Archived: Red Rose Nursing Home

Red Rose Nursing Home is a ‘care home with nursing’. 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.

Red Rose Nursing Home accommodates up to 65 people across three separate units. One unit provides care for people living with dementia, another provides care for people with nursing care needs, and a third provides care for people who have residential care needs. At the time of our inspection 45 people lived at Red Rose Nursing Home. The manager told us, although they had vacancies across all units, they were specifically not accepting any new admissions on to the nursing unit. This was because they wanted to ensure improvements identified at our last inspection had been achieved.

At our comprehensive inspection in December 2017, we rated the service was 'good' overall. In response to further information of concern received, we completed a responsive comprehensive inspection in January 2018 and we rated the service as 'Requires Improvement.' We found four breaches of the Health and Social Care Act (Regulated Activities) Regulation 2014, and issued three requirement notices and a warning notice telling the provider to improve. At this inspection we found the required improvements had not been made. This was the provider's third inspection in 10 months.

Risks associated with people’s care needs, such as those associated with the use of bed rails, and from refusals of personal care were not well managed. Assessments of people’s health and care needs were not consistently in place and care plans were not always up to date and comprehensive. Accidents and incidents, such as falls, were not analysed and used to help identify how to reduce the likelihood and make improvements. People did not always receive timely referrals and reviews of their care when their needs changed or their care and treatment had become ineffective.

Risks associated with the premises, such as the regulation of water temperatures to reduce the risks associated with scalding were not effectively managed. The facilities on the nursing unit did not fully meet people’s needs as people had to use showers on other units within the building.

Infection prevention and control practices did not protect people from the risks associated with infection. Cleaning products and thickening powder were not stored securely.

Guidance for medicines given when people needed them, rather than at set times, did not contain sufficient detail to ensure they were administered consistently. Not all creams had dates of opening recorded and thickening powder prescribed for one person was used for another person.

Staff were not competent to provide care in line with some people’s care plans as they had not been trained to safely hold people. In addition, competency checks on staff were not always completed and many staff had not completed the training identified by the provider as required for their role. Many staff did not have the level of training required to care for people with the assurance that they did so with appropriate levels of skill, knowledge and understanding. This included staff knowledge on how diversity and equality issues may affect the people they cared for. Staff supervisions did not prompt staff to complete their training.

There were not enough staff deployed to meet people’s needs in a timely manner, and to provide people with emotional support when they needed it.

Staff did not always check people’s consent to care before they provided it, and assessments and provision of people’s care had not always followed the Mental Capacity Act 2005 (MCA). Staff knowledge on the MCA and DoLS varied and staff did not always understand how this legislation applied to the people they cared for.

People enjoyed their food, however they did not always receive food that met their preferences. People’s privacy and dignity was not always maintained and promoted. People’s personal care needs and people’s needs associated with their anxiety or behaviours that challenged, had not always been met in a personalised and responsive manner. Staff did not always use language that showed empathy for people and their care needs. There was a lack of meaningful activities for people to enjoy.

People and most relatives were not involved in the development and review of care plans.

Responses to complaints had not been made in line with the timescales in the provider’s complaints policy.

Actions to fully meet the accessible information standard were not always in place to provide assurances people’s communication needs would be met.

People had care plans in place for when they required care at the end of their lives; however, some arrangements were not clear.

Systems and processes designed to assess, monitor and improve the quality and safety of services, and reduce risks were not effective. Records were not always kept securely. A registered manager was not in place; however the manager had taken steps to begin the process of registration with the CQC.

Views gathered from people, relatives and staff did not cover a breadth of issues to help inform the development and improvement of the service. Statutory notifications had not always been submitted as required.

People told us they felt safe with the staff that cared for them, however not all staff were knowledgeable about how to follow procedure in order to safeguard people. Staff recruitment included pre-employment checks that helped the provider make judgements about the staff employed to work at the service. Staff told us about some steps they took to promote people’s dignity and privacy and people’s independence was supported.

Assessments under the deprivation of liberty safeguards (DoLS) had been applied for when identified as required. Referrals to other professionals had been made, however not always consistently. People could access other healthcare services, such as their GP when needed.

The design, adaption and decoration of the dementia and residential unit had been used to help meet people’s needs.

At this inspection we found eight breaches of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014.

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.

Red Rose Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The care home accommodates up to 68 people across three units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia and is called the memory unit. Another provides nursing care and is called the Willows and another provides residential care and is called Castle. At the time of our inspection there were 53 people living at the home.

There was not 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.’ The provider had put in place an acting manager who was intending to apply to register as registered manager.

This inspection took place on 25 January 2018 and was unannounced. At our last inspection in November 2017 the overall rating for Red Rose was 'Good'. At this inspection we found the overall rating to be 'Requires Improvement'. This is the first time the service has been rated Requires Improvement. We also found breaches of regulation. The provider failed to provide sufficient and appropriately skilled staff to provide safe care to people. People had their liberty restricted but arrangements were not in place to ensure this was in their best interests and in the least restrictive way possible.

On the day of our inspection staff interacted well with people in the memory unit. However in the other two units we found interaction was not consistent. Three of the relatives we spoke with raised concerns about the care their family member received. Staff knew how to keep people safe. The provider had systems and processes in place to keep people safe.

The provider did not have systems in place to ensure the safe management of medicines and consistent recording of medicine administration. Medicines were stored safely and according to national guidance.

We saw that staff obtained people’s consent before providing care to them. Where people could not consent, assessments to ensure decisions were made in people’s best interest had not been consistently completed.

We found that people’s health care needs were assessed and care planned and delivered to meet those needs. People had access to healthcare professionals such as the district nurse and GP and also specialist professionals. Arrangements were in place to facilitate working relationships with other professionals and care providers. People had their nutritional needs assessed and were supported with their meals to keep them healthy. Where people had special dietary requirements we saw that these were provided for. People and relatives raised concern about the standard of meals.

There was insufficient staff available to meet people’s needs. Staff did not consistently respond in a timely and appropriate manner to people. Staff were kind to people when they were providing support. People were not consistently treated with dignity and respect.

An induction process was in place and training was available on a variety of subjects to ensure that they had the skills to meet people’s needs. However not all staff had had accessed the training. The provider had a training plan in place. A process for supervision was in place. People were provided access to limited social activities. Relatives felt welcomed and people were supported to maintain relationships that were important to them.

Arrangements were not in place to protect people against the risk of infection. The environment was not consistently clean in Castle and audits did not review staffs practice. In the Willows adaptations had not been made in order to meet people’s specific needs.

People and their relatives did not know who the new manager was. Staff did not feel listened to. Relatives were aware of the process for raising concerns but were not confident that they would be listened to. Audits were carried out but action plans were not consistently put in place to address any issues which were identified.

Accidents and incidents were recorded and investigated. The provider had informed us of notifications. Notifications are events which have happened in the service that the provider is required to tell us about. The previous rating was displayed in the home but was not displayed according to CQC guidance on the website.

Red Rose Nursing Home accommodates 65 people across three separate units, each of which have separate adapted facilities. One of the units specialises in providing care to people living with dementia. At the time of the inspection 54 people were using the service.

A registered manager was present during 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.

During the home’s previous inspection we identified a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) 2014. This was in relation to the way people were safeguarded from avoidable harm and abuse. This contributed to the home being awarded a rating of Requires Improvement. During this inspection we checked to see whether improvements had been made and we found they had.

People were now protected against the risks of experiencing avoidable harm. Staff could identify the potential signs of abuse and knew who to report any concerns to. Regular assessments of the risks to people’s safety were carried out, although some assessments would benefit from more regular review. People were supported by an appropriate number of staff. People’s medicines were managed safely; some refresher training courses for the administration of medicines were needed. The home was clean and tidy and the provider was working towards an action plan with the local Clinical Commissioning Group to ensure adequate procedures were always in place to reduce the risk of the spread of infection. Accidents and incidents were regularly reviewed, assessed and investigated by the registered manager.

People were supported by staff who had completed an induction and training programme. However, we identified some gaps in staff training. After the inspection we had been notified that some of these gaps had been addressed. Staff received supervision of their work and felt supported by the registered manager. People and relatives had a mixture of opinions on the quality of the food provided, however when we observed the lunchtime meal, people had a positive experience. Some nutritional monitoring intake charts required completing in more detail. The registered manager had built effective relationships with external health and social care organisations and ensured people received care from health and social care specialists when needed. People had access to their GP and dentist.

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

People were supported by staff who were kind, caring and compassionate and were knowledgeable about their needs. Staff responded quickly if people showed signs of distress. People were treated with dignity and respect and their privacy was respected. People’s diverse needs were respected. People were involved with decisions made about their care and were encouraged to lead as independent a life as possible. People were provided with information about how they could access independent advocates. The home had been appropriately adapted and decorated to support people living with dementia. People’s friends and relatives were able to visit whenever they wanted to.

People felt sufficient activities were provided. A new full time activities coordinator was in the process of being recruited to further enhance people’s experience. People and their relatives were involved with agreeing the level of care and support people would receive when they came to the home. Care records were in the majority of cases detailed and provided appropriate guidance for staff to support people effectively. People were treated equally, without discrimination and systems were in place to support people who had communication needs. People felt able to make a complaint and were confident it would be dealt with appropriately. Plans were in place to support people who were approaching the end of their life, although some care plans lacked detail and required review.

The home was well led by a dedicated, enthusiastic and caring registered manager who was well liked and respected by all. They ensured the provider’s aims and values were respected by staff who in turn provided people with dignified, high quality care and support. The registered manager was supported by an effective team of staff who carried out their roles with confidence and dedication. Representatives of the provider played an active role in driving improvements at the home. There was an open and transparent approach to the service with people and their relative’s views actively requested and acted on. People felt their views mattered. Staff enjoyed working at the home and were encouraged to develop their skills and knowledge further with external training in areas such as leadership, as well as being assigned ‘lead roles’ within the home. The registered manager continually looked to improve the service provided and expanded their knowledge by attending locally run forums with registered managers of other services. Quality assurance processes were in place and these were effective, although closer scrutiny was needed in relation to staff training.

Red Rose Nursing Home is situated in Farndon in Nottinghamshire. The service is split into three distinct units each with communal living spaces; Memory, Willow and Castle. People living in Willow and Memory are supported by a team of nurses and care staff. People living in Willow primarily have complex health needs, whilst people living in Memory have dementia related needs. In Castle people who require support are supported by a team of care staff.

The service had a registered manager in place at the time of 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.

During our visit to Red Rose Nursing Home we found that people were not always protected from the risks associated with their care and support. Action was not taken to protect people from the risk of improper treatment.

There were enough staff to provide care and support to people and safe recruitment practices were followed. People received their medicines as prescribed.

People were supported by staff who received training, supervision and support.

People’s rights under the Mental Capacity Act (2005) were not always respected. However, where people had capacity they were enabled to make decisions about their care and support.

People were supported to eat and drink enough, had access to healthcare and their health needs were monitored and responded to.

Staff were kind and compassionate. People were treated with dignity and had their right to privacy respected. Staff understood how people communicated and people were provided with information in a way that was accessible to them.

People were at risk of receiving inconsistent support as staff did not always have access to information inform support. People were provided with the opportunity to get involved activities but many people lacked meaningful occupation.

People were supported to maintain relationships with family and friends and visitors were welcomed into the home. People and their families were involved in planning their care and support. People were supported to raise issues and concerns and there were systems in place to respond to complaints.

The registered manager was passionate about their role and the service, kept up to date with good practice and was involved in innovative projects. People and staff were provided with opportunities to give their views on how the service was run. There were systems in place to audit the quality of the service.

We found a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This breach was in relation to protecting services users from abuse and improper treatment. You can see what action we told the provider to take at the back of the full version of the report.

We observed staff interaction with people throughout the home. We spoke with the manager, three team leaders and four care assistants. At the time of the inspection there was a manager in post who was registered with the CQC.

Throughout this inspection we focused on these five key questions; is the service safe,

effective, caring, responsive and well-led?

Below is a summary of what we found. The summary describes what we observed, the

records we looked at and what people who used the service and the staff told us.

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

Is the service safe?

People did not always receive care in an environment that was safe. We saw and were told about some unsafe moving and handling of people at the home.

The CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Deprivation of Liberty Safeguards (DOLS) are part of the Mental Capacity Act 2005. Correctly applied DOLS make sure that people in care homes are looked after in a way that does not inappropriately restrict their freedom.

People in the home were assessed to establish whether a DOLS would be required. The manager told us applications had been sent to the authorising body for some people who needed to live in a part of the home with locked doors for their own safety.

One person who lived at the home told us, 'A member of staff takes me out on shopping trips in a taxi, and friends visit me regularly. I feel safe here, and the food is very nice.' We saw staff generally respond well to people's needs throughout the inspection.

Is the service effective?

We saw some physical improvements had been made to the environment of the home since our last inspection. More areas of the home had been designed and decorated in a way that was stimulating and welcoming to people with dementia related conditions.

A district nurse we spoke with told us about concerns they had about a dressing they had been changing daily for a person. They told us the dressing was taken off or changed by staff members in a way which indicated that their advice had not always been followed.

Is the service caring?

We spoke with relatives of people who used the service and asked them if they felt their

family member was safe and well cared for by the staff. One relative told us they were relieved to know that their family member was being well cared for.

We saw people's rooms which were personalised to their own tastes, including their own furniture and pictures of family members.

We were told about a person who showed confused behaviour which caused them to walk around the home. Half hourly checks were made to ensure they were safe throughout the night and a pressure mat was also used to alert staff if they moved during the night.

Is the service responsive?

There had been a relative's meeting the day before our visit. No complaints were raised at the meeting. The meeting was used as an opportunity to keep relatives up to date with changes and events at the home and to listen to and build closer ties with relatives. The manager told us they operate an 'open door policy' for visitors and staff members to express any concerns. There was a complaints system which showed clearly how many complaints were responded to and any problems resolved.

We saw staff responding to the needs presented by people at the home. Staff responded promptly to people in ways which respected each individual.

We saw some people being helped to eat their meals by members of their own families. Some of the family members were provided with lunch to enable them to eat with their relative.

Is the service well-led?

We asked people who used the service, their relatives and staff whether they felt the service was well led by the management team. One person told us, 'I don't have any reason to complain, but if I did I would feel confident to go to the manager to get help.'

The provider carried out regular surveys of the views of people who used the service. We saw a person's relative had written on a questionnaire about the home, 'Now the home is very well managed, the home has outstanding nurses and compassionate carers.'

The manager told us about, and we saw copies of, monthly audits of care plans which were then checked by a senior member of the provider company.

We carried out this visit to check the provider had responded appropriately to some recent events we had been notified about. These included some physical changes to one of the units to enable them to care for people who had dementia, and there had been an outbreak of norovirus. We had also received some concerns about some care practices.

We found people received care and support that met their needs. A person who used the service told us, 'Someone (staff) is always nearby.' We found the provider assessed and monitored the quality of the service. The manager described how effective auditing systems enabled them to respond promptly and identify when any action or improvements were needed.

People we spoke with told us they felt staff listened and respected their views and wishes and that they were asked for their consent before care and treatment was provided. One person said, 'The night bell is answered, the food is varied and a choice is given,' and added, 'I am bewildered they put up with me'.

People who used the service told us they were happy with their care and treatment and that they felt their needs were well met. One person told us, 'They (staff) look after me well, I enjoy it' and added, 'Can't grumble at anything'.

We observed people being served their lunch and drinks throughout the day. We saw people were offered choices and the menu provided nutritional and well balanced meals.

The cleanliness of the home appeared good, we saw housekeeping staff at work. Both communal areas and bedrooms were clean and tidy. A person told us, 'My room is cleaned and hovered every day.'

The relatives of people who used the service told us that staff involved them in their relatives' care, treatment and support programme. They also told us that their relatives had received input and treatment from other health care professionals such as their GP, opticians, chiropodists and community psychiatric specialists.

The relatives of people who used the service told us that their relatives were encouraged to undertake a wide range of social activities within both the home and the community. They aslo felt that the provision of activities was appropriate in meeting peoples needs.

The relatives of people who used the service told us that they felt people were safe in the home. They also said that they felt the staff had the right qualifications, skills and knowledge to perform their duties in a safe manner.

The relatives of people who used the service told us they were provided with the opportunity to comment on the quality of service provision and were able to discuss any issues which were important to them with the acting manager.