Swarthdale Nursing Home

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

People were not protected against harm because all risks to their safety had not been identified and managed. Health and safety management was inadequate. Some staff had not completed required training related to providing care safely. The registered manager reported any concerns about abuse to the local authority, however, not all incidents were reported to all relevant people and reviewed appropriately. Safe systems were used when new staff were recruited.

The provider had not ensured effective oversight of the quality and safety of the service to ensure people were protected from harm. The provider had not implemented adequate reasonable adjustments to support the registered manager to carry out their duties effectively.

The provider had no effective oversight of the care home or governance arrangements to ensure people received high quality care. Staff told us there was an absence of communication from the provider and registered manager. Staff had no confidence concerns they raised would be acted upon to ensure people were cared for appropriately.

People did not always receive effective care because their needs were not always promptly reassessed or monitored as they changed. People were included in choosing their meals and mealtimes were flexible to people's wishes and preferences. The home had been adapted to meet people's needs. People were not consistently supported to have maximum choice and control of their lives in the least restrictive way possible and in their best interests. Policies and systems in the service were out of date and did not adequately involve people’s choice, independence, and best interests.

Staff were committed to providing people with person-centred care. They were open and honest with people. Interactions between staff and people were kind, caring, and respectful. People told us staff “are nice” and “they look after me very well”. However, the provider had not ensured people’s care plans adequately reflected their preferences and actively involved them in making decisions about their care, treatment, and support. The provider had not ensured people nearing the end of their life had current care plans in place or people’s preferences and choices were respected to give them a comfortable, dignified, and pain free death. People told us they did not like to bother the staff because “they’re so busy”.

People told us there was “nothing to do” and there were not enough activities to meet the needs of different people. An activity coordinator was in post but absent during our inspection and the provider had not arranged effective cover. Staff told us there were no activities for people at evenings and the weekends. Not all people living in the home knew who the registered manager was or how to complain. We saw no evidence the views of people and staff had been sought to improve the service. There was no evidence of involving people in planning activities and the provider was unable to show us records of compliments, complaints, or actions which had been taken to share learning from feedback.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence, and good access to local communities most people take for granted. ‘Right support, right care, right culture’ is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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 26 August 2022). The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

Why we inspected

We received concerns in relation to infection control, management, and staffing, along with the results of an unannounced comprehensive inspection of this service on 20 July and 1 August 2022 where breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment and establishing systems to monitor and improve the quality of the service.

We undertook this focused inspection to review the key questions of safe and well-led only. A decision was made for us to inspect and examine those risks. We inspected and found there were additional concerns with management of medicines, quality assurance, and health monitoring so we widened the scope of the inspection to become a comprehensive inspection which included all the key questions: safe, effective, caring, responsive, and well-led.

We looked at infection prevention and control measures under the safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

We have found evidence the provider needs to make improvements. Please see the key question sections of this full report for details. You can see what action we have asked the provider to take at the end of this full report. The provider had taken some action to mitigate the risks and was starting to establish improvements.

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

Enforcement and Recommendations

We have identified 6 breaches in relation to safe care and treatment, person-centred care, need for consent, receiving and acting on complaints, staffing, and good governance at this inspection. There was 1 further recommendation in relation to staffing.

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

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

Swarthdale Nursing Home is a care home providing accommodation and nursing and personal care to up to 43 people. The service is a large property which has been adapted to meet people’s needs. The home provides care for older people and people living with dementia. There were 31 people living in the home at the time of our inspection.

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

People were not protected against harm because risks to their safety had not been identified and managed. Some care records had not accurately identified risks to people or how these were managed. Although there were enough staff to provide people’s care, some staff had not completed required training related to providing care safely. The manager had identified shortfalls in staff training and had arranged for staff to complete required training during our inspection. Safe systems were used when new staff were recruited. The manager reported any concerns about abuse to the relevant authorities.

The provider had not ensured effective oversight of the quality and safety of the service to ensure people were protected from harm. The registered manager was absent from the home due to long-term sickness. The provider had employed an interim manager who had identified some areas where improvements were needed to the service. The manager had developed an action plan to address issues they had identified. The manager and staff were committed to providing people with person-centred care. They were open and honest with people. The manager sought the views of people and staff to improve the service.

People did not always receive effective care because their needs were not always promptly reassessed or monitored as they changed. People were included in choosing their meals and mealtimes were flexible to people’s wishes and preferences. People were supported to see their doctors as they needed. The home had been adapted to meet people’s needs. 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

The last rating for this service was good (published 22 June 2018).

Why we inspected

We received concerns in relation to infection prevention and control and how the provider managed risks to people who had multiple needs. As a result, we undertook a focused inspection to review the key questions of safe, effective and well-led only.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from good to requires improvement based on the findings of this inspection.

We have found evidence that the provider needs to make improvements. Please see the safe, effective and well-led sections of this full report.

The manager took immediate action to improve the safety of the service following the inspection. They provided a robust action plan showing how they were addressing the issues identified.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold register providers to account where it is necessary for us to do so.

We have identified breaches of regulation in relation to managing risks and governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from 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 continue to monitor information we receive about the service, which will help inform when we next inspect.

We found the following examples of good practice.

Staff were trained in infection prevention and control and using Personal Protective Equipment (PPE) safely.The provider had ensured sufficient quantities of PPE were available.

The manager ensured clear information about maintaining social distancing was in place to guide staff and visitors. They had rearranged communal areas in the home to support social distancing.

The manager had followed government guidance about visiting. They had supported relatives to visit people and stay in touch. Consent for testing and vaccination had been obtained from people, with appropriate support from their representatives, families and professionals.

The manager followed best practice around safe admissions when people moved into the home.

The manager had arranged for regular COVID-19 testing for staff and people who lived in the home.

The staff team kept the home uncluttered, clean and hygienic. Audits were done. Frequently touched surfaces were cleaned regularly throughout the day to reduce the risk of infection.

The manager had reviewed staffing arrangements. Staff were allocated to consistently work in specific areas of the home to reduce the risk of transmission of infection.

The provider had robust contingency plans in place to ensure the safety of the service during the pandemic.

Swarthdale Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Swarthdale Nursing Home accommodates up to 43 older people.

The home is in a residential area of the market town of Ulverston in an older building that has been adapted and extended for its current purpose. Accommodation is provided on two floors, with two passenger lifts. There is a seating area and car parking at the front of the building.

There was a registered manager at the home. 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 who lived in the home told us they were satisfied with the way the home was run and the care they received. One person told us, “I would rather be in my own home but they do look after you in here.” We observed that staff were polite and considerate and that people who lived in the home seemed to be at ease with care staff.

Risk assessments had been developed to identify and minimise the potential risk of harm to people during the delivery of their care. These and individual care plans had been kept under review and updated when necessary to reflect people's changing needs. We have made a recommendation that the registered manager review their risk assessments on bedrails and bumpers to follow the manufacturer’s instruction on their use.

Care plans were based upon the individual needs of people and contained information about people's personal needs, likes and dislikes. We have made a recommendation that the service seek advice about ways of supporting people in the home to be more involved in decisions about their care, treatment and support and record this.

The service worked with local GPs, district nurses and health care professionals and external agencies to provide appropriate care to meet people’s different physical, psychological and emotional needs. We found that medicines were being administered safely and records were being kept of the medicines in the home.

Systems were in place to deal appropriately with any complaints or concerns raised about the service. Staff had received safeguarding training and were aware of their responsibilities to report.

We found staff had been recruited safely and were being trained and supported to carry out their roles. Staffing levels were observed to be sufficient to meet the needs of people who lived at the home.

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 service support this practice. People's privacy and dignity was being promoted.

People told us they were happy with the variety and choice of meals being provided and that there was always a choice. We observed regular snacks and drinks were provided between meals to help make sure people received adequate nutrition and hydration.

The registered provider continued to improve the environment for the people who lived there. The building was being maintained and was a clean place for people to live. We saw that equipment in use had been serviced and maintained as required.

Quality assurance surveys and meetings were used to seek the views of people who used the service and there were a number of audits being carried out to monitor systems. We have made a recommendation that when the registered providers visit they record their quality assurance monitoring and include the people who lived there in the process.

The registered manager and deputy manager were experienced, knowledgeable and familiar with the needs of the people they supported and worked together to develop the service. We have made a recommendation that the registered providers give greater support to the registered manager and deputy in respect of dedicated time to implement major changes.

Further information is in the detailed findings below

We visited the home to follow up on a compliance action made at the last inspection 11 June 2014 in relation to consent to care and treatment. We also followed up concerns that had been brought to our attention in relation to staffing, the suitability of equipment in use and the infection control and maintenance of the home environment.

Below is a summary of what we found. The summary is based upon our observations, discussions with people who used the service, their relatives and the staff who supported them and from looking at the records held in the home. We also observed the interactions between people living there and the staff supporting and caring for them.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We saw that risk assessments had been carried out to help make sure that people who lived in the home received safe and appropriate care and treatment. This included in the important areas of nutrition, personal care, skin care and wound management, mobility and moving and handling and the risk of falls.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes and we saw that proper policies and procedures were in place. We found that there was evidence that each person's capacity to consent was being assessed and recorded in relation to care and treatment decisions.

We made a tour of the home and the areas used by the people who lived there. We found that the home was in need of an upgrading of the facilities and the environment and some redecoration.

At the previous visit the manager had told us that environmental issues we highlighted to them would be attended to under the home's general maintenance. The work had not been carried out when we visited again although there was evidence shown to us to indicate that a contractor had been contacted to do some of the refurbishment work.

We observed during the visit that the home environment was not 'dementia friendly' and was not well maintained to promote people's wellbeing. The laundry environment continued to pose problems with keeping the laundry easily cleanable and hygienic.

We found that the moving and handling equipment being used in the home was regularly serviced. We observed staff undertaking moving and handling procedures and they demonstrated a good knowledge of equipment and techniques. However slings used for moving people were being used communally which can pose an infection risk.

During our visit we looked at the staffing levels, staff deployment and at staff rotas for the previous weeks. We found that there were sufficient staff available to support people. The manager, in collaboration with staff, had made changes in the times staff started and finished work and took their breaks. This change had improved the numbers of staff available at the busiest times of the day when people needed more support.

Is the service effective?

We found that mobility equipment was in place and people had been assessed for its use. The equipment and how it was to be used was set out in people's care plans.

We saw that there were records in place documenting people's choice and preferences. There were also records of why and how a person's best interests had been discussed and their mental capacity assessed. People also had the opportunity to make decisions about future care, treatment and their wishes should their health needs change radically and this was recorded in their plans.

Is the service caring?

People had access to organised activities in the home and to take part in activities that were important to them, for example attendance at their own church.

We could see in people's care plans that assessments of individual's care and support needs had been carried out using appropriate clinical tools and how they would be managed. Care plans had been written with a focus upon people's own preferences.

Some of the people living in this home were not able to easily express their views about the support they received. We spent time in communal areas of the home to observe staff interactions and approaches to people living there. We observed that some care staff took opportunities to interact positively with people living there. For example, making conversation with people, offering them more drinks, encouraging them with their meal and asking if they wanted anything else to eat.

We also observed that there were several members of staff who did not take up valuable opportunities to positively interact and connect with the people living there. We observed that there were some staff that did not ask people what they wanted or include them in conversations. This can affect people's wellbeing and social inclusion.

Is the service responsive?

People living there that we spoke with told us, 'I have never found that they (staff) don't come when I have used my bell for help'. We were also told, 'I have never needed to make a real complaint, if I did I would tell the manager or the nurses'.

People living there were able to join in organised activities if they wanted to and some people went out into the local community. We saw people were able to follow their own faiths and attend religious services if they wanted to.

People who lived there told us that they could see their doctor if they needed them and saw them in their own rooms. We could see from care records and speaking with people that they had support from relevant healthcare professionals. This included seeing the chiropodist, the dietician, speech and language team and community mental health team.

Records confirmed people's preferences, interests and different needs had been recorded and personal care had been provided that met their assessed needs.

Is the service well-led?

At our visit in June 2014 we did not find clear evidence that tests, set out in legislation, had been applied to assess the person's understanding or 'capacity' to take a decision. The information about who held held Power of Attorney for people was not clear in their care plans. At this visit we found that the manager and staff had worked well with the local GPs and people's families and representatives to make sure that all actions were in line with legislation. We could see that all decisions about resuscitation had been reviewed and updated to make sure they were clear and as required by legislation. We found that the information on file for decisions made around resuscitation were now of a consistently good standard.

At our last visit staffing levels in the home had been affected by staff sickness and staff leaving to take up other posts. In response to this the manager had looked at redeploying staff to use them more effectively, this helped to make sure there were sufficient staff to meet people's need at busy times of day. Additional nursing staff had also been recruited.

Quality assurance processes were in place. We saw that audits were done by the manager to monitor the environment but that these had not been acted upon by the provider. Monitoring of equipment cleaning and visual checks had also not been effectively monitored.

We found that there were shortfalls in the home's infection control measures. These were related to the environmental issues that needed to be addressed to improve hygiene and minimise the risk of infection.

Below is a summary of what we found. The summary is based upon our observations, discussions with people who used the service, their relatives and the staff who supported them and from looking at the records held in the home. We also observed the interactions between people living there and the staff supporting and caring for them.

If you want to see the evidence that supports our summary please read the full report.

Is the service safe?

We saw that risk assessments had been carried out to help make sure that people who lived at Swarthdale received safe and appropriate care and treatment. This included the important areas of nutrition, personal care, skin care and wound management, mobility and moving and handling and the risk of falls.

We saw that the premises and grounds were being maintained and were accessible to the people living there. Appropriate measures were in place to ensure the security of the premises to keep people safe. The service had systems in place to manage and monitor the prevention and control of infection.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes and we saw that proper policies and procedures were in place. The home had appropriate policies and procedures regarding The Mental Capacity Act

2005.

We saw that people who had capacity to make decisions about their care and treatment had been supported to do so.

However we did not see clear evidence that tests, set out in legislation, had been applied to assess a person's understanding or 'capacity' to take a decision. The information about who, if anyone, held Power of Attorney for people was not clear in care plans. (Powers of Attorney concern who has legal authority to make decisions on a person's behalf).

We found that the information on file for decisions made around resuscitation were not of a consistent standard.

Is the service effective?

We found that people's health and care needs had been assessed and care planned to meet their identified needs and preferences. People were supported to carry out as much of their care as they could themselves, with the care staff assisting them with tasks they couldn't manage on their own.

We saw records that showed staff had undertaken accredited end of life training to give them the skills and knowledge to look after people properly. Where people had been identified as at higher risk due to complex needs, appropriate specialist services had been contacted for advice and support.

The manager had a small bank of nurses and carers who would cover for staff. The manager had used agency staff who knew the home to help maintain effective staff levels

Is the service caring?

People who lived at Swarthdale that we spoke with made positive comments about the staff employed at this home. We were told, 'They (staff) take good care of me' and also 'I have nothing bothering me, I'm happy here, thank you, as a matter of fact I feel quite fortunate'. People we saw in the home were supported by suitably trained and supportive staff.

We saw many positive interactions between the staff on duty and people who used this service. People told us that staff were, 'polite' and 'pleasant'.

A relative told us 'They (staff) have taken on board any suggestions we have had and changed to suit us'.

Is the service responsive?

We saw that there were meetings for people living there and relatives to attend to discuss what they wanted in the home. People were able to take part in activities they wanted to inside and outside the home and to decide for themselves how they spent their time.

People's needs had been appropriately assessed before they moved into the home. We saw from the sample of care plans we looked at that the management plans of care, treatments and support were subject to evaluation, review and alteration in response to changes in people's needs and preferences.

We could see that the manager and staff monitored people's conditions and weight. Staff had made timely referrals to other agencies, health care professionals and specialist nurses and to access the care or support people needed.

Is the service well led?

Quality assurance processes were in place and people living there and their relatives were asked for their feedback on the service they received. This was done through satisfaction surveys and via regular home meetings.

The staff told us that the management team was supportive and they had been given opportunities to train and develop professionally.

There were regular meetings to promote good communication. Staff told us they were supported by the management team and that the manager had 'High standards'.

Staff expressed confidence in the manager to support them in reporting poor practice and in maintaining confidentiality. We were told the manager was 'approachable' and that their ideas and suggestions were listened to and some taken forward.

The service worked well with other agencies involved in people's care including the community mental health team, the local authority and safeguarding teams.

People told us they were satisfied with the care they received although they knew staff were often busy they "do their best for me". One person told us that "I go into the lounge and meet up with a lady I know and her visitors and we have a laugh and a joke with the girls."

Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We did not observe any overtly negative or harmful interactions between staff and people in the home. People told us the food was "good" and told us that they were always given a choice and asked what they liked and wanted. We saw the food choices on the menu board.

On our walk around the building we saw that people had been able to personalise their rooms with their own pictures and personal items.

People told us the food was "good" and told us that they were always given a choice and asked what they liked and wanted. We saw the food choices on the menu board.

People who were able to speak with us said that they had not felt the need to complain about their care and they all felt the staff would help them if something bothered them. We had evidence to show that complaints were managed appropriately. People told us they liked the staff who worked there.

We spent time observing daily life in the home and at the lunch time meal and saw that there were staff available to help people with their meals and prompt them to eat and drink. Some people in the home had limited verbal communication, therefore we spent time observing people's behaviour and their interactions with staff. We observed lively and positive interactions between staff and people in the home which made for a relaxed and friendly atmosphere. We also observed staff responding sensitively to people and picking up cues from body language when they needed assistance or reassurance.