Archived: The Shrubbery Nursing Home

The Shrubbery Nursing Home is a ‘care home’. 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. A maximum of 38 people can live at the home. There were 25 people living at home on the day of the inspection, a number of whom lived with dementia. Nursing care is provided.

In August 2017 we inspected and rated the service as Inadequate. We placed the service into Special Measures. This was because the provider had failed to ensure systems and processes were in place to assess, monitor and mitigate risk to people living in the home. The provider had a condition placed on their registration to provide us with a monthly review to demonstrate how they were working towards making the required improvements. This was to ensure people living at the home remained safe while improvements were made. The provider sent an action plan to show what they would do, and by when, to improve the quality and safety of the service.

At this inspection the provider demonstrated to us that a number of improvements had been made, therefore the service is no longer in Special Measures. However, some areas of the service required further improvements to be made and improvements to be further embedded.

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.

People had access to other healthcare professionals that provided treatment, advice and guidance to support their health needs, however records did not reflect guidance needed to support people and accurate records of care provided were not always kept.

The registered manager had a range of audits that had been implemented to demonstrate how they monitored the quality and safety of people’s care and support. The provider’s planned improvements will need to demonstrate that continued improvements are sustained over time.

The registered manager had started to make improvements to the overall leadership of the home and both people and the staff team told us there were now opportunities to raise concerns and issues which were listened to.

We will check these improvements have been sustained during our next planned comprehensive inspection.

People’s incidents were now being recorded by staff and a new reporting process had been implemented. People living in the home, their friends and relatives told us that staff support and guidance had improved. Staff understood how they were able to minimise the risk to people’s safety.

We saw staff helped people and supported them by offering guidance or care that reduced their risks of harm. Care staff now had a clearer understanding of their responsibilities in reporting any suspected risk of abuse to the management team. Overall, staff were available for people and had their care needs met in a timely way. People told us their medicines were managed safely and administered for them by staff. Staff wore protective gloves and aprons to reduce the risks of spreading infection within in the home.

People told us staff acted on their wishes and their agreement had been sought before staff carried out a task. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the provider’s policies and systems supported this practice.

Staff had been provided with training that reflected the needs of people who lived at the home. The training information showed that staffs’ knowledge was being updated. People told us and we saw their privacy and dignity were respected and staff were kind to them.

People told us they liked the staff and felt they knew how to look after them and were included in day to day decisions about their care and support. People were supported to eat and drink enough to keep them healthy.

People were involved in planning their care and if requested their relatives were involved, which include end of life planning. The care plans reflected people’s life histories, preferences and their opinions. People told us staff offered encouragement to remain active and try activities on offer. People also told us they enjoyed the social aspect of the home and the activities offered.

People were aware of who they would make a complaint to if needed. People told us they were happy to talk through things with staff or the registered manager if they were not happy with the care.

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 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.

The Shrubbery provides personal and nursing care and accommodation for up to 39 older people. There were 29 people who were living at the home on the day of our visit.

The registered manager had resigned from their post in June 2017. At the time of our inspection an interim manager had been in post since the 17 July 2017. 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 were not fully protected from harm and abuse. Where incidents of abuse had occurred the provider had failed to take the necessary action to report this as staff had not followed safeguarding protocols and incidents had not been reported to external agencies. Measures that the provider had put in place to protect people were not adequate, and people had experienced further incidents of abuse. The provider had not identified potential risks and put plans into place to protect people from further harm. The provider contacted relevant authorities at CQC request, which had been accepted for investigation by the external agencies.

People were not supported to have maximum choice and control of their lives. We saw an example where staff had not worked with the person or their family member’s to make decisions about a person’s care that was in their best interest. We found the care the person received was restrictive and the provider had not considered the person was being subjected to a Deprivation of liberty (DoL). Staff’s training was inconsistent, their knowledge and understanding were not checked by the provider to understand if staff were delivering high quality care. People were supported to eat a healthy balanced diet and with enough fluids to keep them healthy. People had access to healthcare professionals when they required them.

Some people told us that staff did not always treat them kindly when they called for assistance or asked for support. We saw examples where people’s dignity was not always protected when they needed assistance to the toilet. People choices about their care and their views and decisions they had made about their care were not always listened to and acted upon.

People were not involved in the planning and review of their care and relatives felt that where it was necessary for them to be part of the review of their family members care they were not actively involved. People were not supported to continue with their hobbies and interests. People reported they had no means of occupying their time. Where people had any concerns they were able to make a complaint, however the records that we saw about complaints could not evidence that these had always been responded to the complainant’s satisfaction.

There was a lack of continuity in the management of the service, had meant there was not always clear and visible leadership. The culture of the service was not open and transparent, which meant serious incidents had not been discussed with the person, where relevant their family members, staff or external agencies. The poor record keeping of the incidents of abuse meant that the provider could not be assured that those harmed had received the right and proper treatment. The provider was reactive to concerns. The providers systems to check the service was delivering high quality care was inadequate in identifying areas for improvement which had resulted in people receiving poor quality care and treatment. The provider had not informed CQC of important events that occurred at the service, in line with current legislation.

There was a manager in post and they were currently completing the process 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 in the home and the staff helped to keep them safe. People were not concerned about the risk of potential abuse and staff told us about how they kept people safe. During our inspection staff were available for people and were able to support them by offering guidance or care that reduced people’s risks. People told us they received their medicines at the same time daily. If needed extra pain relief or other medicines were provided on request or as assessed by the nursing team.

People told us the care and nursing staff looked after them well and knew the care they needed. Care staff felt their training reflected the needs of people who lived at the home and were supported by the nursing staff and clinical management team.

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. People were supported with a choice of meals and drinks they enjoyed and kept them healthy. People had access to other healthcare professionals that provided treatment, advice and guidance to support their needs.

People told us and we saw that their privacy and dignity were respected and staff were kind to them. People received support to have their choices and decisions respected and staff were considerate when providing care and support in the communal lounges.

People’s health care needs were assessed, and care planned and delivered to meet those needs. People had been involved in the planning of their care or relatives felt they were involved in the care of their family member and were asked for their opinions and input. People told us staff offered encouragement and supported them to remain part of the homes community and offered a variety of things to do.

People and relatives we spoke with told us they were aware of who they would make a complaint to, but were confident to approach the manager if they were not happy with the care. The provider had reviewed and responded to all concerns raised.

Regular checks had been completed to monitor the quality of the care that people received and look at where improvements may be needed. Management and staff had implemented recent improvements and these would need to be regularly reviewed to ensure people’s care and support needs continued to be met. The management team were approachable and visible within the home which people and relatives liked.

Further information is in the detailed findings below.

At this inspection we found improvements had been made in the areas where we previously had concerns. During the inspection we spoke with one person who used the service and a relative of a person who used the service. One person we spoke with said: 'I like it here', and, 'The staff are really nice'.

We spoke with the chief operations officer, the manager, a clinical lead, a registered nurse, one care staff and two maintenance people to find out their views about the service provided at the home.

We found that staff had access to people's care plans. We spoke with one staff member who told us: 'I have access to the care records and if I have any concerns, I can ask the nurse'. We found nursing staff provided regular handovers so staff were aware of people's current health needs.

We found that the processes and checks in place to monitor risks to the quality and safety of care had been improved. We saw evidence that learning from audits and regular checks had taken place.

At this inspection we found that progress had not been made in relation to the outcome areas where we had previously had concerns. We also identified further concerns for the care and welfare of people that used the service.

We spoke with the manager, a business development manager, a registered nurse, two care staff, two housekeeping staff and a maintenance person to find out their views about the service provided at the home.

We found that staff had limited access to people's care plans. We spoke with one staff member who told us: 'I don't have access to the system so I don't see people's care plans'. We found people may be at risk because staff may provide care without access to people's individual health needs. .

We found that the processes and checks in place to monitor risks to the quality and safety of care were not effective. There was a lack of evidence that learning from audits or checks had taken place. We found there were no records that supported what improvement actions had been made.

Relatives that we spoke with were complimentary about the care and support provided. One relative told us: 'Excellent service, they go out of their way to help'. Another relative told us: 'This is the best of the lot'.

People's needs had been assessed and care and treatment was planned and delivered in line with their individual care plan. Staff told us they were aware of each person's needs and how to provide support to meet their individual needs.

We found that there were adequate numbers of staff allocated to day and night time shifts that ensured people received the care and support required.

We last inspected this service on 29 November 2012 and found the provider did not have effective systems in place that monitored the quality of service. At this inspection we found that the provider had not made sufficient improvements to their systems and processes.

We looked at the complaints that the provider had received. We found that complaints made had been dealt with according to the providers own policies.

People were complimentary about the care and support they received. One person told us, 'It is a lot better than the previous home'. People said, 'The staff are very good here' and 'I like it because I feel safe'.

Staff were visible throughout our inspection and there were people using various rooms throughout the day. We saw staff providing one to one care throughout the day, consistently supporting and providing comfort and positive interaction.

There was a variety of personal interaction such as games and conversation observed during the day. We found staff respected people as individuals and knew about their personal lives, background, families and preferred choices. People's changing needs were regularly assessed and reviewed. Staff knew people's current care needs.

People were safeguarded as the provider had taken steps to ensure any potential instances of abuse could be identified and reported. Care staff we spoke to told us they felt supported by the manager to take the appropriate action.

The provider had a system in place to make sure staff had the required levels of training to meet people's individual care needs. The provider completed monthly checks through internal audits and meetings however on occasions did not complete follow up action