Archived: Nightingale Nursing and Care Home

Nightingale Nursing and Care Home is a nursing and residential care home providing personal and nursing care to people aged 65 and over. At the time of the inspection 33 people lived at the service. The service can support up to 49 people in one adapted building over two floors.

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

The registered manager had been in post for six months and was working with the local authority quality team, the infection control team and the medicines management team to put improvements in place.

Staff training was out of date, so we could not be sure that staff had received effective training. There were enough staff to meet people’s needs.

Peoples nutritional needs were not always met, and records were not always up to date.

End of life planning was not detailed enough. An activity program that was meaningful and personalised to people’s needs was not fully established.

People and their relatives were positive about the staff and the registered manager. People felt safe and staff had a good understanding of how to protect people from harm. People received safe care, their health needs were monitored, and staff supported people’s independence. People received their medicines safely. Staff followed infection control policies to protect people against the spread of infection, and the environment was clean and well maintained.

Risk assessment were in place to reflect people’s changing needs. People told us there were enough staff to support them and safe staff recruitment practices were followed.

People told us staff were caring and the registered manager was visible and responded to concerns. The registered manager was very motivated to improve the service. Staff were knowledgeable about people’s needs and supported people well.

There were quality assurance systems in place to monitor the service, however actions needed to be closely monitored to ensure they were followed up. The registered manager had made a number of service improvements however these were not fully established at the time of the inspection. The registered manager was well supported by the provider.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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 last rating for this service was Requires improvement (published 19 May 2018) There were no breaches found at this inspection

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

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.

The service had a registered manager at the time of our visit. 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 our last inspection in August 2017 we identified a failure to assess risks to health and safety of people and mitigate risks as much as possible. We found that staff had not always been recruited safely and did not always receive appropriate supervision or training. We had not been notified of certain events as required by law and the quality and safety of the service was not adequately monitored. The service was rated as Inadequate and was placed in Special Measures.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Risks to people’s health and safety had been assessed. However, further improvements were required to ensure the risks were correctly calculated and mitigated the risk of harm as much as possible. People were supported by sufficient amounts of staff who had been recruited safely.

The staff understood their responsibility to protect people from abuse. People received their medicines safely and lived in a clean and hygienic home.

People received care and support in line with their preferences, however improvements were needed to ensure that care plans fully reflected people’s needs and the support they required to meet these. People could access the community; however there was a lack of stimulation at times. People were provided with opportunities to make a complaint about their care; however improvements were required to ensure that these were fully responded to. Staff were knowledgeable about what support people required at the end of their life.

The staff had received appropriate training and support. People received an assessment of their needs before they moved to the home. People were helped to eat and drink sufficient amounts and staff monitored and responded to changes in people’s health. People lived in a building which had been designed to meet their needs. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the home supported this practice.

People were supported by staff who showed them kindness and compassion. Staff knew the people well and told us they got to know people by spending time with them and reading care plans. People were given choices and were involved in making decisions about their own care as much as possible. People could be assured that their privacy and dignity were respected by staff.

People were provided with opportunities to comment on the quality of the service they received. People were supported by a staff team who felt supported and involved in the running of the home. Effective systems were in place to monitor the quality of the service provided. The provider had complied with conditions of their registration and we had been notified of certain events which had taken place in the home.

The service had a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered provers, they are ‘registered persons.’ Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our last inspection on 17 January 2017, we asked the provider to take action to make improvements to the governance and quality assurance processes. The provider sent us an action plan detailing the action they would take and told us actions had been completed in May 2017. We found that the provider had not effectively implemented and monitored the actions identified.

People could not be assured that risks to their safety were always assessed, kept under review and that these were reduced as much as possible. In addition, people could not be assured that staff were recruited safely, that staff had received training in safeguarding adults and that incidents of abuse or possible abuse were referred to the local authority when required.

People were supported by sufficient amounts of staff and received their medicines as required, although improvements were needed to systems which recorded medicines administration.

People were not always supported by staff who had received sufficient supervision, appraisal and training. People were supported to eat; however, improvements were required to ensure that people were drinking sufficient amounts of fluid when needed.

People were asked for their consent before care and support was provided however, decisions which had been made in people’s best interests had not been clearly recorded.

People were supported to see external healthcare professionals when required and were not deprived of their liberty without an application being made or authorised.

People were supported by staff who were caring; however people could not always be assured that sufficient care was taken to maintain their dignity.

People told us they were given choices about some aspects of their care but not others, and it was not always clear how people were involved in planning and reviewing their care. People had access to independent advocacy services.

People’s care records did not always contain an accurate and up to date account of their needs and how these were being met. Staff displayed knowledge of people’s needs but systems to ensure they were aware of any changes required improvement.

People were provided with activities but had limited opportunities to access the outside or local amenities. People knew how to raise concerns but these had not always been reported due to a lack of confidence that changes would occur. When they had been recorded, it was not always clear what action had been taken.

Systems to monitor the quality and safety of the service were not effective and people were at risk of avoidable harm as a result. There was a lack of effective oversight by the provider and we had not received information about certain events which had occurred to enable us to monitor the service.

You can see what action we told the provider to take at the back of the report. 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.

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 of 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.

The service had a registered manager at the time of our inspection. 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.

When we last inspected the service in March 2016 we found there were improvements needed in relation to people’s safety. This was because not all incidents had been shared with the local authority for consideration under safeguarding procedures as they should have been. During this inspection we still could not be assured that incidents had been referred to the safeguarding team when they should have been.

People’s care records were not always updated or reviewed following incidents which had occurred at the service.

There were not always sufficient staff deployed at the service to provide people with interaction and stimulation.

People were supported to take their medicines however, some improvements were required to ensure these were administered in a timely manner.

Staff had not been provided with all of training required to care for people effectively. Staff told us they received supervision and felt supported.

People told us they were offered choices however, people's rights under the Mental Capacity Act (2005) were not always protected. Relevant applications to deprive people of their liberty had been made.

People had access to sufficient quantities of food and drink and told us they enjoyed the food. Referrals were made to healthcare professionals for support and guidance if people’s health needs changed.

Staff supported people in a caring manner and had developed positive relationships with people. People were treated with dignity and offered choices which were respected by staff.

People’s care plans contained limited information about their likes, dislikes and backgrounds. Advocacy information was not available with the service.

People were not always offered the opportunity to be involved in planning their own care although attempts had been made to involve people’s relatives.

People’s care plans were not always regularly reviewed to ensure they contained the correct guidance for staff. Staff were aware of people’s care needs and tried to provide activities and stimulation. However, limited activities were provided during our inspection. Information was available to assist people to make complaints and when these were made they had been responded to.

At our inspection in March 2016 we asked the provider to take action to make improvements in respect of the systems used to monitor the quality of the service and to ensure that we were notified of certain events which occurred at the service. During this inspection we found that sufficient improvements had not been made.

The quality assurance systems in place were not sufficiently robust in detecting issues of concern and bringing about improvements. We had not been notified of certain events which had occurred in the service which the provider is required to do by law.

People and their relatives were given opportunities to provide feedback on the service. People, relatives and staff commented positively on the atmosphere of the service

We identified two breaches of regulations. You can see what action we told the provider to take at the back of the full version of the report.

The service had a registered manager at the time of our inspection, but they had left the service in October 2015 and had not completed the process to deregister. A new manager had been appointed in August 2015 and had submitted their application to become registered. 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.

When we last inspected the service in May 2014 we found there were improvements needed in relation to people’s safety. This was because not all incidents had been shared with the local authority for consideration under safeguarding procedures as they should have been. During this inspection, we found that systems to ensure that safeguarding referrals were made, when required, were still not robust and referrals had not been made when they should have been.

People felt safe in the service but not all incidents had been shared with the local authority for consideration under their safeguarding procedures prior to the intervention of external agencies.

Staff did not have time to sit with people and at times they did not notice when people required support.

People received their medicines as required and action was being taken in relation to infection control issues to reduce the risk of harm to people.

We found that people were not always protected by legislation designed to ensure that their rights were protected because the principles of the Mental Capacity Act 2005 (MCA) had not been consistently applied.

People were not always provided with the right level of support at mealtimes. Referrals were made to health care professionals for additional support or guidance if people’s health changed.

We observed mixed interaction between people who used the service and staff. People’s privacy and dignity was respected but people were not always routinely involved in decisions about their care.

Risk assessments and care plans had not always been regularly updated or contain sufficient information about how the risk of harm could be reduced.

People were at risk of receiving support which did not reflect their individual preferences and some people felt that the amount of activities at the service were limited. We saw that information was provided to assist people in making a complaint and that complaints were responded to.

Improvements were required as to how people’s views were gathered on how the service was run. Improvements were required in relation to management systems to ensure they were effective in addressing shortfalls in the service.

You can see what action we told the provider to take at the back of the full report.

People said, "Staff here are very kind. It's lovely." And, "They know what I like. They treat me with respect." People told us the staff had discussed with them how they wanted to be cared for and we found people's privacy, dignity and independence were respected.

People we spoke with were satisfied that their needs were met as they wanted. Staff demonstrated that they were following the agreed written plans of care and these plans showed a clear improvement had been made since our previous visit in February 2013.

People told us they were happy to have staff to manage their tablets. One person said, "Its the best way, they bring me what I need when I need it, so I can't forget." We saw that senior staff followed good practice. They explained which tablets they were giving to people and asked people if pain relief was needed. We found appropriate arrangements were in place to manage medicines.

There were enough qualified, skilled and experienced staff to meet people's needs. One person said, "They are usually quick to come to help me when I need help." We observed staff responding to people when asked.

Generally, we found people were satisfied with the service.

We found it was not always documented when people gave consent to their care. We also found people received care and support that met their needs, but their care was not always planned and delivered in line with their individual care plan. A person told us, 'I am happy with my care.'

We found people were safeguarded from abuse. Staff we spoke with were aware of the types of abuse that people could face and knew how to would report any concerns that arose. One person told us, 'I feel very safe here, I wouldn't be here if I didn't.'

We found the staff team were supported through training and the provider assessed and monitored the quality of the service. A person told us, 'These care staff are very good. I trust them completely.'