Abbey Grange

Rockley Dene Nursing Home is a residential care home providing personal and nursing care for up to 34 people in one adapted building over two floors. Seventeen people were living at the home at the time of inspection.

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

We found systems and processes used to ensure the service was running safely were not effective. We observed a lack of leadership, direction and oversight.

People’s safety and welfare was compromised and there was a lack of understanding of the risks and issues and the impact on people using the service. Quality assurance systems were ineffective and unreliable in identifying shortfalls, and where improvement was needed.

We identified significant shortfalls with how the provider and management team were responding to the COVID-19 pandemic. People's health and safety was at risk due to shortcomings in infection prevention and control. The building was not hygienic. This put people at risk of infection.

Risks associated with people's behaviours were not managed safely. Risks had not always been assessed and there was a lack of guidance about how to manage some people's behaviours. Incidents and accidents were not effectively reviewed to ensure lessons were learnt to drive improvements.

Staff were not always deployed effectively to ensure people's needs were met and the staffing levels meant people did not always receive a dignified service. Systems in place to safeguard people from abuse were not effectively implemented. Following the inspection we shared our concerns with the local authority.

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

Rating at last inspection

The last rating for this service was requires improvement (published 26 August 2021) and there was three breaches of regulation. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The overall rating of the service has changed from requires improvement to inadequate based on the findings of this inspection.

Why we inspected

The inspection was prompted in part due to concerns received about areas of concern such as infection control and staffing. A decision was made for us to inspect and examine those risks.

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 have found evidence the provider needs to make improvements. Please see the safe, caring and well-led sections of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to fire safety, infection control, risk, environment, staffing, staff training, dignity and respect, personalisation, leadership, management and governance.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will continue to monitor information we receive about the service. We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Rockley Dene Nursing Home is a residential care home providing personal and nursing care for up to 34 people in one adapted building over two floors. Nine people were living at the home at the time of inspection.

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

Risks associated with people's care were not always assessed prior to them living at the home. Risks were not identified and mitigated. Reviews of risks were not always undertaken. Staff were not always recruited safely. Infection prevention and control was not always monitored appropriately. Staffing levels met assessed dependency needs, however resource had not been allocated to ensure care plans were always in place. Medicines were administered safely. Processes for sharing from lessons learnt was in place.

There was a clear focus on developing an electronic system to accurately provide care, however, appropriate resource to ensure care plans were updated accurately was not in place. Governance was undertaken using the electronic system, however, there was no clear and planned oversight of the home and checks and audits had not identified the issues identified during our inspection visit. Surveys for people and relatives were planned, and had been received by visiting health professionals. Accidents and incidents were monitored and used to review and improve safety.

People’s needs and choices were not always assessed or recorded. Not all people’s dietary needs were known and stocks of alternative choices and snacks was poor.

We have made a recommendation about how the provider ensures people have choice and variety in their meals and snacks.

Premises supported people who lived with dementia, however some people were living in areas where refurbishment had not been completed. Staff had not received regular supervision, although a plan was in place for these. Staff received an induction and regular training. Handovers took place and changes were recorded on the electronic system. People were supported to access health professionals. People had consented to their care and best interest decisions had taken place. 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.

Staff treated people with dignity and respect, however files and a room containing people’s confidential information were not secured. Staff treated people with kindness and compassion. Staff were patient and encouraging towards people. People’s views were sought through regular residents’ meetings, however it was not always clear when people or relatives had been involved in planning their continuous care.

We have made a recommendation about how the provider records people’s and relatives’ involvement in care planning.

Care staff told us they undertook the main activity provision.

We have made a recommendation about how the provider resources and organises activity provision.

Care plans were personalised and staff knew people well. Complaints were monitored and recorded. People were supported at the end of their life and the service worked with palliative care nurses to facilitate this.

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)

The last rating for this service was requires improvement (published 5 July 2019) and there was one breach of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. The service was closed from May 2020 and re-opened on 22 March 2021. At this inspection enough improvement had not been made and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating. This inspection was carried out to follow up on action we told the provider to take at the last 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 have found evidence that the provider needs to make improvements. Please see the Safe, Effective and Well-led sections of this full report.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to risks, premises, governance and recruitment at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan for the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Rating at last inspection: Inadequate (report published November 2018). We placed the service in special measures as breaches of the regulation were found in relation to person-centred care, need for consent, safe care and treatment, good governance and staffing.

Following the last inspection, we met with the registered provider to discuss their action plan which showed what they would do and by when to improve the ratings in respect of our key questions. At this inspection we found improvements had been made in most areas. However, concerns remained regarding systems of governance to demonstrate clear management oversight.

People’s experience of using this service: Action was needed in response to the January 2019 fire risk assessment as issues identified had not been followed up. These actions were completed during and following this inspection. All of the registered provider’s policies and procedures had been reviewed on the same day which was not a robust check to ensure they were still valid. Actions from various audits had not demonstrated these tasks were always completed.

Legal requirements relating to the displaying of the last rating we allocated this home and reporting two notifiable events to the Care Quality Commission had not been fulfilled.

Staffing levels to meet people’s needs were calculated, although records relating to staffing were not robust.

People’s privacy and dignity was not always upheld as two people were weighed in the lounge in view of others in this area. People were satisfied living at this home and relatives we spoke with gave more positive feedback. Staff were seen to be kind and attentive.

People felt safe and staff were trained in how to identify abuse. Recruitment procedures were checked and found to be safe. The storage, administration and disposal of medicines was managed safely. Risks to individuals had been assessed and reviewed.

The home was clean, although some areas looked worn. We asked the management team to review storage of linen as there was an unpleasant smell in this cupboard. The registered provider was taking steps to make the living environment more dementia friendly.

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 supported this practice. Discussions to promote people’s equality, diversity and human rights had started.

Staff received regular formal support through training and ongoing supervision. People received access to healthcare and visiting professionals told us staff followed their guidance.

People were supported to maintain a healthy weight and largely had a positive mealtime experience. We discussed concerns with the management team about two people who needed additional support with their meals.

The procedures for making complaints was transparent and a single complaint received was dealt with appropriately. The activities programme met people’s needs, although people told us there were no trips out.

Care plans were difficult to use due to the volume of information and key details about people’s needs was not immediately obvious. The registered manager has since addressed this.

A system of audits was in place and the registered provider had oversight of the home. Regular meetings with people, relatives and staff were taking place. Satisfaction surveys captured their feedback.

Why we inspected: To follow up on enforcement action we took at our last inspection and to review whether the action plan the registered provider submitted to us had been acted on.

Enforcement: We have taken enforcement action in relation to the governance of the service. Whilst improvements were found, there were actions which had not been fulfilled.

Full information about CQC’s regulatory response to the more serious concerns found in inspections and appeals is added to reports after any representations and appeals have been concluded.

Follow up: We will continue to monitor intelligence we receive about the service until we are scheduled to return. We inspect according to a schedule based on the current rating, however may inspect sooner if we receive information of concern.

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.

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

We had previously inspected the home in January 2018 and rated it overall as requires improvement. Our key question ‘safe’ was rated as inadequate and other key questions were all rated as requires improvement. We found breaches of the regulations concerning dignity and respect, need for consent and staffing. We took enforcement action in relation to safe care and treatment and good governance. The registered provider sent us an action plan dated March 2018 which we followed up at this inspection.

Rockley Dene 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. Rockley Dene Nursing Home provides care and support for people with nursing and residential needs. The home has a maximum occupancy of 34 people. On both days of our inspection, 15 people were living in the home and the local authority had taken the decision to suspend new placements at this home. Due to their concerns, the local authority was visiting on a daily basis to check on the care provided and to ensure shifts were fully staffed.

At the time of our inspection a manager was still registered with the Care Quality Commission. However, the week before our inspection, they left the home and were no longer in day-to-day control. 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 home did not have a deputy manager in post, although by day two of our inspection, a clinical lead had been temporarily appointed to manage the home. The registered provider was in the process of appointing a permanent new home manager.

The majority of nursing staff were agency workers which meant consistency of care was difficult to provide. During our inspection, the registered provider made us aware they would de-register from nursing care and run the home providing residential care only.

We found a continued breach of the regulations as staff training gaps were identified in first aid, fire safety, dementia care and safeguarding. Limited supervision had taken place since our last inspection and there were no staff appraisals.

The storage of medicines was not well managed and staff were not using body maps or topical medication administration records. Individual risks to people had not been properly assessed. Concerns regarding fire safety seen at the last inspection were still evident at this inspection.

People are not supported to have maximum choice and control of their lives and staff do not support them in the least restrictive way possible; the policies and systems in the service do not support this practice. Deprivation of Liberty Safeguard (DoLS) authorisations had not been appropriately managed. Capacity and consent was not consistently recorded. Staff understanding of DoLS was poor.

Some gaps in the recruitment processes followed for two staff members were identified. Complaints were recorded, although evidence of responses was not always evident.

The home was generally clean and free from odours. Technology was used in the home to assist people in their day-to-day lives.

Dignity and privacy was seen to be improved. People and relatives spoke positively about the staff. People were consistently offered choice during our inspection, although people’s preferences regarding waking times had not been respected.

Staffing levels were insufficient to meet people’s needs. Calculations used to determine dependency levels had not been updated since May 2018. People were unable to enjoy their afternoon meal in the dining room as there weren’t enough staff members to assist people to this area.

The quality of care plans was inconsistent and there were gaps in some of the records we looked at. People and relatives were not consistently involved in the review of their care plan. End of life care discussions had been attempted. One person was receiving support with their religious needs. People received access to healthcare services.

Relatives and staff provided poor feedback regarding the registered manager and the working environment which had developed. Regular meetings for people, relatives and staff were taking place.

The registered manager’s audits had stopped in May 2018 and the registered provider acknowledged they had no evidence of their own checks to ensure the service was well managed. Staff told us they were unable to approach the registered provider and the registered manager had discouraged this. The registered provider had failed to meet its own action plan submitted in March 2018.

At this inspection we found people were unlawfully deprived of their liberty and consent and capacity was not consistently recorded. Individual risks to people had not been properly assessed and fire safety was not effectively managed. The storage and records relating to the management of medicines were not safe. There were insufficient numbers of suitably qualified staff deployed to meet people's needs effectively. Staff had not received appropriate induction support, training, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform. Records relating to people’s care needs were not adequately recorded. Detailed records of responses to complaints had not been maintained. There were continued breaches of the regulations and there was insufficient leadership and oversight.

The Care Quality Commission is considering the appropriate regulatory response to resolve the problems we found. 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 overall rating for this service is ‘Inadequate’ and the service therefore 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.

Rockley Dene 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. Rockley Dene Nursing Home provides care and support for people with nursing and residential needs. The home has a maximum occupancy of 34 people. On the day of our inspection, 24 people were resident at the home.

At the time of our inspection 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.

People told us they felt safe, but during the course of the inspection we found aspects of the service were not safe. Risk assessments did not include adequate detail to reduce the risk of harm to people or staff. People were not adequately protected from the risk of fire as staff had not received sufficient training, people’s personal emergency evacuation plans were not fit for purpose and we could not evidence a recent fire risk assessment had been completed. The registered manager was not able to evidence checks on lifting equipment had taken place in line with Lifting Operations and Lifting Equipment Regulations 1998 (LOLER).

People told us there were not always sufficient numbers of staff on duty to meet their needs and some staff felt they had recently had to work excessive hours, however, this was in part due to a recent outbreak of sickness in the home.

Procedures for the recruitment of staff was not always robust. Checks on nurse’s registration had not been kept up to date and there was insufficient information in the personnel file for one nurse to evidence pre-employment checks had been robust.

Records relating to some people’s medicines needed to be improved. We could not evidence nursing staff had received regular medicines training and competency assessments.

Policies were not reflective of current good practice guidance.

New staff with no previous experience in providing care to people, they were not enabled to complete the Care Certificate. We were unable to evidence staff had received practical moving and handling training.

Feedback regarding the meals at the home was mixed. We saw meals were plated up in the kitchen and then served to people, on the second day of the inspection we saw the serving of the lunchtime meal was more person centred. People were not always encouraged to eat their meals and records of people’s diet and fluid intake were not always accurate. We have made a recommendation regarding meeting peoples nutrition and hydration needs.

Peoples weight and nutritional risk was monitored and action was taken where concerns were raised.

People were not supported to have maximum choice and control of their lives, we found records in peoples care plans did not evidence the home was compliant with the requirements of the Mental Capacity Act 2005.

People told us staff were caring and kind, but we saw a number of examples where staff did not treat people with dignity and respect. This included staff not explaining to a person what they were doing and where they were taking them and not offering people a choice in regard to the drink they were given.

There was a programme of activities, but some people felt they were not suited to the people who lived at the home.

Information in people’s care files was recorded consistently throughout the document and the content was person centred, although some care plans lacked detail. Peoples care plans recorded how they were able to communicate their needs, although no alternative communication aids were available to support people in communicating their preferences.

There was a system in place to manage complaints and people told us they would speak to the registered manager if they were unhappy with their care.

Feedback about the management of the home was positive. However, we found systems of governance were neither robust nor effective. A range of audits were completed, but where shortfalls were identified these were not always rectified.

Staff meetings had been held at regular intervals, but there had not been a meeting with people who lived at the home and/or their relatives since April 2017.

During this inspection, we found breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014 related with safe care and treatment, premises and equipment, safe recruitment, training, dignity and respect and good governance.

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. You can see what action we told the provider to take at the back of the full version of the report.