Archived: Denison House Nursing Home

At the last inspection on 17 August 2016 we found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014 in Regulation 9 Person centred care, Regulation 11 Consent, Regulation 12 Safe Care and treatment, Regulation 17 Good Governance and Regulation 18 Staffing. At this inspection we saw that improvements had been made and there were no breaches of regulations.

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

Denison House is registered as a nursing home but has not provided nursing care since September 2014. The service is registered to accommodate 30 people. There were 13 people living at the service when we inspected. One person was in hospital so only 12 people were present during the inspection.

There was a registered manager employed at the service. They had only recently been registered but had worked at the service since November 2016. 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.

Risks to people's health and safety had been identified. Care plans contained risk assessments relating to people’s health and there were risk management plans to guide staff.

Safe recruitment procedures were in place to ensure suitable staff were employed to work with people at the service. There were sufficient staff to meet people's needs. The registered provider used a tool to determine the numbers of staff required to meet people’s needs. We recognised that the numbers of people who used the service were low accounting for suitable staffing levels but the registered manager assured us that this would be reviewed when numbers increased.

Accidents and incidents were recorded, analysed and trends identified.

Medicines were managed safely.

The service had some signage in place to encourage people to find their way around. Signage covered communal areas. There were plans in place to develop this further.

Staff knew the people they cared for and were trained in areas that related to their role. They were supported through supervision.

Staff worked within the principles of the Mental Capacity Act 2005. Consent was sought from people about what assistance they needed with daily activities. Deprivation of liberty safeguard (DoLS) authorisations had been submitted by the registered manager in order to ensure that people were not being detained without authorisation. Where day to day decisions were taken for people, staff had completed a mental capacity assessment and best interest decision tool to evidence the decision.

People's nutritional needs were met. Although drinks were always available unless staff assisted some people they were unable to access them. We have made a recommendation about best practice in hydration.

The service was caring. Staff approached and spoke with people kindly and with respect.

Care plans were person centred and were regularly reviewed.

There was an activities organiser employed at the service and staff assisted in organising activities for people which reduced the risk of social isolation.

There was a complaints policy and procedure and people knew how to make complaints.

The quality assurance system in place used audits in each area of the service so that there was a consistent approach to improvement.

Staff were happy in their work and were positive about the support they received from management. They worked together with health and social care professionals in order to ensure good outcomes for people.

The provider had allocated a quality manager to support the registered manager. They and the staff were provided with sufficient direction and leadership to ensure that people received a consistently good standard of care.

This inspection took place on 17 August 2016 and was unannounced.

At this inspection, whilst it was evident that some improvements had been made the service remained non-compliant with five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulation 9 Person centred care, Regulation 11 Consent, Regulation 12 Safe care and treatment, Regulation 17 Good Governance and 18 (1) Staffing.

The overall rating for this service is ‘Inadequate’ and the service remains 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.

As our rating for the service remains inadequate we are taking action against the provider and will report on this when it is complete.

The service is registered as a nursing home however they have not provided nursing care since September 2014. The registered provider has applied to the CQC to de-register the regulated activities associated with nursing care. Denison House Nursing Home registration certificate stated that they could accommodate up to 35 people but no longer have shared rooms and so the number has reduced to 30. The service accommodates older people and people living with dementia. It is a large building with communal areas downstairs for people to spend their time. There is a secure garden.

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

People told us they felt safe. Risk assessments and risk management plans had been significantly improved since our last inspection, however, we saw two examples where these were not followed which placed two individuals at risk of avoidable harm.

Staffing levels were not always sufficient to meet the needs of the people who used the service.

Although some improvements had been undertaken to make the environment safe an electrical environment assessment report had been sent to the registered provider in May 2016 and had noted some concerns, these were yet to be rectified.

The environment was clean but further work was required to ensure the environment was suitable for people living with dementia.

Although we saw care staff seeking consent from people this was not routinely recorded within their care plans. Care planning documentation was generally improved. However, we saw examples of care being provided which was not person centred and placed people at risk of harm notwithstanding the improved documentation and guidance for staff.

Staff understood how to safeguard people and the manager had made appropriate referrals to North Yorkshire County Council to ensure these were effectively investigated. Accidents and incidents were now reviewed.

People told us the food was good. There were a range of activities which people enjoyed. Relatives gave positive feedback about the service and we saw kind and caring interactions between staff and people they supported. People and their relatives were asked to give their feedback to the service via a questionnaire.

Staff told us they felt well supported by the manager and we saw evidence supervision of staff was now taking place on a regular basis. Staff told us morale was good and the staff team were keen to work together to make the required improvements. Despite this we still saw some examples of poor care so the required improvements were not consistently evidenced.

Although improvements had been made to the governance arrangements within the service we continued to see examples of poor care and people at risk of harm which had not been identified through internal audits. Some audits were not fully effective and all were at an early stage of development so their impact on maintaining and improving the quality of the service was not yet demonstrated. Also the systems and processes put in place had not always mitigated the risks to the health safety and welfare of people using the service.

The service is registered as a nursing home, however they have not provided nursing care since September 2014 and can accommodate up to 35 people but no longer have shared rooms and so the number has reduced to 30. The service accommodates older people and people living with dementia. It is a large building with communal areas downstairs for people to spend their time. There is a secure garden.

At the time of our inspection there were 25 people living at the service.

The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

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.

People told us they felt safe. One relative raised a concern about the safety of people who used the service because of the behaviour of a person who lived at the service. However, we found risk assessments and risk management plans did not provide adequate guidance for staff about how to keep people safe. Due to our concerns about the care and treatment we saw we made five individual safeguarding referrals to the local authority.

We saw evidence the manager had made some safeguarding referrals. However, there were other safeguarding matters which had not been referred and this meant the risk of harm remained. In addition to this accidents and incidents were not always recorded accurately and the manager had failed to notify the CQC of a number of serious injuries. This is a requirement by law and the CQC will investigate these matters further.

There were a number of environmental risks such as raised carpets and loose tiles which were trip hazards, the electrical safety certificate was out of date and water tests had not been followed up. We saw evidence of poor cleanliness across the service.

The service was not working in line with the principles of the Mental Capacity Act. Assessments of people’s ability to make informed decisions were not completed correctly and were not decision specific. We did not see records of best interest decisions. Some people were being restricted of their liberty without having the legal authorisation in place.

There was insufficient staff to meet people’s needs. Staff told us they felt well supported by the manager but we saw evidence of gaps in training and a lack of supervision which meant the manager could not be assured staff had the required skills to deliver effective care.

Care staff were warm and genuine and we saw some positive interaction between staff and people who used the service. We also saw some skilled interaction with people who had behaviour which placed themselves or others at risk. Despite this we saw evidence people did not receive the care they required to meet their individual needs. We saw evidence of people with complex health care needs and we asked the local authority to consider the appropriateness of the placements for some people.

People told us the food was good. The chef described ways of ensuring people’s individual preferences were met. However, we were concerned about the lack of systems in place to ensure people received their meal in a way that reflected professional advice based on their individual dietary needs.

Care plans did not reflect people’s current needs, where people’s needs were changing we did not see evidence of the service taking robust action to address this. Care plans did not contain information about people’s individual preferences or their previous life history. For people unable to direct care staff, due to their health needs, this meant we could not be sure they received care which was in line with their previous wishes.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, affecting people’s safety, well-being and the quality of service provided to service users. We did not see evidence of good leadership with robust policies, systems and record keeping which would enable the provider to assure themselves they were delivering high quality care. CQC is considering the appropriate regulatory response to resolve the problems we found.

We re-visited the service to check that these improvements had been made. We did not speak with people about the way they received their medicines on this occasion as we had not identified any concerns in this area at our previous visit.

We found people's rights were respected and their consent to care was checked before care was provided.

We found that whilst the service was monitoring and providing safe care the pre-admission assessment process, was not always robust.

We noted that people overall were receiving their medicines appropriately. However some improvements were needed to some medication processes to minimise the risk of medicines being managed in an unsafe or inappropriate way.

We found staff were supervised and supported to attend training, so they could provide safe and appropriate care.

There were systems in place to monitor how the service was operating. This meant the quality of the service was being kept under review.