager had introduced a new system to improve this. The complaints/concerns file showed that complaints had been received by the service and had been responded to swiftly and in a timely manner in line with the organisation’s complaints procedure.

We found that with the recruitment of the operations manager improvements were being introduced and staff were positive about the direction the service was taking. We found that shortfalls in relation to staffing numbers, complaints, staff training and support, activities provision and care planning had already been identified as areas for improvement and plans were being implemented to address these shortfalls.

During this inspection we identified a number of areas where the provider was not meeting expectations and where they had bre

Below is a summary of what we found. The detailed evidence supporting our summary can be read in our full report.

Is the service safe?

We saw that people were cared for in an environment that was clean and hygienic. We found that the equipment in place for staff to use was appropriately serviced. This meant that people were cared for in a safe, well maintained environment.

Suitable arrangements were in place for staff to respond to emergencies, deal with incidents, or seek guidance from their manager. This meant that staff received the advice and support they needed to manage problematic situations safely, effectively, and in a timely way.

There were sufficient numbers of experienced and competent staff on duty to safely meet people's personal and healthcare needs. We saw that staff had been appropriately trained to provide safe care. One person said, 'I feel safe here because they do a good job and look after me.'

Staff said they had received training in the safeguarding of vulnerable adults (SoVA) and the staff that we spoke with knew how to report concerns. We saw documentary evidence that incidents or accidents had been appropriately reported to the Local Authority and the Care Quality Commission (CQC). This meant that people were protected from the risk of neglect or unsafe care.

We found that people's needs had been appropriately assessed before they were admitted to The Cottage Nursing Home. After admission to the home we saw that their needs were regularly reassessed to ensure they continued to receive safe care when their needs changed. This meant that staff had the up-to-date information they needed to minimise identified risks to people's safety and welfare.

Is the service effective?

Staff had received the information, training and managerial support they needed to do their job effectively. We saw there were arrangements in place that ensured staff had the most up-to-date information about people's personal care and nursing needs. These arrangements included verbal 'handovers' of pertinent information to staff that had arrived for duty. We saw that care records had also been updated so that staff were able to access recorded information that confirmed what had been said at the shift 'handover'. This meant that the staff were able to do their job effectively because they had received the information about people they needed.

We spoke with three staff and during our inspection we had observed them going about their duties without rushing. They were able to tell us about people's individual needs and how they delivered their care. This meant that because staff had a good knowledge of each person's care needs and preferences they were able to provide effective care.

Is the service caring?

The staff presented as friendly and helpful. We heard staff encourage people to do things for themselves but they made sure people were safe and provided them with timely assistance whenever that was appropriate. People were offered support at a level which encouraged independence and ensured their individual needs were met.

We saw that people nearing the end of their life were treated with compassion and sensitivity so that their final days were as comfortable and pain free as possible.

Is the service responsive to people's needs?

We saw that there was enough staff on duty to meet people's nursing and personal care needs. This was also confirmed by the three staff, two visitors, and three people in residence we spoke with.

We heard that call bells were always answered in a timely way, with people rarely kept waiting. One person said, 'I never have to wait if I need help.'

Is the service well-led?

There was a registered manager in post when we inspected. The three care staff we spoke with individually were aware of their roles and responsibilities and they confirmed they were well supported by their manager, deputy manager, and other senior staff, including the nurses. They all said that the manager maintained an 'open door' approach so that staff could readily express any concerns or ask for guidance whenever they needed to.

We found that the provider ensured that there were appropriate staff recruitment procedures in place and that staff were suitably trained to meet people's needs.

We found that there had been an improvement in the record keeping. However we found concerns with the management of medicines and the storage of people's valuable belongings.