Archived: Court Nursing Home

We found the following examples of good practice.

The provider and registered manager had implemented appropriate procedures within the service to help minimise the spread of infection and help maintain people’s safety during the COVID-19 pandemic. Infection prevention and control (IPC) guidance was displayed around the home so everybody was aware of guidance and the procedures in place, including visitors.

Staff had received IPC training, including the correct use of personal protective equipment (PPE). We observed staff using and disposing of PPE appropriately during the inspection. Regular cleaning schedules were in place and the provider had increased the number of domestic staff on duty each day to support the increased cleaning requirements.

Risks to people and staff had been assessed and appropriate measures taken to reduce risks relating to COVID-19. Social distancing was encouraged and communal areas, such as lounges, dining rooms and staff break areas, had been adapted to enable social distancing where possible. Improvements had been made within the home and new bathrooms created, as well as some en-suite bedrooms.

Staff and people living in the home underwent regular COVID-19 testing in line with government guidance. There were policies in place to guide staff of actions to take should anybody test positive or develop symptoms of COVID-19. People had their temperature monitored each day and this was increased to twice daily following the inspection, in line with current guidance.

Visitors were welcomed into the home following current guidance and a separate entrance and testing area was in use. Visitors completed a lateral flow test on arrival and had their temperature monitored. When relatives were unable to visit, staff supported people to maintain contact with their family members.

We were assured this service were following safe infection prevention and control measures to keep people safe.

People’s experience of using this service:

At the last inspection in November 2017, we found safe recruitment practices were not always adhered to, the environment was not safely maintained and medicines were not always managed safely. At this inspection we looked to see if improvements had been made and found that they had.

Staff had been subject to all required pre-employment checks before they began in post to help ensure they were suitable to work with vulnerable people. People told us and our observations confirmed, that there were sufficient numbers of staff on duty to meet people’s needs in a timely way.

Systems in place to manage medicines were safe and people told us they got their medicines when they needed them.

The environment was safe and a programme of refurbishment was in place to update areas of the home that required some attention.

At the last inspection in November 2017, we found the provider to be in breach of Regulation as systems to monitor the quality and safety of the service were not always effective. During this inspection we looked to see if improvements had been made and found that they had.

The registered manager and staff had a good understanding of their roles and responsibilities within the service. Relatives and health and social care professionals told us the service was managed well. Systems were in place to monitor the quality and safety of the service. Any issues identified were addressed to ensure quality of care was maintained.

People told us they felt safe living in the home due to the support they received from staff. Individual risks to people had been assessed and measures were in place to mitigate those risks. For example, sensor mats were used to alert staff when people were at risk of falling. Appropriate actions had been taken when accidents or incidents occurred.

Staff were knowledgeable about safeguarding processes and concerns had been referred to the local authority appropriately to help protect people from harm.

A system was in place to monitor applications and authorisations to deprive people of their liberty and any conditions attached to them. Consent to care and treatment was sought and recorded in line with the principles of the Mental Capacity Act. Staff supported people in the least restrictive way possible.

Care and support was planned, delivered and monitored in line with current evidence-based guidance, legislation, standards and best practice. Care plans were detailed and reflected people’s needs and preferences.

Staff were supported in their role and had access to relevant training to help ensure they had the necessary skills to meet people’s needs.

People received the support they needed to eat and drink and maintain a healthy and balanced diet. Staff knew people’s dietary needs and preferences and people told us they enjoyed the food available to them.

Improvements had been made to the environment to help ensure the environment was suitable for people living with dementia and the registered manager had plans to develop this further. Some areas of the home were quite tired and required work and redecoration and plans had been made for these improvements.

People told us staff were kind and treated them with respect. Staff knew the people they were supporting well, including their preferences and used this information to build effective relationships with people and encourage meaningful conversations.

Systems were in place to gather feedback from people, although not all people recalled taking part in meetings or surveys. People and their family members told us they felt confident to be able to raise any concerns they had with the management and that they would be dealt with.

Rating at last inspection: The last report was published in January 2018 and the service was rated as requires improvement.

Why we inspected: This was a planned comprehensive inspection based on the previous rating.

Follow up: We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. If any concerning information is received we may inspect sooner.

Court Nursing Home is a privately owned care home with nursing services situated in Rock Ferry, Wirral. The home provides residential and nursing care for up to 31 older people living with dementia or other mental health difficulties. At the time of the inspection there were 28 people living in the home, two of whom were in hospital.

At our last inspection in April 2017, we found that the provider was in breach of Regulations in relation to seeking consent, person centred care, care planning, risk management, safety of the environment, complaints processes, audit systems, systems to gather feedback regarding the service and safe recruitment of staff. The service was rated as requires improvement overall and we issued the provider with a warning notice in relation to Regulation 12; Safe Care and Treatment. This inspection looked to see whether sufficient improvements had been made to ensure the provider was meeting the fundamental standards of care.

In April 2017, we found that risks to people were not always managed appropriately as not all risks were assessed. During this inspection, we saw that detailed risk assessments were in place for specific risks. This helped to ensure that staff had access to clear guidance on the risk people faced and how this could be mitigated. The provider was no longer in breach of regulations regarding this.

At the last inspection we found that care records did not provide clear advice on what support people required and plans regarding the management of wounds were poor. During this inspection we saw that care plans were detailed regarding people’s needs. This included detailed plans regarding wound care. We saw a letter from a tissue viability nurse which congratulated staff in the home on the improvement in the care they provided to people with regards to wound management. The provider was no longer in breach of regulations regarding this.

At the last inspection we found that emergency evacuation procedures were not clear. During this inspection we saw that the provider had developed a new evacuation procedure and staff had been provided with training regarding this. Personal emergency evacuation plans (PEEPs) were in place for people and included detailed information regarding the support they required in the event of an emergency. We found however, that not all safety concerns addressed at the last inspection had been fully addressed, as fire drills had not been completed and not all legionella checks had been undertaken.

Systems were in place to help ensure that the environment and equipment within the home remained safe. However, we saw that not all fire doors closed appropriately within their frames and a radiator in the dining room was very hot to the touch and posed a burns risk should people lean or fall against it. Although improvements had been made since the last inspection we found that risk was still evident and further improvements were required and the provider was still in breach of regulations regarding this.

During the last inspection we found that there was a lack of assessments in place to establish whether people were able to make specific decisions regarding their care and treatment and best interest decisions were not evident for people who were unable to make specific decisions.

During this inspection we found that applications to deprive people of their liberty were made appropriately and mental capacity assessments were in place to establish if people could consent to live in the home. However, mental capacity assessments were not completed for all relevant decisions. This meant that the principles of the Mental Capacity Act 2005 were not followed.

In April 2017 we found that systems in place to audit the quality and safety of the service were ineffective. During this inspection we saw that the provider completed a series of detailed audits which identified areas for improvement. We saw that most of these actions had been addressed, but not all of them. The audits in place did not identify all of the concerns we highlighted during the inspection and not all actions identified on the action plan submitted by the provider following the last inspection had been met. Sufficient improvements had not been made and the provider was still in breach of regulations regarding this.

At the last inspection we found a lack of systems in place to gather feedback from people regarding the service. During this inspection, we saw that quality assurance questionnaires for relatives had been redesigned and issued to relatives. Staff meetings took place regularly and staff told us they were encouraged to share their views. We found however, that meetings had not been held for people living in the home or their relatives.

At the last inspection we found that safeguarding notifications had not been submitted to the Commission as required. During this inspection we found that there had not been any safeguarding incidents, but the registered manager was aware of what needed to be reported.

During the last inspection we found that people did not have person centred care plans in place to meet their needs. During this inspection we looked at the newly developed care plans and saw that people had detailed, personalised plans in place, including plans to address their medical health needs. Care files included people’s preferences in relation to their care and treatment and provided information on what was important to them. The provider was no longer in breach of regulation regarding the provision of person centred care.

At the last inspection we found that the complaints procedure lacked sufficient detail. At this inspection we saw that a new complaints procedure had been developed which provided clear information on how to raise concerns and included contact details for the local authority and the ombudsman. The provider was no longer in breach of regulations regarding this.

We saw that medicines were stored securely and medication administration charts had been fully completed and reflected people’s allergies. However, most of the stock balance checks we made were inaccurate and there were no protocols in place to guide staff when to administer medicines prescribed as and when required. We found that medicines were not always managed safely.

When we looked at how staff were recruited at the last inspection, we found that this was not always completed safely. During this inspection we saw that there were gaps and in one case, inconsistencies, in staff’s employment histories and it was not clear that the most appropriate references had been received. We found that sufficient improvements had not been made and staff were still not recruited safely.

We looked to see if the environment had been adapted to support people living with dementia, to maintain their safety and assist with orientation. Although some adaptations had been made, such as a sensory garden and photographs on bedroom doors, the service could benefit from further developments which may assist people living with dementia. We made a recommendation regarding this in the main body of this report.

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. Feedback regarding the management of the home was positive.

There were sufficient numbers of staff on duty to meet people’s needs in a timely way. People told us they felt safe living in the home and staff were knowledgeable about safeguarding procedures.

Records showed that people’s needs were assessed holistically and planned care was based on current guidance and best practice. Staff sought advice from other healthcare professionals when required and systems were in place to ensure people’s needs could be met when they transferred between services.

Systems were in place to support staff in their role, such as regular supervision and an annual appraisal, as well as regular training.

People’s nutritional needs were assessed and met by staff. This included choice from a well-balanced diet and support from the dietician when people were assessed as at risk of malnutrition.

People told us that staff were kind and caring and that they were treated with respect by staff. Interactions we observed between staff and people living in the home during the inspection were warm and familiar.

Care files we viewed showed that people were encouraged to be as independent as possible and people we spoke with agreed. Care plans showed that family members had been involved in the development of care plans.

An activity coordinator was employed and a schedule of planned of activities was advertised. People told us they enjoyed the activities available.

The registered manager told us they had undertaken a locally recognised end of life training course; ‘Six Steps.’ The principles of this training had been implemented within the home. This helped to ensure people had a comfortable and dignified death.

The rating from the last inspection was clearly displayed within the home as required.

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

Court Nursing Home is located in Rock Ferry, Wirral and offers accommodation with nursing care for adults living with nursing and mental health needs. Accommodation is in single or shared bedrooms and some of the bedrooms have en-suite toilet facilities. There are 15 single and eight shared bedrooms. At the time of the inspection, 27 people lived at the home.

On the day of our visit, 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 manager had been in post approximately 18 months at the time of our visit.

During this visit, we found breaches in relation to Regulations 9, 11, 12, 16, 17 and 19 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches related to the management of risk, the implementation of the mental capacity act, poor care planning and recording keeping, lack of an adequate complaints procedure, poor recruitment practice with regards to staff and ineffective quality monitoring systems. You can see what action we told the provider to take at the back of the full version of this report.

We looked at the care files belonging to five people who lived at the home. We found that people’s care plans did not cover all of their needs and risks and lacked clear information about the management of risks. Information about people’s care was unclear and where professional advice had been given, care plans had not always been updated to reflect this. This did not demonstrate that people’s health and welfare risks were monitored and managed safely.

We found that dementia care and person centred care planning was poor. Care plans lacked adequate information about people’s preferences and did not provide staff with person centred guidance on how best to support them when they became upset or displayed behaviours that challenged. Information relating to people’s like and dislikes, end of life wishes and support to remain independent was limited and did not show that people’s needs were properly assessed so that personalised care could be provided.

The home was clean, free from offensive odours and well maintained. Equipment was properly serviced and maintained. The risk of Legionella had been assessed but the water checks undertaken did not show that the risk of Legionella was managed safely. We also found that some of the hot water temperatures dispensed from taps in the home’s communal bathrooms were too hot and presented a scalding risk. There was no evidence any action had been taken to address this.

The provider’s fire evacuation procedure was unclear and information in place to assist staff and emergency services personnel in the event of a fire or other emergency evacuation was inadequate. This meant staff and emergency personnel lacked vital information to protect people from harm during an emergency situation.

Where people’s capacity to consent to decisions about their care was in question, the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguard legislation (DoLS) had not always been followed. People’s capacity to consent had not always been assessed to ensure legal consent was obtained. We saw people had access to independent mental health advice and support as and when required to help them understand and participate in decisions about their liberty which showed the beginnings of good practice.

People we spoke with said the food at the home was good and they got enough to eat and drink. We found however that some people had special dietary requirements which were not always met in accordance with dietary advice or in a way that mitigated risks of malnutrition. Staff lacked sufficient knowledge of people’s nutritional needs. There was no evidence that the people who were at risk of malnutrition, had their dietary intake monitored in any meaningful way to ensure their nutrition and hydration needs were met.

People who lived at the home, relatives and visitors we spoke with during our visit spoke positively about the home and the staff. They told us staff were kind and caring and that all staff including the manager and provider were approachable and easy to talk to. None of the people we spoke with had any complaints or concerns about the service and no formal complaints had been recorded by the manager. The provider’s complaints procedure required improvement. It lacked sufficient information on which organisations people could contact should they wish to make a complaint about the service. It was not readily accessible to people who lived at the home, as the procedure was displayed in an area that people could not voluntarily access.

We observed that staff treated people kindly and spoke to them with respect. It was obvious that people felt comfortable and relaxed in the company of staff. The atmosphere at the home was warm, homely and caring and we saw lots of positive interactions between people who lived at the home and staff to demonstrate that they had positive relationships with each other.

Staff we spoke with told us they felt supported to do their job and records confirmed this. Some staff training had expired which meant that the knowledge of some staff may be out of date.

A satisfaction questionnaire had been devised but had not been circulated to enough people, to enable the provider to be confident of the overall quality and safety of the service. No resident and relatives meeting took place and there were no other formal systems in place to enable people’s feedback on the service.

We looked at the quality assurance systems used by the manager and provider to monitor the quality and safety of the service. We found improvements were required. This was because the systems in place failed to effectively identify and address the areas of concerns we found during our visit. For example, poor risk management, a lack of person centred care planning, inadequate emergency arrangements, poor staff recruitment practices and poor record keeping. As the systems in place failed to identify the areas were improvements were required no action to address these had been taken. This demonstrated that the governance systems in place were ineffective and that the management of the service required improvement.

An action plan by the home outlined improvements they intended to make which included the removal from people's records of generic risk assessment information and the initiation of person centred plans. Arrangements had been made for staff to attend training relevant to their roles and a supervision plan was to be agreed.

During this visit we found person centred care plans and risk assessments had been introduced with information to staff about how care should be met and risk should be managed. 20 care staff had attended training in the managment of difficult behaviour and all qualified staff had the required mental capacity act certificates. Some supervisions had taken place since our last visit and there was a plan to continue these throughout the year.

People who used the service and relatives we spoke with said:

'I love it here, the staff are great, I just sing all day long';

'It is a very good home and there is always a wonderful atmosphere';

'Staff seem to understand people'; and

'We are very happy with the home. Mum is well looked after'.

A relative told us "It is more like a family here, people are not left in their rooms and the staff are happy and very approachable".

A person who uses the service said "It's a good place; they look after me well and the staff are all nice".

Arrangements had been put in place around consent to treatment and staff had been provided information on the Mental Capacity Act 2005 to read prior to attending a training course. We spoke to three staff who confirmed they were aware of mental capacity, deprivation of liberty and the need to obtain consent.

We looked at the assessment process and reviewed care records of six people living at the home. We found improvements were needed to demonstrate that staff had access to sufficient and up to date information about the care and support people required. We discussed this with the provider who was in the process of making improvements in this area.

We found there were systems in place to meet people's nutritional needs and manage medication and the provider ensured that standards of quality and safety were maintained by regular audits and quality assurance processes.

Supervision and training had been implemented to better support staff in their roles and training was planned to support staff in the management of people with challenging behaviour.

We spoke with five people who used the service who said that they got the support and help they needed from the staff. Some comments made were:-

'The home is alright. I feel well looked after.'

'Its okay here. I'm quite happy.'

'The staff help when I need it. Any problems and I speak to the manager.'

We spoke to one relative who described the staff as caring and attentive.

We spoke to two social care professionals who said that a good service was provided.

We spoke to two health care professionals who said that the service referred people to them appropriately and followed any advice given.

We found that people experienced care, treatment and support that met their needs. The home was clean and safe. We found that there were suitable arrangements in place to manage complaints about the service.

We found that improvements were needed to ensure that the best interests and rights of the people who used the service were fully supported and promoted.

Improvements were also needed to the training provided to staff to ensure that they had the knowledge and skills to appropriately support the people who used the service.

No current information was available from Wirral Borough Council the time of writing this report.