Archived: Priory Park Care Home

Priory Park Care Home is a nursing home registered to provide accommodation and personal care for 40 people with either nursing or residential care needs. Care is provided between two floors with people living with dementia on the second floor and people requiring residential and general nursing care on the first floor. At the time of the inspection, 34 people lived at the home.

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

People told us they felt safe and staff were kind and caring. However, our observations showed that people did not always receive safe care and treatment. Practices in the home did not always demonstrate that staff understood how to safeguard people from neglect and abuse. People’s safety had been compromised due to lack of adequate numbers of staff to support them with their care needs. We found a significant number of incidents of people being left unsupervised and causing harm to each other. Risks to receiving care were poorly managed and planned for. People were not always offered their medicines in a safe manner and medicines administration practice exposed them to risks.

People were not always monitored following a fall or incident. The provider had not adequately analysed accident and incidents to identify themes and trends and reduce re-occurrences. There were no lessons learnt processes to show how staff had learnt from events. This led to a repeat of incidents that exposed people to risk. The registered manager and staff had not always followed safeguarding protocols to ensure all reportable concerns were reported to the local authority.

People were not always supported by staff who had received induction, supervision or had the right skills and competence to carry out their role safely. People were not always supported to have maximum choice and control of their lives. Staff had not always sought consent before delivering care. People’s ability to make their own decisions was not always assessed. People received support to maintain good nutrition and hydration, however they were not effectively monitored for deterioration or changes in their needs.

Our observations during the inspection, were of positive and warm interactions between staff and people who lived in the home. However, we also found evidence which showed people were not always treated with dignity and respect because their needs were not always responded to appropriately. Some people told us staff treated them with dignity and were respectful. However, two people felt this was not always the case with some of the staff. People’s dignity had been affected by the shortages of staff. Staff promoted people’s independence, but this lacked consistency.

People’s care records contained personalised information on their health and communication needs plus their likes and dislikes. We found care records were not always up to date and did not provide staff with adequate guidance on how to support people and reduce risks around them. People and family members knew how to make a complaint and they were confident about complaining should they need to. They were confident that their complaint would be listened to and acted upon quickly. Previous complaints had been investigated however outcomes had not always been used to improve care delivery.

There had been a rapid decline in the quality of the care at the home due to lack of leadership and oversight. Staff had not been given adequate leadership and oversight which led to poor care delivery. There had been instances when people had suffered injuries and deterioration of their conditions. Staff had not always recognised a deterioration in people's conditions and provide them with the right clinical support. The system did not proactively monitor areas where the care delivered was not safe or meeting standards.

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 24 October 2018) and there was a breach of regulation in relation to medicines management. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found further deterioration in medicines management, no improvements had been made and the provider was in continued breach of the regulation.

Why we inspected:

This was a planned inspection based on the previous rating.

Enforcement:

We have identified multiple breaches in relation to the arrangements for keeping people safe from harm, the management of medicines , seeking consent and staffing levels. We also found breaches in relation to dignity and respect, record keeping, staff training and supervision, failure to submit notifications and good governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up:

We will meet with the provider to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If any concerning information is received, we may inspect sooner.

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Priory Park Care Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Priory Park is in the Penwortham area to the outskirts of Preston. The home provides accommodation and support for up to 40 people with either nursing or residential care needs. At the time of the inspection there were 29 people living in the home, some of whom were living with dementia.

On the ground floor of the building was an office area and the home's hairdressing salon, laundry and kitchen facilities. There was a lift to both the first floor unit and to the second floor unit which was for people with nursing needs who were living with dementia.

The home was last inspected October 25 and 30 October and 2 and 8 November 2017. At that inspection we found there were six breaches of the regulations. The provider was failing to provide safe care and treatment in relation to mitigating risks and was not consistently supporting people with their nutrition and hydration needs. We found that the registered provider had not made sure they had all the relevant information when they employed people and did not have a comprehensive system of quality audit. We also found that the registered provider had not ensured that people giving consent on behalf of others had the legal authority to do so and that care was person centred in practice.

Following our inspection, October 25 and 30 October and 2 and 8 November 2017 the provider developed a plan to make improvements to the service. During this inspection, 17 and 18 September 2018 we found the provider had taken significant action to improve the quality and safety of the service. We found, at this inspection, that improvements were actively underway. These needed to continue to make sure positive changes were fully embedded so people received a consistently high level of care.

At the last inspection the domain of well led had been rated inadequate. At this inspection we found that the new manager had made significant improvements in the way the home was being run for the people who lived there. Quality assurance and audit systems were being used to monitor and critically assess the service's performance. The staff reported improved morale and that the manager was promoting a culture of improvement. The changes underway needed to show consistency in the long term.

Everybody we spoke with who lived at Priory Park said they were happy living there and that they could approach the manager or senior staff [nurses] “at any time.” People we spoke with told us they felt safe living in the home. There were procedures in place to minimise the risk of unsafe care or abuse. Staff knew the actions they needed to take and had received training on safeguarding vulnerable people. However, we asked the manager to raise an alert with the safeguarding team during the inspection. They did this immediately.

We found that there were some systems errors in the management of medicines and systems for managing medicines used at the end of life were not sufficiently robust. We found this to be a new breach of regulations.

We could see that the manager was actively recruiting new staff and that the permanent staff establishment was not at its optimum level. Staffing shortfalls were being managed using agency staff to fill gaps on shifts. The home was not taking any new admissions to try to mitigate risks to people using the service whilst recruitment and service improvement was underway.

People we asked told us that they felt they could choose when to get up and go to bed, or have baths/showers, but said that if they needed support to do so, this depended on staff availability and time. We saw that people could move freely around the unit and there was signage in place to support people living with dementia.

The service followed the Mental Capacity Act 2005 Code of practice and Deprivation of Liberty Safeguards. This helped to protect the rights of people who were not able to make important decisions themselves. Advocacy services were accessible should people need this help and support. People are supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. We have made a recommendation that the manager makes sure information about powers of attorney be made more easily available to staff to avoid confusion.

We saw that the service was following its procedures for safe recruitment and that when employing staff the the recruitment process had included all the required checks of suitability.

People were being asked for their feedback on the service provision and about the food and menus. The environment of the home was welcoming and the communal areas had been arranged to make them homely and relaxing and to support the needs of people living with dementia. We found that all areas of the home used by the people living there were clean and tidy.

People who lived in the home and the relatives we spoke with knew about their plans and reported involvement in planning and deciding on how they wanted to be supported and cared for. On some occasions changes that had been identified in care plans had not been updated in the relevant files. Work was underway to help ensure greater consistency. We have made a recommendation that the manager reviews the current monitoring system to include all records being held in people’s bedrooms as well as in care their plans.

People who lived in the home had access to a range of organised activities that went on in the home for them to attend if they wished and that they were supported their own interests. There was an effective system for logging formal complaints made about the service and the care received.

Quality assurance and audit systems were being used to monitor and assess the service's performance. People who lived in the home were asked for their views of the service and their comments had been acted on.

Further information is in the detailed findings below.

We inspected this service on the 25 and 30 October and 2 and 8 November 2017. The first day of the inspection was unannounced which meant the provider was not expecting us on the date of the inspection.

Priory Park Care Home is located in the Penwortham area to the outskirts of Preston. The home provides support for up to 40 people with either nursing or residential care needs. At the time of the inspection there were 38 people living in the home.

The ground floor of the building was non-residential and was primarily an office area. The home’s hairdressing salon, laundry and kitchen facilities were also on the ground floor.

There was a lift to both the first floor, where people were supported with nursing needs and to the second floor, where people were living with residential needs.

The home was last inspected in October 2016 where one breach to the regulations was found for a failure to notify the CQC in the event of other incidents. These included allegations of abuse, serious injuries and any police incidents. We made recommendations at the last inspection for the home to ensure appropriate recruitment practices were followed and to ensure appropriate consent was gathered. We found on-going concerns in the two areas where we had previously made a recommendation. For this reason the provider has been found in breach of the associated regulations. We also found incidents that should have been reported to the commission at this inspection, as at the previous inspection, which has resulted in an on-going breach.

The provider forwarded the commission an action plan following the last inspection which we referred to as part of this inspection.The provider had a registered manager who was based at the home. 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.

When we arrived on site to conduct the inspection we found the home was partly being refurbished and redecorated. As a consequence on the first day of the inspection we conducted mainly reviews of paperwork and returned a week later to complete our observations. We returned to provide feedback and gather any additional information required when the registered manager returned from leave.

During this inspection we found the home was staffed by different job roles and different numbers of staff on most days. This may have compounded on the number of concerns found. We have made four recommendations throughout the report to address the concerns with the staff team.

We found records used to manage the day to day delivery of the service were not consistent and in some cases were inaccurate. Contemporaneous records are important to enable the home to evidence they are aware of the service required and can evidence the required service is being delivered. We have found a breach in this regulation.

We had concerns around the care files for the people living in the home. This included information held in them about how peoples’ needs and associated risks were assessed and how the records were used to show person centred care was being delivered that met peoples’ assessed needs. We have made two breaches to the regulations around risk assessment and person centred care.

We have also noted a breach about how the home was delivering support to people who were at risk of receiving inadequate nutrition and hydration. We found assessments were not consistent and action required to support people in this regard was not always taken.

We had concerns about how the home was managed. We found the home did not have a comprehensive quality audit and assurance system. We found audits were not completed as required and feedback received was not acted upon in a timely way. We have made two breaches to the regulation under well-led around good governance.

We have also made 16 recommendations including the four noted above for staffing. These are made when the providers need to take additional steps to ensure regulations are not breached moving forward.

We have made recommendations around consistency of the implementation of the MCA, ensuring actions are undertaken as identified within audits and action plans and formalising systems and procedures to ensure safe and effective care and support is delivered.

We found staff at the home were friendly and worked well together. There was a number of new staff due to join the team which should, following suitable induction allow for better service delivery.

We found the home had complete and accurate records around the options of people at the end of their life.

We found the home sought the support of other professional teams when they assessed people needed more specialists support.

Staff described good on line training and told us they had completed both mandatory and requested additional training to better meet people’s needs.

We found the provider ensured all the equipment at the home and systems used to keep the home safe were regularly tested by suitable professionals.

The staff at the home administered and recorded medicines safely and in a dignified manner. Person centred care plans supported staff with the information they needed to do so.

The home had comprehensive hospital passports, ready for final completion in the event someone was admitted to hospital in an emergency. These included details around medication and the risks and needs associated with the person's health.

The provider took immediate advice and redecorated the upper floor immediately upon concerns being raised.

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

Priory Park Care Home is part of the Four Seasons Group and provides residential and nursing care. Nursing care is provided on the first floor and residential care is provided on the second floor. The ground floor accommodates the administration team, laundry and kitchen facilities. The home can accommodate up to a maximum of 40 people. It is situated in a quiet residential area in Penwortham near Preston. At the time of the inspection refurbishment of the whole building was planned and work had commenced with the replacing of the lift that accessed all floors.

There was a registered manager in post. A registered manager is a person who has registered with the (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.

When accidents and incidents had occurred these had not always been reported to the appropriate authorities. We found that some of the incidents should have been reported to us (CQC) but the provider had not done so.

This is a breach of Regulation18 of the Care Quality Commission (Registration) Regulations 2009. The failure to notify us of matters of concern as outlined in the registration regulations is a breach of the provider's condition of registration and this matter is being dealt with outside of the inspection process.

When employing fit and proper persons the recruitment procedures of the provider were not always followed. We made a recommendation that the provider follows their own policy and procedures when employing people to ensure that all the checks of suitability made were robust.

Where the need for consent was required it was not always obtained from the appropriate person.

We have made a recommendation that the provider review their best interest decision making process to ensure it follows guidance outlined in the Mental Capacity Act 2005 in order to gain the appropriate authority for consent.

Records to show that areas of cleaning in the home had been done were not always completed and we found some areas of the home had not been kept in a clean state.

People living in the home and visitors to the home spoke highly of the staff and were very happy with the care and support provided.

Medicines were being administered and recorded appropriately and were being kept safely.

There were sufficient numbers of suitable staff to meet people’s needs and promote people’s safety.

People were only deprived of their liberty if this had been authorised by the appropriate body or where applications had been made.

Staff had completed training that enabled them to improve their knowledge in order to deliver care and support safely.

People were supported to maintain good health and appropriate referrals to other healthcare professionals were made.

There was a clear management structure in place and staff were happy with the level of support they received.

People living in the home were supported to access activities that were made available to them and pastimes of their choice.

Auditing and quality monitoring systems were in place that allowed the service to demonstrate effectively the safety and quality of the home.

We had also been given concerning information about the staffing levels in the home and in particular, on the unit where people with dementia lived. We had been told that on given days, there had not enough staff on duty to meet people's needs.

We looked at medication records and systems in place. We spoke with staff on duty and looked at documentation in people's care plans to ensure that correct procedures had been followed and people's human rights protected. We found that people received their medicines in a safe way and that their rights were protected.

We looked at the staff rotas for the days when we had been told that there had not been sufficient staff on duty. We looked at staff rotas for the day of our visit, as well as the weeks either side. We carried out a physical head count of staff on duty and observed care provided by staff. We found that there were sufficient numbers of staff on duty to meet people's needs.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records.

Is the service safe?

We observed staff had a good understanding of the home's safeguarding procedures. One staff member explained, 'If I had any concerns I would inform the nurse, manager or area director and document this'.

Our discussions with staff confirmed they understood the needs of the people in their care. This matched the information we found in people's care records. This meant the provider had protected people from unsafe care by ensuring care planning and risk assessment was appropriate.

Is the service effective?

We observed that staff had a good understanding of consent and related principals. This meant people were safeguarded against inappropriate care because the service gained people's consent prior to giving support.

Documents we reviewed showed people's changing needs were monitored and, where necessary, acted upon. Support plans and risk assessments were individualised and regularly updated. This meant people were protected against ineffective care provision because people's changing needs were monitored.

All the staff we spoke with confirmed they felt supported in their roles and received frequent supervision and training. One member of staff said, 'It's good in helping us to understand what we're doing with care, for example'. This demonstrated staff were enabled to deliver care safely because the manager had ensured they were adequately supported.

Is the service caring?

We spoke with people and their relatives to gain an understanding of their experiences of the support they received. Their response was positive. A relative told us, 'I commend the staff for their tolerance and, indeed, kindness for the care of my daughter'.

Staff explained that they worked in a caring and friendly manner. They described being respectful to and working with people to understand their needs. One staff member told us, 'It's brilliant here. I like that I can build up relationships with people'. This showed people were safeguarded against inappropriate care provision because staff understood people's individual needs.

Is the service responsive?

People's needs were properly assessed, monitored and reviewed. This meant the provider had continuously assessed whether the service was able to maintain people's care levels. One staff member told us, 'We've built up a brilliant relationship with our GPs now. We assess each individual person to check what we can manage or where we need to call out the GP'.

Care records we reviewed evidenced that where people's needs changed, care planning was amended to incorporate these changes. This demonstrated the home had minimised the risks of unsafe care because the service had responded to people's changing needs.

Is the service well-led?

Priory Park had a range of quality audits in place. Other regular processes underpinned this, such as staff supervision and team meetings. This meant people were protected against inappropriate care because the manager had systems to check the quality of care.

Staff told us they felt the service was well-lead. One staff member told us, "The managers are very flexible and approachable. This is important as it bounces down the line. If the staff are happy so are the residents".

Staff told us they had received additional training regarding care plan documentation and that they understood the care plans and their responsibilities. One member of staff said, "Carers feel more involved (with records). It's been made clear to us now what we have to record and we know the day to day information we get is very valuable".

We viewed a sample of three care plans. We found these were accurate, up to date, and fit for purpose. The staff we spoke to understood the content of the plans and were able to demonstrate how to find relevant information. One member of staff told us, "I'm confident in our care records now, they're up to date, everyone understands and it is clear. Training definitely helped".

People told us that they were treated well by staff and that they were happy with the care they received. Comments included, 'I'm happy here, I'm looked after and there's plenty going on.' Another person said, 'No problems. Things seem much better now'.

We observed staff talking to and treating people with kindness and respect.

We found the home to be clean and free from odour. Areas of the home which had been identified as in poor repair had been rectified by the provider.

During this inspection we found staff were aware of information relating to specific dietary requirements and that this was recorded.

However, we found that the records held in relation to people's care and welfare were, in some cases, incomplete and confusing. This matter had been raised recently during a safeguarding investigation and by other professionals.

There were twenty seven people living at the home at the time of our inspection. We judged that based on this that the amount of staff employed by the service was sufficient. We would expect that if the amount of people living at the home, or the dependency level of the people there increased, that the provider should implement suitable systems to meet the increased demand.

We found that people's needs were assessed and care plans were in place. One person said, 'I have a care plan. They discuss it with me and I sign it.' We found inconsistent and incomplete care information for one area of care.

People had their nutritional needs assessed and monitored. Specialist advice and support was sought in response to identified risks. People had access to a choice of food and drinks.

We found that suitable and safe medicines storage arrangements were in place. We found that some medicines records were not completed properly.

We saw that some areas of the home were unclean and some areas were in need of repair and upgrade.

There was a range of suitable equipment in place to assist in meeting peoples' needs.

Some people who used the service and relatives told us they was not enough staff to meet their needs properly. Two people told us they could not always have a shower when they wanted. We saw that some people who lived on the dementia unit were left unattended for short periods of time. The provider was unable to show us how they knew there were sufficient numbers of care staff to meet people's needs at all times.

Arrangements were in place to monitor the quality of the service.

We found staff to be suitably supported by the provision of relevant training, in order to enable them to safely deliver the care and treatment required by the people living at Priory Park.