Azalea Court

Azalea Court is a residential care home providing accommodation, nursing and personal care for up to 83 people. At the time of the inspection, there were 82 people living at the home which is a 3 storey purpose built home and an 8 bed unit in a separate building, called Willows unit. This unit is for people with specialist high dependency nursing needs.

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

People and their relatives were generally happy with their care at Azalea Court. The nursing care was good. Staff supported people to take their prescribed medicines, and this was managed safely and in people’s best interests. Risks to people's health and safety were assessed and addressed to help them keep safe.

People had good support to access the healthcare services they needed. Staff helped people to eat and drink and people were generally happy with the food in the home.

Staff were recruited safely, trained to meet people’s needs and were supported well by the management team. Staff were kind and caring to people living in the home. There was a positive culture which promoted good care and treatment. There was good engagement by the management team with people, staff, professionals and relatives.

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

Management oversight was effective, and there were systems in place to monitor the quality of 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

At the last inspection we rated this service good (published 27 November 2021). At this inspection the rating remained good. At our last inspection we recommended that the service improve oversight of medicines to ensure there were no problems with stocks of medicines. At this inspection we found the service had made this improvement.

Why we inspected

The inspection was prompted in part due to concerns received about a person dying after sustaining a serious injury and the care of people who had tracheostomies (tube to assist with breathing). A decision was made for us to inspect and examine those risks.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe and well-led key questions of this full report. The provider had taken action to mitigate the risks.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Azalea Court on our website at www.cqc.org.uk

We looked 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 COVID-19 and other infection outbreaks effectively.

Follow up

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

Azalea Court is a nursing home providing personal and nursing care to 79 people aged 65 and over at the time of the inspection. The service can support up to 83 people.

Azalea Court is a large building with three separate floors supporting people with varying physical and nursing needs. The service also supports people living with dementia. In addition, Azalea Court has a separate eight bedded high dependency unit which supports people with specialised nursing needs.

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

Throughout the inspection we observed people to be supported by care staff with care and compassion.

Whilst medicines were administered safely, processes and systems in place did not always ensure that people received their medicines as prescribed.

We have made a recommendation that the registered person ensure effective governance arrangements are implemented and followed to reduce risk to people.

People told us that they felt safe living at Azalea Court. Safeguarding processes were in place to help safeguard people from abuse. Risks associated with people's care had been assessed and guidance was in place for staff to follow to ensure people were kept safe and free from harm.

People were protected from the risks associated with the spread of infection. The service was clean and well maintained. There were enough numbers of staff deployed to meet people's needs and ensure their safety. Appropriate recruitment procedures ensured prospective staff were suitable to work in the home.

Staff received appropriate induction, training and support and applied learning effectively in line with best practice. This meant people’s needs were safely and effectively met ensuring a good quality of life.

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.

Care plans in place detailed people’s needs and preferences. Staff knew people and their care needs well. People’s needs were assessed prior to admission and regularly thereafter. Staff supported people to meet their health and nutritional needs. Staff worked with health care professionals to maintain people's health and wellbeing.

There were quality monitoring systems and processes in place to identify how the service was performing and where improvements were required.

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 good (published 20 March 2020).

Why we inspected

We received concerns in relation to the management of people’s nursing care needs, staffing and staff morale. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We looked 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 COVID-19 and other infection outbreaks effectively.

We found no evidence during this inspection that people were at risk of harm from these concerns. Please see the safe, effective and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Azalea Court on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

¿ A specific Covid 19 training programme was developed for staff. Staff underwent regular training and competency assessments in the use of PPE and handwashing.

¿ The provider had well organised arrangements in place to test people and staff for Covid 19 and was following government guidance on testing. A number of staff were trained to carry out testing.

¿ Hospital discharges and admissions to the service were well managed with a strict admissions procedure to minimise the risk of spreading infection into the home. The service had no current or previous cases of Covid 19 within the home.

¿ The provider was in the process of adapting an existing communal room with separate access into a dedicated visitors’ room with screening where people could meet their families safely.

Further information is in the detailed findings below.

Azalea Court is a nursing home providing personal and nursing care to 77 people at the time of the inspection. The service can support up to 83 people; across three separate floors. Two of the floors specialise in providing care to people living with dementia and nursing needs. In addition there is a separate eight bed high dependency unit in the grounds for people who have specialised needs such as brain injury, tracheostomy care and non-invasive ventilation.

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

Although medicines were generally managed safely, the controlled drugs were not managed safely as the disposal of these drugs was not carried out appropriately in line with the service’s medicines policy on one unit. The provider’s medicines audits had not picked up this concern. This had not had a negative impact on people who were getting their prescribed medicines safely. We have made a recommendation to make improvements in the management of medicines.

People and their relatives were generally happy with the standard of care provided at Azalea Court. Their health needs were met, and they had good support from healthcare professionals who worked closely with the home.

People had comprehensive care plans which addressed their needs and wishes. They found staff to be caring.

There was mixed feedback about the choice of food provided and we have made a recommendation to review people’s preferences.

Staff were suitably trained and supervised to carry out their duties. The building was clean and well maintained.

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.

People’s religious and cultural needs were met.

There was a new registered manager since the last inspection. Staff said they felt supported and found the registered manager to be approachable. The manager was supported by a management team including a training manager, hospitality manager and quality assurance managers. The nominated individual representing the company who own the home was very involved in running of the home on a day to day basis.

The service had quality assurance systems in place to monitor the safety and quality of the care.

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 good (report published 28 April 2018).

Why we inspected

This was a planned inspection based on the previous rating.

We had also been informed of an incident regarding medicines. This incident was subject to a safeguarding investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management of medicines. This inspection examined those risks.

We found that people were receiving their medicines appropriately at the time of this inspection. We have made recommendations for improvements in the disposal of controlled medicines and improving the quality of the medicines audits, which the provider acted on immediately during and after the inspection. Please see the safe section of this full report for details. The provider took suitable action to mitigate any risks and this has been effective. We found no evidence during this inspection that people were at risk of harm from this concern.

The overall rating for the service has remained good. This is based on the findings at this inspection.

Follow up

We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We carried out an unannounced comprehensive inspection of this service in April 2017. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breach. We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. We had also received a number of safeguarding alerts and complaints about the service which prompted us to undertake this inspection. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Azalea court nursing home on our website at www.cqc.org.uk.

This was a focussed inspection looking at whether the service was safe and well led. There were safeguarding allegations being investigated at the time of the inspection by the London borough of Enfield and we did not know the outcomes. We looked at safety and safeguarding issues and we did not find any concerns.

At our last inspection we rated the service Good. At this inspection we found the evidence continued to support the rating of Good and there was no evidence or information from our inspection monitoring that demonstrated serious risks or concerns. This inspection report is written in a shorter format because our overall rating of the service has not changed since our last inspection.

At the last inspection there was a breach of legal requirement as risk assessments did not meet the required standard. At this inspection, we found that the registered manager and provider had made improvements to risk assessments. This meant that people had risk assessments that addressed the risks for them as an individual, helped to keep them safe and respect their freedom.

Nurses working at the service demonstrated good clinical knowledge and a good understanding of infection prevention and control, risk assessments and safety. Staff were trained in safety topics including medicines management, fire safety, first aid, basic life support and safeguarding people from abuse.

There were enough staff on duty but at mealtimes staff were very busy so a few people had to wait for support. At other times people said staff were responsive and there were enough staff on duty to meet people's needs.

There were no breaches of regulation found at this inspection. We have made a recommendation for improvement in the giving and recording of medicines.

The home was well led with a commitment to continuous improvement. The provider and management team carried out regular audits and had good daily oversight of the care provided in the home. There was a clear management structure. The management team worked well with partner agencies to ensure safe care. People and their relatives had good and regular opportunity to contribute to their care planning.

This inspection took place on 24, 25 and 26 April 2017. At our previous comprehensive inspection on 24 October 2014 the service was not providing medicines safely to all people or auditing medicines administration to identify if any issues were present. Subsequent to that inspection we carried out a focused unannounced inspection on 25 April 2015 and found that these previous issues had been rectified and the service overall was rated as good.

There was a registered manager in place. 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.

There was a lack of clarity regarding potential risks for some people living at the home. Some people living at the home were at risk of unsafe care due to some risks to people not being clearly identified or reviewed when necessary.

Staff had access to the organisational policy and procedure for protection of people from abuse. They also had the contact details for the safeguarding team at the local authority in which the service is located. Staff had been trained in abuse awareness.

Medicines were well managed and people received their medicines in a safe way and at the time they needed them.

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 support this practice.

People were supported to maintain good health. Nurses were on duty at the service 24 hours and a local GP visited the home each week. Healthcare needs were met effectively and staff supported people to make and attend medical appointments. The GP told us of their confidence in the way the service managed healthcare needs.

People who used the service, relatives and friends, praised staff for their caring attitudes. Staff were approachable and friendly towards people and based their interactions on each person as an individual, as well as demonstrating how well they knew the people they were caring for.

Audits of the service were carried out. The audits carried out since December 2016 identified issues around risk assessments and care planning requiring updates and improvement. Issues had not been fully addressed on each unit. The provider showed us an action plan which stated the remaining improvements they had identified were to be completed within the next month.

The service was transparent with communication and involving people, and took people’s views seriously and responded to those views.

As a result of this inspection we found one breach 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.

Below is a summary of what we found. The summary describes what people using the service, their relatives and the staff told us, what we observed and records we looked at.

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

Is the service safe?

People's needs were not always being met as staff were not deployed effectively to care for them in a way that maintained their safety and well-being. Most people and relatives spoken to were concerned that staff were not always available to meet their needs. One person said, "staff are very busy and don't have a lot of time for us."

Two relative's commented, "they often seem to be short of staff," and "they needed more carers on this floor (the third floor) as most people need a lot of assistance." Staff spoken to told us that they did not feel that they had enough staff to meet people's needs. Staff gave examples when they were short in the morning, which meant that people did not receive their personal care when they needed it.

We saw that appropriate arrangements were not in place in relation to the recording of all medicines. We saw evidence of people's current medicines on the Medication Administration Records (MAR). One person had no warfarin recorded as administered for two days and our stock count indicated that no stock had been used. For this same person a hormone medication was not recorded as given and the stock remained in the packaging.

We saw on one MAR that one person did not receive their medicine for Parkinson's disease and then heard that they had been given the wrong persons medication. We heard how the error happened and the action the home took which included seeking emergency health advice. This incident meant that two people did not receive their medicines as prescribed and were put at risk.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. People who use services were only deprived of their liberty when this had been authorised by the Court of Protection, or by a Supervisory Body under DoLS. We found that the service had proper policies and procedures in place that ensured staff had guidance if they needed to apply for a deprivation of liberty for a person who used the service. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective?

People who used the service were positive about the care they received. One person said, 'staff are very good.' People felt that staff knew how to meet their needs. However, staff said that they had not been supervised and supported in their work with people. The manager told us that supervision should take place six times a year. We looked at three staff records of supervision and these showed that staff had not received regularly supervision. Staff told us that they had received an appraisal in the last year. Staff had not received appropriate professional development.

People's health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services. People told us that when they asked staff to contact their general practitioner this was done quickly. One person told us, "I can ask to see the doctor."

Is the service caring?

We observed staff supporting people at lunchtime on Lavender unit. Staff were caring and responsive to people's needs and assisted them to eat and drink. However, people who use the service and relatives told us that care was not always provided that met people's needs and maintained their well-being. Two relatives spoken to said that they had found on the day of the inspection that there were relatives had not received personal care and were wearing soiled clothing. Relatives had raised similar concerns with the Care Quality Commission and professionals prior to the inspection.

Is the service responsive?

Two relatives said that people who use the service often spent long periods in their bedrooms without receiving any attention from staff. We found, and professionals had told us that checks to see if people were safe and comfortable were not always being carried out. These checks had not been recorded. A relative summed this up when they said, "if you are alone in your room you miss out."

Is the service well- led?

People who use the service were at risk of receiving unsafe and inappropriate care as care and treatment had not been monitored effectively. While the service had carried out an annual survey of the views of people, relatives and professionals this had not been used to inform how care could be improved. People who use the service and relatives did not feel consulted or that their views will be acted upon about the care and treatment being provided by the service. One relative told us, "you have to initiate all discussions about care. Staff listen, but then there is no feedback about what if anything will change."

We found that the last medication audit had been completed in March 2014. We looked at the medication administration records and found that there were gaps in recording and examples when administration of medicines had not been recorded to show that people had been given their medicines. We saw 17 omissions in recording administration of medicines in 33 of the records we inspected. These issues had not been highlighted or addressed as the service did not have a system for carrying out random checks of medications to ensure that they were being administered safely. No action plans were in place that addressed how the service would prevent these omissions in recording of people's medication from re-occurring.

At this inspection we found that matters had been dealt with. The provider was taking appropriate steps to ensure that there were sufficient numbers of suitably qualified, skilled and experienced persons employed to safeguard the health, safety and welfare of people. There was a system in place for identifying, receiving, handling and responding to complaints and comments made by people using the service and those acting on their behalf. Complaints were being investigated and monitored and improvements were made.

We saw and were told by people, relatives and staff that people gave their consent verbally and in writing. One relative told us 'I am here nearly every day and sign all the forms.'

Records showed that appropriate checks were undertaken before staff began work and effective recruitment, selection and employment processes were in place.

We were told of some dissatisfaction from people living at the service who told us that staff were slow to assist and were rushed. One member of staff told us that they needed more one-to-one time with people. Records showed that there was no overlap of staff time between shifts. This meant that the provider was not taking appropriate steps to ensure there were enough staff to provide a handover and continuity of care.

The provider had a system in place for identifying, receiving, handling and responding to complaints and comments made by people using the service and those acting on their behalf. However this was not effective as some people told us that they were not aware that there was a complaints system. One person we spoke with told us 'the manager should come to see us and ask us how we are doing.' Whilst individual complaints had been responded to there was no action plan to deal with issues affecting the service.

Staff were supported to develop their skills and received training relevant to their role. Staff received supervision and new staff completed an induction.

Systems were in place to monitor and make improvements to the quality of care and support provided to people by the home including the management and administration of medication.