Wavertree Nursing and Care Home

Wavertree Nursing and Care Home provides accommodation and nursing/personal care for up to 46 people. At the time of our inspection there were 40 people living in the home.

People's experience of using the service and what we found

Safe recruitment processes were mostly being followed to check new applicants' suitability to work for the service. However, we identified some improvements were needed to ensure that references were obtained from suitable people and verified where needed and that any gaps in employment history were explored and explained. We have made a recommendation regarding this.

People's needs and risks to their health and safety had been assessed and care plans contained information for staff to follow to provide the right support. However, we identified some improvements were needed to the level of detail and accuracy in some people's care plans. The provider was already aware that improvements were needed to care plans and had implemented new care planning documents to address this.

Accidents and incidents were recorded and acted upon appropriately to ensure people received the right support, for example referrals to external health professionals. However, we identified that some improvements were needed to ensure that a thorough review and analysis of incidents was completed in order to look at patterns and trends and prevent them occurring in the future. Staff received safeguarding training and knew how to respond to any concerns or allegations of abuse. People told us they felt safe living at the service.

There were enough staff on duty to support people safely. Observations showed that staff responded to requests for support in a timely manner.

Relevant safety checks were completed on the environment and equipment used by people to support with their mobility needs. The home was clean and well-maintained. Domestic staff completed regular cleaning schedules to evidence tasks they had completed. Visits to the home were permitted in line with current visiting guidance for care homes.

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 worked closely with external health and social care services to ensure people received the right support. Relevant referrals were completed when people's needs changed or when concerns about their health or well-being were identified.

Governance systems had identified areas in need of improvement and the provider showed us evidence of how they planned to make necessary improvements to the service.

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 good (published 22 December 2018).

Why we inspected

We received concerns in relation to risk management. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

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.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe, effective and well-led full sections of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Wavertree Nursing and Care Home on our website at www.cqc.org.uk.

Follow-up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Wavertree Nursing and Care 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.

The service provides accommodation for older people who require nursing and personal care. The service is registered to support 46 adults. At the time of our inspection there were 45 people living at the service of which there were 17 people requiring nursing care. Accommodation for all residents is provided on the first floor, which can be accessed via a stair case or lift. The service is located in the Wavertree area of Liverpool and is close to local public transport routes.

The home had a registered manager who is also a registered nurse. 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 and their relatives told us they felt the home was safe. One person said, “As soon as I walked in I felt very safe.” The home had effective systems in place to safeguard people from abuse. Staff had received safeguarding training and told us they were confident in identifying and acting upon any concerns.

Staff were safely recruited by the home. This ensured that only people who were suitable to work with vulnerable adults were employed by the home.

People told us they thought there were enough staff at the home and we saw that staff attended to people promptly through our inspection. One person also told us that the staff come quickly when they press their buzzer especially at night. They said, “If I need them, they are there.”

Medication was correctly administered, stored and recorded at the home. The medication administration records (MARs) and medication stocks we looked at had been appropriately completed and medication stocks were accurately accounted for. This included acting in line with best practice regarding administering and recording ‘as required’ (PRN) medication.

The home was well-maintained and the safety of the environment was regularly checked by staff. Fire safety at the home was also well-managed.

Environmental health awarded the kitchen a rating of five out of five in February 2018. We noted that the home had achieved the same rating when it was inspected in August 2016. Therefore, it had maintained a high standard in this area.

The home effectively assessed people’s care and support needs and helped them to achieve positive outcomes.

Staff received regular training relevant to their roles and were supported with regular supervision and appraisal meetings. Staff told us that they felt supported in their roles and all other staff, including the registered manager and deputy manager, were approachable and helpful.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been followed by the service. We saw that the service carried out appropriate capacity assessments when necessary. Deprivation of Liberty Safeguard (DoLS) applications had been appropriately submitted to the Local Authority and there was a clear system in place to closely monitor and renew them when needed.

People were supported to have enough to eat and drink and we saw that people that required assistance to eat and drink were given this support by staff. Most people gave us positive feedback about the food at the home.

People told us the staff were caring and friendly. One person said, “The staff are great, caring and kind, they respect my dignity”. We also observed many caring interactions between staff and people living at the home throughout our inspection.

People told us that staff respected their privacy and treated them with dignity and respect. One person said that staff always knock on their door and wait for them to answer before entering. We observed this happening throughout our inspection and staff used respectful and caring language when communicating with people.

People had developed positive and friendly relationships with the staff and staff could tell us about people’s likes, dislikes, interests and the support they needed.

People living at the home had personalised care plans and risk assessments. This meant staff had the information they needed to safely and effectively meet people’s needs.

People’s different communication needs were considered and met in line with the Accessible Information Standard. This included people’s audial, visual and language support needs.

We reviewed the home’s complaints records and found that complaints were appropriately recorded and responded to in a timely manner.

People, relatives and staff gave positive feedback about the management of the home and felt that it was well-led. We also saw there was a positive and caring culture amongst the staff at the home.

There were effective systems in place to monitor and assess the quality and safety of the service being provided. Staff also had access to a range or regularly reviewed policies to help guide and support them.

The service is required to 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 registered manager, who is a registered nurse, was appointed in June 2017. This followed a long period of time in which the service did not have a registered manager.

We spoke with the provider, registered manager and the registered manager from the neighbouring residential home which is part of the same organisation. They were open and transparent in accepting there were a number of valid concerns highlighted during our last inspection. However, considerable efforts to improve the service had been made.

The people we spoke with told us they felt safe, secure and well-cared for living at the service. People's relatives also told us they felt people were safe and they praised the standard of care provided by staff at the service.

During our last inspection we found breaches in relation to Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to inadequate risk assessment, poor management of pressure care equipment, the lack of a registered manager for a considerable period of time and the failure to send us statutory notifications. During this inspection we noted that the service had made improvements in these areas.

Quality assurance and audit systems were in place and had improved since our last inspection. However, they were not always effective, nor were they always up-to-date. For example, we found that some people’s ‘when required’ (PRN) medication was not recorded properly, which meant there was no way of knowing what PRN medication had been given or what amount of PRN medication should have been in stock. We saw that some of the waterproof covering on one person’s bed bumper had worn away exposing the foam cushioning underneath. This was unhygienic and posed a potential infection control risk. We also found that a room used by a hairdresser who visited the service was dirty and did not appear to have been cleaned since it was last used, as there was some hair left on the floor. We noted that these issues were immediately addressed when we highlighted them. However, all of these issues should have been identified by effective audit systems and therefore this remains an area requiring improvement.

People living at the service had personalised care plans and risk assessments. The care plans we looked at were regularly reviewed by the registered manager and, where possible and appropriate, the people, their relatives and other relevant health professionals were involved in the process of reviewing this information. Although, we saw that some documents were not always fully completed. For example, some documents were missing staff signatures.

Pressure care equipment was appropriately maintained, monitored and used by staff at the service.

Staff were recruited safely and they were appropriately supported with an induction process at the start of their employment. We saw that staff had received suitable training to carry out their job role effectively. The majority of staff had had supervision and appraisal meetings. The registered nurses had appropriate checks of their registration with the Nursing and Midwifery Council (NMC).

People were given a choice of nutritious food and drink at the service. We saw that staff assisted and encouraged people with food and drink where necessary. People told us that they thought the food at the service was “ok” and they got enough to eat and drink.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been followed by the service. We saw that the service carried out appropriate capacity assessments when necessary. Deprivation of Liberty Safeguard (DoLS) applications had been appropriately submitted to the Local Authority and there was a clear system in place to closely monitor and renew them when needed.

We saw there were policies and procedures in place to guide staff in relation to safeguarding adults. All of the staff we spoke with were able to tell us who they would contact both internally and externally if they were concerned about a person living at the service. There was clear information about safeguarding procedures and contact details in various communal locations at the service, including the entrance to the service.

The home is required to 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. There had been no registered manager in post since March 2015. There was a ‘home supervisor’ and a clinical lead in post.

We spoke with the provider and the home supervisor and they were very transparent and told us that they recognised that the home needed to improve and that they were committed to the work required.

People we spoke with told us they felt safe at the home. They had no worries or concerns. People’s relatives and friends also told us they felt people were safe. During our visit, however we identified concerns with the service.

We found breaches in relation to Regulations 12 and 17 of 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 this report.

The service had not submitted statutory notifications to the Care Quality Commission regarding incidents that had happened at the service.

Quality assurance systems were in place but did not operate effectively and had not embedded into the culture of the service enough to ensure people received a safe, effective, caring, responsive and well led service.

We reviewed people’s care plans and risk assessments as well as monitoring information. Not all of these were clear or legible regarding people’s needs. Some monitoring information and risk assessments were also misleading and gave little guidance to staff on how to meet people’s needs. We also identified concerns regarding the monitoring of equipment for pressure area care with inappropriate settings of air flow mattresses. There were no infection control procedures for mattresses, beds, pumps for the air mattresses and cushions as no one was allocated to clean or check them.

Staff were recruited safely, however there was not sufficient evidence that staff had received a proper induction at the start of their employment. We saw that staff had received suitable training to do their job role effectively. The majority of staff had been supervised and appraised. The registered nurses had appropriate checks of their registration with the Nursing and Midwifery Council.

People had access to sufficient quantities of nutritious food and drink throughout the day, however we observed that people were not always supported with accessing food at mealtimes and some monitoring information was incomplete or misleading. We received a mixed response regarding the food provided with both negative and positive comments from the people living in the home.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been followed by the home. The home supervisor told us about people in the home who lacked capacity and that the appropriate number of Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority.

We saw there were policies and procedures in place to guide staff in relation to safeguarding adults and staff were able to tell us who they would access both internally and externally if they were concerned about a person living in the home. There was information regarding safeguarding procedures in the entrance to the home as well on a communal notice board on a main corridor.

The overall rating for this provider is ‘Inadequate’. 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.

The service will 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 we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location from the providers registration.

This was because people who used services were not protected against the risks when receiving care or treatment. The premises used by the service was not always safe, medicines in the home were not always managed in a proper or safe way and the provider had not ensured infection control was properly managed. These were breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider did not have effective systems in place to assess and monitor their service against Health and Social Care Act Regulations or to assess, monitor and mitigate the risks to the health, safety and welfare of people who used the service. These were breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We issued the provider with warning notices in relation to the breaches. A warning notice is an enforcement action used by the Care Quality Commission to direct a provider to improve their service to meet requirements of a specific regulation within a set time period. We gave the provider until the 01 March 2016 to meet their legal requirements in relation to assessment and mitigation of risk.

We undertook a focused inspection on the 07 June 2016 to check that they had met the requirements of the warning notice in order to meet the legal requirements in relation to the breaches described above. This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Wavertree Nursing and Care Home’ on our website at www.cqc.org.uk’.

Wavertree Nursing and Care Home provides accommodation for older people who require nursing care. The service accommodates up to 46 adults. The service is located in the Wavertree area of Liverpool and is close to local public transport routes. Accommodation is provided on the first floor and this floor can be accessed via a stair case or passenger lift.

The home did not have a manager in place as the manager at the time of the last inspection was no longer in post. There was a Home supervisor, a clinical lead nurse and the providers were in attendance at the time of our inspection. 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.

We saw that some improvements had been made to medication processes, premises, infection control and quality assurance processes.

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. There was not a registered manager in post.

We spoke to three people who used the service, three members of staff, the manager and the deputy manager.

We found a number of breaches related to medicine management, receiving and acting on complaints, good governance and cleanliness and infection control. You can see what action we told the provider to take at the back of the full version of the report.

We observed a medication round and saw that the way medication was administered was unsafe. There were omissions in the records which indicated that some medicines had not been administered this included PRN medication, controlled drug administration and topical medications. Topical medications are in the form of creams, gels and ointments.

Parts of the environment were unsafe, dark and in disrepair and areas of the home were malodorous. Infection control standards at the home were not good nor monitored and managed.

Quality assurance systems were in place but did not operate effectively enough to ensure people received a safe, effective caring, responsive and well led service.

We reviewed the home’s complaints policy and records. We found a number of concerns with complaints management at the home.

We reviewed peoples’ care plans, not all of these provided sufficient information about people’s needs or gave guidance to staff on how to meet them.

We found that the Mental Capacity Act 2005 and the Deprivation of Liberty (DoLS) 2009 legislation had been followed by the home. The manager told us about people in the home who lacked capacity and that the appropriate number of Deprivation of Liberty Safeguard (DoLS) applications had been submitted to the Local Authority.

We found that improvements had been made to the service since our last inspection visit.

We found that improvements had been made to how people were involved in decisions about their care and support. People's care and support had been reviewed and care plans updated. Staff had been provided with up to date training in a range of topics including safeguarding people from abuse.

At this visit we found that some improvements had been made but further improvements were still required in relation to care planning, risk assessments and the effective management of medication.

We also found that written consent was not regularly gained for people living at Wavertree and that processes for the recording and management of incidents and safeguarding of vulnerable adults were not always managed correctly.

People told us that they were looked after well. We found that staff had completed training relevant to their role and that this was in the process of being reviewed.

We spoke with five people who used the service and their relatives. People told us that the care they had received had been positive and no one had any negative comments about the care they had received at the home. Their comments included, "My relative has improved very much during their time here" and 'The staff are always lovely with my relative".

The provider was effectively assessing and monitoring the quality of service delivery and systems for the management of complaints had been put in place. The provider had taken steps to improve the quality of food prior to our visit and actions were in place to improve the overall dining experience.

We spoke with three people and their relatives who used the service who told us that the care they received was delivered in a way that respected their privacy and dignity. Their comments included:

'Respectful always knock on the door'.

'Excellent'.

'Very caring, they go above and beyond'.

'Nurses are always bubbly, not a depressing place'.

During our visit we saw evidence that care plans were detailed and contained enough information for people to be cared for safely and effectively. We looked in detail at six care records of people using the service and saw that they were up-to-date and included relevant risk assessments.

There were effective staff recruitment and selection processes in place. We saw evidence that systems had been put in place to carry out regular checks on the quality of service provision.

We found that not all staff were clear in terms of their responsibilities in relation to safeguarding concerns.