Archived: Abbey Court Nursing Home - West Kingsdown

We inspected the service on 17 December 2019 and 19 December 2019.

Abbey Court Nursing Home – West Kingsdown is registered to provide accommodation, nursing and personal care for 22 older people and people who have physical adaptive needs. There were 10 people living in the service at the time of our inspection visit. Most people lived with dementia and had special communication needs.

The service was run by Abbey Health Care Limited. The company was operated by two directors one of whom was also the registered manager.

People's experience of using the service and what we found

People said they did not consistently receive care meeting their needs and expectations. A person said, “The best you can say is the staff do try hard but it’s just not organised right. It’s hit and miss if you get the help you need. I’m not happy here and I want to move.”

We found there were continuing, multiple and serious shortfalls significantly increasing the risk people would not receive safe care and treatment. Safeguarding incidents were not reported or investigated appropriately. The registered provider and staff did not recognise or respond to safeguarding incidents or follow established local procedures for reporting and investigating them.

People were not adequately protected from the risk of harm in the event of a fire due as staff did not know what they should do in the event of an emergency. Known risks to people in relation to skin integrity, how people were moved safely and choking risks were not managed well which placed people at an increased risk of harm. Poor medicines practice and recording was identified as well as a lack of robust oversight of what actions should be taken to reduce the risk of incidents and accidents re-occurring.

There was a lack of staff which impacted on the care people received and recruitment practices were poor with little or no action taken by the registered provider when concerns about staff conduct were raised. Staff did not have the appropriate knowledge, competency or skills they needed to consistently provide people with the right care. This should have been identified by the registered manager and provider.

There were continuing, multiple and serious failings in the systems and processes used to monitor the safety and quality of the service. Quality assurance systems were ineffective and had not identified the serious concerns we found. The registered provider did not fully understand the duty of candour and had not always been open and honest when things had gone wrong. Important incidents that required CQC to be notified were not completed meaning we could not be assured we could effectively monitor the service.

People had not been fully consulted about the development of the service and good team work was not promoted. These shortfalls had resulted in people not consistently receiving the high-quality care they needed and had the right to expect. There were defects in the accommodation. The provision and recording of care did not enable people to be fully supported to receive coordinated care when they moved between or used different services. The registered manager had not worked effectively with other agencies to develop the service. Suitable provision had not been made to comply with the duty of candour.

Care was not always provided in ways promoting people’s dignity and respecting their right to privacy. Staff did not always consider or uphold peoples dignity. The culture in the service was one of being ‘done to’ rather than people having genuine choice and freedom to live as individuals.

People were not always supported to safely eat and drink enough to have a balanced diet and food choices were not always available to people. People were not supported to have maximum choice and control of their lives and they were not always supported in the least restrictive way possible and in their best interests.

People did not always receive responsive, person-centred care. Information was not given to people in a user-friendly way and they were not given regular opportunities to review their care. People were not suitably supported to pursue hobbies and interests to reduce the risk of social isolation. Activities were extremely limited and we saw people spending large parts of their day having no meaningful engagement.

Complaints were not robustly managed, responded to or learned from. Feedback from people who could tell us was that when they raised issues or concerns with the registered manger these were not taken seriously or acted upon.

Equality and diversity were promoted and people were supported at the end of their life to have a dignified death. The quality-rating we gave the service at our last inspection had been displayed in the service and on the registered provider’s website.

After the inspection visit the registered manager sent us positive feedback received from five relatives. One of the relatives said, "The staff are always polite, helpful and friendly."

For more details, please read the full report which is on the Care Quality Commission website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 5 February 2019). The registered provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection, enough improvement had not been made and the registered provider was still in breach of regulations.

Why we inspected

This inspection was brought forward. This was because we received concerning information people were not receiving safe care and treatment. In addition, there were concerns people were not being robustly safeguarded from the risk of experiencing abuse.

Enforcement

We have identified two continuing breaches of regulations. One concerns failure to provide safe care and treatment. The other continuing breach of regulations concerns shortfalls in quality checks and governance. There were nine new breaches of regulations concerning safeguarding, staff deployment and training, recruitment and selection, eating and drinking, dignity and respect, person centred care, management of complaints and the submission of statutory notifications.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have cancelled the registration of the provider and registered manager. This means the provider can no longer deliver accommodation and care for people who require nursing or personal care. CQC had commenced the enforcement action to cancel the registrations of both the provider and registered manager prior to the COVID-19 pandemic.

Abbey Court Nursing Home – West Kingsdown is registered to provide accommodation, nursing and personal care for 22 older people and people who have physical adaptive needs. There were 13 people living in the service at the time of our inspection visit. The service was run by a company who was the registered provider. The company was owned and operated by two directors one of whom was also the 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.

At the last comprehensive inspection on 7 November 2017 the overall rating of the service was, ‘Requires Improvement’. This was because our domains ‘responsive’ and ‘well led’ were rated as ‘Requires Improvement’. In relation to our domain ‘responsive’, nurses and care staff had not been fully supported to consistently provide people with person-centred and responsive care. This was because care plans that were intended to describe the assistance people had agreed to receive were not sufficiently detailed to guide nurses and care staff to provide care in the way people preferred. In relation to our domain ‘well led’, we found that sufficient provision had not been made to ensure that people who lived with dementia were suitably supported to pursue their hobbies and interests.

At the present inspection we found that although progress had been made more still needed to be done to address both these shortfalls.

In addition to this we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because there were shortfalls in the provision made to ensure people consistently received safe care and treatment. These included oversights in the support people received to manage healthcare conditions, fire safety, the management of medicines and the prevention and control of infection. There were also shortfalls in the systems and processes used to monitor, assess and improve the quality of the service. You can see what action we have told the registered provider to take at the end of the full version of this report.

We also raised other concerns with the registered manager in relation to which we have made recommendations. These recommendations were because of shortfalls in the deployment of staff and the provision of reassurance to people who lived with dementia. They also referred to the provision of care that promoted people’s dignity and the arrangements made to support people to make and review decisions about their care.

Due to these shortfalls we have again rated the service as, 'Requires Improvement. This is the third consecutive occasion when we have rated the service as, 'Requires Improvement'.

Our other findings are as follows: Recruitment checks for two care staff had not been completed in the right way. People were safeguarded from situations in which they may experience abuse. Lessons were learned when things had gone wrong.

The accommodation was not designed, adapted and decorated to meet people’s needs and expectations. People had been supported to eat enough to have a balanced diet. Suitable arrangements were in place to obtain consent so that people only received lawful care. People receive coordinated care when they moved between different services and they had been helped to obtain any healthcare they needed.

People’s right to privacy was not always respected. People were supported by relatives, friends and representatives to make decisions about things that were important to them. Confidential information was kept private.

Equality, diversity and inclusion were promoted. There were arrangements in place to resolve complaints. People were supported at the end of their life to have a comfortable, dignified and pain-free death.

Nurses and care staff were supported to understand their responsibilities. This included speaking out if they had concerns about the wellbeing of a person who lived in the service. The registered provider had informed the Care Quality Commission of important events that had happen in the service. The quality rating we gave the service at out last inspection had been displayed in the service and on the registered provider’s website. The registered manager was actively working in partnership with other agencies to support the development of best practice.

Abbey Court Nursing Home is a large detached building with large gardens. It provides nursing care for up to 22 older people some of whom are living with dementia. At the time of the inspection there were 15 people living at the service.

The provider was also the registered manager of the service. A registered manager is a person who has registered with the Care Quality Commission to manage the agency. 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 agency is run. The provider was supported in the day to day running of the service by a matron who had worked at the service for many years.

We last inspected the service in March 2017 and found a number of breaches of regulation. These related to management of medicines, not involving people and their loved ones in planning their care and a lack of meaningful activities. There were also concerns relating to the number of staff on duty and the safety of the premises. The provider had failed to establish effective systems to manage complaints and audit the quality of the service. They had also failed to inform the Care Quality Commission (CQC) of incidents which they were required to report. The provider sent the Care Quality Commission an action plan to address the shortfalls, with a timescale to become complaint with the regulations. At this inspection improvements had been made.

People told us they felt safe at the service. They were supported by staff who had been trained in safeguarding and who understood their responsibilities in relation to reporting any concerns. Staff had guidance about how to support people in order to keep them and others safe. Risks to people and the environment had been assessed and the plans in place to minimise risks gave staff the guidance required to keep people safe. We previously made a recommendation about the contents of risk assessments related to the management of diabetes, this had been followed and the risk assessments contained all the required information. At the last inspection people were at risk due to maintenance issues and a lack of cleanliness in the service. A programme of works was underway at the service and progress had been made. People were no longer at risk and the refurbishments had made it possible for staff to maintain cleanliness and minimise infection control risks. The refurbishment plans took into account the needs of the people at the service and making the service as accessible and comfortable as possible for them.

People’s needs were assessed prior to moving to the service and this information was used to form the basis of their care plan. People’s care plans showed what support they required and how they liked staff to meet their needs. People’s care plans included information about their wishes for end of life care. However, care plans would benefit from more detail and step by step guidance for staff to ensure care was provided consistently. At the last inspection there was a lack of meaningful activities for people, some improvements had been made. There was a part time activities co-ordinator in post; they spent time with people in the communal areas and in people’s own rooms. The provider told us there was a plan in place to continue to expand the activities on offer to people.

People were supported by staff who told us they had the training and support they needed to carry out their roles. There were enough staff on duty to keep people safe and meet their needs. Staff had been recruited safely and appropriate checks had been completed to ensure they were suitable to work with people. Staff and the provider used handovers to ensure effective communication about people’s needs and any changes staff needed to be aware of.

People’s medicines were managed safely by qualified nurses. At the last inspection there were no protocols in place for ‘as and when required’ (PRN) medicines and there were discrepancies in the number of medicines stored at the service. Improvements had been made. People told us they had their medicines as they liked them and that they were offered pain relief on a regular basis. PRN protocols had been put in place and there were no discrepancies regarding stock levels of medicines. People were referred to health professionals promptly when required and any advice received was incorporated into people’s care plans and implemented by staff. Staff used effective communication systems to ensure they understood any changes in people’s needs and any actions which had been taken.

People told us they enjoyed the meals and that they always had a choice of what they would like to have. Staff encouraged people to drink during the day offering a selection of drinks both hot and could. When people had specific dietary needs the cook was aware of these and ensured their meals were suitable. 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 routinely asked people for their consent before providing support and people told us staff encouraged them to make as many choices for themselves as possible.

People and staff knew each other well and had built positive relationships. People lit up when staff approached them and often reached out to hold their hand or for a hug. There were communication tools such as picture cards available to people to support them in making their needs known. Staff talked to people about their interests and families throughout the inspection. Visitors were welcomed, offered a drink and obviously knew staff and the other people at the service well. Staff supported people in a way which promoted their dignity and privacy. People told us they were supported to be involved in planning their care and that they were encouraged to remain as independent as possible.

At the last inspection the provider had failed to implement an effective system for managing complaints. At this inspection a system was in place and complaints had been responded to appropriately. People were encouraged to raise any concerns as they occurred or in residents meetings. Some relatives told us they were not happy with how their complaint had been resolved; the provider showed us evidence of the continued actions they had taken to attempt to resolve the family’s concerns. The provider had taken action following complaints or concerns to address how the service could improve.

Staff told us they felt supported by the provider and the matron and felt able to express their ideas. The provider had started attending registered manager’s forums which they told us had given them an opportunity to increase their own knowledge and keep up to date with new practice. Information about best practice was then used to review the provider’s current practice and changes were made as required. At the last inspection the provider had failed to effectively audit the quality of the service. The provider now carried out a range of regular audits of the service. Any learning from the audits was shared with the staff team and used to drive improvement.

Feedback was sought from people, their relatives, staff and visiting professionals. Any concerns raised were addressed directly with the person who raised them, and actions taken were recorded. A summary of the outcome of any surveys or meetings was shared on a noticeboard in the hallway of the service. At the last inspection it was found that the provider had failed to inform CQC of notifiable incidents as required by law. The provider had submitted required notifications and could identify which information needed to be submitted and understood their legal responsibilities in relation to this.

There was a registered manager in post who was registered with the 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.

At our last inspection on 7 and 8 April 2016, we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was in relations to people’s records not being effectively updated to accurately reflect their current need. At this inspection, we found that the provider had not acted on this previous breach of regulation and this was a continuing breach of the Regulations.

There were not enough competently trained staff to fully support people at the service. People, relatives and staff told us there was not enough staff at the service.

The registered provider had not ensured effective medicine management systems were in place at the service. There were no protocols in place for medicines that are prescribed as and when needed. We found discrepancies in stock levels of medicines and staff were not double signing for medicines where needed.

The registered manager had not done all that was required to reduce risk. Cleaning equipment was left unattended and staff were not recording all accidents and incidents appropriately. Moving and handling risk assessments were not being updated when required.

The registered manager had not ensured that the building was well maintained. We found that an exit door required an emergency repair to make it safe and the carpets in communal areas were, in places, ripped and lifting from the floor.

The registered manager had not ensured the cleanliness of the service. There were bad odours in areas of the home, pieces of food left on the floor and the carpets required a deep clean.

The registered manager had ensured that people were safe to work with vulnerable adults. Staff files showed that people had relevant safety checks along with two references and photographic identification.

Staff could identify the forms of abuse and how they should report any suspected abuse. Staff could identify that they could contact the local authority or Care Quality Commission with any concerns.

The principles of the Mental Capacity Act 2005 (MCA) were adhered to. People were being assessed appropriately and best interests meetings took place to identify the least restrictive methods of keeping people safe. Staff had training on MCA and had good knowledge.

The CQC is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Appropriate applications to restrict people’s freedom had been submitted and the least restrictive options were considered as per the Mental Capacity Act 2005.

The training provided was not completely robust as staff received moving and handling training, but we saw poor moving and handling techniques during inspection.

The registered provider took into account people’s nutritional and hydration needs. However, the registered manager had not identified all risk regarding those living with diabetes. We have made a recommendation about this in our report.

People’s records showed that there were appropriate referrals being made to health professionals. Staff were effectively managing people’s wound and pressure areas.

People and their relatives were not being consulted with the reviews of their care. People and relatives told us they were not involved with the reviews and their records confirmed this.

Staff were seen to be kind and compassionate to people during our inspection. Staff understood the importance of people’s privacy and independence. People’s confidential information was kept safe and never left unattended in public areas. We have made a recommendation about this.

The registered provider had not ensured that there were meaningful and stimulating activities for people at the service. People and relatives told us there were no organised activities at the service. During inspection, we saw a quiz and hand massages take place.

The registered manager did not have effective systems in place to record complaints. There was a complaints file and we found that the most recent recorded complaint finished mid-way through a sentence. People also told us of situations where they took concerns to the manager and these had not been recorded in the complaint log.

The registered manager had a sign in the entrance hall that restricted visiting times. Some relatives confirmed that at times they had trouble visiting outside of these times. However, others told us they had visited during the advertised restrictions without hindrance. We have made a recommendation about this in our report.

People were given choices on how they decorated their rooms, food and if they wanted to take part in the activity that was seen during inspection. People were also invited to meetings regarding the service.

People’s records were not organised in a way that it was easy to read and follow. The registered manager had not ensured that people’s records were being updated when required by staff. Auditing systems had not been effective in finding shortfalls within the service. The registered provider did not ensure that people, relatives and staff were consulted through feedback to identify shortfalls and good practice at the service.

The registered manager had not informed the Care Quality Commission of all notifiable events such as DoLS authorisations, safeguarding referrals and events that cause a disturbance to the service.

We found breaches in the regulations. You can see what action we took at the end of this report.

There was a registered manager 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 last inspection on 29 June 2015 the service was placed in special measures. The purpose of special measures is to ensure that providers found to be providing inadequate care significantly improve. This also provides 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.

At this inspection we found the registered manager had made significant improvements to the service. They had worked with the local authority to improve standards of care and practice. We have judged the service is no longer in special measures. Whilst significant improvements have been made, there are further areas identified for improvement. We will inspect the service again within 12 months to ensure the provider has made the required improvements.

People had care plans to record the care and treatment needs. Although staff had updated evaluation records every month, people’s care plans did not always reflect people’s most current needs.

People received prescribed medicines from staff who had been trained in medicines management. However, guidelines were not in place for staff to administer people’s PRN (as required medicines) and topical medicines safely. Although we did not identify poor outcomes for people, the lack of guidelines could increase the risk of people not receiving PRN medicines in line with people’s individual guidelines. We have made recommendations about medicines management. The registered manager was responsive to making the necessary improvements.

Where the responsibility for people’s care and treatment was shared with other people to include health care professionals, one person’s review of care had not taken place in a timely way. Whilst improvements had recently been noted, we have made recommendations about improving joint working protocols.

We have made a recommendation that ‘All About Me’ documents are completed to support effective handover with external health professionals in the event people are admitted to hospital.

Staff training was renewed annually, was up to date and staff had the opportunity to receive further training specific to the needs of the people they supported. Staff completed training in dementia awareness. The registered manager had plans to develop staff knowledge and competence in dementia care practice. We have made a recommendation about dementia practice.

The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. At the last inspection in June 2015 improvements were needed to ensure people were not unlawfully deprived of their liberty and had their right to make decisions upheld. At this inspection we found improvements had been made. The registered manager understood when an application should be made and how to submit one. We have made a recommendation to further develop this practice.

At the last inspection we made a recommendation that suitable signage and environmental items of benefit for people living with dementia are provided in line with current guidance. At this inspection the registered manager had acted on this and had made improvements to the environment. We have made a recommendation about further improvements to the premises.

People had advance care plans in place. These provided general information on people’s end of life decisions, with the focus on resuscitation status and preferred place of care. The staff had a good rapport with relatives to support end of live planning to enable people to have choices at the end of their life. We have made a recommendation to ensure people’s preferences and individual wishes are recorded about their end of life care.

We observed positive interactions between people and staff where people were living with dementia. Care plans recorded some guidance as to how staff should communicate effectively with each person using person centred methods. We have made a recommendation about further development of people’s care plans.

At the last inspection we made a recommendation that meaningful activities needed to be considered for people living with dementia. At this inspection the registered manager had acted on this and had implemented an activities programme based on people’s wishes and preferences and had recorded activities that people took part in. The registered manager told us they were continually developing their activities programme.

The registered manager carried out audits to identify how the service could improve. The registered manager had significantly improved the audit system since our last inspection and additional audits had been implemented. However, some shortfalls we found during the inspection had not been identified as part of the audit process. The registered manager was responsive to taking the necessary measures to continuously improve the quality of the service and care.

At the last inspection improvements were needed to infection control. At this inspection cleaning schedules had improved. They contained a good level of detail to enable the registered manager to monitor which areas of the home had been cleaned each day. People were protected from the risk of cross infection. Hand wash facilities were available in all toilets and bathrooms and the premises were observed to be clean.

At the last inspection improvements were needed to fire safety. At this inspection all fire protection equipment was serviced and maintained. Personal Emergency Evacuation Plans PEEPs were in place for people to guide staff and emergency services as to how people would be supported to vacate the premises in the event of a fire.

Staff were trained in how to protect people from abuse and harm. They knew how to recognise signs of abuse and how to raise an alert if they had any concerns. People told us, “Nothing bad happens here, the staff make sure we feel safe, they watch over us.”

There were sufficient staff on duty to meet people’s needs. There were safe recruitment procedures in place which included the checking of references.

All members of care staff received regular one to one supervision sessions and had an annual appraisal to ensure they were supporting people based on their needs and to the expected standards.

People gave us positive feedback about the food and drink available to them. At the last inspection improvements were needed to ensure people had a positive dining experience. At this inspection the dining experience was adequately adapted to the needs of people living with dementia.

Staff communicated effectively with people, responded to their needs promptly, and treated them with kindness and respect.

People were able to spend private time in quiet areas when they chose to. People’s privacy was respected and people were assisted in a way that respected their dignity.

The staff promoted people’s independence and encouraged people to do as much as possible for themselves.

The registered manager sent satisfaction surveys to people, their relatives or representatives and recorded what action had been taken to develop the service in light of people’s feedback.

The registered manager notified the Care Quality Commission of any significant events that affected people or the service.

The provider wrote to us on 15 November 2013 and told us about the action they were taking to address the non- compliance.

At this inspection we found that people's care records had been reviewed and were up to date. We found that where people needed additional checks to be made on their health and welfare by staff these had been completed.

We found that staff were receiving the support and training that they needed for their role. However, the systems for tracking and planning training needed improvement as they did not provide up to date information to help the provider monitor and plan training.

We found that people's records were stored securely and confidentially.

We observed that staff supported people safely and that staff were kind and caring.

Most of the people living at the service had complex needs which meant they were not able to tell us about their experiences. We spoke with two people who told us they liked the home and their rooms. We also spoke with three members of staff.

We saw that people had care plans that reflected their individual needs. People told us they were well cared for. However, people's care records were not always kept up to date to reflect changes to their needs. One person told us they were 'very comfortable here' and another that 'we get looked after and there are enough staff'.

There were enough staff to provide people with the support they needed and staff told us they felt well supported. However, systems for tracking and recording training were not always effective.

People told us they liked the staff and we saw that staff were kind, patient and respectful towards people. People told us 'the staff and carers are good ', 'they are very patient with me' and that "there is nothing I would want to improve".

We found that care and staff records were not always kept up to date to reflect current information and that confidential information was not always stored in a way that protected people's personal information.

At this inspection we found most of the required improvements had been put into place. Written quotes had been obtained for the carpeting and flooring and the work was due to start later the same week.

We spoke with three people who used the service. They told us they were satisfied with the cleanliness of their rooms and the building in general. One person said that 'the cleaning has got better, it is more thorough' and another person told us that 'the bedroom is lovely and clean'.

People told us they received the care and support they needed and made choices about how their care was provided. People and relatives confirmed that their needs had been assessed before they moved to the service. Some people said they were aware of their care plans and that their needs were regularly reviewed.

People and relatives said staff were kind, caring and respectful. They said 'The staff are all so nice', 'They work hard' and 'Some are nice and jovial'. People said staff came quickly if they used their buzzers and understood how they liked to be supported.

People said they liked the meals provided, there was choice and plenty to eat and drink. They said 'Food is pretty good and 'I have plenty of choices'.

People liked their rooms and said they were kept clean and tidy, if possible when they moved in they had been offered a choice of room. People in shared rooms had given their consent to sharing.

Whilst overall the service was clean, safe and hygienic. We found that people would benefit from the provision of new commodes and some improvement to the environment.