Archived: Newton House

Newton House is a care home providing personal and nursing care to 11 people with progressive neurological conditions. It is one of six adult social care locations and a hospital registered separately with CQC that are on the same site.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

One adult social care location (Pembroke Lodge) is currently closed as there were ongoing and continual issues with the provision of heating and hot water.

The hospital is also currently closed due to a flood caused by a major water leak. People from the hospital were transferred at short notice to some of the adult social care locations on site. Works to repair the fabric of the hospital building are currently underway. People from the hospital were not being accommodated at Newton House.

People’s experience of using this service:

The service did not have a registered manager in post. The service was being managed by an interim manager.

People were placed at risk from poor management. We found systemic overarching poor management systems and that improvements were not prioritised. There had been sudden and persistent changes of senior managers. There was a lack of regulatory response from the provider. There were poor recruitment procedures, and a lack of investment with equipment and maintenance of the property. The morale of the staff was low and they were reluctant to give feedback because of fear of reprisals. This had an impact on the care people received.

Whilst we saw that some improvements had been made these were not sufficient to improve the ratings. Improvements had been made since the focus inspection dated November 2019 with the provision of equipment. However improvements with the supply of equipment had not always resulted in better outcomes for people. The environment still required improvement and there were still concerns about maintenance of the premises

People were not always protected from risks associated with their conditions. Medicines continued to be managed in a way that was not always safe.

Some staff were positive about management changes and felt supported by the home manager of Newton House.

There were still concerns about staff trust in the provider and the overarching management systems for the site as a whole. There continued to be a clear disconnect between management on the Glenside site and the provider resulting in poor responses to the areas of concerns identified by CQC; partner agencies and as a result of the previous inspections.

Rating at last inspection:

Requires improvement. Full comprehensive inspection published 2 October 2018.

Why we inspected:

This inspection was brought forward due to information of risk or concern. Following the comprehensive and focus inspections CQC have received on going whistleblowing concerns. After the last inspection CQC requested assurances from the provider about the action they would take to improve the service. To date these assurances have not been forthcoming.

Enforcement:

Following the last inspection we imposed a condition on the providers registration to submit monthly improvement action plans to CQC. However, the action plans from February 2019 had not been received.

Follow up:

The overall rating for this service has changed to Inadequate. We are placing the service in 'special measures'. This means that it has been placed into special measures by CQC. The purpose of special measures is to:

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

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

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

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 the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

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

Newton House is a care home providing personal and nursing care to 11 people with progressive neurological conditions. It is one of six adult social care locations and a hospital registered separately with CQC that are on the same site.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

People’s experience of using this service:

People were not safeguarded from abuse and were placed at significant risk of harm.

Following the inspection in March 2019 CQC were informed of two incidents involving the poor management of Percutaneous Endoscopic Gastrostomy (PEG) tubes. These incidents are currently under investigated by the local authority safeguarding team. CQC will consider these incidents under our specific incident guidance.

Despite these incidents during this inspection we found that the needs of people with PEG’s continued not to be managed safely. There was little evidence that checks, and management routines were consistently followed.

Following the inspection in March 2019 CQC were informed of two incidents involving poor medicines management. Despite these incidents at this inspection we found that medicines were not safety managed leaving people at significant risk of harm

The service was not well led. The management had not taken action in response to events that had or could cause harm to people. There have been persistent changes of senior managers. There was a lack of regulatory response from the provider.

Rating at last inspection: The overall rating was changed to Inadequate at the focused inspection dated March 2019.

Why we inspected: This inspection was brought forward due to information of risk or concern following the last inspection, in March 2019. After the inspections in August & November 2018 and March 2019 CQC requested assurances from the provider about the action they would take to improve the service. The responses provided by the provider did not give assurances that the service would improve.

Enforcement: Following the last inspection we imposed a condition on the providers registration to submit monthly improvement action plans to CQC. The action plans provided did not give assurances that the service would improve.

Section 31 of the Health and Social Act 2008 allows the Commission to serve a Notice of Decision upon providers if it has reasonable cause to believe that, unless it acts any person will or may be exposed to the risk of harm.

The Commission used its powers pursuant to the urgent procedure (for suspension, or imposition or variation or removal of conditions of registration) under Section 31 of the Health and Social Act 2008. Although the provider told us they intended to close the service we continued to urgently remove the regulated activity from the registration.”

Follow up: This service has been placed in special measures. The purpose of special measures is to:

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

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

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

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 the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

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

The team inspected the service against two of the five questions we ask about services: is the service well led and safe. This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Effective, Caring and Responsive through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Newton House provided nursing care for up to 16 adults with progressive neurological conditions. It is one of six adult social care locations which also has a hospital that is registered separately with CQC. Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain. 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.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the previous inspection dated 29 and 30 August 2018 we found breaches of Regulations 9 and 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider following the inspection to tell us how they were going to meet Regulation 9 and 12. The provider failed to report on the actions to meet Health and Social Care Act 2008, its associated regulations, or any other relevant legislation on how regulations were to be met. At this focused inspection we found continued breaches of Regulation 12 and a breach of 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The CQC following the inspection formally requested under Section 64 of the Health and Social Care Act 2008 to be provided with specified information and documentation by 16 November 2018. We received some of the information requested but not all.

Quality assurance systems were not effective. We requested copies of audits on how the delivery of care was assessed and monitored and only received copies of the environmental audits. We noted there had been shortfalls and poor standards of cleanliness and lack of hand washing equipment. Where shortfalls were identified action plans were not developed to improve care and treatment to people. The CQC was not notified of accidents and incidents reportable under the Care Quality Commission (Registration) Regulations 2009: Regulation 18.

The CQC received whistleblowing concerns about staff not being able to speak sufficient English. These staff were referred to as “agency staff” and were working without appropriate checks. We found there were some staff working across the site without the appropriate disclosure and barring checks or written references in place.

Recruitment procedures did not ensure the staff employed at the home were suitable to work with adults at risk. There were staff employed through a recruitment agency and referred to as “agency staff” because of their terms and conditions. The HR assistant was not able to show that agency staff recruited were suitable to work with adults at risk.

New staff did not always have an induction to prepare them for the role they were employed to carry out. We were not able to verify that new staff had an appropriate induction before starting work. We were informed that not all staff had received an induction or mandatory training due to the level of the English they spoke and understood. We were told staff responsible for training would not be able to sign new staff as competent as their English was so poor.

Whistleblowers told us senior managers were unaware of staff working and accommodated within Glenside Manor. We received concerns about staff known as “agency staff” as they were not directly employed by the provider but introduced to the provider by recruitment agencies. There were a number of staff on site whose identity could not be confirmed by the most senior staff on duty. The list of agency staff provided on the first day of the inspection was not up to date as we met another 11 agency staff not included in the list and covering a variety of roles

The documents provided under Section 64 did not provide confidence that staff working at the home were trained for their role. The staffing list provided included the names of 15 staff with the role of delivering direct care for up to 12 people. While the training matrix listed the names of nine staff as having attended training there were eight staff in the staffing list that were not included in the training matrix. This meant there was no evidence that the six staff were trained.

Staff morale was poor and staff told us they feared about their jobs as they had witnessed other staff being dismissed almost daily. The staff survey provided under Section 64 of the Health and Social Care Act 2008 indicated that 13 of the 38 staff responding would recommend the home.

The CQC received whistleblowing concerns about the competency of the staff undertaking maintenance checks of systems and equipment. The CQC following the inspection requested proof of the competency of these staff from the provider. The documentation provided under Section 64 of the Health and Social Care Act 2008 did not give CQC reassurances that staff undertaking maintenance checks were skilled or competent.

The information received from relatives about raising concerns was not consistent with the complaints log.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

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

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. 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.

The home is registered to provide nursing and personal care for up to 12 people with complex nursing care needs. At the time of the inspection 10 people were living at the service.

The inspection took place on 29 and 30 August 2018. The first day was unannounced.

At the previous inspection on 15 June 2017 we found improvements were required because care plans were not person centred and lacked details of people’s preferences for how they wanted their care to be provided. People's life histories were not included in care plans. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found some improvements had been made; however further work was needed.

There was 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.

Quality assurance systems did not always identify shortfalls found during this inspection. There were quality assurance systems in place; however, the lack of consistently person centred care planning had not been identified during audits.

Care plans were not consistently person centred; although the registered manager said work had begun to rewrite plans this had not been completed.

We saw examples of task focussed care rather than person centred care. Staff told us that night staff regularly washed two people before the day shift arrived “to help us [day staff] out.” There was a list which showed people had a bath or shower a set day each week rather than as often as they liked. Most of the staff we spoke with were unfamiliar with the term ‘person centred care’.

Staff had been trained to keep people safe. People using the service and their relatives told us they felt safe. Care plans contained risk assessments. When risks were identified the plans provided clear guidance for staff on how to reduce the risk of harm to people. At the previous inspection we found there was no process in place to check air mattresses were set correctly. At this inspection a checking process was in place, but it was not effective because 7 of the 8 air mattresses we looked at were set incorrectly.

Medicine administration records showed people had received their medicines as prescribed. However, protocols to inform staff when to administer as required (PRN) medicines were not in place. These protocols provide information for staff on when and why people might require additional medicines and should also include information for staff on how to recognise when people might need them. Some people had been prescribed creams or lotions. Although care staff applied these when providing personal care to people, the nurses signed the medicine recording charts. This meant nurses were signing the MAR without being involved in the procedure. There were no transdermal patch records in place. These records ensure that staff can identify where previous patches were positioned in order to prevent placing a patch in the same place. The use of these records ensures that manufacturer guidance is followed. All of these issues were highlighted during the last inspection.

The environment was not always clean. We saw dirty floors and dirty crash mats beside people’s beds. Door frames were scuffed and chipped. The kitchen flooring was not fully sealed and there was a hole in the linoleum. This meant it would be difficult to ensure the environment was free of infection.

Incidents and accidents were reported and analysed to identify trends. There was evidence that lessons were learned when incidents happened.

Comprehensive pre-assessments had been completed before people moved to the service.

Staff were trained to undertake their roles. Staff had regular supervisions with a supervisor.

There was enough staff on duty to meet people’s needs. Although there was regular use of agency staff, these were block booked in order to ensure continuity of care.

Consent to care was sought in line with legislation and guidance.

People using the service spoke highly of the permanent staff and were happy with the support they received. One person told us they didn’t feel agency staff offered the same level of support as other staff with their communication needs. We observed positive interactions between staff and people.

Complaints were logged. Investigations and outcomes of complaints had been documented.

All of the staff told us the service was well managed. Relatives of people gave positive feedback about the registered manager.

There were systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of people who used the service. Reports were produced following audits which showed how the service was meeting their own targets and identified business development plans with areas for improvements. These were discussed at management meetings. Although audits were undertaken to assess how standards of care were being met, findings from this inspection identified other areas for improvement.

We found two breaches of the Regulations in 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.

At Newton House up to 12 people with complex nursing care can be accommodated. Staff provide a service to people with neuro degenerative or previous brain injury.

A registered manager was in post. ‘A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.'

Care plans lacked person centred detail. Clinical care needs were met and plans were generally detailed. Risk assessments in place and care plans provided clear guidance for staff. Recording charts did not always reflect care plan guidance. For example, position change charts. Also air mattresses were not set correctly and there were no checks in place. The operations manager said formats were to be introduced for staff to monitor air mattresses were set correctly.

While the medicine records showed staff administered medicines as required, procedures were not in place for staff to administer medicines prescribed when required (PRN). These procedures provide information for staff on when and why people might require additional medicines and should also include information for staff on how to recognise when people might need them. Some people had been prescribed creams or lotions. Although care staff applied these when providing personal care to people, the nurses signed the medicine recording charts. There were no transdermal patch records in place. These records ensure that staff can identify where previous patches were positioned in order to prevent placing a patch in the same place. The use of these records ensures that manufacturer guidance is followed.

“There were systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of people who used the service. Board documents were developed from the audits undertaken which showed how the organisations were meeting their own targets and identified business development plans with areas for improvements. While audits were undertaken to assess how standards of care were being met we found the findings from this inspection had identified other areas for improvement. However the audit had not assessed the content of the care plan. For example if care plans were person centred.

People we spoke with said they felt safe and we observed positive interactions between staff and people. We observed staff treat people in a compassionate and sensitive manner. The staff we spoke with knew the people they were supporting and spoke to people with patience and explained tasks. The people at the service were not able to give us detailed feedback about the service and we saw people were treated with kindness and in a compassionate and sensitive manner by the staff. The staff we spoke with knew the people they were supporting and spoke to people with patience and explained tasks although people were not able to respond.

The staff were able to tell us the types of abuse and the procedures for safeguarding people from abuse and avoidable harm. However, most people at the service

Staffing levels were appropriate to meet the needs of 11 people. There was a system in place to determine the number of staff required and agency staff were used where shortfalls were identified or to cover planned absences. One registered nurse and four rehabilitation assessments were on duty during the day.

Consent to care had been sought in line with legislation and guidance. Care plans contained mental capacity assessments and where people lacked capacity best interest decisions had been made.

Clear induction processes were in place and staff on induction said their training was good. Staff said they attended mandatory training set by the provider.

Staff attended core and some specialised training. Specific training needed to meet people’s needs was available Staff were able to attend training in epilepsy awareness, diabetes management, person centred care and record keeping. However, there was a low take up of these subjects which could impact on the standard of care people received. There was a re-validation programme for nurses. Staff can apply for nursing degree and staff must work at the service one shift per week.

Staff were supported to perform their roles and develop their personal goals. One to one supervisions with their line manager were regular and staff said they were able to approach the registered manager with concerns. Staff were able to appraise themselves. However, the appraisals we saw were not linked to a discussion with their line manager and action plans of future goals and development needs were not part of the appraisal forms.

Some people at the service had their nutrition needs met through percutaneous endoscopic gastrostomy (PEG) tubes while others ate and drank small amounts and care plans reflected this.

Activities were limited. We saw activities coordinators in the morning reading the newspaper to people, chatting to them and involving them. In afternoon, people sat and watched a film or went back to their rooms. We found records held limited information about people’s preferences such as music preferences.

The staff spoke highly of the registered manager. All said they felt involved and valued by the organisation.

You can see what action we told the provider to take at the back of the full version of the report. We recommend that the service consider current guidance on the recording of applications of creams and patches to people.