Pytchley Court Nursing Home

Pytchley Court Nursing Home provides nursing and residential care for up to 40 older people, including people living with dementia. There were 29 people receiving care at the time of the inspection.

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

Infection control procedures required improvement. Personal protective equipment [PPE] had not been disposed of appropriately and cleaning schedules were not detailed with actions taken.

There were insufficient systems in place to identify any shortfalls in the care received. Audits that had been completed, had not always identified the concerns or had actions documented. Records of care were not consistently completed and had not audited.

Not all staff and relatives felt there were enough staff on duty to meet the needs of everyone living at Pytchley Court Nursing Home. Although people were supported by staff who knew them well and had been safely recruited.

Risk assessments were in place to protect people from harm, however these were not consistently followed by staff. Although, we saw no evidence of harm occurring.

People were supported with their medicines safely.

Staff told us they felt well supported by the management and enjoyed their job.

People were supported to feedback on the service they received and significant people were kept up to date regarding peoples changing needs.

Relatives we spoke to were all positive about the care and support given by staff.

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 27 April 2019).

The service remains rated requires improvement.

Why we inspected

We received concerns in relation to staff training, record keeping and clinical oversight. 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.

You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Pytchley Court 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 monitor the service.

We have identified breaches in relation to oversight of the service 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.

People’s experience of using this service:

¿ The provider had overseen changes to the management and implemented systems to improve clinical safety. There continued to be areas that required improvement and existing systems required embedding into practice.

¿ The interim manager had involved all staff in the improvement plan. Some staff had taken on responsibilities for areas of the home which had improved the reliability and quality of the care provided.

¿ Changes to people’s health was identified early and staff sought medical help in a timely way. People were supported to access relevant health and social care professionals. There were systems in place to manage medicines in a safe way.

¿ Staff understood their roles in safeguarding people from abuse or improper treatment. The managers were responsive to staff concerns.

¿ There were enough clinical and care staff deployed to provide people's care; there was a high use of regular agency nursing and care staff who had received induction to the service. The provider continued to recruit staff.

¿ People received care from staff that had received the training and support to provide for their individual needs.

¿ People were involved in the planning of their care which was person centred and had been recently updated. People were encouraged to make decisions about how their care was provided and their privacy and dignity were protected and promoted.

¿ People had developed positive relationships with staff. Staff had a good understanding of people's needs and preferences.

¿ People were supported to express themselves, their views were acknowledged and acted upon and care and support was delivered in the way that people chose and preferred.

¿ People using the service and their relatives knew how to raise a concern or make a complaint. The manager followed the provider's complaints procedures to respond to complaints and use the issues raised to improve the service.

¿ Staff ensured people received enough food and drink to maintain their health and well-being. People who were at risk of losing weight and dehydration received additional support and monitoring.

¿ People had the opportunity to express their preferences or wishes for their end of life care. People's care plans recorded people's wishes.

¿ People and their relatives had been asked for their feedback and had begun to be involved in the running of the home.

¿ The provider was working within the principles of the Mental Capacity Act (MCA), they identified people who required a Deprivation of Liberty Safeguards (DoLS) assessment and made the appropriate applications.

¿ The interim manager had identified through audits, more areas that required further improvement.

Rating at last inspections:

At the last full comprehensive inspection in April 2018, we rated the service as Requires Improvement. We found the provider to be in breach of three regulations relating to referrals to health professionals, medicines, staffing and governance. The provider was required to provide improvement plans.

We carried out a responsive focussed inspection in September 2018 due to concerns about clinical safety. We inspected the service for the safe and well led domains only. We rated this service inadequate (report published on 15 January 2019). We found the provider was in breach of four regulations. They had not notified CQC of all notifiable incidents that occurred at the home. They had not ensured there was sufficient clinical experience to meet people’s health needs, assessed monitored or made improvements to the home, identified potential abuse of people or deployed enough staff with the right skills to meet peoples’ needs. We placed the service into special measures.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Why we inspected: This was a planned inspection based on the previous rating.

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

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

This was the sixth inspection carried out at Pytchley Court since February 2016. The provider has failed to maintain compliance with the regulations; they have repeatedly breached two regulations relating to safe care and treatment and good governance.

Our last comprehensive inspection on 18 April 2018 rated the service as Requires Improvement in all domains. The provider was in breach of three regulations relating to medicines management and staff not referring to health professionals in a timely manner. The provider was required to submit action plans demonstrating how they were to achieve compliance with the regulations. We were not satisfied the providers action plans as they did not adequately demonstrate how they would ensure people would be referred to health professionals in a timely manner.

There had been a period of one year without a registered manager, in that time the home had four different managers. The new registered manager had been in post since June 2018, they registered with CQC in August 2018. 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 and associated Regulations about how the service is run.

People living at Pytchely Court Nursing Home received either Nursing or Residential Care. We found concerns relating to the clinical care of people receiving Nursing Care.

People were at risk of not receiving prompt medical care as there were a combination of factors that affected this. The registered manager was new to the service and most of the nursing staff were agency; they did not know people well and did not recognise when people were unwell. There was no clinical lead to oversee the nursing care. When people became unwell there were no systems in place to compare their condition with their ‘healthy’ condition as no baseline observations had been recorded. When people did show signs of being unwell there was no system in place to take people’s clinical observations and assess these for referral for medical care. These factors led to delays in receiving medical care; some people were admitted to hospital for emergency care.

During the inspection we found serious concerns relating to recognising when people were unwell and referring people for medical care. We raised safeguarding alerts relating to the care and welfare of 11 people.

People did not have accurate or up to date risk assessments. People with long term conditions did not have risk assessments, care plans or protocols to mitigate their risks.

People did not always receive their medicines safely. People receiving medicines in skin patches were at risk of not receiving their medicines as prescribed as there was no reliable system in place to demonstrate people had their patches applied and removed. People who received their medicines covertly had safeguards in place.

The provider had not ensured there were sufficient processes in place to assess, monitor and improve the quality of the service to maintain the health, safety and welfare of service users. The provider failed to have the systems and processes in place to identify the impact of not having clinical management; people experienced delays in receiving medical attention.

The provider placed resources into Pytchley Court Nursing Home to support the registered manager in setting up some of the governance and corporate processes. However, the evidence from the inspection demonstrated that the resources provided did not adequately address the issues of recognising when service users became unwell, resulting in delays in service users receiving medical treatment.

At this inspection we found that Pytchley Court Nursing Home were in breach of four regulations relating to safe care and treatment, governance, safeguarding and notifications. The actions we have taken are reported at the end of the full report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Further information is in the detailed findings below.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pytchley Court Nursing Home on our website at www.cqc.org.uk

Pytchley Court Nursing Home 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. There were 35 people using the service at the time of our inspection.

The service is split over two floors and a condition of the registration is that there is a registered manager in post. There was no registered manager in post at the time of our inspection. 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.

There had been some instability with the leadership of the service prior to our inspection and this had an impact on the quality of care and treatment being delivered at the service and on staff morale. There had been a high turnover of managers at the service which had resulted in a lack of consistent oversight of people's health and care needs. There was a "Turnaround Manager" in the service at the time of our inspection who was at the service on a temporary basis whilst a newly appointed manager was receiving their induction.

There were insufficient suitably trained and competent staff working at the service to ensure people's safety. Staff were safely recruited, however, we found gaps in training and a lack of suitable staff induction. Some staff had started working in new posts without any induction or training.

People were not receiving safe care and treatment. We found that medicines were not always safely managed, that there was no consistent oversight in relation to people who were having their food and fluid monitored and that people had experienced delay in referrals to health professionals. The premises were not being safely managed and did not provide a suitable environment for people at all times.

People's consent was obtained prior to them receiving care and treatment. However, improvements were needed in relation to how people's capacity was assessed and decisions were made and documented in their best interests.

People’s privacy was not always respected at the service and there was limited evidence in people being involved in decisions about their care and treatment.

People had a choice of nutritious food and drink and people were supported to eat and drink when this was required. The service offered people a range of activities and took into account people's views and preferences.

People were cared for by staff who treated them with kindness. People were encouraged to remain as independent as possible.

Incidents and accidents were reported and appropriate action. Statutory notifications were issued as required by law and the service was displaying their rating as required.

There was a registered manager in post. It is a requirement that the service has a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our previous inspection on 3 November 2016 we found that improvements were required in the management of people's medicines. At this inspection we found that while some improvements had been made, we found other area of concern.

People did not always receive the medicines they were prescribed and protocols were not in place for the management of medicines which were prescribed on an 'as required' basis.

Staff had received training and understood their responsibilities to report suspected abuse. Risk was assessed but risk management plans did not sufficiently protect people from harm.

Safety and maintenance checks were carried out to help ensure that the premises and equipment were safe. There was a fire risk assessment in place and staff knew how to respond to a fire alarm or emergency.

Safe staff recruitment procedures were followed and checks were carried out before people were offered employment.

Staff had not received all the training they required to meet people's needs. People did not always receive care and support that was based on best practice guidance.

Staff were not following the principles of the Mental Capacity Act and people may have had their liberty deprived without authorisation.

People said they liked the food and meals provided. Some people may not have had enough to drink.

People said they liked the staff and they were kind and caring. We saw some instances where staff did not respond appropriately to people's distress or discomfort.

Privacy and dignity was mostly respected and people felt able to be as independent as possible.

Complaints were not always investigated in a thorough way and appropriate action to resolve the complaint was not taken.

There were limited opportunities for people to follow their chosen hobbies and interests.

People and staff felt supported by the management team. Quality monitoring systems were not effective in identifying shortfalls or levering improvement.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social care Act 2008 and associated regulations about how the service is run.

People were not always suitably protected from the risks associated with medicines management because staff did not always follow the provider’s policies and procedures.

People’s care and support needs were continually monitored and reviewed to ensure that care was provided in the way that they needed. People had been involved in planning and reviewing their care when they wanted to.

There were sufficient numbers of experienced staff that were supported to carry out their roles to meet the assessed needs of people living at the home. Recruitment procedures protected people from receiving unsafe care from care staff unsuited to the job. Staff received training in areas that enabled them to understand and meet the care needs of each person.

People were supported to have sufficient to eat and drink to maintain a balanced diet. Staff monitored people’s health and well-being and ensured people had access to healthcare professionals when required.

People were safeguarded from harm as the provider had systems in place to prevent, recognise and report any suspected signs of abuse. Staff knew their responsibilities as defined by the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS) and had applied that knowledge appropriately.

Staff understood the importance of obtaining people’s consent when supporting them with their daily living needs. People experienced caring relationships with the staff that provided good interaction by taking the time to listen and understand what people needed.

People’s needs were met in line with their individual care plans and assessed needs. Staff took time to get to know people and ensured that people’s care was tailored to their individual needs.

People were supported by a team of staff that had the managerial guidance and support they needed to do their job. The quality of the service was monitored by the audits regularly carried out by the manager and by the provider.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Pytchley Court Nursing Home on our website at www.cqc.org.uk

This unannounced focused inspection took place on the 30 August 2016. Pytchley Court Nursing Home provides accommodation for up to 38 people who require nursing or residential care for a range of personal care needs. There were 37 people in residence during this inspection.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social care Act 2008 and associated regulations about how the service is run.

The provider had implemented a tool to calculate the staffing levels that were required in the home to provide people with safe care. Staffing levels had increased and people could be assured that they would be cared for by an appropriate number of staff.

People who summoned support using their call bell could be assured that this would be answered in a timely manner most of the time. There were enough staff to provide safe care and support to people who had been identified as being at risk of falls.

People received the support they need to have sufficient amounts to eat and drink. People at risk of not eating or drinking enough had been identified and staff provided additional support to these people to mitigate the risk of malnutrition.

A new registered manager was in post that was committed to improving the quality of care people living in the home experienced. The provider and registered manager had implemented a range of quality assurance audits that had bene effective in addressing shortfalls in the home and implementing improvements.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social care Act 2008 and associated regulations about how the service is run.

The registered manager had been isolated from the support and guidance they had required from the provider. Recent changes had led to some improvements in the governance and support; however, the provider had not identified the issues raised in this inspection. The audits used to monitor safety and quality had not all been effective at identifying areas for improvement or driving forward improvements.

There had not always been enough staff to meet people’s assessed needs. This had had a direct impact on people’s relationships with staff, the time people waited for care and their ability to attend activities or have the opportunity to socialise.

People did not always have the opportunity to drink sufficient amounts of fluids to help maintain their health and well-being. People who required help to eat their meals did not always receive their meals in a timely way. The registered manager had not ensured that kitchen staff had sufficient information to provide meals that met people’s dietary needs or have adapted cutlery for people to eat their meals independently.

There had not always been appropriate arrangements in place for the management of medicines. Staff did not have access to all the relevant information about people’s identity and allergies and staff did not always ensure that people took the medicines they had been prescribed.

People received care from staff that were not always supported to carry out their roles as staff did not always feel confident to bring up issues about staffing levels. Staff received training in areas that enabled them to understand how to meet the care needs of each person. Recruitment procedures protected people from receiving unsafe care from care staff unsuited to the job.

People were assessed for their suitability prior to their admission to the home. Staff carried out regular reviews of peoples’ assessments and care plans and there was clear communication between staff to update them on any changes in care. People had been involved in planning and reviewing their care when they wanted to.

People were safeguarded from harm as the provider had systems in place to prevent, recognise and report any suspected signs of abuse. Staff knew their responsibilities as defined by the Mental Capacity Act 2005 (MCA 2005) and Deprivation of Liberty Safeguards (DoLS) and had applied that knowledge appropriately. People were involved in decisions about the way their care was delivered and staff understood the importance of obtaining people’s consent when supporting them with their daily living needs.

People’s needs were regularly reviewed so that risks were identified and acted upon as their needs changed. People’s healthcare needs were met. People had their comments and complaints listened to and acted on.

People who were at risk of falls benefited from an initiative by the whole staff team to help prevent falls by identifying the reasons and mitigating the risks.

Records relating to the day-to-day management and maintenance of the home were kept up-to-date. People’s and staff records were securely stored to ensure confidentiality of information.

There were breaches of four of the regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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.

The detailed evidence supporting our summary please can be read in our full report.

Is the service safe?

People were cared for in an environment that was clean and hygienic. When we inspected there were sufficient numbers of experienced and competent staff on duty to safely meet people's care needs. We saw that the equipment in place for staff to use was appropriately maintained. We saw that staff had been appropriately trained and received the managerial support they needed to do their job. This meant that people were protected from the risk of neglect or unsafe care.

There were suitable arrangements in place to respond to emergencies, with the manager or provider's representative always being available 'on call' to support staff to manage the situation safely and in a timely way.

People's needs had been assessed before they were admitted to Pytchley Court. After admission to the home we saw that their needs were regularly reassessed to ensure they received the safe care they needed. This meant that staff had the information they needed to minimise identified risks to people.

Is the service effective?

People said they received all the support they needed to enable them to do what they could for themselves. Staff had received the information, training and managerial support they needed to do their job effectively. We spoke with staff and observed them going about their duties and we concluded that they had a good knowledge of each person's care needs and preferences.

Is the service responsive to people's needs? One person said, "I only have to press my buzzer if I need help from a carer. I can rely on them."

Is the service caring?

When we saw staff interact with people their manner of approach was patient, kind, and good humoured. They encouraged people who struggled to do things for themselves. We saw that staff were purposeful and unhurried so they had not 'rushed' people. One person said, "All the staff are so kind. They always do their best for everyone."

Is the service responsive to people's needs?

We saw that there was enough staff on duty to meet people's needs. This was confirmed by the five staff, three visitors, and four people in residence we spoke with. One visitor said, "Staffing levels have definitely improved. The staff are not having to rush around as much as they did before. It all seems happier and more relaxed."

Is the service well-led?

Staff said they received a good level of practical day-to-day managerial support to enable them to carry out their duties. The provider had ensured there were robust quality assurance processes in place. This meant that people were assured of receiving the care they needed in a way that suited them.

There was not a registered manager in post when we inspected. The new manager is in the process of submitting an application for registration.

We found that there were knowledgeable kitchen staff who were able to provide nutritious meals in pleasant surroundings; however, there were not enough staff to ensure that people received their meals appropriately.

We found that Pytchley Court Nursing Home did not have enough staff to meet the needs of the people who used the service. The impact on people's care was that people had to wait for long periods to receive care and that people did not receive care at the time they wanted.

We looked at how Pytchley Nursing Home managed their medicines. We found that there were appropriate systems in place to order, store, record and dispose of medicines. Most people had their medicines administered safely; however, where people received covert medicines there were not appropriate assessments in place and no evidence of pharmacy advice to ensure that their medicines were administered safely.

We found that staff had received regular supervision but not appraisals.

We spent time observing how people were supported to engage with the staff, other people who used the service, visitors and activities.

We observed that staff worked at a relaxed pace, they provided good eye contact and made positive verbal comments when interacting with people using the service. However we also observed there was an absence of stimulating objects within the lounge environment such as books, magazines or any tactile objects available for people to engage with. The provider may find it useful to note this did not promote people's autonomy, involvement and independence.

The people we spoke with told us the staff were helpful and treated them with respect. The visitors we spoke with said the staff always made them feel welcome whenever they visited. They told us they were very pleased with the care their relative received at Pytchley Court Nursing Home.