Archived: The Green Nursing Home

The Green is a residential care home providing personal and nursing care to 41 people aged 65 and over at the time of the inspection. The service can accommodate 59 people in one purpose-built building which is laid out over two floors.

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

The service has been rated as requires improvement at the last six inspections and the provider had failed to oversee and sustain the improvements required to improve the quality of the service.

The service had gone through a period of significant change with a new management team who had been in post for a short time. People, relatives and staff gave us consistently positive feedback about the changes that were being introduced and the approach of the new manager. However, the manager recognised that many improvements were needed to improve the quality of the environment and care offered and that more time would be needed to fully implement what was required.

Checks were not being carried out to ensure care and support was being delivered effectively. People, staff and relatives had not been consulted about the running of the home although the new manager was now starting to do this.

Improvements were required to make sure the environment was safe and that people’s personal information was stored safely. Although there were enough staff on duty to keep people safe, the service needed to recruit more nursing staff to make sure people received safe and consistent care.

The environment needed updating to ensure it met people’s needs and to ensure was homely and welcoming. Staff needed to receive more training and supervision to help them feel confident to support people with dementia.

Care plans needed to be reviewed as people’s needs changed to ensure they received responsive care. People told us they wanted more activities to keep them active and that were in line with their interests.

Staff understood how people preferred to communicate and this enabled people to make choices. More work was needed however, to ensure information was presented to people in an accessible format.

People received their medication at the right time and staff understood how to keep people safe from the risk of abuse. Improvements had been made to how staff moved people safely.

Staff treated people with care and respect and told us that the home was becoming a better place to work. The service worked well with other agencies to ensure people’s health was promoted.

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.

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

Rating at last inspection

The last rating for this service was requires improvement (published 05 July 2018).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified breaches in relation to the management and governance at this inspection.

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.

The Green provides care and support for up to 59 older people who require nursing or personal care, and who may be living with dementia. On the day of the inspection 35 people were living at the home.

At our last inspection in September 2017 we identified improvements were needed throughout the service. Following this inspection we used our enforcement powers and restricted admissions into the home and imposed conditions on the provider’s registration. We also required the provider to send us evidence of audits undertaken each month along with a summary of actions taken particularly in relation to people’s skin or wound care. This was because we found people were at risk of harm. We judged the home as ‘Inadequate’ in two of our key questions and ‘requires improvement’ in three of our key questions. We rated the home ‘inadequate’ overall and we identified four breaches of the Health and Social Care Act.

Following our September 2017 inspection we placed the home 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.

This most recent inspection we found the improvements had been made in the quality of care provided to people and the service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. We found the service was now meeting the regulations. However, we will continue to monitor the service to ensure the improvements have been sustained and will review this at our next inspection.

Since our last inspection the home has 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 felt safe. Staff understood how to recognise abuse and knew how to escalate any concerns. Risks to people were assessed and care records in place to meet their needs. People received their medicines as prescribed and systems used for the management of medicines were safe. People were supported by adequate numbers of suitably recruited staff. People were protected from the risk of infection and any incidents or accidents were reviewed to ensure learning if things went wrong.

Staff were trained and demonstrated the skills and knowledge to meet people’s needs. People were asked for their consent before care was provided. Where people’s rights were restricted this had been completed lawfully. However improvements were required in the understanding of the principles of the MCA when submitting applications to deprive people of their freedom. People received sufficient amounts of food and drink and staff made referrals to healthcare professionals to support people’s health needs when required.

People received support from caring staff who gave people time to make choices and decisions. Staff treated people with dignity and respect. People were supported to maintain their independence. Relatives and visitors were made welcome at the home by staff who knew them.

People sat for periods of time without stimulation and activities were not always person centred. People and their relatives knew who to contact if they were concerned about any aspect of their care and were confident issues would be dealt with appropriately.

The majority of issues identified at our last inspection in September 2017 had been addressed and systems and processes had been developed to monitor the quality of the service provided to people. Opportunities for people to feedback about the quality of care they received were being developed through meetings. People, their relatives and staff were positive about the management of the home and the effectiveness of the registered manager. The registered manager understood their role and responsibilities for reporting certain incidents to us that have occurred as required by law.

A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered nominated individuals, 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 of the service had left in July 2017 and the home was being managed on a day to day basis by the Nominated Individual who is a person who has legal responsibilities to ensure the service runs safely and well, and is the representative of the provider. At the time of our inspection there was also an acting manager who told us they planned to apply to become the Registered Manager. They were volunteering their time at the service and had not yet been employed by the company.

The home was last inspected in May 2017 when we found the provider was not meeting the requirements of the law in four areas. Of the five key questions, we rated four as Requiring Improvement and the key area of Safe as Inadequate. We spoke with the provider’s representative and the registered manager following our inspection in May 2017. We asked them to send us an action plan detailing what actions they would take to improve the service. We returned to the service to undertake this comprehensive inspection six weeks before the work detailed in this action plan was due to be completed. We expected to see that improvements were well underway and to gain confidence that the improvements would be completed within the time scale on the action plan. At this inspection we did not find that improvements had been made in line with our expectations. This inspection found the provider was not meeting the requirements of the law in four areas. Of the five key questions, we rated three as Requiring Improvement and the key areas of Safe and Well Led as Inadequate. The provider had failed to secure adequate improvements to improve the safety and quality of service provided to people.

Prior to our inspection we had received a larger than expected number of safeguarding alerts in relation to The Green Nursing Home. We worked closely with the local Clinical Commissioning Group (Part of the NHS) who were providing nursing support and visiting the home regularly. They provided us with information about the safeguarding concerns and how they had been addressed. During our inspection we found that when a safeguarding alert had been made it was dealt with appropriately. However we were not confident that all areas of concern had been identified by the service as safeguarding issues. We found that four peoples care was not safe and had not been recognised as such by staff. The poor management of wound care was highly concerning and people were experiencing inadequate care and medical intervention. After the inspection safeguarding alerts were made to the local authority by the inspection team in relation to these concerns. We are awaiting the outcome of these.

The provider had failed to consistently notify us when they were legally required to do so.

People told us they felt safe. We saw safe techniques were used to move people. Staff understood the risks to people’s health and safety but risks such as support to people who had skin wounds were not always managed well. Recording of these risks was not always evident. There were sufficient staff to meet people’s needs, although some people felt that more staff were needed on occasion. The provider operated a safe recruitment system which meant people were supported by suitable staff. Staff understood their responsibility to raise concerns regarding potential abuse.

People told us that staff had received training to support them, but the support was not consistent. Staff understood the need to ask for consent and we saw that they asked people before providing any care. The Nominated Individual had started to apply the principles of the Mental Capacity Act, but some people may have been unlawfully deprived of their liberty as applications to do that had not been submitted when deprivations were identified. People’s nutritional needs were being met. People had access to some health professionals when their health needs changed, however we were not confident that all healthcare needs were well met.

People were supported by kind and considerate staff. People had some day to day choices about their care and staff listened to them and respected their choice. People were not always treated with dignity and respect by staff. Staff encouraged people’s independence where possible.

People received care which was not always responsive to their individual needs Improvements were required to ensure people’s care records contained up to date and accurate information about the care they received. People and their relatives told us they felt comfortable raising complaints with the Nominated Individual, and we saw there was a formal complaints process in place.

Although people told us they were happier with the care provided they had not been included in any of the on going or proposed improvements. People had not been involved in planning or reviewing their care. The governance system had only just started to be implemented and had not been effective at the time of the inspection. The nominated individual did not have a full awareness of the extent of the problems and issues which needed to be addressed. It had also not been effective in improving quality or mitigating risks.

During this inspection we found that provider to be in breach of four regulations. 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 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.

Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded. You can see what action we told the nominated individual to take at the back of the full version of the report.

We undertook the inspection in December 2016 to ensure that shortfalls we had identified in our last comprehensive inspection had been fully addressed. In December 2016 we found that the registered manager and registered provider were ensuring people received support that was safe and caring. However we found further improvements were required to ensure the home was well led. At this inspection in May 2017 we found that people could no longer be confident they would receive safe care and that the improvements that had started to increase the effectiveness of monitoring systems had not been sustained.

The Green Nursing Home is registered to provide nursing care to up to 59 older people who may also be living with dementia. At the time of our inspection there were 56 people living at the home. The home has a registered manager and they were present throughout our inspection. 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.

Feedback from people living at The Green and their relatives was that they felt safe at the home. People went on to describe the kind and caring interactions they experienced from staff. We saw individual staff supporting people with kindness and compassion. However we had concerns about the management of people’s medicines, staff were not always available at the times people needed them, action had not been taken to protect people from injuries and incidents of a safeguarding nature had not always been reported.

People were offered and supported to eat a wide range of nutritious and tasty meals. People told us they enjoyed the food. The food we saw looked and smelt tasty. Adjustments people needed to their food and drinks to ensure they could eat and drink safely had been made. However we could not always be sure that people were supported to eat and drink enough to maintain their health.

Staff had received training in the specific needs of the people they were supporting, as well as safe working practices. Some of this knowledge had been applied to staff practice, however we observed staff working in ways that were not always consistent with good practice guidelines, or which would keep people safe.

People were offered the opportunity to make a wide range of every day choices. We saw and heard people being asked about what they would like to wear, to do, to eat and drink for example. Processes to help people make bigger decisions were not all established, and there was a risk people would not get the support they required.

Some aspects of people’s healthcare were well met, and we saw staff providing people with equipment and special cushions for example that would reduce the chance of them getting sore skin. There were good relationships between the staff working at the home and local health care professionals. Changes in people’s healthcare were noted and the relevant support was sought for people. We looked in detail at some people’s care and found that other parts of their healthcare were not as well planned, and the staff responsible for planning and providing this care were not all fully informed about people’s needs. We observed that this placed people at risk of receiving unsuitable or unsafe care and treatment.

Individual staff demonstrated kindness and compassion in their interactions with people. We saw some staff offer people a hug or reassurance when they were anxious or confused. We saw this brought the person comfort. On other occasions we observed that there were no staff in the areas where people required support. In these instances people did not receive comfort or reassurance. People’s privacy and dignity was not consistently protected.

Permanent staff that we met knew people well, and we saw they often used this knowledge to provide care and support in line with people’s preferences and wishes. This knowledge about people had not all been documented, or used to personalise people’s plans of care. Some people’s preferences had been recorded however we observed the care and support provided was not always consistent with this.

People and their relatives told us the manager was approachable and that they could share concerns or complaints at any time. This had resulted in positive changes happening quickly for people, once the manager had been made aware. No record had been made about complaints, which meant that the number, type or any themes could not be tracked. Doing this would enable wider improvements to be made across the service.

Most people, staff and relatives we spoke with described the home manager as being approachable and involved in the day to day running of the home. We found that the governance systems (Processes to ensure the safety and quality of the service) had not been effective, and had not ensured that people would receive a consistently safe service that met their needs and the requirements of the legal regulations.

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.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for The Green Nursing Home on our website at www.cqc.org.uk

This inspection took place on 15 December 2016 and was unannounced. The inspection was focussed and concentrated on three of the areas that we look at, safe, caring and well led. The breach of regulation in June 2016 identified that the provider did not have effective systems in place to assess, monitor and mitigate the risks to health, safety and welfare of people who used the service. At this inspection we found some significant improvements had been made.

The Green Nursing Home is registered to provide care and support for up to 59 older people who have needs relating to their age or dementia. Nursing care is provided. On the day of our inspection there were 54 people at the home and two other people were in hospital.

The registered manager was present during our inspection. 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 that they had no concerns about their safety. People were supported by staff who had received training on how to protect people from abuse. Risk assessments had been completed to minimise the risk to people. People told us that there were adequate numbers of staff on duty to meet their personal needs. Medicines were managed well.

People told us and we observed that staff were kind and compassionate in the way they supported and cared for people. People were given support to make their own decisions about their individual care and support needs. We saw that staff respected people’s privacy and dignity. Some areas of confidentiality could be improved.

All the staff we spoke with said that the registered manager was supportive and approachable. The registered manager had continued to make improvements so that people were supported better than at the previous inspection. However people were not as involved in their care and the running of the home as they could be. A quality assurance process had been completed but the registered manager had not consistently taken the actions identified within it. The registered manager had developed and used a variety of internal audits which helped to ensure the service being offered was safe and of good quality.

The inspection team comprised of one inspector, a specialist advisor and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. The specialist advisor had experience in nursing care.

People, their relatives and staff told us they felt people were safe in the home. Staff were aware of the need to keep people safe, but not all staff knew how to report allegations or suspicions of poor practice. We saw that people were happy around staff and with the support they were receiving. Staff were not always available to meet people’s needs in a timely manner. We found that people were kept waiting for care for longer than they found acceptable.

People were protected from possible errors in relation to their medication because the arrangements for administration and recording of medication were good and there were systems for checking that medication had been administered in the correct way. We saw that there were some concerns relating to the safe storage of medication.

People told us that they were very happy with the care provided. People had opportunities to participate in a range of activities in the home. People’s relatives and friends were encouraged to visit and made welcome by staff.

Staff were appropriately trained, skilled and supervised and they received opportunities to further develop their skills.

The registered manager and most staff had supported people in line with the appropriate legislation when the care and support they received may have deprived them of their liberty. We saw that consent to care was not always gained before staff supported people. Staff did not always ask people how they wanted to be supported. In some cases people were not treated with dignity and respect. We saw that staff communicated well with each other.

People were provided with a good choice of food in sufficient quantities and ate meals which met their nutritional needs and personal preferences. The registered manager sought and took advice from relevant health professionals when needed.

The registered manager did not have robust systems or processes that monitored the quality of care consistently through observation and regular audits of events and practice. You can see what action we asked the provider to take at the back of the full version of the report.

People were complimentary about the staff who supported them and their living environment. Comments included, 'I'm fine thanks, the staff are very good and I'm well looked after' and 'I can't fault them, the food is good, my room is comfortable.'

We examined care plans and found that people's needs were properly assessed and that care and support was planned and delivered in line with their individual care plans. From our observations it was apparent that care staff were attentive, polite and sought consent before providing care and support.

We examined staff training and recruitment records and spoke to care and nursing staff. We found that people who lived at this home were safe and their health and welfare needs were being met by staff who were fit, appropriately qualified and competent.

The provider had effective monitoring systems and processes in place to identify, assess and manage risks to the health, safety and welfare of people who lived, worked and visited the home. We found that care was provided in an environment that was safe, accessible and suitably designed and adequately maintained.

We concluded that The Green Nursing Home was a comfortable, well maintained home that was safe, caring and well led.

Most of the people using the service were unable to speak with us because of their medical conditions. Therefore, we observed the care and support being provided to these people.

We observed that staff supported people in a respectful manner and that they were available at the times that people needed them. Staff offered people choices of how and where they wanted to spend their time. A person using the service told us 'If I need support with anything I ask the staff and they sort it out for me.'

People told us that they were happy with the choice and quality of food provided. The relative of a person using the service told us 'My wife's meal is pureed and it is good that all of the portions are pureed separately. This encourages her to eat well.'

People told us that they felt safe living at the home and that they or their relatives would speak to the manager or staff if they had any concerns. The relative of a person using the service told us 'If we have any slight problem the manager sorts it out, no messing about. She is so helpful.'

Systems were in place to monitor the quality of service provided at the home. People using the service and their relatives were involved in this. The relative of a person using the service told us 'I would give this place 110% for quality.'