Flixton Manor

Flixton Manor is a nursing home providing accommodation and personal care to older adults, including people living with dementia. Flixton Manor accommodates up to 38 people in one adapted building. At the time of our inspection, there were 35 people living at the home.

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

People and their relatives were positive about the care provided at Flixton Manor. The staff reported a significant improvement in the leadership of the home since the new manager had started. The provider had responded positively and worked in partnership with Trafford Council to respond to all the concerns raised prior to the inspection.

We identified shortfalls in the management of medicines. Immediate measures were taken during the inspection to address these issues to ensure safe care was provided. Staff understood how to safeguard people and when to raise concerns. Recruitment practices were safe. Risks associated with people’s care were assessed and monitored. Staff followed infection prevention and control guidance to minimise risks related to the spread of infection.

Staff were responsive to people’s needs and people and their relatives were happy with the standard of care provided. Staff were kind and caring and people were treated with dignity and respect. People were supported to access relevant health and social care support and people had access to a range of activities to meet their needs.

Plans were in place to ensure all staff training and supervisions were up to date. People were happy with the quality of the food and plans had started to refurbish the home.

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.

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 13 August 2018).

Why we inspected

The inspection was prompted in part due to concerns received from Trafford Council on 4 October where a formal notice to suspend all placements was issued to Flixton Manor. This was removed on 4 November as the home had demonstrated positive improvements in response to the concerns raised. CQC also received concerns from a whistle-blower in October about poor care. A decision was made for us to inspect and examine those risks.

Enforcement

We have identified a breach in relation to medicines at this inspection.

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

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

¿ Robust admission procedures were in place. The registered manager ensured they received a written copy of people's negative COVID-19 test results prior to anyone moving to the home.

¿ All new admissions then also isolated in their rooms for 14 days and had a negative COVID-19 test before accessing communal areas of the home. During this time staff wore full PPE in line with government guidelines. Laundry was bagged and stored for 72 hours before being washed separately from other people's laundry, to reduce the risk of COVID-19 coming into the home.

¿ If staff on annual leave went away - within the UK or abroad - they had to have a negative COVID-19 test before returning to work.

¿ Additional staff training for COVID-19 and infection control had been completed. One staff member had attended specific COVID-19 related training with the Clinical Commissioning Group and had cascaded this learning to the whole staff team.

Further information is in the detailed findings below.

Flixton Manor is registered to provide accommodation with personal and / or nursing care for up to 38 older people. At the time of our inspection there were 36 people living at the home, the majority of whom were living with dementia. Accommodation is provided over three floors, including a basement level, ground floor and first floor. 36 bedrooms are single occupancy. One double room is available if a couple wish to share; however, this is usually used as a single room. Newer bedrooms have an en-suite toilet. There are two communal lounges and a small dining area on the ground floor.

At our last inspection in June 2017 we found three breaches of regulations with regard to the use of unsafe moving and handling techniques, a lack of staff interaction when supporting people and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe, effective, caring and well led to at least good. At this inspection we found improvements had been made and these regulations were now being met.

Flixton Manor had 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.

We observed staff engaging with people throughout the inspection. Staff sought people’s permission before providing support and explained to people the support they were about to provide. We observed safe moving and handling techniques being used.

A quality audit system was in place to monitor the service. Daily walk arounds had been introduced to observe staff and check around the building. The observations were documented and we saw positive feedback had been given to staff where good practice had been seen.

People and their relatives thought they were safe living at Flixton Manor. The staff said they enjoyed working for the service and felt well supported by management team.

People received their medicines as prescribed. Guidelines for when a person may require a medicine that was not routinely administered (PRN) were not always in place.

Staff added thickener to fluids where people had been assessed as being at risk of choking. However, they did not document when they had done so. The registered manager said they would introduce a form for staff to sign when they added thickeners to fluids.

We have made a recommendation that best practice guidelines are followed for the recording of variable dose medicines.

Care plans and risk assessments were in place which provided guidance and information about people’s support needs, their likes, dislikes and preferences and how to mitigate the identified risks. Staff we spoke with knew people and their needs well. Care files were reviewed each month.

A pre-admission assessment was completed when people moved to the home. Key information about a person’s needs was identified and written up for the staff to refer to. However, initial care plans and risk assessments were not written for around two weeks after the person moved to Flixton Manor so they had time to get to know their needs better. We have made a recommendation that the service follows best practice guidelines in developing initial risk assessments and care plans in a timely manner.

People were supported with their health and nutritional needs. A health professional told us the pressure area care at the home was good. The menu had recently been changed to offer people a wider choice of meals. A picture menu had been introduced to assist people choosing their food.

People and relatives thought there were sufficient staff on duty to meet people’s needs. Additional staff were being recruited to increase the staffing levels at night and in a morning. Staff told us that whilst they could manage, the extra staff member was needed at these times.

An activities co-ordinator had been working at the home for 12 months. Planned activities were arranged, including external entertainers. A reminiscence aid called the Daily Sparkle was used to talk about past events and prompt people’s memories.

People’s wishes at the end of their life and in the event of their death were recorded in advanced care plans.

A recruitment system was in place to recruit suitable staff. Staff received an induction and ongoing training to be able to carry out their role. Regular supervision meetings were held, although a member of the night care staff told us they had not had a supervision, but was able to speak with the registered manager or care co-ordinator if they needed to. Staff meetings were also held where staff could raise any ideas or issues they had.

A complaints policy was in place. Complaints had been investigated and responded to appropriately.

A survey had been used to gain feedback from relatives. The responses had been positive. Comments made in the survey had been reviewed by the registered manager and changes made where appropriate, for example with the food menu.

People’s cultural and religious needs were being met by the service.

The service was meeting the principles of the Mental Capacity Act (2005). People’s capacity was assessed and applications made for a Deprivation of Liberty Safeguard (DoLS) where a person was found to lack capacity.

The home was visibly clean throughout. The communal areas had been re-decorated and stencils applied to the walls depicting old style corner shops and community scenes.

Flixton Manor is registered to provide accommodation with personal care with nursing for up to 38 older people. At the time of our inspection there were 34 people living at the home, the majority of whom were living with dementia. Accommodation is provided over three floors, including a basement level, ground floor and first floor. All bedrooms are single occupancy. Newer bedrooms have an en-suite toilet. There are two communal lounges and a small dining area on the ground floor.

The service had a registered manager who had been in place since September 2016. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 previous inspection took place in September 2016 where six breaches of the Health and Social Care Act 2008 were identified. The provider was placed into special measures by the CQC. We took enforcement action and issued two warning notices to the provider.

This inspection was carried out to check what improvements had been implemented since our last inspection. We found that improvements had been made and these were sufficient for the CQC to be able to take the service out of special measures.

People and their relatives told us they felt safe living at Flixton Manor. Staff had undertaken training in safeguarding vulnerable adults and were able to describe the different types of abuse and how they would report any concerns.

The number of staff on duty in the morning had been increased since our last inspection. However we noted that staff were very busy and task orientated. People and relatives told us they sometimes had to wait for staff to be available to support them to use the toilet. However other relatives told us their loved ones always looked well cared for.

Staff had little time to speak with and interact with people. We observed that some staff interacted well with people when they were supporting them, whilst others did not. The management team at Flixton Manor were aware of this and had taken some steps to address this issue.

We saw no activities taking place during our inspection although an activities officer was due to start work at the service in June 2017. They would be able to interact with people and organise activities for people to participate in. The activities officer was also due to complete details of people’s life histories. We did note that more external entertainers were now being arranged to come to the home. People had daily papers available and the home had Sky TV installed which some people enjoyed for watching football.

The care plans and risk assessments had been reviewed and any duplication removed. They provided clear person centred guidance for staff to follow in order to meet people’s care needs.

Staff had completed training to give them the knowledge to undertake their roles. However we observed three occasions of an unsafe moving and handling procedure (called a drag lift). We have made a recommendation for the service’s moving and handling training is reviewed so it meets current best practice guidance for safe moving and handling techniques.

Team meetings and staff supervisions had been introduced. This meant staff were better supported in their roles.

Handovers were held between each shift to update the staff on any changes in people’s needs or health. This meant staff had the information to support people and meet their needs.

The staff recruitment procedure had been improved so staff were safely recruited who were suitable to work with vulnerable people.

We saw medicines were administered as prescribed. Guidelines for any ‘as required’ medicines such as pain relief had been introduced.

Some improvements in the environment had been made. Signs were in place to assist people living with dementia, carpets had been replaced, a new accessible bath was being installed and a sloping floor on the first floor was now clearly identifiable.

Systems were in place to meet people’s health and nutritional needs. People told us they enjoyed the food. Some staff raised concerns about the presentation of the food when the part time chef was on duty. The registered manager was aware of this and was addressing it with them. People were regularly weighed in line with the assessed risk and referrals made to the Speech and Language Team (SALT), district nurses and other medical professionals as needed. Medical professionals told us the service made appropriate referrals and followed any advice they were given.

People’s wishes for their care at the end of their lives were established with them or their relatives. Staff had received training in end of life care.

All areas of the home were clean. On our arrival we checked the lounge chair cushions had been cleaned by the night staff and found that they had been. Procedures were in place to prevent and control the spread of infection.

Systems were in place to deal with any emergency that could affect the provision of care, such as a failure of the electricity and gas supply. Regular checks were in place of the fire systems and equipment.

The registered manager had introduced relative meetings, although they were not well attended. A relatives survey had been handed to people and had a good response. This meant the service was now seeking feedback and involvement from relatives. Relatives also told us the service kept them fully informed about any changes in their loved ones health or wellbeing. The service had a system in place to respond to concerns and complaints.

A series of audits were in place, including for medicines and care plans, so the registered manager could monitor and improve the service. The registered manager and clinical lead attended provider and nursing forums. This meant they could keep up to date with current best practice and seek advice from other registered managers.

The provider had provided a link to the last inspection report on the CQC website when we requested that they do this. However the overall rating from the last inspection was not displayed on the provider’s website. The last inspection report was available at Flixton Manor.

During this inspection visit we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to safe moving and handling techniques, lack of staff interaction with people who used the service, not displaying the overall rating of the last inspection on the provider’s website and the governance of the service due to the issues we found at this inspection. You can see the action we took at the end of this report.

Flixton Manor is registered to provide accommodation with personal care with nursing for up to 38 older people. At the time of our inspection there were 33 people living at the home, the majority of whom were living with dementia. Accommodation is provided over three floors, including a basement level, ground floor and first floor. All bedrooms are single occupancy. Newer bedrooms have an en-suite toilet. There are two communal lounges and a small dining area on the ground floor.

The previous inspection took place in September 2014. We found four of the standards we looked at were met; however we found care plans did not include written assessments of people’s capacity to consent to their care and treatment at Flixton Manor. Following the inspection in September 2014 the provider wrote to us to tell us the action they intended to take to ensure they met all the relevant regulations. Part of this inspection was undertaken to check whether the required improvements had been made. We found improvements had been made in relation to undertaking capacity assessments for people living at Flixton Manor.

The service had a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 was due to retire shortly after our inspection. A senior carer who had worked at the home for many years had been appointed as the new manager and was applying to be registered with the CQC.

During this inspection visit we found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to recruitment processes, training and staff supervision, lack of staff interaction with people who used the service, assessments and reviews of care, managing complaints, meeting people's social needs and quality assurance and auditing systems. We also found breaches of the Care Quality Commission (Registration) Regulations 2009 relating to not submitting the required notifications to the CQC. A notification is information about important events which the service is required to send us by law.

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.

Everyone we spoke with said they felt safe living at Flixton Manor. They said the staff were kind and caring. Staff had received training in safeguarding adults and knew the correct action to take if they witnessed or suspected abuse. Staff were confident that the registered manager would act on any concerns raised.

Assessments of people’s needs had been completed. However there were duplicated assessments and different assessment tools used for the same area of need resulted in different outcomes. Care plans and risk plans were identified from the assessments. People’s personal life history was not recorded. Staff did not have access to the care plans and relied on verbal information and their memory to know people’s needs and preferences. People and relatives were not involved in the formulation or review of the care plans.

All the people living at the home required two staff to support them to mobilise and with personal care. The staff on duty were busy throughout the day. They did not have time to sit and talk to people. Some staff did not talk to people when providing support for example when supporting a person to have a cup of tea.

The home did not have an activities organiser in place. The staff did not have time to arrange activities for people to be involved in. Appropriate music or films were not played, the television being on low volume throughout our inspection. Reminiscence books were not seen. People were seen to be asleep or withdrawn throughout the inspection.

The staff recruitment process was not robust in ensuring suitable people were employed. Full employment histories were not recorded and two references were not obtained for each applicant. Staff did not receive supervisions and staff meetings were not held. The senior care worker had started to undertake staff appraisals and aimed to do these annually. Staff had received training in mandatory subjects such as manual handling and fire safety. Staff had not received any training in supporting people living with dementia.

We saw the first floor corridor was uneven and presented a trip hazard. The carpets were also rumpled. We saw items stored in the basement corridor outside one person’s bedroom. There was only one shower available for people to use. The en-suite toilets were not large enough for people who needed to use mobility aids to access, therefore there was sometimes a queue to use the shared accessible toilets. The home was not decorated in a way to aid people living with dementia. Signage was not in place in the home. We have made recommendations about seeking best practice for facilities and decoration of the home.

Relatives and people said they were able to raise any issues with the staff or registered manager and were confident the issues would be dealt with. However one relative had asked for more activities for their loved one and this had not been actioned. We also saw the provider had not responded to complaints contained in the minutes of a safeguarding case conference.

The service had audit systems in place however they had not been robust enough to identify the shortfalls found during this inspection. The registered manager did not recognise the need for staff to be able to have sight of the care plans or for relatives to be involved in writing or agreeing them.

Medicines were administered and stored safely. People received their medication as prescribed. Guidelines were required for when ‘as required’ medicines needed to be administered where a person was not able to verbally inform staff themselves.

Systems were in place to help ensure people’s health and nutritional needs were met. Records we reviewed showed that staff contacted relevant health professionals to help ensure people received the care and treatment they required.

We found the service was working within the principles of the Mental Capacity Act (2005). Capacity assessments were completed and applications for Deprivation of Liberty Safeguards (DoLS) were appropriately made.

All areas of the home looked clean. Procedures were in place to prevent and control the spread of infection. An infection control audit in June 2016 had identified areas for improvement and these were being implemented.

Contact details in case of utility failure were available. We have recommended best practice guidance is sought for formulating a written business continuity plan to deal with any emergency that could affect the provision of care. Regular checks were in place for fire systems and equipment.

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, it 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.

Before the inspection we looked at information we held about this service, such as notifications and monitoring reports undertaken by the local authority.

During the inspection we spoke with three people who used the service, three visitors and a National Vocational Qualification (NVQ) Assessor. We also spoke with the provider and seven staff working in the home; the person in charge, two care staff, the clinical nurse lead, activities coordinator, the cook and the handyperson. We checked the environment for safety, hygiene and cleanliness and looked at policies, care plans and other records.

The registered manager was on holiday when we visited. After the inspection we asked them for feedback on the improvements they were making in relation to infection control. The registered manager provided the information requested.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

Is the service safe?

Care plans provided evidence of good risk management. For example, information in records provided evidence of staff taking prompt action to make referrals when they identified concerns relating to people's health and welfare.

Environmental risks had been assessed and the home's equipment had been subject to servicing and maintenance at regular intervals.

An application had been made for authorisation to restrict a person's liberty in order to protect them from accidental harm. The application was made appropriately under the Deprivation of Liberty Safeguards.

The registered manager had developed an action plan for making improvements to infection control systems in the home. This was in response to recommendations made following an infection control audit of the home in May 2014.

Seven staff told us they were confident that they had sufficient training and support to develop the knowledge and skills needed to safely care for and support people living in the home.

Auditing of the medication administration system had ensured that errors and omissions were identified and corrected.

Is the service effective?

The service was not always effective. Three relatives and a person living in the home confirmed that they had been consulted and contributed to developing care plans, although we found no evidence of this having been recorded in care plans.

Care plans did not contain evidence of capacity assessments to ensure that actions in care plans were being taken in the best interests of people who used this service. Consequently there was no evidence to show if decisions taken by staff complied with MCA guidance on best interest decision protocols.

Care plans and risk assessments had been kept up to date and people living in the home had been referred for professional advice when healthcare concerns had been identified.

Three relatives told us they were always made welcome when they visited and that there were no restrictions placed on visiting times. This enabled people living in the home to maintain and develop their relationships with family and friends.

Systems for dealing with complaints, suggestions and compliments made sure that the views of people using the service and their representatives were responded to by making improvements where appropriate.

People living in the home had access to a range of daily activities, which provided them with stimulation and interest.

Is the service caring?

Three relatives and a person living in the home confirmed that staff always treated people in a respectful and dignified manner. A relative said, "I visit most days and can honestly say that all the staff respect people's privacy and dignity.'

During both our visits to this home we observed care and nursing staff use good observational skills to provide person-centred and compassionate care. A person living in the home told us, 'It's really good here. They look after us very well."

A senior member of staff told us they spent time sitting and talking to relatives when they visited, to ask their views on the quality of the service. This was confirmed in our conversation with three relatives.

During the midday meal we observed interactions between care staff, nurses and the people they cared for. We saw care staff use good observational skills to provide person-centred and compassionate care. Staff addressed people by their preferred titles and spoke with them in a quiet and calming manner to preserve their privacy and dignity.

Is the service responsive?

People living in the home had their needs assessed and their care plans showed how staff would provide care and support to meet their needs. The people we spoke with during our visit made positive comments about the way the service was provided. They said they were listened to and consulted about the care and support they received.

The registered manager and provider had taken responsive action to make improvements to the service. They gave us examples of the changes they had made in response to recommendations made by the NHS Infection Control Nurse and local authority contract monitoring. This demonstrated that the provider was responding by making improvements to the quality of the service being provided.

Is the service well-led?

The registered manager had implemented quality assurance processes to protect people living in the home from accidental injury, medication errors and the risks associated with providing care and treatment.

The people we spoke with during our visit told us the home was managed well. A visiting National Vocational Qualification (NVQ) assessor said, "This is one of the better homes. The staff are well trained and the home is well run. Staff receive good support to achieve their NVQ qualifications."

Staff working in the home told us, "The manager is fair, approachable and firm. Things get done and it's a really good home to work in. We work well as a team."

We saw people were offered hot and cold drinks throughout the day of our inspection. We spoke with people who lived at the home who told us: "They always ask if I would like tea or coffee." "We get lots to drink, they make sure of that." "When they bring a drink they ask if we would like a biscuit too."

We spoke with the relatives of two people who lived at the home. Comments included: "I don't have any concerns at all I think X is quite happy here.' 'I know they look after X." 'There are no concerns about the staff they are all very nice.' 'If I had any concerns about X's safety I would speak to X.'

We looked at a sample of staff recruitment files and saw appropriate safety checks had been undertaken prior to new staff commencing employment. This included a Disclosure and Barring Scheme (DBS) check and a check against the Independent Safeguarding Authority (ISA) list to make sure applicants were not barred from working with vulnerable people.

We saw care plans and staff files were held electronically. Computer files were password protected and files were backed up on a daily basis to ensure information was kept safe.

Two people living in the home confirmed that staff always asked their permission before providing them with personal care support. One person commented, "The staff are very good. They always listen to me and take me seriously. Staff do things the way I like them to be done."

Three of the four care plans looked at were found to be accurate and up to date. Immediate action was taken to amend the fourth care plan to ensure that it accurately reflected the care and support received by the person accommodated.

Suitable arrangements were in place to protect people using the service from abuse or accidental harm. A person told us, "The staff always make sure that covers are fitted to the bed rails. This makes sure that I am kept safe in my bed."

Two people and a visitor to the home were satisfied that sufficient staff had been deployed. The visitor told us, "I can say that I have never had a problem finding a member of staff when I needed to ask something."

Staff had received appropriate training and management support to enable them to safely meet the needs of the people accommodated in the home.

People who used the service and their representatives had been given information about the home's complaints system. A relative said, "If anything is wrong I just mention it to one of the staff and it gets sorted."

We wrote to the registered manager on 30 October 2012, requesting evidence that their action plan had been completed. The manager responded three days later by sending us copies of the fluid intake charts belonging to the two people we had raised concerns about. We saw that each person had been consistently monitored for their fluid intake on a daily basis since our visit to the home in June 2012. The charts had been redesigned to provide important information for nursing staff when they reviewed the care and support people had received with their fluid intake. Daily and weekly totals of fluid taken meant that nursing staff could immediately identify concerns and take the appropriate action to support people safely.