Archived: Crawfords Walk Care Home

Crawford's Walk nursing home comprises of four purpose-built units in the Hoole area of Chester. The service is owned and operated by BUPA care homes. Northgate is a unit for people with enduring mental health illness, Watergate and Eastgate are units for people living with dementia and Bridgegate unit provides support for those with physical health needs. At the time of our inspection there were 109 people living at the service.

At the time of our March 2017 visit the service was not managed by a person registered with the Care Quality Commission (CQC). 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. Subsequent to our visit the manager was successfully registered with CQC in April 2017.

At the last comprehensive inspection on the 16 and 17 May 2016 we identified a breach of Regulations 11 and 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014 and found that a number of improvements were required at the service. The registered provider did not have effective systems and processes in place to assess, monitor and improve the quality and safety of care. Consent to care and treatment was not always sought in line with relevant legislation. The registered provider was issued with a requirement notice for Regulation 11 and a warning notice for Regulation 17. We asked the registered provider to take action to address these areas.

At our subsequent focused inspection on the 8 and 9 August 2016 we identified a breach of regulations 10, 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) 2014 and found that further improvements were required at the service. People were not always protected from the risk of unsafe care and treatment or supported or treated in a dignified and respectful manner. Staffing levels at the service were insufficient to meet people’s needs and the skills and knowledge of staff to effectively undertake their roles required improvement. The registered provider was issued with a requirement notice for Regulation 18 and a warning notice for Regulations 10 and 12. We asked the registered provider to take immediate actions to minimise the risk of harm to people supported.

We told the registered provider they would need to meet legal requirements in relation to the breaches identified by 3 October 2016. This inspection found continued breaches of Regulation 10, 12, 17 and Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) 2014. The CQC are now considering the appropriate regulatory response to the concerns we found. We will publish the actions we have taken at a later date.

People living on Bridgegate and Eastgate units were not always treated with dignity and respect. We identified continued institutional practices in place between the day and nights shifts. People’s human rights and choices had not always been respected and this had not been identified or addressed by the registered provider. People’s personal appearance was not always well maintained. Language used in care records at the service did not always afford people dignity and respect.

Staffing levels on all units were regularly assessed by the registered provider through the use of a dependency assessment tool. However, people told us and our observations showed that care and support during the day time was not always provided to people in a timely manner on Bridgegate and Eastgate units. Our visit on the 5 June 2017 identified that staffing levels on Watergate unit did not effectively meet the needs of people supported. Allocated 1:1 support hours on Eastgate unit were not fulfilled. This placed people at the risk of harm due to a lack of staff, reduced observation and support.

The quality assurance systems in place were not effective. We found continued issues as part of our inspection relating to the analysis of accident and incidents, accurate completion of supplementary charts and care records at the service. Information analysed regarding accidents and incidents was not always accurate or reviewed in line with the registered providers own timescales. There were no actions recorded to identify that the registered provider had considered risks, patterns or changes required to people’s care needs. Quality assurance systems used by the registered provider had not identified issues we raised as part of this inspection.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible. The registered provider had policies and systems in place regarding the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff practice on Northgate and Watergate units showed that consent was sought (where possible) from people prior to care being provided. However practice observed on Bridgegate and Eastgate units did not afford people the right to make decisions about their morning care routines. During our visit of 5 June at 6am we found that several people had been washed, dressed and placed back in bed. Records evidenced how people’s capacity had been assessed and how decisions had been made in people’s best interests in line with the Mental Capacity Act (2005). However, this information was not always adhered to or respected by staff.

People had access to regular drinks and food. The registered provider had supplementary records which were used to record food and fluid intake for people who may be at risk of dehydration and malnutrition. However, we found that charts were not always completed effectively or in a timely manner by staff. There were gaps of up to 20 hours where no food or fluid intake had been recorded. Information relating to what people had eaten was not always completed in detail to accurately reflect what they had consumed. Food and fluid charts were not consistently totalled to accurately assess whether people had received adequate food and fluids to protect them from the risk of dehydration and inadequate nutrition.

Personalisation of care plans had improved and records contained information about people’s individual preferences about how they would like their care and support to be provided. However, we noted information relating to peoples preferred night routines was limited. Advice and guidance was sought from other professionals where appropriate to ensure that people remained well. However, records viewed did not always evidence how, why and what decisions had been made where people required the use of ‘thickening agents’ in their fluids.

New staff underwent an induction programme, which included training relevant to their role and shadowing experienced staff, until they were competent to work on their own. Staff confirmed they had received supervision and training in line with the registered provider’s own timescales. We noted that mental health training had not been provided to staff working on Northgate unit. The registered provider confirmed following our inspection that training had been accessed and dates had been arranged for staff to attend. However, observations of institutionalised practice during our visit on 5 June 2017 raised concerns with regards to the level of supervision, training and competency assessments undertaken by the registered manager and provider.

Health and safety checks had been carried out and equipment serviced. The service was clean and the manager and maintenance staff carried out regular checks of the environment to ensure it was safe. However, during our visit on the 5 June 2017 we noted that a fire exit on Bridgegate unit was blocked. We raised this with the registered provider and asked them to take immediate action to address this concern. Following our inspection the Fire authority confirmed that appropriate actions had been taken by the registered provider to minimise risk.

People or their family member’s involvement in the review of care plans was not always clearly recorded. Care plans and risk assessments for four people living at the service had not been reviewed or updated following the receipt of important information or incidents that had occurred. Actions taken in response to changes had not been recorded by staff. The registered provider completed a review following our visit and provided us with updated care plans for these people.

Day staff morale had improved and there was a more relaxed atmosphere throughout the service. Discussions with night staff identified that improvements had started to be made, however the shortage of night staff continued to impact on their roles. We noted that staff who usually worked on days had been requested to undertake night shifts to cover staff shortages. Day staff were aware of the importance of encouraging people to maintain their independence and respecting their confidentiality. Family members said they had always been made to feel welcome when visiting.

The majority of people we spoke with said they were happy with the service that they received and that they felt safe. The registered provider had clear policies and procedures in place for reporting any concerns they had about the safety and well-being of people they supported.

Medication management on Watergate and Eastgate units was good. People received their medication as prescribed and staff were competent in the administration and management of medication. Medication administration records

Crawford’s Walk nursing home comprises of four purpose-built units in the Hoole area of Chester. The service is owned and operated by BUPA care homes. Northgate is a unit for people with enduring mental health illness issues, Watergate and Eastgate are units for people living with dementia and Bridgegate unit provides support for those with physical health needs.

The service does not currently have a registered manager in place. 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. The service has a manager in place who has recently applied for the registered manager’s position.

A comprehensive inspection of the service was completed on the 16 and 17 May 2016 and we found that the registered provider was not compliant with the Health and Social Care Act 2008 (Regulated Activities) 2014. We issued the registered provider with a warning notice and told them to be compliant by the 3 October 2016. We conducted this focused inspection due to concerns that we had received following our last inspection regarding the safe care and treatment of people living at the service. We looked at the safe and well led domains. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. The registered provider submitted an action plan within 18 hours of our inspection visit highlighting the actions that would be taken to address immediate areas of concern we raised regarding the risks to the health, safety and welfare of people living on Watergate unit. You can see the action we have told the provider to take at the end of the report.

People on Bridgegate unit told us that they felt safe living at the service. Staff had an understanding of different types of abuse, such as financial, physical and verbal abuse. The registered provider had recently shared information with staff as to how to safeguard people from abuse and how and who to report concerns too. However, we identified institutional practices in place between the day and nights shifts on Watergate unit. People rights and choices had not always been respected and this had not been identified or addressed by the registered provider.

Areas we raised related to poor and restrictive practices that had not been identified or addressed. Mobility aids such as walking sticks and Zimmer frames were placed out of peoples reach. The environment had not been adapted to aid and support people living with a visual impairment. This meant people’s movements were restricted in the environment and the registered provider had not recognised or addressed cultural restraint within the service.

Staffing levels were not sufficient to meet the needs of people supported. Staff sickness and cover had not been reported and staff told us that it was usual practice to work short staffed on night duty at the service. People were left unsupported and not observed at times and this led to a number of situations were inspectors intervened to prevent accidents and incidents occurring. This meant that people had been placed at risk of harm due to a lack of staff, reduced observation and support.

Risks to people health and safety were not always identified by the service. We found on Watergate unit that the kitchen and sluice room doors were left open and accessed by people living with dementia at the service. Some people were unable to independently call for help or support from their bedrooms. There were no alternatives other than night time checks to ensure that people were safe and observations showed that these were not completed on a regular basis. This meant that people were placed at increased risk of harm and cross infection.

During our visit we found that sufficient checks were not made on pressure relieving equipment on Watergate unit. Seven pressure relieving mattresses were set at the wrong pressure settings and one pressure mattress was unplugged from the power. Staff referred to out of date and inaccurate information to complete checks on pressure mattresses. Following our inspection we were informed by the registered provider that the appropriate checks on this equipment had not been completed at the service.

Fire safety management at the home required reviewing. Staff were not confident in describing how to support people and undertake an effective evacuation of the units in the event of an emergency or a fire. This meant that people were at risk of not having the appropriate support they required in the event of an emergency.

People told us that the majority of staff were kind, patient and caring. However, observations showed that some staff were abrupt and dismissive in their manner and approach towards people. Staff did not always effectively meet people’s needs and people were not always treated in a respectful and dignified manner. The registered provider has addressed areas of concern we raised with them relating to staff approach following our inspection.

During this inspection we focused on Watergate and Bridgegate units due to concerns that we had received following our last inspection. In addition we requested the support of a specialist advisor nurse who visited Watergate and Eastgate unit to review clinical practice at the service.

Crawford’s Walk nursing home comprises of four purpose-built units in the Hoole area of Chester. The service is owned and operated by BUPA care homes. Northgate is a unit for people with enduring mental health illness issues, Watergate and Eastgate are units for people living with dementia and Bridgegate unit provides support for those with physical health needs.

There was a registered manager that had oversight of the whole service. 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 the last inspection on 21 and 22 September 2015 we found that a number of improvements were needed. These were in relation to people not being protected from risk when left unsupervised or due to unsafe care and treatment because there was a lack of information about their needs. People were not always supported or treated in a dignified way. We asked the registered provider to take action to address these areas.

After the inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breaches identified. They informed us they would meet all the relevant legal requirements by the end of December 2015. However, whilst the registered provider had made improvements, they had not fully met their own action plan. We found a continued breach of the Health and Social Care Act 2008 (Regulated Activities) 2014 and also identified some additional concerns. You can see the action we have told the provider to take at the end of the report.

Quality assurance systems in place were not effectively used to assess and identify improvements needed to ensure the quality and safety of the care provided. Issues we raised during our inspection relating to care planning, documentation, and analysis of accidents and incidents had not been identified or fully addressed through the provider quality assurance processes. This was a repeated breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014 as the provider did not effectively use systems and processes to assess, monitor and improve the quality and safety of care.

Records that we looked at were not always accurate, comprehensive and up to date. Care plans contained varied levels of information on each person and how their care and support was to be delivered. Daily records were not always completed in enough detail to reflect what care and support people had received on a daily basis. Records did not always provide sufficient information to ensure that people who used the service received the necessary care and treatment. This meant that people were at risk of not receiving personalised care in line with their wishes, needs and preferences.

The registered manager had knowledge and understanding of the Mental Capacity Act 2005 and their role and responsibility in regards to this. However, staff had a varied understanding of their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People’s care records did not contain information about their mental capacity, and mental capacity assessments had not been completed as required by the MCA. Furthermore there was no information outlining how decisions for people who lacked capacity had been made in their best interests.

People told us they felt safe and we found there were enough staff on duty to meet people's needs. Staff understood how to identify abuse and were aware of the action to take if abuse was suspected or reported. We saw safeguarding procedures had been followed when incidents had occurred. However, following our inspection concerns have been raised around the care of some people in the home. These are currently under investigation by the relevant authorities.

People were supported to eat their meals by care staff appropriately and sensitively and people told us they enjoyed their meals. Although we observed that people's nutritional and hydration needs were met, this was not always recorded accurately or in detail.

Staff attended regular training sessions in areas such as moving and handling, first aid and safeguarding adults to update their knowledge and skills. Where training in MCA and DoLS had not been effective the registered provider accessed coaching sessions for staff to enhance and develop their skills. Staff had access to regular supervisions to discuss matters that affected them and also to focus on aspects of their performance that were good or where improvement was required.

People received their medication as required. Nursing staff had completed competency training in the administration and management of medication. Medication administration records (MAR) were appropriately signed and coded when medication was given. However, we noted that care plans for PRN (as required) medication were not always in place for staff guidance.

Staff were caring and treated people with kindness and respect. Most people and relatives were happy with the overall care that they had received. Observations showed that staff were mindful of people’s privacy and dignity and encouraged people to maintain their independence

Robust recruitment processes were followed and there were sufficient qualified, skilled and experienced staff on duty to meet people’s needs. This meant people were cared for by staff that had been deemed of suitable character to work within the service.

People who used the service we spoke with were positive about the care and support people received at the home. People told us they were well cared for. Comments from them included: "The staff are great. They do a really good job", "I enjoy the activities here","I was made to feel very welcome by the staff" and "It's great here."

We found the views of people who used the service were generally mixed when we asked them about the food at the home. Comments from them included: "The food is great", "The food is ok" and "The worst part is the food."

We found the home to be clean throughout. All of the rooms we examined were in a good state of repair. In addition to this the carpets and flooring were in a good condition. We saw the gardens and grounds of the home were tidy and well maintained. The kitchen areas had also received a five star food hygiene rating recently.

We examined the induction plan and found that all areas of basic training such as nutrition, medication, safeguarding and moving and handling had to be completed during the induction process.

We found there was an effective system in place to deal with complaints. It was evident there was a detailed audit trail of how concerns were managed and dealt with to the complainants satisfaction where possible

Records showed 78% of the staff had received this training with the remaining staff due to complete it by 16 January 2013. We spoke with two care workers. Two staff spoken with told us that they felt they had good training opportunities and had received dementia essential training. Both stated they felt well supported in their roles and enjoyed working at the service.

Training records showed challenging behaviour training had been provided to those staff teams who supported people who presented with aggressive behaviour.

We spoke with three people who used the service they told us they were happy with the service provided and felt cared for. There were systems in place to monitor the quality and safety of the service provided. As part of the audit of Crawfords Walk surveys were sent out annually to people who used the service, family members and the staff team to seek their views about how the service offered care and support.

Information held in records such as accident/incident logs showed there was evidence that learning from incidents / investigations took place and appropriate changes were implemented.