Archived: Moorwood Cottage

The people living at Moorwood Cottage were older people with complex needs, limited mobility and dementia. Some people were unable to communicate with us. At the time of this visit 13 people were living at Moorwood Cottage.

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?

This is a summary of what we found '

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was not safe. We found that people using the service were not protected from the risk of abuse because some staff had not received safeguarding training.

The cleanliness of the home had improved but was not sufficiently clean to reduce the risk of infection. Wheelchairs were not clean and there was a bed rail stained with faeces. Records showed that cleaning schedules had not been completed.

People were protected against the risks associated with medicines. The provider had appropriate arrangements in place to manage people's medicines safely.

There were not sufficient numbers of suitably qualified trained and experienced nurses to meet people's needs. The service relied heavily on agency nurses to provide medical care as they had been unable to recruit nurses. Agency nurses were often left in charge of the home and this had resulted in them making decisions about the home and people's care when they were not familiar with the service or people using the service.

The acting manager was not familiar with the recent supreme court ruling in respect of Deprivation of Liberty Safeguarding (DoLS). A deprivation of Liberty occurs when 'the person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements.' No DoLS applications had been made for people using the service and this meant they were potentially being illegally detained.

Is the service effective?

The service was not effective. The provider was not complying with the requirements of the Mental Capacity Act 2005 (MCA). Whilst mental capacity assessments were in place for people in relation to the activities of daily living, mental capacity assessments were not in place for other key decision areas. One person who had fluctuating capacity did not have a mental capacity assessment in place. Staff had not received training in the requirements of the MCA. This meant staff did not understand their responsibilities when acting or making decisions on behalf of those individuals who lack capacity to make these decisions for themselves.

Staff did not receive sufficient training to provide effective care to people using the service. Very little training had been provided since our last inspection.

A quality monitoring visit had identified improvements which needed to be made in respect of care planning. The provider had made a decision not to respond to these requirements as they planned to close the service although at the time of our inspection, no applications had been made in this respect. This meant that effective care planning was not in place.

Is the service caring?

The service was caring. We saw staff interacting kindly and sensitively with people using the service. People were reassured and supported to move around the home in a safe way. Some people told us they liked living in the home. People using the service reported an improvement in the attitude of staff towards them.

People were dressed in an appropriate manner and people who were distressed were comforted.

Is the service responsive?

The service was not responsive to people's needs. We found improvements to the responsiveness of the service to people's needs. However, we found inconsistencies which meant that people's needs were not always responded to in a timely way. For example one person had to stay in bed for 24 hours as a soiled sling was not laundered in time and staff did not have a clean sling to ensure they were hoisted safely. Another person did not receive the hourly checks they needed as the home was short staffed.

The home had responded to non-compliance identified during our inspections in May and June 2014. We found improvements in the standard of care provided, however multiple non-compliances remained. For example, we could not be assured that people using the service were receiving enough baths and showers to meet their hygiene needs and one person did not receive their required hourly checks.

Is the service well led?

The service was not well led. We found there was limited senior management support available at the home. Signing in records showed that senior management had spent little time in the home during previous weeks. The improvement plan stated that senior management would be in the home two to three days a week but this did not happen. The acting manager was also registered manager at another home owned by the provider and was therefore not able to spend all their time managing Moorwood Cottage.

The people living at Moorwood Cottage were older people with complex needs, limited mobility and dementia.

We considered all the evidence we had gathered under the outcomes we inspected. During our inspection as further non-compliance was identified we included additional outcomes. 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?

This is a summary of what we found '

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was not safe. We found that care plans were improved as there were less inconsistencies, however we found examples of care plans not being followed. For example people were not being repositioned in order to minimise the risk of developing pressure areas. People did not receive the consistency of food determined by a professional and recorded in their plan of care. At least eight of the 23 people using the service at the time of our inspection did not receive the care they needed and this meant that people using the service were not safely cared for.

There were not sufficient numbers of suitably qualified trained and experience staff to meet people's needs. There were significant numbers of agency workers staffing shifts. New care workers employed lacked experience and time to shadow more experienced staff. The meant there was a risk that some people received unsafe care. The provider had not carried out checks to ensure that staff were suitable qualified to provide care. A check carried out on the day of our inspection, at our request, showed that an agency nurse had been removed from the register (held by the Nursing and Midwifery council) by a malpractice panel.

Is the service effective?

The service was not effective. The provider was not complying with the requirements of the Mental Capacity Act 2005 (MCA). We saw that, where appropriate, people's mental capacity had not been assessed. Two people were in receipt of covert medication, although GPs were involved in the decision making, there was no evidence that their mental capacity had been assessed in relation to decision making around their medicine.

Overall we found there had been some improvements in people's care since our last inspection, for example we saw that efforts had been made to offer drinks more frequently. However records continued to show that some people went long periods of time without fluids and without their incontinence pad being changed. Following our inspection one person using the service was found to be dehydrated. Care was not delivered in line with care plans, for example we found that people who required repositioning were not repositioned in line with the frequency recorded in their care plan.

Staff had not received sufficient training or support to provide effective care to people using the service.

Is the service caring?

The service was not caring. We observed that staff did not interact with people using the service when providing care. For example, a person being hoisted was distressed but staff did not provide reassurance or explain what they were doing. A care worker told us that they felt some of the care workers were, 'Like robots, they just get people up, with no talking to them'.

Is the service responsive?

The service was not responsive to people's needs. Evidence from this inspection indicated that concerns raised during our previous inspection had not been adequately addressed. The service remained non-compliant in the four areas we looked at.

Is the service well led?

The service was not well led. The registered manager was no longer in post following our last inspection. We received a notification from the provider reporting the registered manager's absence. They told us the home would be managed by the project manager and a registered manager from another home. However the arrangements changed again following the inspection on 17 June 2014.

New care workers did not receive adequate shadowing time in the home to familiarise themselves with people's needs, as a result some unsupervised staff made mistakes as they had not received sufficient support to meet familiarise themselves with people's individual needs.

Basic monitoring checks were not being carried out in respect of people's care. This meant that management were unable to identify gaps in people's care and put action plans in place.

We considered all the evidence we had gathered under the outcomes we inspected. During our inspection as further non-compliance was identified we included additional outcomes. 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?

This is a summary of what we found '

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

The service was not safe. We found that people's care needs had not been properly assessed and documented. Some people did not receive the care they needed and this meant that people using the service were not safely cared for. For example we saw that people's mental health needs had not been met and that wound care plans had not been followed.

We found people using the service were not protected from the risk of abuse and that some people had sustained bruises and other injuries from unsafe moving and handling and care. Staff were not able to protect people from the risk of abuse because more that half of the staff had not received safeguarding vulnerable adults training. The service did not respond appropriately to risk of abuse because they were not aware that a person using the service had a grade four pressure ulcer.

The home was not clean on the days of our inspections and this meant people were at risk of infection.

Appropriate information was not recorded to assist the administration of medicines. During our visit we reviewed the Medicines Administration Records (MAR) for 26 service users. These records were incomplete as they did not record allergies. Additional specific and personalised information on 'if required' and 'variable dose' medicines was not recorded. Therefore we were not assured that sufficient information was recorded to ensure the correct administration of medicines to service users.

There were insufficient numbers of suitably qualified trained and experience staff to meet people's needs. People's basic care needs were not met because there were not enough staff on duty to ensure that people ate and drank sufficient quantities, had their call bell answered and have their incontinence needs met.

During our inspection there was no one who was subject to a Deprivation of Liberty (DOLs) arrangement.

Is the service effective?

The service was not effective. The provider was not complying with the requirements of the Mental Capacity Act 2005 (MCA). We saw that, where appropriate, people's mental capacity had not been assessed. Mental capacity should be assessed where people are required to make decisions about their care and their mental capacity to make decisions is not clear. Mental capaicty should be assessed in respect of a specific decision. One person was given covert medication, this meant they were being given medication without their consent or knowledge. Their mental capacity to make decisions in respect of their medication had not been assessed. There was no record that a decision had been made in their best interest to administer medication in this way.

People's care was not effective as it did not meet their basic care needs. People told us they were cold and thirsty. Records showed that some people went long periods of time with food and fluids. Staff were not able to provide effective care as they had not read care plans and handover information was inaccurate or incomplete.

Staff did not receive sufficient training to provide effective care to people using the service. Basic training to meet people's needs had not been carried out. For example staff had not received fire drill, food hygiene, moving and handling training or infection control training.

Is the service caring?

The service was not caring. People told us their call bells were not answered or were not answered in a timely way which meant people waited long periods to receive support to use the commode for example. One person told us that staff had made them feel like they were a "nuisance" for ringing their call bell. A relative of a person using the service told us how staff became frustrated when they were unable to communicate with their relative.

People's dignity was not respected. Some people were dressed in a way which did not respect their dignity even after we pointed this out to management. People were heard shouting out and showing signs of distress and staff did not provide comfort for people.

Is the service responsive?

The service was not responsive to people's needs. We found evidence which showed that the service had not responded to people's mental health needs. For example we saw a person who was very distressed, shouting and calling out but there was no care plan in place to address this. Records showed that some people had suffered a severe weight loss and the service had not responded to this by appropriately referring to a GP or a dietician.

Following our visit on 1 May we gave feedback to management about our concerns. This included feedback that paeople were cold and dressed in an undignfied way. On 5 May we saw that people continued to be cold, dressed in an undignified way and wait long periods of time without food and fluids.

Is the service well led?

The service was not well led. The provider had identified areas of concern within the service. The registered manager had failed to address these at the time of our inspection. Management had not put into place processes to ensure that staff received appropriate training and supervision. Referrals were not made to other professionals such as a GP, a dietician or a tissue viability nurse. They had not ensured that enough staff were on duty to meet people's needs and they had not addressed serious failings in the home. As a result some people did not receive the care they needed.

On 8 May we carried out an inspection to follow up action on the warning notices. We found that the home had made major improvements in terms of the planning and provision of care and that people's nutritional and hydration requirements were now being met. Specifically we saw that the organisation of staff meant that care was provided more efficiently, that care plans were now clear and ordered and that a plan of care was being followed. A 'fluids champion' meant that people were receiving fluids on a regular basis and that this was recorded in their notes of care.

We noticed a change in the wellbeing of people living in the home. People appeared to be happier and more alert. Previously very few people had been able to communicate with us but during our follow inspection we were able to talk to ten people about the care they were receiving. People reported they were happy with the care they were receiving.

We saw that consistent staff numbers were rostered on a regular basis and that sickness rates had fallen considerably. This meant that staff were able to deliver the plan of care.

We reviewed the care plans of three people who use the service. We found that the records were out of date, not filed in date order and it was not clear what the current plan of care was. Details in the care plans did not concur with the current plan of care being delivered. Three care workers told us they had not read the care plans.

We spoke to relatives of three people who use the service. Two relatives told us they had concerns about staffing levels and that they were particularly concerned about staffing levels at the weekend. One relative told us they had to wait outside the front door for long periods of time at weekends before a member of staff was available to come to the door. Another relative told us that people were left in bed at weekends as there were not enough staff to get them up.

During our visit we observed six people being nursed in bed over a period of hours. We noted that the fluid in jugs and cups in those people's rooms remained unchanged during that period which meant that those people had not been given any fluid for a period of several hours.

We looked at the staff training matrix and saw that the number of staff trained in first aid had increased. The registered manager told us that she was now able to ensure there was somebody with first aid training available on each shift.

People we spoke with told us that staff were able to support them when needed. One person said 'If I ring my bell they come quickly, there may be times when you have to wait, but nothing you can't put up with." Another person who liked to spend time in the garden told us 'Staff take me out when I want to go.'