Ringway Mews Care Home

Ringway Mews is a care home providing personal and nursing care to 146 people aged 65 and over at the time of the inspection. The service can support up to 150 people and has five single level units, with each unit being able to support up to 30 people. All rooms are single occupancy with shared toilets and bathrooms.

Three units provide general nursing care, one supports people with dementia nursing needs and one is a residential dementia unit.

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

People and relatives were positive about the care and support they received at Ringway Mews. They said the staff were kind and caring and treated them with respect. Staff knew people and their needs and explained how they maintained people’s privacy and independence.

Staff were also positive about working at Ringway Mews. They received the training and support required to carry out their roles. Staff also told us that training opportunities had improved since HC-One had started to manage the home in 2017. Staff were safely recruited.

People’s needs were assessed. Care plans and risk assessment provided guidance on how these identified needs were to be met. All plans were reviewed and current.

People received their medicines as prescribed. We have made a recommendation about the management of some medicines.

People were supported to maintain their health and nutrition. People’s weights were monitored, and fortified foods offered to those at risk of losing weight.

The service worked with medical professionals to meet people’s health needs. Two medical professionals said the staff followed all instructions they were given. However, the nursing home team said, that whilst there were no specific concerns, they felt the home relied on them a lot and instructions were not always followed.

There were sufficient staff on duty to meet people’s needs. A hostess was employed on each unit to support people with their meals. An activity officer was employed on each unit. A regular plan of activities was in place. When people were nursed in bed 1:1 activities were arranged in people’s rooms instead of group activities.

The quality assurance system was robust, with action plans in place where issues were identified. Incidents and accidents were recorded and reviewed by the unit managers and the deputy and registered managers.

The home was visibly clean. Equipment was checked, maintained and serviced in line with regulations and guidelines.

An end of life care plan was available to record people’s advanced wishes for the end of their life. We found that most had not been completed. Unit managers told us many families did not want to discuss their relatives end of life.

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.

People’s cultural needs were recorded and were being met. A range of culturally appropriate meals were available. People’s communication needs were recorded and provided clear guidance for the staff. Staff knew how people communicated their wishes and made decisions.

The service had a formal complaints procedure in place. Complaints had been responded to appropriately. People and relatives said they would speak directly to the staff and unit manager if they had any concerns.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection and update

The last rating for this service was requires improvement (published 18 October 2018) and there were two breaches of regulations. CQC issued two warning notices and met with the provider to follow up on the action we had told the provider to take.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

report to 'the last inspection' concern this inspection.

Ringway Mews 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.

Ringway Mews accommodates 150 people across five separate units, each of which have separate adapted facilities. Three units are general nursing (Lancaster, Halifax and Wellington), one specialises in providing nursing care and support for people living with dementia (Halifax) and one is a residential unit for people living with dementia (Shackleton). Wellington unit also had six ‘discharge to assess’ beds contracted with the local authority. These were used where people were able to be discharged form hospital but required further assessment of their care and support needs. People were meant to stay on Wellington unit for a period of six weeks whilst being assessed, however some people had lived in Wellington unit for several months whilst a suitable care placement was found for them by their social worker.

Each unit has a lounge, dining area, a conservatory, and a kitchenette. All bedrooms are single with no ensuite facilities. Accessible toilets and bathrooms are located near to bedrooms and living rooms.

There was a registered manager at Ringway Mews. 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.

At our last inspection in June 2017 we found three breaches in regulations because care plans did not always reflect people’s current needs, medicines were not safely managed, sluice rooms and cleaning cupboards were not locked and issues identified in internal audits had not been addressed during the registered manager’s extended leave.

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, responsive and well led to at least good.

At this inspection we found that the home had changed its care files, paperwork and management tools to the HC-One systems. The care plans reflected people’s assessed needs and were evaluated each month. Risks had been identified and steps taken to reduce the likelihood of the identified risk occurring. Where people might have behaviour that challenges, care plans gave details of potential triggers and behaviours.

People in the ‘discharge to assess’ beds had shorter 7 day care plans to briefly identify their needs. It was not evidenced that these had been evaluated. Two people had lived on Wellington unit in the discharge to assess beds for up to six months but their care plans were still very brief. The HC-One intermediate care plan was to be introduced which would enable more information to be recorded about people’s identified needs.

We found continued breaches in regulation because medicines were not safely managed and actions had not been taken when the internal auditing systems had identified there was an issue with medicines re-ordering.

You can see what action we told the provider to take at the back of the full version of the report.

Medicines were found to be out of stock on the first day of a new medicines cycle on one unit. Medicines audits showed this had also occurred on two different units since May 2018. Robust action had not been taken to address the issues with the re-ordering system.

Creams were not always safely managed in the home. Care staff applied topical creams but the nurses signed the medicines administration records (MARs). On one occasion the MARs had been signed as being applied when it was not in the cream basket. Cream labels had become unreadable due to use, increasing the risk of cross infection if two people were prescribed the same cream.

The amount of thickener to be added to people’s fluids on one unit had not been accurately transcribed from the speech and language team guidance, resulting in three peoples drinks not being thick enough, increasing the risk of choking.

Action was taken during our inspection to address these issues.

The home was clean and well maintained; however, the secure gardens for each unit had become overgrown. This had been noted in the August area manager visit and an advert placed to recruit a gardener. The registered manager's audit of the general appearance of the home on 17 August 2018 had not identified these areas as an issue.

A new HC-One quality auditing system had been introduced which covered a wide range of areas within the home. Action plans were in place following these audits and an overarching home improvement plan had been written.

All falls, incidents, weights and pressure area sores were recorded, logged on to the ‘Datix’ computer system and reviewed each month. A falls team had been established to review all falls, look for patterns and ensure steps had been taken to reduce the risk of a re-occurrence.

People living at Ringway Mews felt safe and thought there were sufficient staff on duty to meet their needs. Relatives and staff gave mixed feedback about the staffing levels, with some saying they thought there were enough staff and others saying additional staff were needed. The registered manager used a dependency tool which assessed each person’s needs for nursing support and care support. Our observations showed that people did not have to wait too long for support and there was always one staff member present in the communal lounge areas of each unit.

A safe recruitment process was in place. Staff had completed an induction programme when they joined Ringway Mews. HC-One e-learning was being introduced to the home and staff had started to complete these courses. Annual refresher training in manual handling and medicines administration was in place. Clinical training was organised for the nurses; however, one nurse had been employed for six months and had not completed catheter training.

Staff had regular supervisions and staff meetings for each unit were held. Both were open discussions with staff saying they were able to raise ideas or concerns during these meetings. Staff said they enjoyed working at the service and felt well supported by their unit managers and the deputy and registered managers.

Staff we spoke with knew people and their support needs. Staff said they received information about people’s support needs before they moved to the care home.

A FACE capacity assessment tool was used and applications made for a Deprivation of Liberty Safeguard (DoLS) if a person lacked capacity to consent to their care and treatment. The FACE assessments were decision specific; however, on some units these had been photocopied and people’s names added. The home had identified that the FACE assessments were not person centred and set an action to review these.

People’s health needs were being met by the service. The nursing home team (NHT) visited the four nursing units twice per week. NHT feedback was generally positive, but with variations between the units and individual nurses in the timely request for a re-active NHT visit when someone was unwell.

People’s nutritional needs were met. Culturally appropriate food was cooked where required. People’s dietary requirements were known and catered for. People told us they enjoyed the food and had a choice of meals.

People living in the care home had advanced care plans in place detailing their wishes in the event of their death.

A planned activity programme was in place. This concentrated on the units for people living with dementia as there were vacancies within the activity co-ordinator team. Activity co-ordinators had been recruited and were completing their pre-employment checks at the time of our inspection.

Residents and relatives meeting were held and a survey had been completed with the majority of responses being positive. Where comments had been raised in the survey the registered manager was due to report on these at the next planned residents and relatives meeting in August 2018.

Ringway Mews had a complaints policy in place. We saw all issues raised had been looked into and responses provided to address the issues raised.

Ringway Mews Nursing Home is owned by BUPA Care Homes. The service consists of five 30 bedded units; Lancaster, Shackleton, Anson, Halifax and Wellington. Wellington had recently been re-opened and fifteen people lived there at the time of our inspection. Each unit specialises in either nursing or residential care. Each unit has a lounge, dining area, a conservatory, and a kitchenette. All bedrooms are single with no en-suite facilities. Accessible toilets and bathrooms are located near to bedrooms and living rooms.

The service had a registered manager in place. 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. Shortly after our last inspection the registered manager took an extended period of leave, returning in February 2017. During their leave the home had two different relief managers.

The clinical service manager (CSM) for the service had moved to the position of unit manager shortly before our inspection. Two CSM’s had been recruited to support the registered manager, both of whom were due to start working at the service shortly after our inspection took place.

At the last inspection we found two breaches of the Health and Social Care Act 2008 because additional care plans were not in place for some people’s identified needs and the audits completed by the service had not identified the issues found during the inspection or issues that had been identified had not been actioned. At this inspection we found similar issues; however an improvement plan was in place for the service and all care plans were in the process of being re-written.

A new breach with regards to medicines was identified during this inspection. You can see what action we have told the provider to take at the end of the full version of this report.

Daily and weekly medicine monitoring sheets were in place on each unit to check that all medicines had been administered as prescribed. New cream charts had recently been introduced for care staff to sign when they had applied any creams. However these were not consistently completed so it was not possible to tell if the creams had been applied as prescribed. We identified a missing tablet on one unit. Bupa procedures for reporting and investigating this had not been followed. The registered manager initiated these procedures when we informed them of what we had found.

People and their relatives told us they felt safe living at Ringway Mews and that the staff knew their needs well. They also said staff were respectful, kind, caring, supported them to complete some tasks themselves and offered them day to day choices, for example about what they wanted to eat or wear.

A robust process was in place to recruit staff suitable to work with vulnerable people. New staff undertook a week’s induction and completed training, including safeguarding vulnerable adults, commensurate with their roles. Staff said they felt supported by the unit managers. Supervisions and staff meetings were held where staff were able to contribute to discussions about the service.

People and their relatives thought there were enough staff on duty to meet people’s needs, although one person said they had to wait longer at night time. Staff on one unit thought they needed more staff or a hostess to help with people’s meals and the night staff on another unit thought they needed more staff to support people to go to bed. The registered manager used a dependency tool to calculate the staffing levels for each unit. This was updated weekly to take account of any changes in people’s needs. We were told the staffing on one unit had recently been increased as people’s needs had changed.

All areas of the home were clean and there was no malodour on any of the units. A carpet cleaner had been purchased since our last inspection to ensure carpets could be thoroughly cleaned whenever required. Procedures were in place to prevent and control the spread of infection.

A new breach with regards to premises and equipment was identified during this inspection. You can see what action we have told the provider to take at the end of the full version of this report.

We noted on three units the doors to the sluice rooms and cleaning cupboards were not always locked. The registered manager was aware of this and had previously brought it to the attention of the staff that these doors should always be locked so people did not have access to chemical products kept in these rooms. One sluice in one unit had not been operational for over six months at the time of our inspection. A new sluice machine was on order and it was installed the week after our inspection.

Regular checks were made of the firefighting equipment. Equipment was serviced and maintained in line with the manufacturer’s instructions.

Care records were in the process of being re-written. Support was being provided by central Bupa staff to the unit managers, nurses and senior staff so they gained the skills to write care plans to the required standard. We noted that some people’s care plans did not include guidance for staff to follow when people had been assessed as being non-compliant with care or having behaviour that may be seen as challenging. Risk assessments were in place, including how the service mitigated the identified risks. Relatives said they had been involved in their loved ones care plans.

Daily notes made for each person were seen in their care files. However on Shackleton unit these were written in the early afternoon and so did not contain any details of events during the afternoon or early evening before the night shift started.

People were supported to maintain their health and nutritional intake. Records were kept were appropriate of what people had eaten and drunk. We saw referrals to relevant health professionals were made, for example to the Nursing Home Team, district nurses and GP’s.

We saw people were supported to make advanced decisions about the care they wanted at the end of their lives. Four units had been accredited by the Six Steps programme for end of life care and support. Staff from the unit that had recently opened had been enrolled for the Six Steps training. We saw that one person who was receiving end of life care did not have a specific end of life care plan for staff to follow. The information was written in the evaluations of the care plans so was not easily accessible for staff.

We found the service was working within the principles of the Mental Capacity Act (2005). New capacity assessments were being introduced, with associated best interest decision forms for each decision needing to be made on a person’s behalf.

Activities were arranged on each unit and monthly trips were organised, for example to Blackpool or the zoo. Fiddle items and dolls for doll therapy had been purchased for two units. Staff said this gave people living with dementia something to handle and fiddle with, which had reduced their anxiety.

Staff said they enjoyed working at the service and that they received support from the unit managers, CSM and registered manager. Some senior staff expressed they had felt ‘vulnerable’ during the registered manager’s extended leave. The feedback from the Nursing Home Team was that the home had missed the registered manager whilst they had been off work.

We saw that during the registered manager’s extended leave staff training had not been provided, supervisions not done and actions from our last inspection and internal audits not completed. Since their return the registered manager had addressed these issues. A home improvement plan was in place and support for re-writing care plans had been secured from the Bupa central team.

Bupa has a number of quality assurance audits in place, including monthly care plan audits, medicines audits, monthly area manager audits, quarterly health and safety and infection control audits. Actions from these audits are now being completed.

Systems were in place to record, investigate and respond to any complaints made to the service. All accidents and incidents were reviewed by the registered manager. A number of statistics were compiled for monitoring purposes, for example falls, pressure sores, nutrition, medicines errors, the use of bed rails and hospital admissions. This meant any trends or patterns of behaviour could be identified and action taken when necessary to keep people safe.