Archived: Longbridge Deverill House and Nursing Home

Longbridge Deverill House and Nursing Home is made up of two buildings on the same site. The house is a residential care home for up to 20 people and is located at the front of the grounds. The nursing home is situated towards the back of the grounds and up to 60 people can live there for residential, dementia, and nursing care.

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

This inspection took place at 5.30am due to concerns about people having to get up early. We found most people were in bed in their nightclothes. Some people were in the communal lounges, but this was their choice. Whilst staff explained people were encouraged to get up when they wanted to, there were some comments about specific staff assisting people from 4am onwards. The manager said they were aware of this and had spoken to staff. However, checks to ensure this practice was not taking place, had not been undertaken.

Staff told us they generally started assisting people with their personal care at around 6am. They described this as, “starting their rounds” or “pad changes”. This terminology and practice were not person centred and did not promote a 24-hour approach to care. The manager said they would address this within staff meetings.

Audits to check the safety and quality of the service had been undertaken. However, whilst the audits had identified some shortfalls, action plans had not been documented. This increased the risk of shortfalls not being appropriately addressed.

Not all risks to people’s safety had been identified. This included one person who had their legs over their bed rails and another who had their table too high to eat safely. There was a hot water urn in a nurse’s station, and staff took drinking water from a hand wash basin, next to a toilet in an en-suite. The manager told us they would consider and address these areas without delay.

Food and drink within the kitchenettes were not stored safely. Dates of opening and expiry dates were not recorded, which did not ensure the items were safe to use. People had snacks, such as biscuits and crisps, available to them during the night but there was no access to the main kitchen. The manager told us they had identified the range of food available at night, was limited. They said a review of all food and snacks was being undertaken.

People were encouraged to give their views about the service. Records of ‘resident’ and relative meetings showed the points raised, but action plans were not in place. This did not show people were being listened to, and their views were being addressed.

Whilst staff said they had a good team, they felt there needed to be an increased management presence within the home. They said the manager’s leadership did not fully inform them of the ethos or direction of the service. Staff told us the manager was often office based and did not know people or staff well. The manager was aware of this and said they would be addressing the amount of contact they had with people and staff.

The manager was aware of their responsibility regarding the duty of candour. Since their appointment, they had spent time considering what worked well and what needed improvement. They were committed to improving the service and had recruited additional staff to minimise the use of agency staff.

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 07 February 2019).

Why we inspected

The inspection was prompted due to concerns received about some staff assisting people to get up as early as 4am. There were also concerns about the lack of food available to people during the night, and staff not being able to access continence supplies.

Following the receipt of the concerns, a decision was made for us to inspect and examine the risks. We undertook a targeted inspection to review the key question of well-led only.

CQC have introduced targeted inspections to follow up on a Warning Notice or other specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We have found evidence that the provider needs to make improvements. Please see the well-led section of this full report.

After the inspection, the manager sent us an improvement plan. This showed actions that were being undertaken to monitor and develop the service.

You can see what action we have asked the provider to take at the end of this full report.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

At the previous inspection in November 2017, we rated the service overall as Requires Improvement. This was because mental capacity assessments did not contain enough information and the quality monitoring systems had not identified this. At this inspection, we found that the required improvements had been made and the service is now rated as Good.

Longbridge Deverill House and Nursing Home are two buildings on the same site. The house is a residential care home for up to 20 people and is located at the front of the grounds. The nursing home is situated towards the back of the grounds and up to 60 people can live there for residential, dementia, and nursing care. At the time of the inspection, 16 people were living in the house, and 56 people lived at the nursing home. Longbridge Deverill House and 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 and registered person were available throughout the inspection.

People told us they felt safe living at the home. People’s relatives felt confident that their family members received safe care.

Staff understood their responsibility to identify and report any concerns of abuse. Staff received safeguarding training. They told us they felt confident that action would be taken by any member of the nursing and management team in responding to concerns.

Risks to people’s safety were identified and assessed. Risk reducing measures were incorporated into people’s care plans, directing staff about how to avoid risks occurring.

There were enough staff to meet people’s needs. We observed staff responding to people’s needs promptly. People told us staff were there when they needed them. New staff were appointed through safe recruitment and selection processes.

Accidents and incidents were reported and analysed by the registered manager. Any trends or themes were identified. Where there were opportunities to learn from accidents or incidents, this was shared with the staff team. There were clinical governance meetings with the nurses, to reflect upon different aspects of their nursing practice.

Medicines were managed safely. Where people required creams or lotions to be applied, there were detailed plans for staff to follow. Technology was used in medicines management to ensure timely communication between the home, GP, and pharmacy.

People had received a health review from the GP, two months prior to the inspection. This was to ensure that medicines and care plans were reflective of their needs. All of the health and social care professional we received feedback from, praised the quality of care at the home. We saw that health and social care referrals were made in a timely manner.

Health and social care professionals told us that people with behaviours that other services had found challenging to manage, had notably improved. The registered manager told us that they supported successfully, a lot of people who had been “failed placements elsewhere”. This included reducing reliance upon medicines, where people had been overmedicated in other services.

People with diabetes received personalised care that had been effective for one person in reducing their reliance upon insulin. For another person, there had been significant improvements in their diabetic condition.

The home was well-maintained, with the required water, fire, gas and equipment safety checks completed. The majority of the home was clean and free from odours and people felt their bedrooms were kept to a good standard of cleanliness.

People were cared for by staff who received an outstanding standard of bespoke and creative training. Training programmes were designed around people’s needs and staff competencies were assessed through regular training refreshers and observations.

People had been involved in the creation of dementia training. This provided a personalised insight into how people feel while living in a care home and how dementia affects them. Other people living in the home, as well as relatives, staff and professionals were invited to attend the session.

Mental capacity assessments were detailed and explained how the person had been involved in their assessment. Best interest decisions had been made with the person’s legal representative, as well as involvement from professionals. Deprivation of Liberty Safeguard applications were submitted to the local authority.

People had access to food and drink throughout the day. People who required one to one support during meal times had staff sit with them to provide this. Where people needed their food and drink intake monitored to ensure their dietary needs were being met, the records reflected that targets were being met.

Equality and diversity were in the provider’s policies. This included a policy on sexuality, which focussed on the importance of respecting people’s choices and supporting relationships.

People told us staff respected their choices. People’s choices, preferred routines, and how they communicated decisions were included in their care plans. Care plans reflected people’s physical, emotional, and social wellbeing.

Staff understood how to support people by respecting their privacy and dignity. We observed examples of kind and respectful care being delivered.

The environment was designed to meet people’s visual and cognitive needs. People could personalise their bedrooms, assisted by the maintenance operative when they moved in. People also had access to different areas in the home and were supported to access the community with relatives and staff.

There was an activities team, providing a set programme, as well as ad-hoc and impromptu activities, based on people’s hobbies, interests and feedback received. Technology was used to enhance the activities provision, with people viewing photographs and videos via an electronic tablet.

People’s visitors were welcomed to visit the home at any time. Technology was used to help people maintain contact with family overseas, through online video chats.

The registered manager maintained an up to date knowledge of clinical and care skills, as well as knowing people who lived at the home. They kept their professional nursing registration and ensured that clinical governance meetings took place with the nursing team. They also completed initial and ongoing assessments for people at the home, to ensure they knew people and their relatives well.

People and their relatives, staff and professionals all felt that the registered manager was approachable, knowledgeable, and would take prompt action if needed.

We discussed with the registered manager about ensuring there was continuous improvement in the delivery of care. While there had been improvements some areas needed time to embed into practices and to develop partnership working.

The Longbridge Deverill site provides care to 20 older people at Longbridge Deverill House located at the front of the grounds. Towards the back of the grounds is a 60 bedded nursing home divided into two purpose built units for people with general nursing needs and dementia care needs. 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.

A registered manager was 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 were supported to have choice and control of their day to day lives and they were supported by the staff to make some decisions. Documents showed staff lacked an understanding on when they were to assess people’s capacity to make complex decisions. For some people the staff reached best interest decisions without consulting families and where lasting power of attorney were in place these individuals were not consulted.

Quality assurance systems were in place and action plans were developed on how shortfalls identified through audits were to be met. However, audits had not identified that frameworks to gain consent from people identified as lacking capacity were not meeting the principles of the Mental Capacity Act 2005.

Safeguarding procedures were in place. People told us they felt safe and staff told us they had attended safeguarding of vulnerable adults from abuse. The staff we spoke with knew the types of abuse and the actions they must take for reporting alleged abuse.

Systems were in place to identify and manage potential harm . Risk assessments to support people to take risks safely were devised and regularly reviewed.

Staffing levels were well maintained. There were sufficient staff to meet people's needs and staff had time to spend with people.

People received their medicines safely. Medicine administration records (MAR) sheets were signed to indicate when medicines were administered. Where people were prescribed medicines with specific instructions for administration we saw these instructions were followed.

People received effective care from staff who had the skills and knowledge to support them and meet their needs. Staff attended training set as mandatory by the provider and attended refresher training when the training had become outdated or expired. Staff had regular meetings with their line manager to discuss their performance, concerns and training needs.

People were supported to access health professionals when needed and staff worked closely with people's GPs to ensure their health and well-being was monitored.

Arrangements were in place to maintain the environment clean and we found the home was free from unpleasant odours. We saw housekeeping staff maintaining the environment.

We saw good interaction between people and staff. The feedback from people and their relatives was complimentary. Staff knew how to respect the rights of people.

The registered manager monitored the quality of the service and looked for continuous improvement. The registered manager was supported by the provider.

Longbridge Deverill House is an older style property and offers accommodation and personal care. At the time of our inspection there were 17 people living at Longbridge Deverill House. Directly behind the house is another newer building which provides accommodation for people who require personal and nursing care. The nursing home is divided into four units which support people with varying levels of health needs. There were 56 people living in the nursing home at the time of the inspection. The service did not have a registered manager in place, however a new manager had started in November 2016. The manager was intending to register with CQC.

We looked at the concerns raised and found the provider had not protected people from the risk of harm and abuse as some people were being unlawfully restrained as a means of managing their behaviour.

There were systems in place to ensure that medicines were administered safely and people received their medicine on time and in a place of their choosing. Stock levels were correct and disposal of medicine were managed in line with the provider policy.

People and their families told us staff were kind, considerate and caring. However, due to the concerns we found around restraint we did not find this to always be the case. We observed people had developed positive relationships with staff and people told us they felt safe.

There was a lack of equipment to ensure safe infection control practices could be followed. Not all areas of the environment or premises were safe and suitable for the intended use.

Staffing levels were not determined by the needs of people which resulted in people not always receiving timely and appropriate care and support. People told us they liked the staff.

There was a varied range of nutritious food available and people told us they enjoyed their meals and had sufficient to eat. Within some units of the nursing home we found the meal times were not organised enough to ensure people received appropriate support.

Staff supervision was not routinely being carried out and appraisals had fallen behind. Staff told us the training they received was good, however a course intended to enable staff to help people manage their behaviours was not appropriate. This led to a culture of staff perceiving it was in the best interests of people to restrain them when they became agitated. We found the lawful process intended to protect people from abuse had not been followed.

There were varying levels of understanding from staff around the Mental Capacity Act 2005 and the provider had failed to ensure that due process was followed in line with the Act.

People had access to a range of activities and social interaction however some people did not receive appropriate stimulation, social interaction and meaningful occupation if they did not wish to participate in the activities on offer.

Care plans were not person centred and lacked information about how to enable and support people with maintaining daily living skills and their independence. Care records were inconsistently completed between different areas of the service and lacked detail about people’s care and support. Care plans had not been effectively reviewed to ensure their current needs and preferences were known. The monitoring of people’s care and support was inconsistent.

Quality assurance systems, governance and the audits in place had identified some of the concerns we found, however remedial action had not been taken to address the shortfall. Other concerns we raised were not identified by the quality assurance systems in place.

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.

People who use the service told us they were satisfied with the service they received. People felt the staff supported them and met their needs. One person using the service said "we are looked after very well."

People told us that staff treated them with dignity and respect. One person said 'I was flabbergasted by their kindness.' We saw staff speaking and responding to people in a kind and respectful manner.

The care records showed us that people's health needs had been assessed before they came to live in the home. These records included information from health and social care professionals which helped ensure people got the care and treatment they needed.

Recruitment records showed that new staff had been checked to ensure they were suitable to work with vulnerable people. The home trained their staff and had procedures which protected people from abuse. People told us they did not have any complaints but were uncertain of who to speak to if they were concerned. One person said 'I suppose it's my keyworker' whilst another said 'I don't really know.'

The service and the building were monitored and risk assessed to ensure they were suitable for the people using them.

The evidence we collected showed us the service kept people safe and met their care needs.

People's complaints were recorded and addressed.

People's views of the service were collected and action taken where needed.

Incidents and accident reports were up to date. Essential risk assessments had been completed.