Archived: Fountain Place Nursing Home

At the last comprehensive inspection we identified that the service was not meeting the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 We took enforcement action and served warning notice on Regulation 12 Care and Treatment and imposed conditions on the registration of this service. The provider developed a comprehensive action plan detailing how they would take steps to address the conditions of registration , the warning notices and meet the other requirements they had breached.

This inspection was unannounced and took place on the 22 February 2017. Fountain place is registered to provide accommodation for up to 17 people who require nursing and/or personal care. At the time of our visit three people were accommodated.

A registered manager was 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.

Medicine systems were safe overall. Although staff signed medication administration records (MAR) when they administered medicine, MAR charts were not always signed when topical creams were applied. There were PRN (Medicines to take as required) protocols in place and when these were administered, staff documented when they had been given and the reasons why.

Staffing levels were adequate to meet people’s needs despite the high levels of agency staff used. The same agency staff were used to ensure continuity of care was provided. Recruitment of new staff was in progress and the recruitment process was robust.

The people said they felt safe living at the home. Staff knew the procedures for protecting people from abuse and harm. Staff were knowledgeable and understood their responsibilities in reporting any potential abuse. Staff had attended safeguarding training and were aware of the procedures to be followed for reporting abuse.

People received care and treatment from staff that were supported to meet the responsibilities of their role. Members of staff said the training provided was good with pathways for progression within the organisation. One to one meetings took place regularly with their line manager. Annual appraisals were to take place.

People were able to make their own decisions and told us who helped them make complex decisions if they required support.

Care plans were person centred and were reviewed to ensure people’s changing needs were met. They contained lifestyle profiles with people’s preferred routines documented. Risk assessments formed part of the care plans and action plans gave staff guidance on how to minimise the risk. However, action plans had not always been followed in monitoring people’s fluid intake.

Quality assurance systems were in place to monitor the quality of the service. The feedback from relatives had been sought on the quality of the service. Members of staff told us the team worked well together and they were supported to meet the requirements of their role. An agency worker told us they worked at the service regularly to provide continuity of care to people.

This focused inspection was carried out to assess whether the provider had taken the necessary actions to meet the two warning notices we had issued. We will carry out a further unannounced comprehensive inspection to assess whether the actions taken in relation to the warning notices have been sustained, to assess whether action has been taken in relation to the seven requirement notices and to provide an overall quality rating for the service.

This report only covers our findings in relation to the warning notices we issued and we have not changed the ratings since the inspection in May 2016. The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. You can read the report from our last comprehensive inspection by selecting 'all reports' links for Fountain Place on our website at www.cqc.org.uk.

At this inspection we found the provider had taken action to address the issues highlighted in the warning notices. The provider had developed a comprehensive action plan to address the warning notices and other requirements in the inspection report where they were found to be in breach of regulations.

During our last inspection we found staff were not always confident that safeguarding concerns would be listened to and acted upon. At this inspection the provider had addressed the issues with staff surrounding the reporting of safeguarding incidents. The nurse in charge informed us that instructions about informing the local authority safeguarding team about incidents had been discussed with the staff team. This information had been added to the induction for agency staff working within the service to ensure they were aware of how to report safeguarding concerns. One member of staff we spoke with said they now had confidence things would be “Dealt with appropriately” and necessary actions undertaken to deal with the situation. There had not been any new safeguarding alerts raised since our last inspection.

During our last inspection we found that whilst risks assessments had been completed the care plans did not always contain detailed information for staff on how to minimise the risks. At this inspection risks assessments had been reviewed and updated to contain guidance for staff on how to minimise the risk of harm to people.

People were sometimes cared for by agency staff who were unfamiliar with their needs. The nurse in charge explained that all agency staff now undertook a comprehensive induction. The service used the same agency staff, where possible, to ensure people received consistent care. Each person had an accessible care plan in their room which contained an overview of people’s needs, the care they required and how they wished to receive this care. This meant where agency staff did not have the time to read the person’s full care plan they had access to information relating the daily care and support the person needed them to provide. Agency staff spoke positively about this information stating “The information is very helpful and acts as a quick reference of the care people need”.

At our last inspection we found accidents and incidents were not always recorded appropriately and reported to the management team. As a result of this the provider had implemented a new accident/incident reporting form which was reviewed by the interim manager each month to ensure appropriate actions had been undertaken.

People’s care plans had been reviewed to ensure they contained information for staff on how to prevent or minimise people’s risk of distress and how to keep themselves and the people using the service safe.

During our last inspection it was not always clear if people had been supported to have sufficient to eat and drink throughout the day. The systems in place contained conflicting information regarding people’s nutritional needs and monitoring forms were not always completed. During this inspection we saw charts for monitoring people’s nutritional and fluid intake were available in people’s rooms so staff were able to complete them as soon as the person had been supported to have any food or fluid. Agency staff had been made aware of the need to complete these monitoring forms. Records we reviewed had been completed and nutritional advice on these forms corresponded with the information in people’s nutritional care plans.

We carried out this inspection in response to concerns raised relating to the quality of care and support people were receiving. These concerns related to all three locations, Hillcrest Care home, Alexander Heights Care Home and Fountain Place Nursing Home which are all located in Avonpark Village. Due to this we inspected all three locations. The inspection took place on the 18, 19 and 23 May 2016 and was unannounced. At our last inspection at Fountain Place in July 2015 we found the provider did not meet some of the legal requirements in the areas we looked at. The provider wrote to us with a plan of what actions they would take to make the necessary improvements. We found during this inspection that the provider had not undertaken all the necessary improvements required to fully meet people’s needs.

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 and has the legal responsibility for meeting the requirements of the law, as does the provider. 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 not present during our inspection. We found the service was not well led.

People were not always protected from the risk of harm. Whilst risks were identified, people’s care plans did not always contain guidance for staff on how to minimise the risk and in some cases the care plans contained conflicting information.

Accidents and incidents were not always recorded appropriately and reported to the management team. This meant that we were unable to clarify if incidents had been followed up and where necessary appropriate actions taken.

People were at risk of not receiving appropriate care and support to meet their current needs. Care plans did not always contain up to date information and guidance for staff to follow. In addition we found some information relating to people’s care, support and treatment to be contradictory.

We observed caring and friendly interactions between staff and people using the service. People and relatives spoke positively about the staff and the care and support they provided. There was an activities programme, however opportunities for social engagement were limited and some people living in the home did not access meaningful activities to avoid social isolation.

People were supported to eat and drink sufficient amounts and maintain a balanced diet. People had access to specialist diets when required. However there was a risk people were not always receiving food and/or fluid at the right consistency due to the conflicting information provided to staff.

Mental Capacity Act (MCA) 2005 procedures were not clear for staff to follow. Records were not maintained to show the process followed by the staff to assess people's capacity and making best interest decisions. Staff did not always know who should be the decision maker in best interest decisions.

Problems with the service and required improvements were not always identified. We did not always see evidence of actions taken where concerns had been highlighted. Not all staff felt they were supported by management to raise concerns or question practice. They did not feel that concerns raised had been acted on and responded to appropriately.

There were safe medicine administration systems in place and people received their medicines when required. Records confirmed people had access to health care professionals as required such as a GP or consultant specialist.

Staff we spoke with told us they had received training in safeguarding vulnerable adults and were able to explain how they would recognise and respond, should they suspect abuse was taking place. However staff were not always confident that any concerns raised would be listened to and acted upon. People and relatives told us they or their relative felt safe living in Fountain Place.

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.

The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special measures’ by CQC. The purpose of special measures is to:

Ensure that providers found to be providing inadequate care significantly improve.

Provide 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.

Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

A team of four inspectors carried out the inspections across the three locations. On the day of our inspection of Fountain Place there were 14 people living at the home.

This location was inspected by one Adult Social Care Inspector. We spoke with three people who use the service, two visitors, the nurse in charge, one care assistant, the activities co-ordinator and the cleaner. The focus of the inspection was to answer five key questions; is the service safe, effective, caring, responsive and well-led?

Below is a summary of what we found which describes what we observed, what the staff told us, and the records we looked at.

Is the service safe?

People were cared for in an environment that was clean in some areas and not clean in others. Staff were unable to access the provider's infection prevention policies and procedures and there was no designated lead for infection control within the home. No infection control audits had been carried out this year.

One person who used the service told us "I feel very safe here".

Is the service effective?

It was clear from what we saw and from speaking with staff that they understood people's care and support needs and that they knew them well. People who used the service told us staff were "kind" and "caring". We saw and were told that the provider was reliant on agency staff due to staff vacancies

Care plans that we saw had been not been regularly reviewed or updated. This meant that staff did not have access to up to date information regarding the care needs of people.

Is the service caring?

People were cared for by kind and attentive staff. People who used the service told us staff were "kind" and "caring". We observed staff interacting with people in a calm and unhurried manner.

Is the service responsive?

People's needs had been assessed before they moved into the home. Records confirmed people's preferences, interests, and diverse needs had been documented and care and support had been provided that met their wishes. Care assessments had not always been reviewed and not all of the people who used the service had up to date care plans in place. This meant that staff did not have up to date information available to them in order to provide person centred care. People had access to activities on a regular basis.

Is the service well-led?

There was no manager in post during our inspection. Staff told us "staff morale is low at the moment", "we've had no manager for at least 10 weeks; morale is low but better than it was" and "there has been ineffective management". There was no clear leadership of staff and staff told us they did not feel supported.

We were told that until the new manager starts employment in October 2014, staff were being supported by two senior managers.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found -

Is the service safe?

People were treated with respect and dignity by staff. People told us that staff treated them well. People were cared for by staff who were aware of the risks to their safety and health and staff knew how to support them in a safe way.

Systems were in place to make sure that the manager and staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Although no applications had needed to be submitted relevant staff had been trained to understand when an application should be made, and in how to submit one. This meant that people were kept safe from harm. There were effective systems in place where people did not have capacity and best interest decisions were made through a multi-agency approach.

There were arrangements in place for a senior member of staff to be contacted in the case of an emergency.

Is the service effective?

People told us that they were happy with the care they received and their care needs were met by 'excellent' staff. It was clear from observations and from speaking with staff that they had a good understanding of people's care and treatment. One person told us 'I'm very happy here, staff really very good'.

Family members spoken with commented 'Continuity of care is not good. There are too many agency staff' and 'Weekends are a problem'. We received positive comments from family members about the regular care staff such as 'Some of the care staff are wonderful' and 'On the whole care staff are good' and 'Their hearts are in the right place '.

The use of high levels of agency staff had impacted on the consistency of record keeping while recruitment took place. Although improvements had been made in keeping accurate records about people's care and treatment, some of the records we saw did not always reflect this practice.

Is the service caring?

People were supported by kind and attentive staff. We saw that care staff showed patience and gave encouragement when supporting people. The manager and staff had a good awareness of individuals' needs and treated people in a warm and respectful manner. A member of staff told us 'You can't force people. Sometimes some people don't want to get out of bed so you have to respect their wishes'.

We saw people were receiving care in a sensitive way. We observed people being supported in making choices about their daily routines and the activities they would like to do.

Is the service responsive?

The service responded to people's changing needs through regular review of the care they received. People had been involved in the care they received. Their needs, preferences and interests had been documented to help plan an individual service. Staff spoken with told us they had enough information about people's needs and demonstrated their knowledge about individual needs and preferences.

People had access to activities that were meaningful and were supported to maintain relationships with their families.

Is the service well-led?

There was no registered manager at the home. The current acting manager was in the process of applying to be the registered manager of three care homes at Avonpark Village including Fountain Place Nursing Home.

Quality assurance processes helped to make improvements to the quality of the service where they were needed. Actions were recorded and followed up at regular intervals. The processes in place to monitor and audit were being reviewed and improved to provide a person centred approach.

Staff had a good understanding about their roles and responsibilities. Staff told us there had been changes in the ethos of the home with an emphasis on providing an individual service.

People we spoke with told us they received the care they needed. A person described the care as 'fantastic.' We saw all people had access to their call bell. We saw staff assisted people to move in a safe manner, using correct equipment as necessary. We observed a registered nurse being very gentle and kindly towards a person who was unwell.

People told us they felt safe and supported. Three members of staff we spoke with had a clear understanding of their responsibilities for safeguarding people. One member of staff told us 'I am confident I'd be listened to,' if they reported any matter to their manager.

People said staff new how to care for them. A person told us 'oh yes they know their job.' Staff told us they were trained and supported in their roles, this included induction, ongoing training and supervision.

We saw records were completed variably. This included care plans and movement position records on prevention of pressure ulceration, assessments relating to the use of bed rails and staff training records. As records were not completed the provider could not be assured all people were consistently receiving the care they needed and staff were fully trained in their roles.

The people we spoke with said they were well looked after, although one reported a concern about staff competence.

One person told us the menus lacked choice. Another told us they were not given choices about what to wear and about their care. The staff we spoke with said people were cared for as a group and not, as individuals. We were told people were not enabled to make choices such as times to rise or taken to use the toilet according to people's individual regimes.

Two people told us staff did not respond promptly when they summoned help using the call bell system. We looked in 11 bedrooms and we saw four people had nurse pull cord in their reach and seven people did not have a nurse call pull cord within reach.

Staff told us there was a lack of direction on how to meet people's care. They gave us an example of poor moving and handling techniques they observed being used by other staff.

People told us they felt safe at the home, but staff were not clear on their responsibilities towards safeguarding people from abuse. We found from listening to staff, and checking records, when concerns were raised by staff, the managers did not make a safeguarding alert with the local authority responsible for safeguarding. The provider's policy on safeguarding was not being followed by all staff and managers.

People said they were able to read their care records which were kept in their bedrooms. Care plans told staff how to deliver the care people needed, but needed more detail to help staff recognise potential deterioration of mental health and anxiety. A relative told us they were kept informed about important events and they were invited to review meetings.

Although one person said it was 'too quiet in the evenings and at weekends', people we asked told us there were organised group and one to one activities. One relative told us the activities coordinator spent one to one time with people whose choice was to stay in their rooms.

People said there were always enough staff to meet their needs. They told us 'the staff are good and we get what we need' and another person said 'very nice staff and when they leave they always say good-bye or good-night.'

We were told the meals were 'ok' and there was always enough to eat.

The people we spoke with said they would approach the manager if they had complaints.