Archived: Holmwood Nursing Home

Holmwood Nursing Home is a care home providing personal and nursing care to 23 people aged 65 and over at the time of the inspection. Some of the people may be living with dementia. The service can support up to 48 people.

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

There had been some improvements at the service. The previous manager had left which had slowed the pace of improvements, despite the provider remaining legally responsible for the quality of the service at all times. The new manager had been in post since May 2019 and acknowledged more work was needed. The further, recent change in management had led to some confusion to people and relatives about who was responsible for the care to be delivered. Staff felt supported but work needed to be done to ensure staff worked together effectively as a team.

People were not always protected from the risk of abuse as incidents were not always recognised as potential safeguarding concerns or reported where appropriate, to the local authority. Risks to people were managed well with improvements in the recording of people who required specialist input to keep their skin intact. Medicines were administered appropriately however action was needed to make sure medicines did not take too long to be given. There were enough staff to meet people’s needs and action was taken to monitor incidents and accidents to prevent a re-occurrence.

People’s needs were not always appropriately assessed. This is an area that needs to be addressed particularly when the service starts admitting new people. People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. People were not always treated with dignity and respect through occasional lack of thought by staff. Care planning had improved however time was needed for this to be embedded into staff practise.

The mealtime experience was positive for people however there needed to be consideration as to how the environment and people’s rooms could be decorated in line with their needs and wishes. People were involved in the planning of their care and encouraged to be independent where possible. Activities had improved with thought being given as to how people could be encouraged and engaged. Staff were aware of people needs and care planning, including for end of life, care planning had moved fully to an electric system which had enhanced accuracy. Feedback form visiting healthcare professionals was that the service was improving.

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 rating at the last inspection was Requires Improvement (published 3 May 2019) and there were multiple breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection some improvements had been made but these need to be sustained and the provider was still in breach of some regulations.

Why we inspected

This was a planned inspection based on the previous rating and to follow up on action we told the provider to take at the last inspection.

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

Enforcement

We have identified breaches in relation to person-centred care, dignity and respect, consent and good governance at this inspection.

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

The overall rating for this service is ‘Requires improvement’. However, the service remains in 'special measures'. We have done this as there is still one key question rated as 'Inadequate'. 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. We will continue to monitor information we receive about the service until we 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:

There had been improvements to the safety of the service made since the last inspection however, some people were sometimes still at risk of unsafe care and treatment. There was an inconsistent approach to risk management for people who may develop pressure sores or require support with their nutritional needs. Staff competency and responsiveness had improved but some staff did not always know people’s needs well.

There was a new manager in post who had taken steps to improve staff training and had made changes to the environment to help people living with dementia. Whilst this was positive there were further improvements needed to help give people with dementia a better experience of living at the service. Activities had also improved but care planning remained a concern. The provider had introduced a new care planning system which had not been fully used at the time of the inspection. Quality assurance audits had identified and addressed some issues in certain areas but not all those that had been found at the inspection. Further improvements need to be made before we can be satisfied that these will be sustained and embedded into practice.

Rating at last inspection: The rating at the last inspection was Inadequate (3 September 2018). At this inspection the rating had improved. Despite an improvement in the overall rating the service will remain in special measures as the key question of Well-led was rated Inadequate.

Why we inspected: This was a scheduled comprehensive inspection based on the previous rating applied. We were following up to make sure that improvements had been made to the safety and quality of care being provided.

Follow up: We will be monitoring the service and will be re-inspecting to ensure improvements continue and are sustained.

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

There was 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. The registered manager was present during the inspection.

This unannounced inspection took place on 3 September 2018. At the last inspection we identified breaches of regulations as risks to people were not always managed and some areas of the service smelled. There were not always enough staff deployed to meet people’s needs and the quality assurance processes had not been effective at ensuring people received good quality care. At this inspection we found that the safety and quality of the service had deteriorated.

There were not enough staff to safely meet people’s needs which affected all areas of care delivery. Relatives told us that weekends were affected the most however we saw, and staff told us, there were not enough staff working. Safe staffing levels based on the provider’s dependency tool had not been maintained for 27 out of 28 days over a four-week period. Infection control practices were poor which placed people at risk. People’s rooms were dirty and the smell of urine was noticeable throughout the service. Equipment such as hoists were also dirty, the lift had not been working for a month and the premises required improvement.

Risks to people were not always acted upon or reduced to keep them safe. People who were nursed in bed had their pressure mattresses on the wrong setting and were not always re-positioned when they should be. Lessons were not always learned when things went wrong as accidents and incidents were not analysed for patterns or trends. People were not protected from the risk of abuse as safeguarding incidents were not reported appropriately to the local authority. Medicines management required improvement in some areas however medicines were stored and disposed of appropriately.

Staff did not always follow safe moving and handling procedures and training in mandatory areas was not always completed. This affected the quality of care people received. Mealtimes for people were a poor experience as there were limited food choices available. People’s specific dietary requirements were not always followed.

The principles of the Mental Capacity Act 2005 (MCA) was not always followed. Decisions were not always being made lawfully or in people’s best interests. The design and adaptation of the premises did not meet people’s needs. People living with dementia would not be able to orientate themselves as there was inadequate signage to guide them. There were duplicate numbers or no numbers on people’s bedrooms, which made it confusing for people to find their bedrooms. Outcomes for people were not always positive although people had access to healthcare professionals to help maintain good health.

People were not living in a dignified manner. The lack of staff and problems with the environment contributed to a service that was not caring. Staff did not always treat people well or with kindness and respect. People’s privacy and dignity was not maintained and they were not able to express their views about the care they received. There were instances when people were treated well by staff who were able to take time to reassure and help them appropriately.

People who were nursed in bed did not have meaningful activities provided and were at risk of social isolation. For people who could communicate, some activities were provided on the day of the inspection, however for others who could not communicate there were limited things for them to do. Care plans were not person-centred and were not always completed fully. The care plans focused on people’s medical needs and did not give information on people’s likes, dislikes or their personalities. People who were approaching the end of their life did not have information for staff to follow as some advance care plans were not completed.

There was a lack of leadership and direction at the service which affected people’s care and meant staff were not supported or monitored. The provider was not meeting its organisational aims and objectives which affected the quality of care people received. Quality assurance processes were not effective at identifying areas for improvement. Complaints were recorded about various issues such as the smell of urine and missing laundry. These were not always responded to or resolved appropriately.

Areas of concern had not been addressed despite these being raised by the local authority. People, relatives and staff were not always involved in how the service was run. The service did not work in partnership with other agencies. Important events were not always notified to CQC.

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.

During the inspection we found 10 breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one, continued breach of the Care Quality Commission (Registration) Regulations 2009. 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.

Communal areas include two large rooms, one of which leads out to the secured gardens.

Holmwood 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 was 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. The registered manager was present during the inspection.

People and their relatives gave positive feedback about the home, and its staff. However we noticed that aspects of care and support had dropped in quality since our last inspection.

People were not always safe at Holmwood Nursing Home. Risks of harm to people had not always been identified so clear plans and guidelines were not always in place to minimise these risks.

Staff deployment around the home needed to improve. At times people at risk of harm, or in need of support, such as to access the toilet, were left in areas unsupervised by staff.

The effectiveness of the systems to monitor the quality of care and support that people received had declined since our last inspection. Quality assurance records were not all up to date to show that the provider had checked on important aspects of the management of the home. The registered manager had not ensured that accurate records relating to the care and treatment of people and the overall management of the service were maintained.

People had access to some activities; however these were not always focused on supporting people living with dementia. Access to outside trips and visits to the local community were limited for some people who live here.

People had enough to eat and drink, and received support from staff where a need had been identified. People’s individual dietary requirements where met. Overall people were happy with the quality of the food; however they felt the choices dropped when the chef was not there. The registered manager and staff team were working with an outside agency to improve people’s diets.

The staff were kind and caring and treated people with dignity and respect, but peoples experiences were inconsistent. Staff took time to sit and talk with some people and encouraged them to take part in activities. However others were left on their own for periods of time and did not receive as much positive interaction from staff. Caring interactions were seen throughout the inspection, such as staff holding people’s hands. The staff knew the people they cared for as individuals.

People received the clinical care and support as detailed in their care plans, however the care plans were not always person centred, and there were gaps in information. This gave a risk that staff became task focused, with little work being done around people living their lives to the fullest. People and relatives were involved in reviews of care to ensure it was of a good standard and meeting the person’s clinical needs.

Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or the police.

People received their medicines when they needed them. Staff managed medicines in a safe way and were trained in the safe administration of medicines.

People would be protected in the event of an emergency. Each person had a plan which detailed the support they needed to get safely out of the building in an emergency. Appropriate safety checks were carried out on equipment and fire safety systems.

Staff induction and ongoing training was tailored to the needs of the people they supported. Staff received regular support in the form of annual appraisals and formal supervision to ensure they gave a good standard of safe care and support.

Staff recruitment procedures were safe to ensure staff were suitable to support people in the home. The provider had carried out appropriate recruitment checks before staff commenced employment. They had also checked to ensure staff were eligible to work in the UK.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. People’s health was seen to improve due to the care and support staff gave.

People knew how to make a complaint. When complaints had been received these had been dealt with quickly and to the satisfaction of the person who made the complaint. Staff knew how to respond to a complaint should one be received.

During the inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and one breach of the Care Quality Commission (Registration) Regulations 2009. You can see what action we told the provider to take at the back of the full version of the report.

Care and support are provided on two floors. Each bedroom has an en-suite toilet and washing facilities. Communal areas include two large rooms, one of which leads out to the secured gardens.

At our previous inspection in September 2015 we had identified seven breaches in the regulations. The provider had taken appropriate action and addressed all of these concerns.

There was 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.

People told us they were happy living here. One person said, “‘I am well looked after.” Another person said, “It’s a great place.” Staff were happy in their work and proud of the job they do.

People were safe at Holmwood Nursing Home. There were sufficient numbers of staff who were appropriately trained to meet the needs of the people who live here. Staff understood their duty should they suspect abuse was taking place, including the agencies that needed to be notified, such as the local authority safeguarding team or the police.

Risks of harm to people had been identified and clear plans and guidelines were in place to minimise these risks. In the event of an emergency people were protected because there were clear procedures in place to evacuate the building. Each person had a plan which detailed the support they needed to get safely out of the building in an emergency.

Staff recruitment procedures were safe to ensure staff were suitable to support people in the home. The provider had carried out appropriate recruitment checks before staff commenced employment. They had also checked to ensure staff were eligible to work in the UK.

Staff received a comprehensive induction and ongoing training, tailored to the needs of the people they supported. Staff received regular support in the form of annual appraisals and formal supervision to ensure they gave a good standard of safe care and support.

Staff managed the medicines in a safe way and were trained in the safe administration of medicines. People received their medicines when they needed them.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People had enough to eat and drink, and received support from staff where a need had been identified. People’s individual dietary requirements where met. The registered manager was investigating the use of ready meals. They assured us that people would be involved in this process to ensure meals offered choice, and a good quality of fresh food.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. People’s health was seen to improve due to the care and support staff gave.

The staff were kind and caring and treated people with dignity and respect. Good interactions were seen throughout the day of our inspection, such as staff talking with people and showing interest in what they were doing. The staff knew the people they cared for as individuals.

People received the care and support as detailed in their care plans. Care plans were based around the individual preferences of people as well as their medical needs. People and relatives were involved in reviews of care to ensure it was of a good standard and meeting the person’s needs.

People had access to a range of activities. However many people said they were often bored. The registered manager said they would look into this.

People knew how to make a complaint. When complaints had been received these had been dealt with quickly and to the satisfaction of the person who made the complaint. Staff knew how to respond to a complaint should one be received.

The provider had effective systems in place to monitor the quality of care and support that people received. Quality assurance records were kept up to date to show that the provider had checked on important aspects of the management of the home. The registered manager had ensured that accurate records relating to the care and treatment of people and the overall management of the service were maintained.

People lived in a home with good leadership and a stable staff team that worked well together. A relative said, “I’m really happy with the care my family member is given.” Another relative said, “They (Staff) really seem to understand and know the people they care for.”