Background to this inspection
Updated
21 April 2018
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
This inspection visit took place on 27 February 2018 and was unannounced. The inspection team consisted of two inspectors. One inspector returned announced on 7 March 2018 to review more records and to look at the provider’s quality assurance systems.
We reviewed the information we held about the service. This included information shared with us by the local authority commissioners. Commissioners are people who work to find appropriate care and support services which are paid for by the local authority. We looked at the statutory notifications the provider had sent us. A statutory notification is information about important events which the provider is required to send to us by law.
Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. The PIR was an accurate reflection of what we found during our visit and the improvements needed.
To help us understand people’s experiences of the service, we spent time during the inspection visit talking with people in the communal areas of the home, or their own room when invited. This was to see how people spent their time, how staff involved them in making decisions about their care, how staff provided their care and what they thought about the service they received.
We spoke with five people who lived at The Firs. Our conversations with people were limited, because they did not want to spend a lot of time with us, but they gave us an insight into their experiences of living at the home. The report does not contain many quotes from people, but does report their feelings. We spoke with the registered manager, four nurse staff and five care staff (In the report we refer to these as staff).
We looked at two people’s care records and other records including individual risk assessments, quality assurance checks, daily notes for people, medicines, health and safety information and environmental checks.
Updated
21 April 2018
The inspection visit took place on 27 February 2018 which was an unannounced comprehensive inspection. We returned announced on 7 March 2018 so we could review the provider’s quality assurance systems, talk with more staff and to see how the provider supported those people who smoked, to be kept safe.
The Firs is a mental health nursing home, which provides care for up to 25 people over two floors. At the time of our inspection there were 23 people living at The Firs.
People in care homes receive accommodation and nursing and/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.
A requirement of the service’s registration is that they 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 and the associated Regulations about how the service is run. At the time of our inspection visit there was a registered manager in post who had been registered at this location since July 2016.
At our last comprehensive inspection in September 2016, we rated the service Requires Improvement overall. We found a breach of the regulations because risks were not managed safely. We found further improvements were needed to ensure learning was taken to identify patterns and trends when accidents and accidents occurred. Staff did not always support people in line with the mental capacity act and the provider’s quality assurance systems needed to be improved.
We completed a focused, follow up inspection to look only at ‘Safe’ in July 2017, to check whether improvements had been made. We found sufficient improvements had been made so the service was no longer in breach, but further improvements were still needed to show how they analysed accidents and incidents. Medicines management had improved but further improvements were needed around medicine protocols, for 'as and when required' medicines. This was because there was no information for staff about when to administer this type of medicine.
At this inspection we found improvements had been made since our last inspection visit but further improvements were still required in their quality monitoring systems. Analysis of incidents and accidents had been undertaken although the system required more simplification so it provided a clear picture of what had happened. The registered manager was confident any accidents and incidents were brought to their attention and any action needed, was taken. Medicines protocols for ‘as and when’ medicines were in place and being followed. Staff supported and offered people choice, even if they lacked capacity but improvements were still needed in the recording of best interest decisions.
People were pleased and satisfied with the quality of care provided. People were encouraged to make their own decisions about how they lived their lives.
People received care and support in line with their expressed wishes and goals that promoted and improved people’s social skills. Staff encouraged people and supported them to remain as independent as possible so they did not de-skill people. People maintained important relationships with those closest to them and people were happy with living in a shared home.
For people assessed as being at risk, care records included information so staff knew how to minimise risks to those in their care. Staff knew how to support people to minimise identified risks to the person and others.
Care plans contained information for staff to help them to provide the individual care people required, but more detail was needed to support the provider’s vision of person centred care. Staff knowledge of people was comprehensive, but these details were not always included in people’s care plans.
All staff understood what actions they needed to take if they had any concerns for people's wellbeing or safety. Staff felt confident to raise concerns to the management and provider. People’s care and support was provided by a caring and consistent staff team and there were enough staff to provide care when people needed it.
Staff received essential and regular refresher training to meet people’s needs, and effectively used their skills, knowledge and experience to support people.
Staff worked within the principles of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Where people lacked capacity, staff’s knowledge ensured people received consistent support so the right decisions and outcomes were made. Staff understood the importance of seeking people’s permission, before any care and support was provided. Best interest decisions did not always record how decisions had been reached.
People were supported and encouraged to be involved in leisure interests to keep them active and to have fulfilling lives. People and staff worked together to help promote their social and lifestyle skills.
Staff supported people to ensure they maintained a balance diet. People had choice of food and drink at mealtimes and throughout the day.
People received support from other healthcare professionals to ensure their overall mental health and physical wellbeing was maintained. Some people took responsibility for some of their own medicines such as inhalers, while staff supported them with their other medicines for their safety. Regular checks and monitoring ensured medicines continued to be given safely.
Examples of audits and checks were completed that assured the registered manager and the provider that people received a good service. Some improvements to audits and checks had been made by the registered manager but they continued to fall short in some areas, of what was required by the regulations. Training schedules were not completed, falls analysis required further improvement and records to support people’s best interest decisions needed to be completed. Policies in relation to people smoking had not been identified as being incomplete, even though they were reviewed in November 2017.
The registered manager told us they were committed to continually improve the service and wanted people’s experiences to remain positive. The actions and thoughts given to improving people’s experiences was noted when we returned for our second day.
Further information is in the detailed findings below.