Archived: Audlem Country Nursing Home

We asked the provider to send us an action plan following the last inspection on 12 and 13 October 2017. This had not been sent to us so we asked the provider when we met with them to provide us with their action plan which they then provided. Despite this the provider had implemented actions to drive improvements.

Audlem Country Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is set within a rural area of the village of Audlem. There were 33 people living at the home at the time of our inspection. The original building dated back to 1640. There were self-contained flats within the grounds of the care home where people were receiving regulated activity.

Medicines management systems were reviewed. We found Pro Ra Nata [PRN “as and when prescribed medication”] protocols were not in place when they should have been. The provider therefore, did not meet the requirements of the Regulation 12 Safe Care and Treatment.

We checked if the service was safe and we found improvements had been made. Risks were being recorded and reviewed and the comments we had previously made that related to the safety of the premises had been mitigated by the provider.

Recruitment practices were safe with the appropriate checks undertaken by the provider.

The premises were clean and we could see a cleaning rota in place for all areas of the home. The flooring had been replaced and the fire safety concerns had been resolved since the last inspection.

Staff we spoke with were able to explain the different types of abuse and were clear about their responsibilities of reporting alleged abuse. Staff were aware of whistleblowing procedures.

We viewed rotas and made observations and found the staffing levels within the home were sufficient in meeting people’s care needs.

Care plans were being reviewed. Not all care plans were in place or reflected the care being provided such as for delivering one to one care.

Aspects of person centred care were evidenced in some care records but improvements were needed to ensure everyone who received a service had person centred care.

The provider demonstrated they were inclusive of people who had diverse or complex care needs in line with equality, diversity and human rights.

We found staff were caring and respected people’s choices, preferences and independence. We found people’s dignity was not always being upheld such as stained bed linen which had not been replaced.

Consent and the implementation of the Mental Capacity Act 2005 framework had improved and the provider was no longer in breach of Regulation 11 Consent.

People received enough to eat and drink but improvements were needed such as to ensure people received food in a timely manner when food was warm. Due to the design of the building and restricted access from the kitchen, food could not be transported on a heated trolley.

New systems had been implemented to ensure the provider was seeking people’s views. We viewed questionnaires which people had completed and their relatives.

An activities coordinator worked within the home for two days each week. We received feedback this was not sufficient for people and more activities were needed to ensure people were receiving enough stimulation. We observed activities during our inspection and a trip out for two people living at the home.

There was a complaints process in place and we could see a system of dealing with them by the provider.

Policies were in place and some required review due to there being several policies for dealing with incidents and behaviours which were challenging. This meant it was unclear which policy was being followed when dealing with incidents.

Governance systems had improved with monthly audits now in place. Not all audits such as the medication audits had identified an issue we found on this inspection and these were therefore, not robust enough.

The provider had two website links at the time of our inspection, one of which did not clearly display the rating. This was raised on this inspection and the provider promptly corrected this.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Audlem Country Nursing Home is located in the village of Audlem and is an extension of a school building dating back to 1640. There are two levels with no passenger lift. There are stairs for people to access both levels. The outbuildings at the rear were accessed by staff and contained stocks of incontinence products and equipment. There was a garden area with a smoking section for people within the home to smoke outside. Within the external grounds of the home there were four self-contained flats where people received care in their own homes. There were 38 people receiving care at Audlem Country Nursing Home at the time of our inspection.

The home had a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission (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. The registered manager was also the nominated individual and director of the company and was not acting in the capacity of the manager but had appointed a “home manager” to manage the home on a daily basis. We received an application from the home manager to become the registered manager and this was being processed at the time of our inspection.

At the last inspection of this service in May 2017 we identified a number of breaches of the regulations. During this inspection the provider had demonstrated they had met some of the legal requirements and were no longer in breach of Regulations 14 Nutrition and Hydration and 18 Staffing. However, we found that two of the previous breaches in respect of safe care and treatment and governance had not been fully addressed and we identified a further breach in respect of consent. You can read about what action we asked the provider to take at the back of this report.

We found the service was not always safe due to risks not being managed effectively. One person who displayed frequent incidents of verbal and physical aggression did not have any analysis of their behaviour charts. Another person had no behaviour monitoring charts in place despite them being prescribed a new medication to treat their behaviour by their GP.

Risks were not always being reviewed in the records we viewed. One person with a history of falls did not have their falls risk assessment and care plan reviewed each time the person had a fall. Other risks were being reported verbally to us but not recorded in the care records.

There were fire risks identified such as access to a fire extinguisher which was blocked and two people’s doors were propped open. The Cheshire Fire and Rescue Service Fire Inspector visited the premises on 25 October 2017 and issued an action plan with actions to be met within a 6 week period. They identified a number of fire risks such as an inadequate fire alarm system.

There were further risks in relation to the environment identified such as a free standing ladder propped against an external fence where people smoked and a pipe across an external path posing a trip hazard. Radiators were not all protected with radiator guards and some radiator guards were loose.

The environment was poorly signed for people to easily find their way around the care home. People’s bedroom doors did not clearly display their name and lacked personalisation for people to recognise it was their room.

Recruitment procedures in place were not robust enough. One staff file did not have adequate references; two staff files had gaps in employment which were not explained. None of the staff files contained evidence that an interview was undertaken by the provider.

The provider’s training policy confirmed staff were to follow the Care Certificate. This was not being followed by staff and the home manager had not heard of the Care Certificate when we spoke with them. We found a training matrix was in place and staff we spoke with confirmed they were receiving training.

There was one main meal offered each day on the menu at breakfast, lunch and tea time. When we spoke with people we found they were being asked if they would like something different to the meal being offered. Menus were not provided on the tables or pictured menus for people to recognise different foods easily. There was a diabetic range of foods and the chef had a list of people’s dietary needs.

Deprivation of Liberty (DoLS) applications had been made when appropriate by the home manager. The Mental Capacity Act 2005 was not always being followed or being put into practice. One person who had a DoLS application to Cheshire East Council had been commenced on a newly prescribed medication without their lawful consent. Another person who had a DoLS in place and had capacity issues had no decision specific assessments in place.

Since the last inspection the provider had implemented training in how staff were to deal with behaviours which are challenging. The provider had thereby met their legal duty to meet Regulation 18 Staffing in relation to training. The home manager had a supervision structure in place and we found staff supervisions included competency questions to ensure staff had understood aspects of their training.

Staff understood their responsibility to protect people from abuse and there were systems in place to record and report safeguarding concerns.

We undertook a Short Observational Framework (SOFI) and observed positive interactions between staff and people they were providing care for.

Fluid and food charts were being completed and the provider had improved their systems in place to ensure people were receiving enough to eat and drink. The provider was no longer in breach of Regulation 14 Nutrition and Hydration on this inspection.

We found effective storage of prescribed medicines including prescribed thickener being stored in the clinic room. We observed staff administering prescribed medicines safely for people.

Wound care plans were to a high standard and pressure mattresses had been set appropriately for people.

Staff and resident meetings were taking place. Audits were being undertaken by the home manager and not the registered manager.

The rating was not being displayed on the provider’s website at the time of our inspection.

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.

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.

Audlem Country Nursing Home is located in the rural village of Audlem. The oldest part of the building was formerly a school, but the building has a complex history dating back to 1640. It has been extended to provide accommodation and nursing care for people with dementia and/or mental health needs. It is a two storey building and people live on both floors. Access between the floors is by stairs. The home is not equipped with a passenger lift. There are also four flats adjacent to the main building.

The service was last inspected in July 2016. This inspection was carried out as concerns had been raised with us about the standard of care in the home.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission (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. The registered manager was also a director of the company and was not acting in the capacity of registered manager. There had been an acting manager since July 2016 and they were now in the process of registering with the CQC. At the time of our inspection there were 41 people living in the home.

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

Where risk assessments were in place, they were not always followed therefore the risks to people had not been minimised.

Not everyone living in the home had a care plan at the time of our visit. Whilst staff had been verbally updated on the needs of people, there were no written records for one person which meant that staff could not always be clear whether they were meeting their needs at any particular time. We saw that people’s needs were not always being met in a timely way.

Whilst there were sufficient numbers of staff, they were not always suitably competent, skilled and experienced to meet the needs of the people living in the service. We observed that the training had been requested, but this had not been provided. The training which was available to staff did not always provide them with the skills and knowledge to do their jobs effectively.

People being nursed in bed were not provided with sufficient drinks and their hydration needs were not being met. We also observed that some of the people nursed in bed were not clean.

We saw that the service had a safeguarding policy in place. This was designed to ensure that any safeguarding concerns that arose were dealt with openly and people were protected from possible harm. Although we saw that the manager was appropriately referring safeguarding concerns, some staff that we spoke to were unclear of the procedures particularly in relation to whistleblowing.

There was an internal quality assurance system in place to review systems and help to ensure compliance with the regulations and to promote the welfare of the people who lived at the home. This included audits on care plans, medication and accidents. We found that whilst some actions were taken in response to shortfalls identified, in other cases where issues had been raised these had not been addressed by the manager.

The service had a range of policies and procedures which helped staff refer to good practice and included guidance on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards. We saw that applications had been made appropriately and staff were seeking consent prior to any intervention and people were given choices in relation to their care.

Where people had care plans, we found that they were personalised to their needs and wishes. Most care plans contained information to assist support workers to provide care in a manner that respected the relevant person’s individual needs; however we found that the care given did not always reflect what was recorded in the care plan.

There was a complaints procedure, however we found the records of these were not always clear what the complaint was or the outcome. Everyone we spoke to was clear who they could speak to if they had any complaints and they were confident that this would be dealt with.

There were a number of maintenance checks being carried out weekly and monthly. These included water temperatures as well as safety checks on the fire alarm system and emergency lighting.

We looked at recruitment files for the most recently appointed staff members to check that effective recruitment procedures had been completed. We found that appropriate checks had been made to ensure that they were suitable to work with vulnerable adults.

There was a flexible menu in place which provided a good variety of food to people using the service. People living there told us that the food was good.

Whilst there was a registered manager, they had not been working in this capacity since July 2016. The current manager had applied to register in April 2017.

Visiting professionals, staff members, relatives and people living in the home were positive about how the home was being managed and the standard of care provided to the people living in the home.

The home was last inspected on 29 May 2014 and did not meet the required standard, as care plans did not reflect current need and some equipment used to move people was out of use. We followed this up on 03 September 2014 and found that the requirements had been met.

Audlem Country Care Home is a care home situated in the centre of the village of Audlem. It offers accommodation and nursing care for people with dementia and/or mental health needs for up to forty five people and is run by Keenrick Limited. During our visit there were 43 people living in the home.

A range of shops and other local facilities are within walking distance of the home.

The home had a 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.

We identified three breaches of the relevant legislation, in respect of the premises, consent and governance. You can see what action we told the provider to take at the back of the full version of the report.

We found that cleaning schedules had been ineffective in addressing malodours and staining to the fabric of the premises, which may pose a risk to infection control.

Some people who used the service did not have the ability to make decisions about some parts of their care and support. Not all staff had an understanding of the systems in place to protect people who could not make decisions following the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). Not all staff had received training or their training was out of date which would inform them how to adequately safeguard those people they provided support for.

Periodic audits and quality monitoring had been ineffective in addressing shortfalls and in implementing plans to ensure that the quality of the service provided was improved.

People were supported by staff in sufficient numbers to meet their assessed needs.

Medicines were received into the home, stored and administered safely.

Staff had a good knowledge of people’s individual needs and preferences.

People were appropriately supported and had sufficient food and drink to maintain a healthy diet.

People’s needs were assessed and plans were developed to identify what care and support people required to maintain their health and wellbeing and foster their independence where possible.

People were supported well with their fluctuating mental health needs. The home worked well with other health providers.

During the inspection we spoke with the manager and the provider. We also spoke with four of the people who lived in the home.

We considered all the evidence we had gathered under the outcomes 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. The summary is based on our observations during the inspection, speaking with people, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We saw that improvements had been made and people's needs were assessed and care and treatment was planned and delivered in line with their individual care plans. We looked in some detail at the care and support provided to four people who lived in the home. In order to do this we met with some of the people concerned, we spoke with the manager and we looked at people's records.

These records included the person's care plans, risk assessments, and records about the support they had received from professional people outside of the home. We found the information in each person's care plan was detailed and they reflected the person's needs. We looked at two care plans for people who had problems with diet and nutrition. We saw that appropriate monitoring was in place and this was reviewed regularly. We saw that people's mental capacity to make decisions was considered. We saw mental capacity assessments that had been carried out in accordance with the Mental Capacity Act 2005 to ensure that people were kept safe and in accordance with the law.

Is the service effective?

During a discussion with the provider and the manager, we raised concerns that the care plans were very task orientated and did not focus on the person individually and how they wished to be cared for. The manager showed us documentation that they were in the process of completing with each person who lived in the home and their relatives to record the care and support that they wanted.

Is the service caring?

During our inspection we spoke with four people who lived in the home. They all spoke positively about the care that they received. One person said "The manager always puts a smile on your face." Another person said "It’s okay here. They look after me and feed me well."

Is the service responsive?

At the start of our inspection we noted that the building was in need of extensive maintenance and refurbishment and there was a malodorous smell, especially in the reception area. The manager showed us a new cleaning schedule that had recently been put in place which included regular cleaning of the carpets. They also told us that a domestic supervisor had been appointed to coordinate the cleaning. We asked about the replacement of furniture as most of the chairs were worn and stained. The manager showed us an email that confirmed that new furniture was arriving each month and that all of the chairs would be replaced by the end of the year.

Is the service well led?

We saw that the quality of the service provision was now being monitored more closely. We saw that the manager was completing various audits including quality of care documentation, medication, and infection control. We saw that these audits identified issues which were then dealt with and resolved. We saw that the manager had taken steps to make improvements. During our inspection a pharmacist arrived to carry out a full audit of the medication systems in place with a view to making some changes. However we did have some concerns that only 11 care plans out of 42 had been audited since our previous inspection where we had identified concerns. The manager explained that they had ensured that every care plan had been reviewed but the auditing process was taking longer.

We saw that the manager was covering the shift as the nurse on the day of our inspection. We were told that this was happening regularly due to the home being short staffed. We discussed this with the provider as we had some concerns that the improvements the manager had made would be difficult to sustain if they continued to work as a nurse covering shifts in the home. The provider told us that they were in the process of employing new nurses and that this would ease the situation. They also said that they would consider how the role of the manager needed to work in the home.

During the inspection we spoke with the provider, the new manager who had been in post for one week, and six staff members. We also spoke with six of the people who lived in the home.

We considered all the evidence we had gathered under the outcomes 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. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

We were told that staff had a good understanding of the Mental Capacity Act and the Deprivation of Liberty Safeguards (DoLs). We saw that staff were asking people's consent prior to supporting them. We also saw evidence in care files that the home had carried out assessments for people living in the home who had difficulty making their own decisions.

During our inspection we looked at three care plans. We had significant concerns about all three and how they impacted on the care being provided to the people living in the home. The care plans were not being monitored or updated on a regular basis. We also found that the care plans did not reflect the current needs of the people. Many were out of date and the person’s needs had significantly changed. This presented a risk as care plans should inform staff how people want and need to be cared for.

The whistle blower had told us that there was only one stand aid (a device used to mobilise people who cannot move by themselves) in the home and that staff did not use it, they lifted people instead. We asked some of the staff on duty and they showed us that the stand aid was broken and had a note on it saying that it was out of order. We asked how staff had supported a person that morning and they confirmed to us that they had lifted the person. We pointed out that this had put the person and themselves at risk from injury and they told us that they had no alternative.

Is the service effective?

We looked at the rotas for the previous month and for the coming month. We saw that staff levels were consistent. We spoke with staff. Most of them told us that the staffing levels were adequate but two raised concerns that they felt that sometimes people had to wait to be supported for long periods.

None of the people who lived in the home raised any concerns about the numbers of staff. They made positive comments about the staff who supported them. Comments included; "He always finds time to chat with me" and "The staff help you with anything. They are lovely."

Is the service caring?

We spoke with six people who lived in the home during our inspection and all were very complimentary about the staff and the care that they received. Comments included; “We are very lucky, the staff are lovely and they always help us” and “I like living here. The staff are the best. They are my friends.”

We observed how staff communicated with the people they were caring for. All interactions we observed with people who lived in the home were positive. The staff we observed were very skilled in their approach and they appeared to know the people that they were supporting well. We saw that staff had warm relationships with people who lived in the home.

Is the service responsive?

In one care plan we saw that the mobility assessment stated that the person was fully mobile and independently mobilised around the home. We then saw another assessment that stated that this person required assistance with a standing aid. When we spoke with staff we were told that this person could not stand most days and had to use a wheelchair to be moved around the home. The care plan did not reflect the needs of the person. We saw that the continence care plan also did not reflect the current needs of this person.

In another care file we looked at we saw that it had been reviewed only once in the last six months in March 2014. We saw that many areas of this person’s care plan identified them as ‘high risk’ thus making it vitally important that their care was monitored closely and we could see that it had not been. We saw that this person had diabetes but there was no care plan in place to tell staff how and when to monitor their blood sugar. We found a document that showed that some monitoring had taken place but it was inconsistent and there was no rationale to explain why.

Is the service well led?

We reported all our findings to the new manager. The new manager had been in post for one week. They had identified the previous day that the care plans needed updating and they shared their plans with us regarding what they were planning to do to improve them.

We saw that audits had been completed in February, March and April 2014. We looked at the audits and saw that that there was very little detail recorded. The questions were all answered in a way that implied that no shortfalls or issues had been identified and there was no evidence of any actions to follow through. The infection control audits had some actions but then these actions were repeated as still being required in the following months with no evidence of action having been taken.

The new manager told us that they had already identified that further audits needed to be completed and they showed us paperwork that they had arranged to commence audits with immediate effect.

Care planning was of a high standard. People were involved in their own care planning as much as possible. Families and healthcare professionals were correctly involved and consulted and their inputs to the care plan recorded. Adequate numbers of staff were provided and staff were supported in their role.