Chorlton Place Nursing Home

Chorlton Place Nursing Home provides accommodation and personal and nursing care to for up to 48 people aged 65 and over. The service was supporting 45 people at the time of our inspection.

The ground floor provides support to people living with dementia and the first floor provides nursing. All the rooms are single occupancy with en-suite toilets. There are shared accessible bathrooms on each floor.

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

Medicines were not always safely managed which placed people at risk of harm. People told us that there was not always enough staff on duty to meet their needs and recruitment records did not always demonstrate that the policies were being followed. We received assurances from the provider regarding the current recruitment practice. Staff did not always follow good infection control principles and guidance but plenty of personal protective equipment (PPE) was available.

Staff were busy and people did not always feel they were treated with respect. Care records did not always guide staff on how to promote people’s independence. New electronic care plans were not always as detailed and person centred as the paper copies previously used but staff knew people and their needs.

People felt able to raise concerns. People told us that that they were not always offered activities that were individualised although the activity worker worked hard to have regular contact with everyone living at Chorlton Place.

The environment needed updating and consideration to meet the needs of people living with dementia. We have made a recommendation about this.

People’s needs were assessed, and they were supported to maintain their health and nutrition. Staff worked well with a range of external health and social care professionals to ensure people got the right care and treatment. Clinicians had confidence in the ability and knowledge of staff. People were generally supported to have 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.

Manager evaluated the quality of care and support provided to people .However, existing quality assurance processes were not always effective as they had not identified the issues, we found at this inspection. People and staff spoke very complimentarily about the Registered Manager.

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 4 February 2022).

Why we inspected

The inspection was prompted in part due to concerns received about the administration of medicines, infection control, staffing and organisational culture within the home. A decision was made for us to inspect and examine those risks.

Enforcement and Recommendations

We have identified breaches of regulations in relation to the management of people’s medicines and management of the safety and quality of the service at this inspection as well as dignity and respect.

We have made recommendations about reviewing good practice guidance regarding supporting people living with dementia and reviewing staffing dependency tool to ensure safe staffing.

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 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.

Chorlton Place Nursing Home (known as Chorlton Place) is a nursing home providing personal and nursing care to 46 people aged 65 and over at the time of the inspection. The service can support up to 48 people.

Chorlton Place is a large purpose-built home, with all bedrooms having an en-suite toilet. The ground floor is a residential floor for people living with dementia and the first floor supports people who need nursing care.

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

The provider's risk framework had improved and risks to people were assessed and managed in line with their needs. There were clear care plans in place to guide staff in how to provide care safely.

People were receiving their medicines safely. We did however identify some anomalies with the electronic medicines administration records (eMAR) system not correctly calculating the medicines stocks. We were satisfied nobody missed their medicines and we have been assured by the corrective action taken by the provider.

There were enough staff available to meet people's needs. The provider recognised the night staff deployment needed to be increased following our last inspection. The night staff confirmed the additional staff member had made a huge difference.

We observed a range of positive interactions between people and the staff team throughout the inspection, with staff responding appropriately and in a timely manner to changes in people's needs. There was a warm and homely environment, with people relaxed in the presence of staff.

People and their relatives told us they had been well supported throughout the COVID-19 pandemic and the provider worked in line with current guidelines to support safe visiting.

People and their relatives were positive about the management of the service and the management team had a visible presence across the home. People were cared for by a motivated staff team who felt valued and supported to carry out their duties.

The provider monitored the quality and safety of the service. There was a regular programme of auditing in place. People and their relatives were encouraged to provide feedback regarding their views and opinions of the service.

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

Rating at last inspection

The last rating for this service was requires improvement (published 08 March 2021) and there were two breaches of regulations 17 and 18. 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 improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This inspection was carried out to follow up on action we told the provider to take at the last inspection. We undertook a focused inspection to review the key questions of safe, responsive and well-led only.

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

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

Follow up

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

Chorlton Place Nursing Home (known as Chorlton Place) is a nursing home providing personal and nursing care to 43 people aged 65 and over at the time of the inspection. The service can support up to 48 people.

Chorlton Place is a large purpose-built home, with all bedrooms having an en-suite toilet. The ground floor is a residential floor for people living with dementia and the first floor supports people who need nursing care.

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

The risks people may face were assessed, however the guidance for managing these risks was not always consistent throughout a person’s care plan. People had received their medicines as prescribed; however, staff were not confident using the new electronic medicines system. Guidance was not always clear as to when people required medicines not routinely administered.

There were insufficient care staff at night on the nursing floor. The new manager had requested an additional twilight shift (8pm to 2am) to be introduced. Staff were busy during the day but were able to meet people’s needs.

Staff and relatives were positive about the new manager and said communication within the team and with relatives had improved. Staff training had increased and individual staff supervisions meetings were being arranged.

A quality assurance system was in place, with a system of weekly and monthly clinical checks and audits being completed. An action plan was in place for any issues identified in the audits. However, issues with risk assessments and staff guidance had not been addressed since our last inspection in November 2019.

The home was clean throughout and had robust cleaning schedules in place. Staff had received training in the use of personal protective equipment (PPE) and the new manager addressed any concerns if staff did not follow the PPE guidelines.

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 requires improvement (published 10 January 2020).

Why we inspected

We received concerns in relation to the night staff on the nursing unit not meeting people’s needs and not accurately recording the support provided. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe and well-led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

The overall rating for the service has remained the same. This is based on the findings at this inspection. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Chorlton Place Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the inconsistent guidance to manage assessed risks, the new electronic medicines system, the lack of clear guidance for medicines not routinely administered and the lack of staff at night on the nursing floor 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 for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Chorlton Place Nursing Home (known as Chorlton Place) is a nursing home providing personal and nursing care to 46 people aged 65 and over at the time of the inspection. The service can support up to 48 people.

The ground floor is a residential dementia unit and the first floor is a nursing unit. All rooms are single occupancy with an en-suite toilet. People shared accessible bathrooms on each floor.

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

The registered manager had been in post for six months. Feedback was positive about the new registered manager. Staff felt well supported and the completion of staff training had increased.

Care plans and risk assessments were of variable quality and detail. This had been identified by the registered manager through the comprehensive quality assurance system. An action plan was in place and all care plans and risk assessments due to be reviewed, re-written and audited by the end of 2019.

Staffing on the nursing floor had been increased just before our inspection. Staff said this should enable them to support people to get up and serve breakfast more easily in the morning. Pre-employment checks were completed prior to new staff starting work.

People and relatives were complimentary about the kind and caring staff team, saying they treated them with dignity and respect. Staff knew people and their needs and explained how they maintained people’s privacy and independence.

New cultural and gender care plans were in the process of being written for everyone living at Chorlton Place. This would provide more detailed information about people’s needs and preferences than the current care plans.

All incidents and accidents were recorded, reviewed and steps taken to reduce the chance of the same thing happening again. Significant improvements had been made in the management of the kitchens following a poor environmental hygiene inspection.

People were supported to maintain their health and nutrition. Medicines were safely managed.

The home was visibly clean throughout. All equipment was checked and serviced in line with current guidance.

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.

A programme of activities was in place which people enjoyed. Links had been made with local schools, who visited the home to spend time with people.

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 (report published 22 June 2017).

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.

Rating at last inspection.

At the last inspection in January 2015, the service was rated as Good.

Rating at this inspection

At this inspection we found the service remained Good, with the safe domain rated as Requires Improvement.

Why the service is rated Good.

People said they felt safe living at Chorlton Place. Staff received training and information to meet people’s health and social care needs. Risks assessments were in place to guide staff to provide safe support. However we found the scores for one person’s risk assessments had not been calculated accurately, however appropriate support plans were in place to mitigate the risks and a referral was being made to the Speech and Language Team (SALT) with regard to the person’s risk of choking. Care plans were in place for each individual detailing people’s health and social care needs. The care plans were regularly reviewed.

A system was in place to recruit staff who were suitable to work with vulnerable people. A reference from one staff member’s last employer had not been obtained. This was requested during our inspection.

The home had recruited a new handyman who was due to start work the week after our inspection. Since December 2016 a handyman from another service had worked at the home whenever possible. However they had not been able to complete all the weekly fire and safety checks, which had been done monthly instead.

Medicines were administered as prescribed. Body maps for where creams were to be applied were completed for the first floor during our inspection. Health professionals were positive about the service, with the GP visiting the home twice each week.

Infection control procedures were in place. These enabled the staff team to safely support one person who had Methicillin-resistant Staphylococcus Aureus (MRSA) and Clostridium difficile (CDif).

People and relatives we spoke with were positive about the home and the staff team. There were sufficient staff on duty to meet people’s needs, although staff were busy, especially in the morning. Staff knew people’s needs and how to support them.

Staff were supported by the registered manager through regular supervisions and team meetings. Staff said they enjoyed working at the service and that the registered manager, deputy manager and residential unit manager were very approachable.

Where applicable capacity assessments were completed and the service was working within the principles of the Mental Capacity Act (2005).

People’s health and nutritional needs were met by the service. Referrals to medical professionals were appropriately made and any guidance provided was followed. People and relatives told us the food was good and they had a choice of meals.

Staff encouraged people to maintain their independence, with some people able to access the local community on their own. Staff explained how they maintained people’s privacy and dignity when supporting them.

People were supported to make decisions about their wishes at the end of their lives. Support was provided for people who wanted to stay at Chorlton House at the end of their lives.

People and relatives were able to provide feedback on the service provided through regular residents and relatives meetings and annual surveys.

Two part time activities officers had been appointed and a programme of activities was in place, which people said they enjoyed.

The registered manager had a comprehensive system of quality assurance and audits in place. A monthly report was used to monitor any trends in key indicators for the service. The provider’s area manager completed a monthly audit of the service. Any actions identified were recorded and noted when completed.

Further information is in the detailed findings below.

During our inspection we spent time speaking with people who lived at the home, visitors, a visiting general practitioner (GP), a speech and language therapist (SALT), the acting manager, the quality manager and six other members of staff. We carried out observations, looked at medication practices and procedures, examined records including; six care plans and daily records of care, policies and procedures, staff records and quality assurance monitoring records.

Below is a summary of what we found.

Is the service safe?

We found there was a lack of consistency in care plans they had not always been updated to reflect the changing needs of the person. People at high risk of poor nutrition were generally identified as needing frequent monitoring of their weight and diet. However, we identified one person who had lost over 4 kg since admission in April 2014. There was no evidence to show any action had been taken to address this.

We found that people were not protected from the risks of unsafe or inappropriate care because staff used inappropriate moving and handling techniques. For example; we saw two staff members attempt to lift a person up in their chair by using an underarm lift. This is an unsafe and an inappropriate moving and handling technique that had the potential to cause bruising, damage fragile skin and cause shoulder and neck injuries. This was fed back to the acting manager and quality manager who told us they would speak with staff to ensure they used the correct moving and handling techniques.

There were no written guidelines (protocols) to tell staff when or why medicines prescribed 'when required' should be given. This meant there was a risk that some prescribed medicines might not be used as intended by the persons GP and may not be effective in their treatment.

We saw 'gaps' in administration records for prescribed creams. Arrangements for recording the use of creams were not being followed. This meant that medicines might not be used in the right way and may not be effective in their treatment.

Where beds were fitted with safety rails protective bumpers were used. These were used to minimise the risk of limb entrapment and keep people safe.

There were contracts in place to demonstrate equipment was regularly maintained and serviced to minimise risks to people who lived at the home.

The Care Quality Commission (CQC) monitors the operation of Deprivation of Liberty Safeguards (DoLS) to ensure people's rights and freedoms are not unnecessarily restricted. The staff we spoke with told us they had received introductory training in the Mental Capacity Act (MCA) 2005 and the DoLS. However their knowledge of this was limited. This meant people's rights were not recognised, respected or promoted. There had been no applications made to deprive people living in the home of their liberty.

The recruitment process was thorough and the required safety checks such as; a check with the Disclosure and Barring Services (DBS) was made before new staff started work. This ensured that only suitable staff were employed.

The staff we spoke with and the visiting relatives spoken with said there were not enough staff to meet people's needs. Our observations supported this view. Two visiting relatives told us that they had some concerns because staff were not quick to respond to requests for assistance. We saw one relative asked staff for some assistance for their relative. They asked staff twice for assistance and it took 25 minutes for the staff to give the required assistance.

Is the service effective?

We saw that one person was presenting with behaviour that challenged. Staff said they were struggling to meet this persons needs and told us other people living on the first floor of the home were frightened of this person. The acting manager told us that they were addressing this with the appropriate agency.

We spent time observing the interactions between staff and the people they cared for. Staff did not always respond to calls for assistance in a timely manner. This meant people were at risk of receiving inadequate or unsafe care.

People who lived at the home had access to regular support from health and social care professionals such as; GP, district nurses, dieticians, podiatrists and speech and language therapists.

Is the service caring?

People who lived at the home spoke positively about the care and support they received. Comments included: 'I am happy here.' 'I am satisfied with the help I get.' 'Different people have different ways, they are kind in their own way.' 'I have what I need.'

The atmosphere in the home felt busy and staff did not spend much time talking and interacting with people. We saw that a number of people were assisted to eat and drink without much conversation taking place. This meant the mealtime was another task rather than a social and enjoyable experience for the person.

Is the service responsive?

We saw, where necessary, referrals had been made to health and social care professionals such as GP's, dieticians and speech and language therapists.

Care plans included information on people's social, religious and cultural beliefs. We spoke with one person who told us: 'I must go to church it is a very important thing for me, and I like to go every Sunday.' 'They make sure I can get there.'

Is the service well led?

The service did not have a registered manager. The provider is in breach of the conditions of their registration. The service has been without a registered manager for four months. The provider has sought to recruit to this position without success and a number of managers have been employed at the home and have left. The provider recruited a manager in March 2014 and had commenced the process of registration but the manager resigned. This has resulted in an inconsistent management approach for staff in the home. A relief manager has been in place at the home since March 2014.

There was a system of audits in place but these were not robust or effective and this had impacted on the delivery of care to people living at the home including poor record keeping.

Is the service caring?

Is the service responsive?

Is the service safe?

Is the service effective?

Is the service well led?

During our inspection visit to the home we spoke with three people who used the service, two relatives, five care staff, a senior carer, three qualified staff, the interim manager of the home and the quality assurance manager. We also looked at records and spent time in different areas of the home.

Is the service caring?

During the inspection we observed the interactions between staff and people who used the service. We saw staff were attentive to people's needs and were patient when supporting people. During the inspection we spoke with two relatives to gain their views on the care and support provided. Some comments included; 'My (family member) seems happy, the staff are very good.' And 'I speak to the staff when I arrive and they let me know if there are any problems.' Our observations and the feedback from people we spoke with showed us that the service was caring.

Is the service responsive?

The service had systems in place to ensure people were regularly consulted about their views and ideas on how the service should be run. This was done by means of an independent survey and meetings with relatives. We spoke with two relatives who told us that they were kept informed regarding their family member's care. One relative told us; 'I'm very happy with the care, the staff work hard and look after (my relative) well.' We spoke with a visiting health professional who told us that they had no concerns. We saw there were audits in place to identify any areas that needed improvement. From our observations we considered that the service was responsive.

Is the service safe?

We saw that staff were observant of people's needs and that there were sufficient staff available to support people effectively. We saw appropriate safety checks were carried out as required. For example we saw evidence that servicing of equipment was carried out to ensure that it was fit for purpose. This ensured that people's safety and welfare was protected when using the equipment provided.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. During our inspection we saw that care plans and our observation of staff provided evidence of good practice in applying the least restrictive options to promote each person's autonomy.

We checked that there were sufficient staff to meet people's needs. We saw that the home forecast staffing requirements and if there were any shortfalls, these were identified and replacement staff sought. This showed us that the home had systems in place to ensure that people's safety was protected by the effective deployment of sufficient and suitably qualified staff.

Is the service effective?

We saw that people who lived at the home had care records that included assessments of their individual needs and risks. Each person had a care plan which contained information for care staff to enable care and treatment to be delivered in a way that met people's needs. We also saw that each care record we viewed contained risk assessments to identify and manage any risks identified. This meant that the service assessed people's needs in order to provide effective care. We spoke with three people who used the service who told us that they were consulted in the development of their care plans. One person told us that they had visited the home before making the decision to move in. They said; 'I've never regretted it.' We saw that training and development activities were in place to ensure that staff had suitable knowledge and skills to support people effectively.

Is the service well led?

A review of our records showed that the manager of Chorlton Place Nursing Home was currently applying to the Care Quality Commission to become registered by us. At the time of the inspection they were not present. We met with the manager and saw that the service had systems in place to ensure that areas for improvement were identified. We saw that a records audit was carried out to check that the information contained in each person's care records remained up to date and accurate. We saw that records had been reviewed and when identified, action had been taken to improve the documentation. We saw minutes of meetings that showed us that the manager consulted with people who used the service, and their relatives, in addition we viewed an independent survey which had been completed in 2013. We noted that this contained positive comments. During the inspection we noted that the staff were professional and relaxed and that the home was well organised with a calm atmosphere. The documentation we viewed, together with the observations we carried out and people's comments, showed us that the home was well led.

We saw some people had been assessed by a speech and language therapist (SALT). One of the care plans we looked at did not clearly identify a change from a soft diet (fork mashable) to a pureed diet.

We spent time observing interactions between people who lived at the home and staff. We saw staff approached people with respect and interactions were positive.

We spoke with people who lived at the home who told us they were satisfied with the care and support they received. Comments included: 'It's alright.' 'I get help when I need it.' 'The staff are nice, they're alright.'

We spoke with two health professionals who told us the two floors appeared to work in isolation which raised concerns about communication and continuity of care.

We saw people were offered alternatives from the menu choice. We spoke with a member of the catering staff who showed us a list of people's preferences for the day's meal.

We looked at five care plans and saw nutritional assessments had been carried out. Where people were at risk of poor nutritional intake we saw referrals had been made to a dietitian. Where people had been assessed as needing thickened drinks the amount of thickener and consistency of drinks had been recorded.

We found the provider obtained consent from people who used the service before they provided care and support. When a person had limited capacity to make an informed decision, relatives and other relevant healthcare professionals were involved so that decisions were made in the person's best interests.

Care plans and risk assessments were in place for each person. These were reviewed regularly to ensure that staff provided appropriate care. However we found people did not receive appropriate support from staff during mealtimes which put them at risk from inadequate nutrition.

Medicines were administered safely by appropriately trained staff. Staff undertook a range of training and new staff were given an induction to ensure they understood the requirements of their role.

The provider undertook audits to identify any risks or areas that required improvement. Where actions were identified, the provider took appropriate action.

We were told that staff were polite and friendly. Comments included, 'The staff are wonderful'. And, 'They're nice, I like them'. A relative told us, 'I think they look after (their relative) very well'.

We also spoke with one of the health care professionals who supported people who used the service. We were told the new manager was making positive changes to the home. They said, 'She's very dynamic'She's really trying to move things forward'.

We found that people who used the service had detailed care plans in place. This meant Chorlton Place provided people with effective, safe and appropriate care, treatment and support that met their needs. Care and support was person centred and people's views were taken into account in the way the service was provided and delivered. We saw there were sufficient numbers of suitably trained and qualified staff to support the health and welfare needs of people who used the service. There were effective systems in place to regularly assess and monitor the quality of the service provided.