Tweedmouth House

Tweedmouth House is a residential care home providing nursing and personal care for up to 55 people, some of whom are living with dementia, across two units. At the time of our inspection there were 48 people using the service.

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

People were safe from the risk of abuse. Risks were assessed and regularly reviewed when people's needs changed. The building was well maintained and had some new fire safety precautions in place.

Medicines were managed safely. The provider employed sufficient staff, staff were trained appropriately and recruited safely. Staff worked effectively with visiting professionals and wore PPE to keep people safe. Infection control measures were in place, and visiting was managed safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There was a positive culture. Staff and relatives said the management team were effective. Lessons had been learnt from the last inspection and an action plan put in place to improve. Lots of positive changes had been implemented to ensure people received good quality, safe care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk.

Rating at last inspection and update

The last rating for this service was requires improvement (published 28 June 2022).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations 12, 13, 18 (Health and Social Care Act regulations 2014) and 18 (Registration regulations 2009)

Why we inspected

We carried out an unannounced focused inspection of this service on 9 September 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, safeguarding and 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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has changed from requires improvement to good. 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 Tweedmouth House on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Tweedmouth House is a care home providing accommodation and nursing care for up to 55 older people. Accommodation was divided into three smaller areas. People who had general nursing and personal care needs lived in 'Royal' and 'Tweedmouth.' Those who had a dementia related condition lived in 'Orchard House.' There were 47 people living at the home at the time of the inspection.

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

An effective system was not fully in place to monitor the safety of the home. We identified shortfalls with safeguarding people from the risk of abuse, the assessment of risk, fire safety and the maintenance of records relating to infection control and accidents and incidents. In addition, an effective system to ensure notifiable events at the home were reported to CQC was not fully in place. This meant there had been no overview by CQC of certain events at the home to check the correct action was taken.

There were enough staff deployed to meet people’s needs. Safe recruitment procedures were followed. Medicines were generally managed safely. We identified several minor shortfalls relating to the recording of medicines which the registered manager told us would be addressed.

Staff explained they had worked as a team to help promote people's wellbeing throughout the pandemic. We observed positive interactions between staff and people. One person told us, “It’s the best place for me.” Health and social care professionals also spoke positively about the home and staff. One health and social care professional told us, “They seem to have the best interests of those they care for at heart.”

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection (and update)

The last rating for this service was good (published 30 October 2018).

Why we inspected

We undertook this targeted inspection to look at infection control processes at the home. We look at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service

can respond to coronavirus and other infection outbreaks effectively.

When we inspected, we identified shortfalls relating to safeguarding people from the risk of abuse, the assessment of risk, fire safety, the maintenance of records and the provider's governance system, so we widened the scope of the inspection to become a focused inspection which includes the key questions of safe and well-led.

The overall rating for the service has changed from good to requires improvement. 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 Tweedmouth House on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service.

We identified three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to safe care and treatment, safeguarding people from abuse and improper treatment and good governance. We also identified a breach of Regulation 18 of the Care Quality Commission (Registration) Regulations 2009 (notification of other incidents).

Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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.

We last inspected the care home in August 2017 and rated the service as requires improvement. We identified a breach of the regulation ‘fit and proper persons employed.’ One nurse’s registration with the Nursing and Midwifery Council [NMC] had lapsed. Nurses are legally required to be on the NMC register in order to practise. Following the inspection, the provider sent us an action plan which stated what they were going to do and by when to meet this regulation.

At this unannounced inspection on 25 September 2018, we found the provider had taken action to improve. An effective system was now in place to ensure nursing staff were registered with the NMC.

The provider was a husband and wife partnership. One of the partners 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 and associated Regulations about how the service is run.

An assistant manager was in post; they were applying to be registered manager. The current registered manager was planning to reduce their management hours to take on a more supportive role and eventually retire from ‘hands on’ management duties. They would however, be overseeing the management of the service as the provider and owner of the home.

Checks and tests had been undertaken to ensure that the premises were safe and secure. There were safeguarding procedures in place. Staff were knowledgeable about what action they should take if abuse was suspected. They told us that they had not witnessed anything which concerned them. The local authority safeguarding team informed us there were no organisational safeguarding concerns regarding the service. Medicines were managed safely.

There were enough staff deployed to support people to stay safe and meet their needs. The skill mix ratio of registered nurses and care workers helped ensure that people’s needs were met effectively and safely.

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.

Records confirmed that training was available to ensure staff were suitably skilled. Staff were supported though an appraisal and supervision system. Many of the staff had worked at the home for a considerable number of years. This experience contributed to the skill which they carried out their duties.

People's nutritional needs were met and they were supported to access healthcare services when required.

We observed positive interactions between staff and people who lived at the service. Staff talked about caring for people like members of their family. We asked staff if they would be happy for a friend or relative to live at the home. They confirmed they would.

There was an activities programme in place. Two activities coordinators were employed to meet people’s social needs.

There was a complaints procedure in place. No complaints had been received since our last inspection. We discussed with the assistant manager about the introduction of a central system for the recording and monitoring of any minor concerns. A central monitoring system would enable managers to have oversight of all issues to help ensure that appropriate action was taken and reduce the risk of a formal complaint being raised. She told us that this would be addressed.

Various audits were completed to monitor the quality and safety of the service. Action was being taken to streamline the quality assurance process.

Staff told us that they enjoyed working at the home and said morale was good. We observed that this positivity was reflected in the care and support which staff provided throughout the inspection.

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 and associated Regulations about how the service is run.

We last inspected the care home in October 2016 and rated the service as requires improvement. We identified a breach of the regulation relating to the need for consent. There was a lack of evidence to demonstrate that staff followed the principles of the Mental Capacity Act 2005 [MCA].

Following the inspection, the provider sent us an action plan which stated what they were going to do to meet this regulation.

At this unannounced inspection on 22 and 29 August 2017, we found the provider had taken action to ensure records demonstrated that the principles of the Mental Capacity Act were followed. However, we identified a new breach relating to fit and proper persons employed.

We found that one nurse’s registration with the Nursing and Midwifery Council [NMC] had lapsed in October 2016. Nurses are legally required to be on the NMC register in order to practise. The NMC registers all nurses and midwives to make sure they are properly qualified and competent to work in the UK. We referred our findings to the NMC, local authority safeguarding and commissioning teams and Northumberland Clinical Commissioning Group.

There was a quality assurance system in place. We found however, that the provider did not have an effective system in place to ensure nursing staff were registered with the NMC.

Since 2012, we found the provider was breaching one or more regulations at five of our eight inspections at this service. Since 2015 we have rated the service as requires improvement on three occasions. At this inspection, we identified one breach of the regulations. This meant that compliance with the regulations was not sustained and consistency of good practice was not demonstrated.

Prior to our inspection we received information of concern about people’s safety. We checked the concerns raised during our inspection and concluded that people were cared for in a safe environment, with suitable equipment and caring staff.

Checks and tests had been undertaken to ensure that the premises were safe and secure. There were safeguarding procedures in place. Staff were knowledgeable about what action they should take if abuse was suspected. They told us that they had not witnessed any concerns. The local authority safeguarding team informed us there were no organisational safeguarding concerns regarding the service. Medicines were managed safely.

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.

Records confirmed that training was available to ensure staff were suitably skilled. Staff were supported though an appraisal and supervision system.

People's nutritional needs were met and they were supported to access healthcare services when required.

We observed positive interactions between staff and people who lived at the service. Staff promoted people's privacy and dignity. There were systems in place to ensure people were involved in their care and support. Care plans were in place which detailed the individual care and support to be provided for people.

Arrangements for social activities met people’s individual needs. There was a complaints procedure in place. No complaints had been received since our last inspection.

Staff told us that they enjoyed working at the home and said morale was good. We observed that this positivity was reflected in the care and support which staff provided throughout the inspection.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to fit and proper persons employed. You can see what action we told the provider to take at the back of the full version of the report.

Further information is in the detailed findings below.

Tweedmouth House is registered to provide accommodation for up to 55 people. At the time of the inspection there were 48 older people using the service, some of whom were living with dementia. 41 People had been assessed as needing nursing care and support.

The home had a registered manager in place, who was also the registered provider, and our records showed she had been formally registered with the Care Quality Commission (CQC) since October 2010. 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.

At the previous inspection we had noted windows in some areas did not have window restrictors in place that met current Health and Safety Executive guidance. At this inspection we saw devices had been fitted to those windows where there was a potential risk of falls. People told us they were safe living at the home and staff understood safeguarding issues and how to recognise and report them. There was regular maintenance of the premises and fire risk and other safety checks were carried out on a regular basis. Accidents and incidents were monitored and reviewed to identify any issues or concerns.

Suitable recruitment procedures and checks continued to be in place, to ensure staff had the right skills. Checks were carried out to ensure nurses were appropriately registered. Medicines were managed effectively and stored appropriately. Some plans to support people with “as required” medicines needed to be put in place.

People were happy with the quality and range of meals and drinks provided at the home. People told us they could request alternative items, if they wished, and special diets were catered for. Kitchen staff had knowledge of people’s individual dietary requirements and likes and dislikes.

Staff confirmed they had access to a range of training and updating. The home had a dedicated training co-ordinator, who oversaw all training delivery and carried out checks and supervision to ensure that learning was put into practice. Staff told us, and records confirmed that regular supervision took place and they received annual appraisals.

People’s health and wellbeing was monitored, with regular access to general practitioners, dentists, district nurses and other specialist health staff. There was evidence staff had responded appropriately to any health concerns.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). These safeguards aim to make sure people are looked after in a way that does not inappropriately restrict their freedom. The deputy manager confirmed that action had been taken to make applications to the local authority safeguarding adults team, where people may have their liberty restricted. At the previous inspection it was not always clear from records that decisions about people’s care and health had been taken in line with best interests guidance. At this inspection we found records relating to this matter still lacked clarity to demonstrate they met the legal requirements of the MCA.

Some improvements had been made to the environment on the Orchard Unit, which supported people living with dementia. The deputy manager told us she was looking at ways to further improve the homely feel of the unit.

People told us they were happy with the care provided. We observed staff treated people patiently and with appropriate care and consideration. Staff demonstrated an understanding of people’s individual needs, preferences and personalities. People said they were treated with respect and dignity.

Care plans reflected people’s individual needs, although some aspects of the plans were less personal and relied on standard type plans. Reviews reflected changes in people’s care although were often lacking fuller detail. A range of activities were offered for people to participate in. The home had recently acquired a puppy to be the home’s own pet. Relatives told us there were activities although we did not witness any taking place on the Orchard Unit on the day of the inspection. People and relatives told us they had not made any recent formal complaints and would speak to the registered manager if they had any concerns.

The registered manager and deputy manager told us they carried out regular checks on people’s care and the environment of the home. However, the checks had failed to note the lack of clarity around the best interest documentation. Staff felt well supported by management, who they said were approachable and responsive. People and their relatives told us there were regular meetings at which they could express their views. The provider had sought people’s views through the use of questionnaires, which were overwhelmingly positive. Records were well maintained and up to date.

We found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to the Need for consent. You can see what action we told the provider to take at the back of the full version of the report.

We considered all the evidence we gathered under the regulation we inspected. We used the information to answer the five questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found;

Is the service safe?

We saw the infection control issues identified at our last inspection had been addressed and necessary refurbishments and changes in practice made. Additional domestic staff hours had been put in place.

When we asked about cleaning arrangements, one person using the service said, 'Yes it's fine that way.' The relative we spoke with confirmed their satisfaction with cleaning arrangements, and referring to the domestic staff said, 'They're always in.' A visiting professional told us they had seen an improvement since our last inspection.

We found people living at the home were now protected against the risk associated with inadequate infection control practice and the provider had taken steps to provide care in a clean environment.

Is the service effective?

This was a responsive inspection to previous non-compliance against the regulations and we did not look specifically at this area.

Is the service responsive?

This was a responsive inspection to previous non-compliance against the regulations and we did not look specifically at this area.

Is the service caring?

This was a responsive inspection to previous non-compliance against the regulations and we did not look specifically at this area.

Is the service well led?

We found there was a manager in post who was registered with the Commission in line with legal requirements.

' Is the service caring?

' Is the service responsive?

' Is the service safe?

' Is the service effective?

' Is the service well led?

Below is a summary of what we found '

Is the service caring?

This was a responsive inspection to concerning information and previous noncompliance against the regulations and we did not look specifically at this area.

Is the service responsive?

This was a responsive inspection to concerning information and previous noncompliance against the regulations and we did not look specifically at this area.

Is the service safe?

We found that the provider had put in place a range of systems and made changes to the home to improve the cleanliness of the facilities and the general environment of the home. We saw that new equipment had been purchased and changes made to the decoration of the building, including new carpets and vinyl.

We saw that there were still some areas that required improvement in relation to cleanliness and infection control, such as some extractor fans not working and the use of designated equipment for cleaning. A compliance action has been set in relation to this and the provider must tell us how they plan to improve.

Is the service effective?

This was a responsive inspection to concerning information and previous noncompliance against the regulations and we did not look specifically at this area.

Is the service well led?

The manager and provider had put in place a range of systems to check on the care provided at the home and the environment. We saw that a range of audits were undertaken and that there were regular meetings with staff and people who used the service to ensure that they had opportunities to raise concerns or express views.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found.

Is the service safe?

We found equipment was regularly serviced and tested to make sure it was safe and working effectively. There were enough staff on duty to meet the needs of the people living at the home. Staff received training to equip them with the skills to provide appropriate care and support to people.

We identified concerns with the condition of the premises and we issued a compliance action.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. While no applications had been submitted, proper policies and procedures were in place. Staff were aware of when an application should be made and how to submit one.

We saw risk assessments had been completed for people who were assessed as being at risk of falls or of developing pressure sores.

We identified concerns about infection control which included practice issues regarding topical creams, lack of paper towel dispensers and foot operated bins. We have issued a compliance action in regard to this.

Is the service effective?

People told us they were happy with the care that was provided and their needs were met by the staff team. One person told us, 'The care is all right, I would not like to move again.' Another person said, 'Staff know what support I need and respect my privacy and dignity.'

People's health and care needs were assessed and they were involved in this process. We saw that particular needs were identified for example, skin care or dementia care in individual's plans.

Staff training was provided that took account of the needs of the people in the home. For example we saw training in peg feeding, dementia and catheter care had been provided.

We saw that equipment were checked and tested regularly and there were sufficient hoists to suit people's needs.

Is the service caring?

We saw staff responded kindly and promptly to people. Care workers were patient and encouraging to people as they assisted them. People told us the staff were pleasant and kind and respected their privacy and dignity.

People's preferences, interests, aspirations and diverse needs were recorded and staff were able to give examples of these when we spoke to them.

Is the service responsive?

We saw evidence that the care staff identified changes in people's needs and acted to make sure they received the care they needed. For example, there was evidence that concerns about people's health were quickly identified and action taken to seek and act on advice from health professionals.

People had access to activities that were important to them and had been supported to maintain relationships with their friends and relatives.

The staff we spoke to were all aware of the complaints, safeguarding and whistle blowing procedures. All of the staff said they would immediately report any concerns they had about poor practice and were confident these would be addressed.

Is the service well led?

The provider had in place a quality assurance system which was not always effective and we issued a compliance action.

Staff had regular supervision and staff meetings which meant they were able to feedback to the management of the home their views and suggestions. Staff we spoke with confirmed their views were listened and account was taken of them.

We observed the interactions between people and staff in the dementia unit. We saw relationships between staff and people were good and there was a relaxed atmosphere. People were afforded choices about their routines, lifestyle and how they spent their time.

We saw staff delivered care in a calm and pleasant manner. We found they were aware of people's needs. People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

The home was clean. We saw there were effective systems in place to reduce the risk and spread of infection.

People received care in a calm and unhurried manner. There were enough qualified, skilled and experienced staff to meet people's needs.

We saw records were kept securely and were accurate and fit for purpose.