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Inspection carried out on 1 May 2018

During a routine inspection

This comprehensive inspection took place on 1 and 2 May 2018 and was unannounced.

During our last comprehensive inspection in February 2017, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because people’s care records did not evidence that best interest decisions were carried out in line with the Mental Capacity Act (2005). People were not given their medicines in a safe manner and errors had occurred. People were also not supported to have food that was nutritious or appetising or in accordance with their preferences. We found that systems to monitor the quality of the service were not sufficiently robust to ensure issues were identified. We issued the provider with three requirement notices and we imposed a positive condition on their registration.

Following the last inspection, we asked the provider to complete an action plan. This was to show what they would do and by when, to improve the key questions of safe, effective, caring, responsive and well-led to at least a rating of good.

Firlawn Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Firlawn Nursing Home is registered to accommodate 40 people across two separate buildings (The House and The Manor), each of which have separate adapted facilities. The Manor specialises in providing care to people living with dementia. At time of the inspection 27 people were living at the service, of which 22 people lived in The House and five in The Manor.

The service had 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.

People told us they didn’t always feel safe living at Firlawn Nursing Home. They reported that some staff talked to them in a rude manner and of being handled “rough”. From our observations people's care was task orientated and did not reflect people as individuals.

We received mixed feedback about the caring approach from staff. People in The Manor appeared to have more positive interactions with staff, than people living in The House.

People’s call bells were not responded to in a timely way. We observed call bells ringing for up to 10 minutes, without staff responding. The service had no means of monitoring call bell response times.

People told us of incidents where their calls during the night had been ignored and their call bells disconnected. One person described it as “calling from a personal hell”. There was a culture within the home that it was acceptable to leave call bells unanswered.

There was not sufficient numbers of trained staff to meet people’s needs. There were people in The House who needed two care staff to support them in the morning. This meant when other people needed support, no staff were available. We observed people were still getting up at 11am.

People were supported to bed at the time that suited the staff team. Day staff told us they supported people to bed as the night staff did not want to, unless people were willing to wait until midnight. This meant some people were in bed from around 7pm until 10.30am the next morning.

People were not always protected against risks and action had not always been taken to prevent the potential of harm. During the second day of our inspection we heard a person calling for help. The person was falling out of bed. There was no staff available to respond. The inspector had to go and find staff to help the person. On checking this person’s care plan, the nursing staff did not follow the manual handling care plan, which could have prevented this incident occurring.

Staff had not received training necessary to provide them with the skills and knowledge to fulfil their role. This was evident during our inspection as we observed people were not treated with dignity and respect. We saw large gaps in the training staff had received around dignity and respect. Staff had not received regular supervisions and appraisals.

People’s choice and independence were not encouraged. People told us that staff did not consistently ask for their permission before providing care and support.

Consent was not always sought in line with the Mental Capacity Act (2005). It was not clear from people’s care records if the person had mental capacity to consent to their care and treatment, or not. We found one person who lacked capacity to consent, did not have a Deprivation of liberty safeguard in place.

People and relatives told us the quality of the food was poor and there was a limited choice. We observed food left on trays while staff were supporting some people in their rooms, which meant the food was cold by the time it was delivered.

People had care plans in place; however we found the information in the plans was not always person centred and was variable in detail. Terminology used in the care plans was not always appropriate and focused on task based care rather than wellbeing.

People and their relatives told us they had raised their concerns with management. Although they felt the registered manager had listened, they did not feel the issues were resolved.

Quality assurance systems were in place and internal audits had been completed, however these were not robust enough to identify any shortfalls. For example, the registered manager did not have an oversight of issues within the service such as falls.

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.

We found eight breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, of which four breaches were repeated from the last inspection.

We issued the provider with a Notice of Decision, imposing conditions on their registration for two of the breaches: 1. The Registered Provider must not admit any new service users without the prior written agreement of the Care Quality Commission. 2. The registered person must undertake monthly audits of service user care plans, risk assessments and the associated monitoring of these risks, management of medicines, Mental Capacity Act 2005 capacity assessments and best interest decision making and staffing requirements. The registered person must send to the Care Quality Commission a report of the result of the audits and any actions taken or to be taken as a result of those audits by no later than 5pm on the last day of each calendar month.

We issued a requirement notice for six breaches, stating they must take action. We shared our concerns with the local authority safeguarding and commissioning teams. The provider had sent us an action plan with timeframes on what action they were taking to meet the legal requirements.

Inspection carried out on 1 February 2017

During a routine inspection

Firlawn Nursing Home provides nursing care to up to 40 people. The home consists of two buildings on one site, which are separated by a large garden. At the time of the inspection, there were 37 people using the service.

The inspection took place on 01 and 02 February 2017. The first day of the inspection was unannounced.

At our last inspection in November 2015, the provider was not meeting the requirements of Regulations 11 and 12 of the Health and Social Care Act 2008 (Registered Activities) Regulations 2014 and we found breaches of some of the legal requirements in the areas we looked at. Some improvements were seen during this inspection which demonstrated the service had responded to our feedback. However, not all actions had been completed. Improvements to the safe management of medicines and documentation around decisions made in line with the Mental Capacity Act 2005 had not been made and repeated breaches were identified in these areas.

There was a registered manager in post at this service although at the time of the inspection, they were not available. 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 received a notification from the provider to confirm the registered manager was absent for more than 28 day consecutive days. The deputy manager was managing the service with support from the operations director and the clinical team lead in the absence of the registered manager. At the time of the inspection, it could not be confirmed when the registered manager would be returning.

At this inspection, medicines were not managed safely. The documentation to confirm how some medicines should be given and when medicines had been administered had not been consistently completed and therefore the provider could not be assured people were receiving their medicines as prescribed. People were not always supported to receive their medicines safely because staff did not always ensure people had taken the medication they were handing out. Medicines were not always securely stored.

Systems to monitor the quality of the service were not always effective and did not ensure all issues were properly identified and addressed. Regular checks were not undertaken to identify and mitigate risks.

Areas of the home were in poor state of repair which put people, staff and visitors at risk of trips and/or falls. When we spoke to the deputy manager they told us there was a refurbishment program in place. However, these areas had not been prioritised.

Incomplete records in relation to nutrition and hydration meant the provider could not ensure people were protected against the risk of dehydration. Whilst charts to monitor the care for people at risk of developing pressure ulcers were in place and were completed in line with people’s care plans, the documentation to confirm when people who were at risk of dehydration was not consistently completed and therefore there was the risk that issues were not promptly identified.

People and staff told us the quality of the food was poor and there was a limited variability of choice. One staff member told us they had been “embarrassed” to serve a meal and it was “so awful” they had to throw it away. The operations director was aware of the concerns about the food and had recruited a new chef who was due to start in two weeks.

People, their relatives and staff told us there was not always sufficient numbers of staff to support people in line with their needs. Whilst people and their relatives said they had recently seen improvements to staffing, one member of staff told us there were still not enough staff to meet people’s needs.

People told us staff supported them well and had the necessary knowledge and skills to do this.

People told us staff treated them with dignity and respect and always knocked and waited before entering their rooms. However, this was not consistently evident from our observations during the inspection and people were not always treated with dignity and respect.

There were mixed responses from people we spoke with about the caring nature of staff. People and their relatives told us most staff that supported them were kind and caring. However, this was not always the case and some people expressed concerns about two staff members.

Staff received regular supervision and appraisals and told us these meetings were productive and helpful.

People told us they felt safe and staff were able to explain how they would identify signs of potential abuse and how they would report safeguarding concerns.

Staff we spoke with demonstrated a good awareness around the principles of the Mental Capacity Act 2005. They told us decisions had been made in people’s best interests for people who lacked the capacity to make specific decisions and these had been made with the least restriction as possible. However, documentation to support these decisions were not available in people’s care records.

The quality of documentation in people’s care plans had improved since the last inspection. The service had implemented new monitoring tools to ensure care plans were reviewed in a timely manner and people’s health needs were met.

Whilst there was an activities program which some people told us they enjoyed, there was limited opportunity for some people to take part in meaningful activities of their choice and ability. People who chose to remain in their room or were nursed in bed were not offered the same degree of contact as those who spent their time in the communal areas of the home.

People, relatives and staff told us the management team were approachable and they would feel confident in raising any issues or concerns if they arose. One person told us “I feel valued and listened to”. However, some people and staff told us during the period of time the registered manager had been absent; they had not been kept well informed. They told us resident and staff meetings which used to occur regularly now did not happen.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014. You can see what action we told the provider to take at the back of the full version of the report. We are taking further action in relation to this provider and will report on this when it is completed.

Inspection carried out on 3, 5 and 24 November 2015

During a routine inspection

We carried out this inspection over three days on the 2, 5 and 24 November 2015. The first day of the inspection was unannounced. There was a delay in the completion of the inspection, as the registered manager was on annual leave. Our last inspection to the service was on 31 October 2013. The inspection in October 2013 was made to check improvements had been made to keeping people safe. All shortfalls we previously identified had been addressed.

Firlawn Nursing Home provides nursing care to up to 40 people. The home consists of two buildings on one site, which are separated by a large garden.

There was a registered manager. They had been in post since 2013. 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. The registered manager was present throughout the inspection.

People, their relatives and staff told us there were not always enough staff available. This was particularly apparent at times of staff 'calling in' sick at short notice and annual leave. Some comments indicated that call bells were not always answered in a timely manner and staff were not easy to find. People were largely unsupervised on one floor whilst staff assisted one person to have a bath.

Less visible areas of the home such as beading on over-bed tables and skirting boards were not clean. At various points in the home, paint work was chipped and difficult to wipe down. There were toiletries and nail files and clippers in the bathroom. These items presented infection control risks if used communally.

People’s medicines were not safely managed. There had been a number of errors and staff had not consistently signed the records, to show they had given people their medicines, as prescribed. Records did not show people’s topical creams had been consistently applied. Clear guidance was not available to inform staff about “as required” medicines.

Care plans were difficult to follow and did not clearly inform staff of people’s needs and the support they required. The plans lacked detail and were not measureable. Staff had not consistently completed people’s care charts. This did not enable effective monitoring of key areas such as nutrition and hydration, the management of continence and healthy skin. Following the inspection, the registered manager and the operations manager told us staff training in this area had been arranged.

People told us they felt safe. They were complimentary about the staff and the care they gave. Staff spoke to people in a friendly, respectful manner. They had a good rapport with people, which showed effective relationships had been built. Staff knew people well and encouraged decision making and independence. There was a strong focus on Firlawn Nursing Home being each person’s home. There were many positive interactions between staff and people who used the service. This included staff assisting a person to eat and supporting people whilst unwell.

People knew how to make a complaint and were confident any issues would be appropriately addressed and resolved. People said they had enough to eat and drink. There were positive comments about the food. This included the way in which the food was cooked and presented and the choice available. People were offered a range of alternatives, if they did not like what was on the menu.

People received good support to meet their health care needs. A GP and nurse practitioners visited frequently to monitor people’s health and to review treatment plans and medicines. Health professionals could be contacted at other times for advice or to visit, as required. Records showed contact had been made with specialised services such as the speech and language therapist.

Staff received a range of training to help them do their job effectively. The registered manager was passionate about training and said it ensured an effective team. They were looking at ways to develop training provision within the home. Staff received support on an informal basis and within structured meetings with their line manager. This enabled staff to discuss their role and any concerns they might have. The registered manager told us focus was to be given to staff appraisal as they were behind in this area.

People were supported by staff who had undertaken a thorough recruitment process. This ensured all staff were suitable to work with vulnerable people. Staff had received up to date safeguarding training and were clear of their responsibilities to recognise and address potential abuse.

The registered manager described themselves as a “people person” with an emphasis on consulting and enabling. There were many positive comments about the registered manager. They demonstrated a passion for their role and kept up to date with best practice from a variety of sources. A system was in place to monitor the safety and quality of the service provided. The registered manager analysed information such as accidents and incidents to identify possible trends. People were encouraged to give their views about the service. This was informally, at meetings or by using questionnaires. The feedback received was used to help improve service provision.

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 31 October 2013

During an inspection to make sure that the improvements required had been made

We carried out a follow-up inspection to check the provider had achieved compliance with Outcome 7 Safeguarding people who use the services from abuse. At the previous inspection we set compliance actions because the provider was not fully meeting essential standards of quality and safety.

We spoke with people who lived in both houses. The five people we asked told us they felt safe. One person told us they often fell and when we asked how staff ensured their safety this person said “Staff say ring the bell but I try to be independent.” Another person said “they (staff) look after you very well and the staff are nice too.” The third person we spoke with said “yes I feel safe. There is nothing to worry about.”

Relatives who were visiting people during our inspection gave us feedback on their experiences with the delivery of care. The three relatives of people who lived at the home told us in their opinion their family member was safe from abuse.

We spoke with six staff and four staff said they had attended safeguarding adults training. These four staff were clear on their responsibilities for safeguarding people from abuse. They knew the signs of abuse and they knew who to report alleged abuse. Staff were aware that it was their duty to report any poor practice they may have witnessed from other staff. Staff knew the procedure for whistleblowing.

On the day of our inspection we observed staff had entered into the spirit of Halloween and were dressed in costume. We saw people enjoyed watching staff in their outfits and we heard one person say “you all look so beautiful.”

Inspection carried out on 8 May 2013

During an inspection to make sure that the improvements required had been made

The five people we asked told us the care delivered by the staff was good. They told us their rights were respected and gave us examples such as “Staff knock the doors before they enter and I say hold on, if I don’t want them to come in” and “when I first came, staff asked me what name they were to use.”

People said the staff asked them how they wanted their care to be delivered. One person said the manager had discussed their care needs with them and to show their agreement they had signed their care plan.

One relative of a person who lived at the home explained the admission process that was followed. We were told the staff were approachable and acted upon their suggestions.

The people we spoke with said they felt safe at the home. One person told us they had complained and the manager had resolved their complaint. However, the staff had not received adequate advice from the provider about the procedure to be followed for whistleblowing.

We observed the lunchtime meal and we saw staff use a respectful approach. We saw staff supported people to eat and encouraged them to eat their meal.

Inspection carried out on 25 September 2012

During an inspection in response to concerns

We spoke with people who lived in both houses and positive comments were made about their care and the staff. One person said “choice is not an issue; there are no rules about getting up and going to bed at night. We can stay in our rooms and use various parts of the home at will. There are never any concerns regarding the attitude or skills of staff, including agency.”

Although people made positive comments about the delivery of care, they were not involved in the planning or the reviews about their care. People said “I am happy here and staff understand my needs”, “The staff know how to care for me” and “I am well looked after by the staff” The people we asked, said they were not frightened of being left alone with staff and they felt confident to approach the manager with complaints.

One person thought there were staff shortages because when staff were summoned for assistance they took too long to answer call bells. Other people we asked said when they summoned staff for assistance they arrived promptly.

People said they felt safe when staff delivered personal care and they felt confident to approach the manager with complaints.

Inspection carried out on 13 June 2012

During an inspection to make sure that the improvements required had been made

Firlawn nursing home consists of two buildings on one site. The buildings are separated by a large garden. The building closest to the main road is called 'The House'. The building at the rear of the property is referred to as 'The Home'.

During our inspection in April 2012, we spoke with people living in both buildings. We found that peoples' diversity, values and human rights were respected. People were very appreciative of the staff saying, "they work very hard, they are absolutely wonderful". One person told us, "I am treated very well and the staff are always courteous". We spoke with many other people who all had positive things to say about the way in which staff treated them and how the home was run.

We revisted Firlawn nursing home in June 2012 to see if improvements had been made regarding staffing arrangements. We spoke with ten members of staff during our visit. Care workers, kitchen and housekeeping staff were positive about the recent changes to staffing levels and procedures.

Two people said the staffing situation had improved. Another person said, "I've never had any problems". Everyone we spoke with said their call bells were answered promptly and staff carried out care without rushing. People said they were very happy living in the home.

Inspection carried out on 4 April 2012

During an inspection in response to concerns

We spoke with people living in both buildings. We found that peoples' diversity, values and human rights were respected. People were very appreciative of the staff saying, “they work very hard, they are absolutely wonderful”. One person told us, “I am treated very well and the staff are always courteous”.

We spoke with many other people who all had positive things to say about the way in which staff treated them.

We spoke with six people living in the home. Many people told us that on some days, there were not enough staff and people had to wait for their call bells to be answered. People said the care they received was excellent. One person said, “they (the staff) do a fantastic job, you have to be understanding”.

Reports under our old system of regulation (including those from before CQC was created)