Doves Nest Nursing Home

We found the following examples of good practice.

We observed staff undertaking activities with people and getting ready for their day. We observed how this was done in a safe way for residents and staff, with staff wearing full personal protective equipment (PPE). Stocks of appropriate personal protective equipment (PPE) were well-maintained and staff used and disposed of it correctly. Staff had been trained in infection control practices.

The home was clean and hygienic looking and we saw domestic staff undertaking their cleaning and laundry duties. We saw that each had a specific routine to follow to ensure cleanliness was maintained and to limit the transmission of infections.

The home monitored the vaccination status of residents and staff and undertook risk assessments when required. We heard how the home managed an outbreak of Covid -19 when staff and residents became infected. There were management plans for those people required to self-isolate and additional support available for people who may struggle with isolation.

People were able to spend time seeing and speaking to their visitors in different ways. On-site visits were facilitated by pre-booking and visitors went straight to people’s rooms or could sit in one of the designated visiting areas. They did not interact with any other people at the home and visiting times were not restricted. There were also extensive gardens where visits could take place when the weather allowed.

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

People told us they felt safe and risks to people’s health and safety were managed well. People’s needs were met safely with appropriate staffing levels and well trained staff. People were supported by staff who understood how to identify and report potential abuse. People received their medicines as prescribed although some processes could be improved. We have made a recommendation about the storage of medicines awaiting disposal and the recording of thickeners. When accidents or incidents occurred, learning was identified to reduce the risk of them happening again. Checks were carried out on new staff to ensure they were suitable to work in the home. Infection control was well managed and the home was clean and free from hazards.

Staff had opportunities for regular meetings, reviews of performance and access to mandatory and bespoke training. The home worked in tandem with other health professionals to make sure people received the right care and support to maintain good health. Meal time experiences were unhurried and pleasant on both days of our inspection and one person described the food as, “always good and home cooked.”

Staff placed people at the centre of the service, ensuring those who were able to maintained their own independence. Staff promoted positive, caring relationships with the people who lived at the service. Staff respected people’s privacy and dignity and promoted independence, equality and diversity. There was no discrimination in the service. The service involved people and their relatives in the planning and delivery of care.

The service promoted a person-centred approach and people living at Doves Nest Nursing Home achieved good outcomes. Care plans were individualised and reflected people’s specific care needs. There was a good range of activities and events going on in the home and in the community. People and their relatives were confident to raise issues and concerns. Complaints procedures were effective. The service sought feedback to help maintain and improve standards of care. People's wishes regarding their end of life care were explored and documented, so these could be addressed at the appropriate time. The service had received many compliments from relatives following the care and support their family members had received at the end of their lives.

People living at Doves Nest, their relatives and staff all considered the service was managed well. The service operated in a way that demonstrated there was an open and transparent culture at the service. Staff told us they received the leadership and direction they needed. They were happy working at the service and felt part of a team. The service had effective systems of quality assurance in place which assessed and monitored the quality of the service. As the registered manager was also the nominated individual they had the opportunity to take on board ideas and suggestions about how to improve the quality of the service and implement change.

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 Requires Improvement (29 March 2019).

Why we inspected

This was a planned inspection based on the previous rating.

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

This service was selected to be part of our national review looking at the quality of oral health care support for people living in care homes.

Dove’s Nest Nursing Home (Dove’s Nest) was previously inspected in September 2017. We found three breaches of the Health and Social Care Act regulations and the Care Quality Commission Registration regulations. These related to providing safe care and treatment, good governance and requirements to display the service’s performance rating. At this inspection we found some improvements had been made, but there were aspects of the service which still required improvement. These are discussed below and within the main sections of the report.

Dove’s Nest is a 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

Dove’s Nest is registered to provide accommodation and nursing care for up to 40 older and younger age adults with complex physical disability needs. Accommodation is located across three floors, with a passenger lift available between floors. There were 36 people living at the service during this inspection.

There was a manager in post who had been registered with the CQC since September 2013. 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 was supported in the day to day running of the care home by a clinical lead and an operational lead.

In the main, Dove’s Nest provided care and support that was safe but there were areas which required improvements. Though risks to providing care had been identified, specific guidance was not always in place to help staff manage these risks. Risks were not always reviewed regularly.

Not all lifting equipment had been checked as required by industry regulations to help ensure people, staff and visitors to the home were protected from risk of injury. Following our site visit we received evidence that this had been done.

The provider had made the required improvements since the last inspection in September 2017 to help ensure medicines were managed and stored safely.

People were supported by a consistent staff team for whom all relevant pre-employment checks had been completed, to ensure they were appropriate to work with vulnerable people. The provider had suitable systems in place to take action to protect people from abuse including accidents and incidents.

People were protected from the risk of infection because suitable arrangements were in place to ensure hygiene standards were maintained. The home was visibly clean and free from unpleasant smells. Staff were knowledgeable about and demonstrated good infection control practices.

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 supported this practice. The provider had submitted appropriate applications for the deprivation of liberty safeguards to the local authority and the registered manager had a good system in place to track the progress of these.

Staff were competent and had adequate professional support to enable them to support people safely and effectively. Staff received an induction, training considered mandatory by the provider and shadowed experienced colleagues prior to working unsupervised. Staff had regular supervisions and annual appraisals.

People’s nutrition and hydration needs were met effectively. People were very satisfied with the food and drink on offer. The service acted proactively to ensure people maintained a balanced diet and that they received relevant health and medical attention as required. This helped to ensure people achieved a good quality of life and wellbeing.

People were supported in a friendly and respectful way. People, relatives and staff got on well and staff were aware of people’s personalities and behaviours. Staff responded promptly when people asked for help and were seen to support people in a patient and unhurried manner. People and relatives were complimentary about the staff and their caring attitude; they said the care they received was supportive and kind and that staff were genuinely caring.

The care home operated within a diverse and multicultural community and had systems in place to ensure people’s equality and diversity needs were recognised.

Most care plans contained detailed and adequate person-centred information to guide staff to provide personalised care. These plans were reviewed regularly.

Activities and events were meaningful and engaging. During our inspection, we observed activities taking place, including one-to-one activities. Activity records evidenced people’s participation in a range of events outside the home such as concerts, Christmas markets and visits to garden centres and museums.

Concerns and complaints were managed effectively with a clear process in place. People and their relatives told us they knew how to make a complaint or raise their concerns. The registered manager had a good oversight of issues identified which helped to reduce the likelihood of reoccurrence.

People and their relatives knew the registered manager and said they were friendly and approachable. Staff were equally complimentary about the registered manager and spoke about their ‘open door’ policy. People and their relatives were very pleased with the service. They felt very involved in the care provided and were always kept informed and consulted with.

Staff had appropriate mechanisms to support them in carrying out their jobs. These included staff meetings and policies and procedures.

The provider complied with the legal requirement to display its most recent rating within the home and on their website.

Doves Nest Nursing Home provides accommodation and nursing care to up to 40 older and younger age adults. The service provides care to people with complex needs in relation to physical disabilities. Accommodation is located across three floors, with a passenger lift available between floors.

We last inspected Doves Nest Nursing Home on 08 and 09 March 2016 when we rated the service good overall. At that inspection we identified one breach of the regulations, which was in relation to the safe management of medicines. Following the inspection the provider sent us an action plan to tell us about the changes they would make to ensure they were meeting the requirements of the regulation. Whilst there was scope for further improvements to be made in relation to the safe management of medicines, we found the provider was now meeting the requirements of this regulation.

At this inspection we also identified additional breaches regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These related to providing safe care and treatment, good governance and requirements to display the service’s performance rating. You can see what action we have told the provider to take at the back of the full version of this report.

We have also made two recommendations, which were in relation to the provider reviewing good practice guidance in relation to the implementation of the Mental Capacity Act 2005, and reviewing guidance and risk assessing the safety of the premises in relation to the needs of people living there.

People living at the home told us staff were kind and treated them with respect. We saw people were comfortable requesting support from staff, which was provided promptly. Staff knew the people they provided care and support to, including any preferences, likes and dislikes they had.

The chef was proactive in meeting people’s preferences for meals. People provided us with positive feedback about the food on offer and we found their dietary requirements were met.

The home had made improvements to the way they managed medicines. We found protocols were now in place to inform staff when to administer when required medicines, and body maps were being used to help ensure the safe application of topical medicines such as creams. However, we found further improvements could be made. For example, quantities of medicines carried forward from previous months were not always recorded, which meant we were not able to work out if people had received their medicines as prescribed. One person was prescribed a ‘when required’ medicine and there was no plan or protocol in place to inform staff why and when to administer this medicine.

We found the provider had not fully considered potential risks to people’s health safety and wellbeing arising from the management of the premises. For example, we found some people living at the home lacked capacity and were subject to authorised restrictive practices. There was no restriction on people leaving the home without staff being aware. Whilst the registered manager felt no one at the home was at risk, there was no documented risk assessment. Not all windows had restrictors that met current guidance about their required standards. The registered manager did not feel these potential hazards posed a risk to anyone living at the home. However, this was not as a result of any formal risk assessment.

We found risk assessments were not consistently completed for all people living at the home. For example, we found one person did not have a bed-rail risk assessment, and none of the risk assessment tools had been completed for another person who had moved into the home over two months previously. This meant staff may not be fully aware of potential risks posed to these people’s health and wellbeing or how to reduce such risks.

The environment at the home was clean, bright and spacious. The home was set in large, well-maintained gardens that were accessible to people living at the home. The home also had facilities such as a sensory room.

The registered manager had submitted deprivation of liberty safeguards (DoLS) applications to the local authority as required. Staff were aware of the principles of the Mental Capacity Act (MCA) and DoLS. However, we found some forms in people’s care files suggested relatives were being asked to provide consent on their family member’s behalf when they did not have lawful authority to do so.

Staff were mindful to support people in ways that respected their dignity and promoted their independence. We saw staff routinely offered people choices and supported people at a pace comfortable for them.

People had detailed care plans in place that were personalised to individuals’ needs and preferences. Whilst care plans had been regularly reviewed, we found in a number of instances, they were not reflective of the care people were currently receiving.

A range of activities were provided and planned to meet the needs and preferences of people living at the home. However, we received mixed reports from people in relation to whether they felt sufficient activities were provided. There had been a reduction in the level of provided activities whilst the activity co-ordinator was covering care shifts for staff vacancies and leave.

The service had asked for feedback from people using the service. We saw this had been used to make improvements to the home, and to provide feedback to staff during supervisions.

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. Staff felt well supported by the registered manager and told us they were approachable.

We found shortfalls in the home’s audit processes and record keeping. Audits of medicines had not taken place on a routine basis, and checks on the quality of care plans were limited in scope and had not identified the issues we found of care plans not reflecting people’s current care. We found some records of care, such as repositioning for people at risk of pressure ulcers had not been maintained.

Whilst the provider was displaying the home’s rating within the home, it was not displayed on the service’s website, which is a legal requirement.

Doves Nest is a nursing home registered to provide accommodation, nursing and personal care for up to forty people with wide variety of complex care needs. On the day of our inspection there were thirty three people living at the home.

The provider had a registered manager in place as required by the conditions of their registration with the Care Quality Commission (CQC). 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 was responsible for all the services delivered by the provider.

People who used the service told us they felt safe with staff who supported them. They told us staff were available to support them in the activities they wished to do. People were encouraged to make their own decisions and told us staff always promoted their independence. During the inspection we observed staff were caring and respectful in their interactions with people who used the service.

Recruitment processes were robust and should help protect people who used the service from the risk of staff who were unsuitable to work with vulnerable adults.

Systems were in place to help ensure the safety and cleanliness of the environment.

Staff told us they received the training and support they needed to carry out their role effectively. There were systems in place to track the training staff had completed and to plan the training required. All the staff we spoke with told us they enjoyed working in the service and felt valued by both the registered manager and the rest of the team. Staff felt able to raise any issues of concern in supervisions and in staff meetings.

People who used the service had support plans in place. Records were stored securely and were easily accessible by staff. Records reviewed showed that, where necessary, people were provided with support from staff to attend health appointments. People were also supported by staff to maintain a healthy diet as far as possible.

Care records we looked at showed people who used the service had been involved in developing and reviewing their care and support plans. The support plans we looked at were person centred and focused on the care and support people said they wanted.

All the people we spoke with told us they felt able to raise any concerns with the registered manager and were confident they would be listened to. We noted systems were in place to encourage people who used the service to provide feedback on the care and support they received.

Staff had received training in the safe administration of medicines. The competence of staff to administer medicines safely was regularly assessed. However there were no systems in place to support staff to administer ‘as needed’ (PRN) medicine. Some of the records relating to the administration of medicine had gaps which had not been accounted for. We found this was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

One inspector carried out the inspection. We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask:

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well led?

This is a summary of what we found.

Is the service safe?

We saw people were being cared for in an environment which was clean. Processes for the prevention and control of infection were in place. For health, safety and security reasons, visitors were asked to sign in and out. There were enough staff on duty to meet the needs of the people living at the home at the time of our visit. A qualified member of staff was on duty on each shift.

The people we spoke with who used the service told us they felt safe. One person said 'Nothing is done which makes me feel uncomfortable or embarrassed.'

Discussion with staff and examination of records confirmed a programme of training was in place for all members of staff. However, one training system was not available due to technical failure, so staff did not have access to some training, some of which was required to be refreshed periodically. The manager was not able to assure us that this was being addressed.

We saw maintenance records for lifting equipment and noted that on inspection in May 2014, some slings had not been available and one hoist had required repairs. The manager was unable to identify these items or confirm whether they were being used.

The gas safety certificate we were shown had expired in May 2014.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS). DoLS are part of the Mental Capacity Act 2005 (MCA). The aim is to make sure people in care homes and hospitals are looked after in a way which does not restrict their freedom inappropriately. Staff had all received training about the Mental Capacity Act and Deprivation of Liberty Safeguards so they understood when an application should be made and how to submit one.

Is the service effective?

People's health, social and care needs were assessed with them and they were involved in writing and reviewing their care plans. Specialist needs had been identified in care plans, for example, ways to communicate. Care plans were reviewed every month and when people's needs changed.

The people we spoke with told us they were happy with the care they received and said their needs were met. They spoke positively about the staff who supported them. From what we saw and from speaking with staff it was clear they had a good understanding of the care and support needs of the people who used the service.

Is the service caring?

People we spoke with told us they liked living at the home. Comments included 'I love it here', 'The staff are good' and 'They do everything for me in a way I'm ok with.'

We saw the staff showed patience and gave encouragement when they were supporting people so people were able to do things at their own pace and were not rushed.

In September 2013, the home had been commended for high quality end of life care by the local authority's 'Life is for Living' Gold Standard Framework. This is a standard designed to improve care for people living with a life limiting illness.

Is the service responsive?

The records we saw confirmed people's preferences and diverse needs had been recorded and care and support had been provided in accordance with people's wishes. People had access to activities which were important to them and had been supported to maintain relationships with their friends and relatives.

There was a sensory room and outside there was a sensory garden to help stimulate and enhance the senses. There was an assisted learning area, which provided an interactive, memory enhancing, sensory experience. However, some staff we spoke with were unsure how this should be used and some people we spoke with said they did not know about these facilities and had not been offered them.

Is the service well-led?

We saw documentary evidence which showed the service worked well with other agencies and services to make sure people received their care in a joined up way.

From speaking with staff we found they had a good understanding of the home's values. They told us about their roles and responsibilities and they were clear about these. We saw quality assurance processes were in place to make sure the provider monitored the care provided and made improvements where necessary. For example, meetings were held with people who used the service so that they had the opportunity to express their opinions.

We spoke with three people living in the home all told us they were satisfied with the care and treatment they received. They said staff were always quick to respond when they asked for help.

During our visit we heard staff speaking with people respectfully and politely. We saw staff supporting and assisting people at a pace that was unhurried and met their needs.Each person who used the service had a care plan in place and this was being reviewed on a monthly basis or sooner should the need arise.

We found everywhere to be clean, tidy and comfortably furnished with no unpleasant smells detectable.

We spoke with three people living in the home all told us they were satisfied with the care and treatment they received. They said staff were always quick to respond when they asked for help.

Three people using the service and three relatives told us the staff always treated them with respect, and were polite. One person told us they felt 'safe in the staff hands'. A relative told us the staff were 'excellent' and 'top notch'.

We talked with three relatives; one told us the service was 'smashing', an 'excellent nursing home' and provided a 'high level of care'. However one relative told us they had concerns about the nursing care.

We found the care records did not reflect peoples care needs accurately and this had the potential to lead to people not receiving the correct treatment.