Lower Farm Care Home with Nursing

Lower Farm Care Home with Nursing is a 'care home' for up to 49 people. At the time of our inspection the service was providing nursing and/or personal care to 34 people.

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

People did not always have access to their medicines as their prescriber intended. Medicines were not always being managed in line with best practice.

People were still not always fully protected from risk, particularly the risks posed by poor practice when tube feeding and significant weight loss for people. Previously identified risks to the environment had been satisfactorily addressed.

Systems and governance arrangements did not highlight the issues we found in relation to medicines management and risk.

During the inspection visit people were supported by sufficient staff. People and their relatives gave us mixed feedback about the staffing levels and whether these were adequate or not.

We have made a recommendation about the providers continuing to closely monitor staffing levels to ensure there are consistently enough to meet people’s needs.

Despite finding areas of concern the service had been making progress and feedback from a variety of sources was that improved practice was being implemented. This needs to be sustained and fully embedded into the culture of the service.

People were positive about the care staff and told us that their privacy and dignity was promoted.

People were supported and encouraged to participate in activities they enjoyed.

Staff were motivated and enjoyed working at the service. They received training, supervision and were supported in their roles by the manager and provider.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People had to access to healthcare services they needed to maintain good health.

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 inspection for this service was a ‘focussed’ inspection looking at the questions of safe and well led only. Following this inspection, the rating for this service was Inadequate (published 29 April 2019). Prior to that, the most recent comprehensive inspection looking at all questions we ask was in August 2018 where the service was also rated Inadequate (published 19 November 2018).

The provider completed an action plan after the last inspection to show what they would do and by when to improve.

This service has been in Special Measures since August 2018. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

However, we also found that at this inspection not enough improvement had been made or sustained and the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvements. Please see all sections of this full report.

Enforcement:

At this inspection we have identified continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to Regulations 12 around safe management of medicines and risk and Regulation 17 around leadership and governance.

Please see the action we have told the provider to take at the end of this report.

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 following this report being published 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 we receive any concerning information we may inspect sooner.

People’s experience of using this service:

Although the provider had made some improvements in Safe and Well-Led, these were not enough to ensure people always received safe and consistent care. Both key questions remain rated as Inadequate.

People were still not always fully protected from risk, particularly the risks posed by the environment. Where the provider had assessed risks, systems designed to monitor and manage these risks were not always robust.

Electronic and paper recording systems did not work in tandem and oversight of how people’s risks were being managed was not good.

Medicines were not always managed safely and this had the potential to place people at increased risk of harm.

The lack of effective auditing, alongside confusing records and poor assessment of risk, meant that concerns remained with regard to the safety and leadership of the service.

New systems to improve communication within the service required further development so that important information about people’s care was clear to all staff.

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

Rating at last inspection: At the last comprehensive inspection the service was rated Inadequate (report published 21 November 2018.)

Why we inspected: Following the last inspection we received an action plan outlining how the service would make the required changes to improve the service and to address the six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 identified during that inspection.

We carried out this inspection to check that the improvements with regard to the breaches of Regulations 12 (Safe Care and Treatment) and 17 (Good Governance) had been made and sustained. We had also received information of concern which led us to continue to question the safety of the service and the quality of the leadership.

Follow up: We have issued further requirement notices for breaches of regulation as a result of this inspection. We will require the provider to send us another action plan and will meet with the provider to discuss their failure to make the required improvements and to discuss how they plan to ensure significant improvements are made and maintained. Failure to achieve this will result in CQC considering a more robust regulatory response which may include a notice of proposal to cancel the service’s registration.

Lower Farm Care Home with Nursing provides accommodation, support and care for up to 46 people, some of whom are living with dementia. People in care homes receive accommodation and 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. At the time of our inspection 40 people were using the service. Lower Farm is an adapted older building on three floors. The building is spread out and people have access to the ground floor areas via a lift. It is near King’s Lynn town centre but transport would be needed to access local facilities.

There was a registered manager in place. 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, which was carried out on 8, 13 and 19 September 2017, we rated the service as Requires Improvement. During that inspection we identified breaches of Regulations 9, 11, 12, 14 and 18. These breaches related to person centred care, consent, safe care and treatment, nutrition and hydration and staffing. Following the last inspection, we asked the provider to complete an action plan to show what they would do, and by when, to improve the all the key questions to at least good. At this inspection we found that, although the provider had made some improvements and introduced new systems, there were still some significant concerns about the management of risk and the leadership of the service. We have identified continued breaches of Regulations 9, 12 and 18 as well as additional breaches of Regulations 15, 17 and 20a. These new breaches relate to the suitability of the premises, leadership and a failure to display the CQC rating.

We could not be assured that medicines were always managed safely as stocktaking measures were not effective, medicines were not always in stock and medicines were not being stored safely. We also noted a medication error during our inspection.

Risks were not always well managed. Risks assessments were present in care records but the risks posed by an unfenced lake and doors which gave access onto a main road, had not been fully assessed and mitigated. Some risks had been noted at our previous inspection and the provider had not taken effective action to address them. Staffing levels meant sometimes people were left without staff support which increased any potential risks. Systems did not fully protect people from the risk of dehydration or of developing a pressure sore.

Staff understood their responsibilities with regard to keeping people safe from the risk of abuse and appropriate safeguarding referrals had been made. We noted a safeguarding matter during our inspection and this was referred to the local authority by the service.

Infection control procedures were in place but some staff practice placed people at potential risk and had not been addressed by the provider.

Staff received a comprehensive induction and the training they needed to carry out their roles. Staff felt well supported but information systems were not robust and did not ensure that staff always had all the information they needed. This placed people at potential risk.

People had access to healthcare professionals and staff worked well with them to meet people’s healthcare needs. People enjoyed the food and people’s individual likes and dislikes were respected. Where people experienced unplanned weight loss, staff referred them to the dietician for advice and support. Improvements were needed with regard to the oversight of people’s drinking, especially in the extreme hot weather.

The service was working in accordance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals, relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation. We found that staff understanding of MCA and DoLS was adequate and appropriate DoLS referrals had been made for people. Some staff needed to ensure they asked informally for consent before providing care and treatment.

The environment had been refurbished and much improved since our last inspection. However further improvements were needed to ensure it was suitable and safe for the client group, especially those people living with dementia.

Staff were kind and caring and demonstrated that they had built up good relationships with the people they were supporting and caring for. People were supported to be as involved in decisions about their care where they could be. Although staff were respectful, staffing levels sometimes meant decisions were taken by staff which did not always reflect people’s preferences and expressed wishes. Sometimes a lack of staffing meant people’s dignity was compromised.

Opportunities for people to follow their own hobbies and interests were limited and feedback was negative. People were not meaningfully occupied during the day and many people spent a lot of time in their rooms watching television.

Care plans were being transferred onto a new electronic record. Those which had been reviewed reflected people’s individual needs and preferences, others contained some contradictory and confusing information. Regular reviews of plans were taking place, although some current information had not been recorded.

Care for people at the end of their life required improvement. Records did not demonstrate how people were being cared for and did not assure us that people’s individual needs were being met. People’s preferred priorities for end of life care were documented but information was very basic and did not give staff sufficient guidance.

A complaints procedure was in place and complaints were appropriately managed, although we did receive some negative feedback from two relatives. People who used the service and relatives were given the opportunity to raise any issues and informal complaints at residents’ and relatives’ meetings or in the regular surveys which were sent out.

The provider had not carried out all the actions documented in their action plan from the last inspection. We noted some issues had continued and there were further breaches of the same regulations. We found that in introducing new systems and improvements the provider had not had sufficient oversight of the service to ensure that it remained safe and staff were working efficiently.

Whilst we fully recognise the improvements the provider has made, and the scale of the job which faced them when they took the business over, they have failed to ensure systems were in place to fully protect people and maintain their wellbeing. We are, however, pleased with the level of engagement the provider and registered manager have shown and their willingness to bring about the further improvement.

The overall rating for this service is 'Inadequate' and the service is 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.

The service provides residential and nursing care for up to 46 people, some of whom are living with dementia. At the time of our inspection 34 people were using the service and two people were in hospital.

A registered manager was 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.

Archers Healthcare Limited had taken over this service in May 2017. The service had been rated Inadequate under the previous provider and placed into special measures following an inspection on 4 and 5 July 2016. This inspection was carried out to ensure that improvement had been made in the intervening period. CQC would usually give any new provider a longer period to address the issues we found but a number of complaints and safeguarding issues were raised with us and so we brought our inspection forward.

During this inspection we established that many of these issues, which were raised by relatives and by staff acting as whistleblowers, were not fully substantiated. However we did find evidence of a poor staff culture. This impacted negatively on the staff and in turn on the people who used the service. We found the provider and the registered manager to be dedicated to driving the improvements that the service required but questioned the intimidating management style of the provider.

We found the service had improved under the new provider but further improvements were required. It was encouraging that both the provider and the manager were already aware of many of the issues we raised and had tried to start tackling them. The provider had only been registered for a matter of weeks and had many areas of poor practice to address. This meant that our inspection was likely to see only the beginnings of a change and this was the case.

The manager and provider had worked hard to introduce new systems and procedures and to overhaul paperwork and staffing levels. Some areas had been more successful than others and we continued to have some significant concerns regarding the safety of the service. However we found the manager to be open and honest with us and had confidence that any issues raised in this report would be addressed as a priority.

Risks were assessed, documented in care plans and measures put in place to reduce them. However routine health and safety checks were not always undertaken and audit systems did not identify this. Where risks to people’s health and safety were identified action did not always follow to address this. The risks related to pressure care were not well managed. Staff practice with regard to the prevention and management of pressure ulcers was not always effective and records were not detailed and did not guide and inform staff.

Staffing levels, and the deployment of staff, were a concern for some people and had an impact on the timeliness of care provided. Measures had been put in place to review staffing levels and these were viewed positively by some people. Our observations were that, in particular on the third day of our inspection, staffing was not adequate and people did not receive the care they needed.

Staff were patient, caring and treated people with kindness. People’s dignity was occasionally compromised as staffing levels meant that staff did not always have the time they needed to provide care which met people’s needs promptly.

Medicines were managed safely and people received their medicines as prescribed. Staff were confident in the management of medicines and were knowledgeable about people’s healthcare conditions and the medicines they required to support them.

Infection control measures were in place and staff had an appropriate understanding of how to limit the risk and spread of infection. Training and induction for new laundry staff could have been more robust.

Staff were not all trained in safeguarding people from abuse but demonstrated an acceptable knowledge of how to keep people safe. The manager referred incidents appropriately to the local authority safeguarding team for investigation and ensured CQC were notified of any safeguarding incidents.

Staff received a comprehensive induction but some training which could have benefitted staff, was not provided. A new training programme was being prepared and the manager demonstrated a commitment to improving training for all staff. Staff were supported with regular meetings, supervision and appraisal.

Staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS). The MCA ensures that people’s capacity to consent to care and treatment is assessed. If people do not have the capacity to consent for themselves the appropriate professionals and relatives or legal representatives should be involved to ensure that decisions are taken in people’s best interests according to a structured process. DoLS ensure that people are not unlawfully deprived of their liberty and where restrictions are required to protect people and keep them safe, this is done in line with legislation.

Practice related to MCA and DoLS was not always in line with legal requirements. Staff sought consent appropriately for day to day care support but did not demonstrate a good understanding of the principles of the MCA which left people at risk of receiving care to which they had not consented. People who used the service, and their relatives, were not always sufficiently involved in planning and reviewing their care.

Oversight of people’s nutritional needs required improvement. People who used the service praised the food and food was of a good quality. Those at risk of not eating or drinking enough were not appropriately monitored which placed them at risk.

People were supported to access the healthcare support they needed promptly. There was evidence of good partnership working with the GP, matron service and other healthcare professionals such as district nursing team. Feedback from healthcare professionals was positive.

Care records identified people likes, dislikes and preferences and guided staff but guidance was not always followed and some people did not receive the care they wished to receive.

People received care that met their individual needs and took account of their likes, dislikes and preferences. Staff respected people’s individuality.

People were supported to follow a range of hobbies and interests and new activities. Staff were transforming the activities programme to reflect people’s preferences. Further improvement was needed to ensure people who needed one to one input also received social and recreational opportunities.

A complaints procedure was in place and formal complaints were well managed. Informal complaints were not raised as people found the provider could be intimidating to them. People who used the service and staff expressed that they would be hesitant to raise a complaint.

The new provider and registered manager had introduced new systems and procedures to drive improvements. Their approach had been well received by the some people who used the service, relatives and staff. Others had expressed concern about how some changes had been implemented and were worried about the culture of the service.

Audits were in place to monitor the safety and quality of the service and but they were not always effective in identifying concerns and effecting change. The provider and manager were aware of many of the shortfalls we identified and expressed a willingness to continue to drive improvements. Where issues still required some further work we had confidence in the provider to continue to address these and to take on board people’s concerns.