This inspection took place on 19 and 20 September 2017 and was unannounced. The Green Nursing Home provides accommodation for up to 59 older people who require nursing or personal care, and who may be living with dementia. At the time of our inspection there were 46 people living at the home. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered nominated individuals, 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 of the service had left in July 2017 and the home was being managed on a day to day basis by the Nominated Individual who is a person who has legal responsibilities to ensure the service runs safely and well, and is the representative of the provider. At the time of our inspection there was also an acting manager who told us they planned to apply to become the Registered Manager. They were volunteering their time at the service and had not yet been employed by the company.
The home was last inspected in May 2017 when we found the provider was not meeting the requirements of the law in four areas. Of the five key questions, we rated four as Requiring Improvement and the key area of Safe as Inadequate. We spoke with the provider’s representative and the registered manager following our inspection in May 2017. We asked them to send us an action plan detailing what actions they would take to improve the service. We returned to the service to undertake this comprehensive inspection six weeks before the work detailed in this action plan was due to be completed. We expected to see that improvements were well underway and to gain confidence that the improvements would be completed within the time scale on the action plan. At this inspection we did not find that improvements had been made in line with our expectations. This inspection found the provider was not meeting the requirements of the law in four areas. Of the five key questions, we rated three as Requiring Improvement and the key areas of Safe and Well Led as Inadequate. The provider had failed to secure adequate improvements to improve the safety and quality of service provided to people.
Prior to our inspection we had received a larger than expected number of safeguarding alerts in relation to The Green Nursing Home. We worked closely with the local Clinical Commissioning Group (Part of the NHS) who were providing nursing support and visiting the home regularly. They provided us with information about the safeguarding concerns and how they had been addressed. During our inspection we found that when a safeguarding alert had been made it was dealt with appropriately. However we were not confident that all areas of concern had been identified by the service as safeguarding issues. We found that four peoples care was not safe and had not been recognised as such by staff. The poor management of wound care was highly concerning and people were experiencing inadequate care and medical intervention. After the inspection safeguarding alerts were made to the local authority by the inspection team in relation to these concerns. We are awaiting the outcome of these.
The provider had failed to consistently notify us when they were legally required to do so.
People told us they felt safe. We saw safe techniques were used to move people. Staff understood the risks to people’s health and safety but risks such as support to people who had skin wounds were not always managed well. Recording of these risks was not always evident. There were sufficient staff to meet people’s needs, although some people felt that more staff were needed on occasion. The provider operated a safe recruitment system which meant people were supported by suitable staff. Staff understood their responsibility to raise concerns regarding potential abuse.
People told us that staff had received training to support them, but the support was not consistent. Staff understood the need to ask for consent and we saw that they asked people before providing any care. The Nominated Individual had started to apply the principles of the Mental Capacity Act, but some people may have been unlawfully deprived of their liberty as applications to do that had not been submitted when deprivations were identified. People’s nutritional needs were being met. People had access to some health professionals when their health needs changed, however we were not confident that all healthcare needs were well met.
People were supported by kind and considerate staff. People had some day to day choices about their care and staff listened to them and respected their choice. People were not always treated with dignity and respect by staff. Staff encouraged people’s independence where possible.
People received care which was not always responsive to their individual needs Improvements were required to ensure people’s care records contained up to date and accurate information about the care they received. People and their relatives told us they felt comfortable raising complaints with the Nominated Individual, and we saw there was a formal complaints process in place.
Although people told us they were happier with the care provided they had not been included in any of the on going or proposed improvements. People had not been involved in planning or reviewing their care. The governance system had only just started to be implemented and had not been effective at the time of the inspection. The nominated individual did not have a full awareness of the extent of the problems and issues which needed to be addressed. It had also not been effective in improving quality or mitigating risks.
During this inspection we found that provider to be in breach of four regulations. You can see what action we told the provider to take at the back of the full version of the report
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.
Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded. You can see what action we told the nominated individual to take at the back of the full version of the report.