St Nicholas Nursing Home is owned and operated by BUPA, a large national organisation. The home provides nursing and personal care for up to 176 people in six separate units. Three units provide general nursing care; one provides nursing care for people living with dementia. One unit provides personal care to people with dementia and one provides nursing care to people who have a learning disability. The home is set within a residential area and is close to all amenities and public transport.
This was an unannounced inspection which took place over three days on 28, 29 and 30 January 2015. The inspection team consisted of three adult social care inspectors, a pharmacy inspector, a specialist advisor for infection control and an ‘expert by experience’. An expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service.
The service had a registered manager in post. 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.
We asked people whether they felt safe in the home. We were told, “We are looked after very well – I am moving soon but I have felt very safe here’’ and “All the staff are very good here – if I had a problem I could talk to any one of them.’’ One visitor described their relative as appearing to be “settled and safe” since their admission to the home.
We made observations on all units [houses] including those specialising in people with dementia. We saw that people who could not express their thoughts and feelings vocally were settled and supported. Staff were observed to be attentive to people’s care needs as they arose. Nobody we spoke with or observed expressed any issues regarding their safety.
There have been a number of safeguarding investigations at St Nicholas Nursing Home since our last inspection. The home had assisted the local authority safeguarding team and agreed protocols had been followed in terms of investigating and ensuring any lessons had been learnt and effective action taken. Two of the investigations by social services evidenced failings in care at the home.
At our last inspection in September 2014 we had found the home in breach of regulations relating to staffing. At that time, levels of nursing and care staff, were not sufficient to ensure people received a consistent level of safe care. We told the provider to take action. At this inspection we found that overall staffing had been improved.
Staff we spoke with told us there had, overall, been a marked improvement in the level and consistency of staffing. One staff said, ‘’Things have improved. Staff numbers have been quite stable recently. This gives us more time to organise care.’’ When we looked at the duty rotas for each unit we saw that the providers designated numbers of staff were being met.
We observed there were enough staff to carry out care in a timely manner. We saw staff were attentive to the needs of people and no one appeared to be in distress through lack of attention.
Staff files showed appropriate recruitment checks had been made so that staff employed were ‘fit’ to work with vulnerable people.
The registered manager told us staff recruitment would continue with the aim of further stabilising each house and this would help ensure house managers had necessary time to develop their role and carry out their management duties.
We found on inspection that people were assessed for any risks regarding their health care needs. Risk assessments had been carried out to assess people’s risk of developing a pressure sore for example. We saw some assessments for the use of bedrails to help ensure people were safe. We reviewed the care of one person on the house accommodating people with a learning disability. The person displayed some challenging behaviours that staff were closely monitoring. Within the person’s care plan we saw a comprehensive action plan to monitor behaviour including the use of distraction techniques. This helped the person to be as independent as possible.
At our last inspection in September 2014 we had found the home in breach of regulations relating to safe administration of medicines. This was because people were not always protected by the medication administration systems in place. We issued a warning notice and told the provider to take action. The provider’s action plan told us that systems had been reviewed and improved.
At this inspection we found that overall management of medicines had improved, however, from our findings during the visit and the incidence of medicine errors, we found that overall people were still not fully protected against the risks associated with medicines because the provider’s arrangements to manage medicines were not consistently followed.
We have told the provider to take further action.
At our last inspection in September 2014 we had found the home in breach of regulations relating to cleanliness and infection control. This was because people were not protected from the risk of infection because appropriate guidance was not being followed. People were not being cared for in a clean, hygienic environment. We told the provider to take action. At this inspection we found that overall management of infection control had progressed but there were still areas that needed improvement.
On general inspection of units [houses] we found levels of cleanliness to have improved. Toilets and bathrooms had hand wash facilities including liquid soap and paper towels for use. There was better organisation and checking by managers to ensure standards were improving. We found staff had attended training and where more knowledgeable regarding infection control.
There were still however, some areas of concern and inconsistency. For example, not all staff were seen to be adhering to hand washing routines. Some cleaning was not thorough in the dining areas and some bedrooms. There was a commode pan stored in the sluice still contaminated. This was lifted from the shelf it was stored, which was also very dusty. The clinical room on one house had an old air-conditioning unit that did not work this had been there several months and was cluttering the room; it was also very dusty underneath. Overall we found there had been enough progress but there still needed to be further development of staff roles and on-going vigilance.
We have told the provider to take action
We looked in detail at the care received by 13 of the people living St Nicholas Nursing Home. One person, who lived with dementia, had highly dependent and complex care needs. We saw that they had received input from a range of social and health care professionals who had linked in effectively with the home. One health care professional told us the manager and staff had been very proactive in managing the person’s care. Professional support had been documented by the Community Mental health team [CMHT]. There were also some records to show input from the person’s GP and dietician.
We reviewed the care of people who were experiencing pain, or had ongoing health conditions that required constant monitoring. We found that referrals had been made to provide appropriate health care input from external professionals when needed.
We looked at the training and support in place for staff. The training manager told us about the induction programme for new staff. New staff we spoke with said they had attended and felt the induction prepared them for their role. The training manager showed us a copy of the staff training matrix which identified and plotted training for staff in ‘statutory’ subjects such as health and safety, medication, safeguarding, infection control and fire awareness. Staff spoken with said they felt supported by the training provided.
We were told about plans to develop staff education in dementia awareness. There was training to develop ‘person centred coaches’ who would lead in dementia care. Currently there were two staff trained. The home had also identified clinical leads in infection control and there were identified ‘dignity’ champions. We found that these developments were very new and needed to be embedded; for example training in dementia care. The home had identified areas for improvement in best practice for dementia care but these had yet to be fully introduced.
We looked to see if the service was working within the legal framework of the Mental Capacity Act (2005) [MCA]. This is legislation to protect and empower people who may not be able to make their own decisions. People living at St Nicholas’ varied in their capacity to make decisions regarding their care. We saw examples where people had been supported and included to make key decisions regarding their care. Where people had lacked capacity to make decisions we saw that decisions had been made in their ‘best interest’. We saw this followed good practice in line with the MCA Code of Practice.
We also discussed some of the decisions regarding the right to refuse specific medical treatment in case of a cardiac arrest [‘do not resuscitate’ (DNR) procedures]. These did not always include clear evidence of a mental capacity assessment for people lacking the capacity to make a decision. In some cases we could not see whether the person’s family had been consulted as part of the best interest decision. We discussed how some DNR decisions could be better evidenced and recorded.
We found the home supported people who were on a deprivation of liberty authorisation [DoLS]. DoLS is part of the Mental Capacity Act (2005) and aims to ensure people in care homes and hospitals are looked after in a way that does not inappropriately restrict their freedom unless it is in their best interests.
We observed the dinner time meal on some of the houses and saw that meals were served appropriately and the portion size was also appropriate. We saw that people who needed support to eat had sufficient staff time allocated and that staff took time to talk to and socialise with people. There were staff on hand for people who required support with meals. Some menus were not clearly displayed. We discussed this with the manager who said they would look at improving the way the menus were displayed especially on the dementia care houses.
People we spoke with and their relatives said that they (or their relatives) were being treated with respect, dignity and kindness. One relative described staff as, “friendly and helpful.’’ They also said when their relative was being moved using a hoist, “Staff talk to [person] before they lift [them] and talk [person] through it.”
We observed staff in the communal areas of all the houses we visited. Staff interactions towards people were respectful and pleasant. During these interactions, staff appeared to listen carefully to and made efforts to communicate with people effectively.
We asked whether privacy was respected. One relative commented, “I have seen staff knocking on doors before going into a person`s room - they are very thoughtful.” This was not always consistent. We found an example where privacy when using the toilet [for people living with dementia] had been infringed. On one unit we found a lack of effective locks on toilet/bathroom doors for people to use. One toilet had no lock on at all. This was seen to compromise people’s privacy during our inspection.
We told the provider to take action.
We saw different levels of staff social interaction on different houses. If there was a high ratio of very dependent people in terms of personal care [for example the dementia nursing house] this time was reduced. The home employed ‘hobby therapists’ who were responsible for initiating some activities within the home and we saw some interactions at various times which were positive and helped people to have a greater sense of wellbeing.
We saw references in care files to individual ways that people communicated and made their needs known. We also saw examples were people had been included in the care planning so they could play an active role in their care although this was not consistent and generally centred around specific assessments or ‘best interest’ decisions. People and relatives told us they were not included in any of the reviews of care planning and we saw no evidence in care files. People and relatives told us, ‘Staff will always tell us if we need to know anything, such as a fall.’’
We looked at the care record files for 13 people who lived at the home. We found, some examples were staff had not updated care plans and records as care needs had changed. One example was a person who had returned from hospital three days previously with new care needs. The risk of not updating major changes to peoples care plans is that new staff might be unaware of their changed care needs and there is an increased risk that specific areas of care might not be effectively monitored and reviewed.
We found examples where care planning had not been individualised with people’s individual communication needs; for example, a person who had experienced a stroke and a person who had a learning disability. We saw there had been no assessment of the use of any communication aids such as written communication sheets or pictures.
We told the provider to take action
We looked at the daily social activities that people engaged in. We asked people who lived at the home how they spent their day. We found variations between houses as to the level of daily activities for people. People’s comments varied but included, “There is nothing else to do” (but watch television), “Nothing goes on”, “There is not much entertainment.” We saw a good level of activity on a dementia care unit where people were engaged and active. This was not duplicated however in other houses that varied in their level of personalised activities.
A complaints procedure was in place and most people, including relatives, we spoke with were aware of this procedure. We spoke with the registered manager who showed us how complaints were recorded and responded to. We saw recent examples of complaints that had been investigated and a response made.
At our last inspection in September 2014 we had found the home in breach of regulations relating to assessing and monitoring the quality of service provision. This was because management did not always protect against unsafe care and treatment by identifying, assessing and monitoring through effective operating systems. We told the provider to take action.
Unlike our previous inspection the registered manager had now got two clinical services managers [CSM] in post to support the daily management systems in the home. The company had also provided another manager to work alongside the registered manager to provide any extra support needed. We spoke with these managers as well as other senior managers for BUPA. Managers felt they had openly acknowledged previous failings in the home and had developed action plans to improve standards and meet requirements.
The registered manager explained the organisation’s system of audits from ‘house’ level to senior management level and how the results of audits were monitored and fed through to higher managers in the company. Any areas for improvement could be picked up and an action plan devised to help ensure continual improvements. The area manager and quality assurance manager conducted some audits with the registered manager.
Overall we found the management systems in the home were ‘tighter’ and had assisted in the progress the home had made. There was still a need to evidence on-going consistency however.
Some issues we identified on inspection had not been identified by the homes own audits. We discussed some findings where certain auditing processes had not been ‘joined up’. In other words they had not provided effective feedback in good time so that improvement could be actioned. One example was the audit by the specialist dementia nurse into the dementia care environment on two of the houses, which had been undertaken some time ago but not fed back to the respective areas. Another was the annual resident and relative feedback survey. We saw the results of a survey dated January 2014 but this contained the results of a survey carried out in October 2013. The information about people’s feedback was poorly presented and was not user friendly for people reading it. The registered manager could not locate any actions that had been taken regarding any of the feedback. The registered manager said they would look at making this system better presented and timelier.