Applegarth Nursing Home

Applegarth Nursing Home is a residential care home providing personal and nursing care to up to 53 people. At the time of our inspection there were 31 people using the service.

The care home accommodates people across three separate wings, each of which has separate facilities. These include a unit for older people living with dementia, a unit for people with neurological conditions and a unit for people with complex care needs.

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

The provider's quality assurance systems were not effective and had not addressed the clear shortfalls in records and checks. Senior management were unable to access audits so could not be assured key aspects of service delivery were being safely and effective met.

Risk assessments were not always in place to show staff how to manage potential risks to people’s well-being. Some people’s care records were incomplete and were not reviewed at regular intervals. There was no audit evidence available to show if these were kept under critical review nor checked for quality or relevance.

The provider had no demonstrable evidence to show staff had relevant training in order to meet the specific conditions of people who lived there.

People were not always supported to have maximum choice and control of their lives and staff had not always assisted them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. A small number of people had been restricted without a legal framework or training by staff to do so. This was being addressed.

Medicines management and storage records were not always completed in line with good practice. Local safeguarding processes had not always been followed when incidents had occurred.

People said they felt safe and comfortable at the home. They commented staff were “nice” and treated them with kindness. Staff supported people in an unrushed, calm and engaging way.

There were enough staff to support people. Staff displayed caring values and good teamwork. They were respectful of people and their colleagues.

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 15 March 2019).

Why we inspected

The inspection was prompted in part due to concerns received about restrictions on people and lack of staff training in supporting people with distressed behaviours. A decision was made for us to inspect and examine those risks. As a result, we undertook a focused inspection to review the key questions of safe, effective 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 good to requires improvement.

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 inspection reports and timeline’ link for Applegarth Nursing Home on our website at www.cqc.org.uk.

Enforcement and Recommendations

We have identified breaches in relation to risk management and good governance of the service at this inspection.

We have made a recommendation about oversight of the provider’s safeguarding system.

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 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.

People’s experience of using this service: Improvements had been made to the governance procedures since the last inspection. Records were detailed and risks were assessed and minimised wherever possible. Improvements to recruitment procedures had been fully implemented.

People told us they felt safe, cared for and respected by the staff and management. People’s independence was encouraged and people were supported to be active decision makers in the care and support they received.

One person said, “It might not be the flashiest of places, but I’ve been in this home a long time and staff I’ve known for a long time become your family, they kind of replace any family you lose. I’ve never raised a complaint in the 13 years I’ve been here and that has to be a good recommendation for anyone.”

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

There were enough staff to meet people’s needs and staff told us their skills and experience were matched to those of the people living at Applegarth Nursing Home.

Staff were supported by an experienced and effective management team.

A culture of reflection had been established and this was used to ensure lessons were learned following the investigation of any concerns, complaints, incidents or safeguarding issues that had been raised.

A range of healthcare professionals were involved in people’s support and staff worked in partnership to achieve positive outcomes for people.

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

The overall rating for the service after this inspection has improved to good.

Rating at last inspection: Requires Improvement (report published 5 April 2018).

Following the last inspection we asked the provider to complete an action plan to show what they would do and by when to improve the key questions of safe and well-led to at least good. During this inspection we found significant improvements had been made.

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

Follow up: We will continue to monitor the service to make sure people receive safe, compassionate, high quality care. Further inspections will be planned for future dates in line with our inspection programme.

Applegarth 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.

The home is registered to provide accommodation for up to 53 people with a variety of needs. There were 51people using the service at the time of our inspection. The home is divided into three areas: one providing care for frail elderly people, some of whom are living with dementia; one for people with neurological needs; and one for younger people with complex care needs.

At the last inspection of the home in July 2017, we rated the service as ‘Good’. We carried out this inspection because we received concerns about the recruitment and roles of staff and care records.

At the time of this inspection the previous registered manager had retired. A new manager was appointed in December 2017 who had applied to be registered. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found the provider had breached two regulations of the Health and Social Care Act 2008. The provider had not always followed safe recruitment practices when employing some members of staff. The provider’s quality assurance systems were not always operated effectively to monitor the safety of the service and to ensure compliance with the regulations.

People felt safe and comfortable at the service. They felt staff used correct techniques when supporting them with care and when using equipment.

People and relatives felt there were enough staff to support the people who lived there. There was a good range of nurses and support staff on each unit and some people had one-to-one support.

Staff had the relevant training and support to care for people in the right way. The staff team were skilled and confident. Improvements were planned to how nurse competencies were evidenced.

Staff had a good understanding of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s health care needs were continually assessed, and their care was delivered in a way that met their individual needs. Staff were knowledgeable about people’s individual care needs and how they wanted to be assisted. Any changes in their health needs were referred to the relevant health care services and the staff worked in collaboration with other health care professionals to support people’s well-being.

People were supported to eat and drink enough. People who had special diets were not always offered choices about their meals. The provider improved this during the inspection.

People and relatives felt staff were caring and supportive. People were encouraged to make their own decisions and choices about their preferred daily lifestyle. Staff understood what was important to each person and were familiar with their preferences. There were warm and friendly interactions between people and staff. People had opportunities to join in activities or go out with staff.

People had information about how to make a complaint or comment and said these were acted upon. People and staff had confidence in the senior management team who all had specific roles in the running of the service. The provider had plans to redesign and upgrade the older part of the home in order to improve the accommodation and facilities for the people who lived in that unit.

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

The inspection took place on 19 July 2017 and was unannounced.

We previously inspected Applegarth Nursing Home in August 2015, at which time the service was rated good. In May 2017 the provider of the service changed. At this inspection we found the service remained good.

The service had a registered manager in place.

People who used the service felt safe and secure at the home. Relatives and external professionals raised no concerns. Staff had received refresher training in safeguarding and demonstrated a good understanding of how to keep people safe.

There were sufficient numbers of staff on duty in order to keep people safe. Call bells were conveniently placed and utilised by people when they needed extra help.

All areas of the building were clean and generally well maintained. The registered manager had a refurbishment plan in place to ensure standards in the environment were maintained.

Effective pre-employment checks of staff were in place, including Disclosure and Barring Service checks, NMC checks, references and identity checks.

The ordering, storage, administration and disposal of medicines were safe and in line with national guidance. Where minor errors or areas not meeting good practice were identified, the registered manager responded positively to feedback.

Risk assessments were person-centred. Staff had access to clear guidance about how to manage the risks people faced, as well as respecting their desire for independence.

People had access to a range of primary and secondary healthcare, such as GPs, specialist nurses and speech and language therapists to get necessary treatment.

Staff were trained in mandatory topics as well as areas specific to meeting people’s needs, for example dementia awareness, acquired brain injury and Non-Abusive Psychological and Physical Intervention.

Staff received regular supervision and appraisal processes and confirmed these were meaningful conversations. Staff told us they were well supported.

We found lunchtimes to be calm, with people given ample choices and supported to eat where they required it. Staff used recognised tools to help identify when people might be at risk of malnutrition and we saw people’s preferences and specialised diets were well catered for.

Staff had a good understanding of the Mental Capacity Act 2005. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s emotional wellbeing was respected and supported by staff, who interacted compassionately and patiently with people at all times. Feedback from all people we spoke with was positive in this regard.

The atmosphere at the home was calm and inclusive, with people supported to retain their independence and remain a part of the wider community.

Person-centred care plans were in place and there were regular reviews of care plans, involving people, their relatives and external professionals.

There was a range of in-house and external social activities provided, with people having the option to go on trips and outings as well as spending one-to-one time with one of the two activities co-ordinators.

Staff, people who used the service, relatives and external professionals we spoke had confidence in the registered manager. Staff confirmed they took a hands-on approach to the service and we saw they knew people’s needs well. The provider had recently implement a new management structure and we found this to be working well, with clear lines of accountability and quality assurance processes in place.

Further information is in the detailed findings below.