Archived: Friars Hall Nursing Home

Friars Hall Nursing Home provides personal care and nursing for up to 54 older people. There were 39 people living in the service at the time of this inspection.

There was not a registered manager in post at the time of our inspection. The new manager had applied to the Care Quality Commission (CQC) to be registered; however following our inspection they withdrew their application.

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.

Friars Hall is in Special Measures, which resulted from an Inadequate rating following the previous comprehensive inspection carried out in August 2016. At that time we also identified several breaches of legal requirements. There was poor management and leadership and no clinical oversight of the service which led to people receiving poor care and not being adequately protected from risk to their health and welfare.

Services in Special Measures are 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.

Following the inspection in August 2016 we sent an urgent action letter to the provider telling them about our findings and the seriousness of our concerns. We requested an urgent action plan from them telling us what they were going to do immediately to address them. An action plan was returned to us the following day.

This inspection was undertaken within the six months timescale because it was prompted in part by notification of an incident following which a person died. This incident is subject to a criminal investigation and as a result, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk from falls and moving and handling.

We also received information from the local authority and a whistle blower which related to poor staffing levels, staff training, poor care, poor leadership and governance.

This inspection was initially carried out during various times of the day and night over a three day period to get a full picture. We found no improvements had been made to the overall quality of the service. Management and clinical oversight was failing, there was not enough trained, skilled and experienced staff which resulted in a continued poor quality of service which placed people at potential risk. There were continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We took immediate enforcement action to restrict admissions and increase nursing staff. We revisited on 30 November 2016 to see if the enforcement action taken had made an effect. We found that even though the provider had increased the amount of nurses on each shift the clinical oversight, quality of the service and delivery of care to people remained poor. When we returned again on 19 December 2016 we found that more permanent staff had left or had given their notice.

The service relied heavily on temporary staff with basic training and some experienced difficulty with command of English language which meant they could not always understand or recognise people’s needs.

People's dignity, privacy and independence was not always respected. The service was not working within the principles of the MCA and in some cases people were presumed to not have capacity when they in fact had. Therefore choice, preference and consent was also not respected and people were not safeguarded from improper treatment.

We immediately shared our concerns with commissioners (local authorities and Clinical Commissioning Group) because of the very poor care we had observed and because of the registered provider’s lack of ability to demonstrate they were capable of taking effective action to address it. As a result commissioners started to find alternative care providers for some people.

The registered provider informed us that they did not know what they could do to improve and made a decision to close the service entirely on 23 December 2016.

Friars Hall Nursing Home provides accommodation and support to older people and those with physical disabilities and dementia. The service is registered to provide the regulated activities of accommodation for people who require nursing or personal care, treatment, disease or injury and diagnostics and screening procedures. The service can accommodate a maximum of 54 people. On the days of our inspection there were 43 people using the service.

There was not a registered manager in post at the time of our inspection. The new manager was in the process of seeking registration with the Care Quality Commission (CQC).

A registered manager is a person who has registered with CQC 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 on 3 June 2015 we found a breach of Regulation 16 (2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because the registered person had failed to establish and operate an effective and accessible system to receive record, handle and respond to complaints made by people using the service The provider sent to us an action plan telling us how they would make improvements in order to meet the relevant legal requirements.

At this inspection we found the provider had taken sufficient action to meet this legal requirement.

However, during this inspection we found other areas of concern.

We found that staff were not recording accurately the care provided to people with continence needs with regard to recording when leg bags attached to catheters were changed. We also found that re-positioning charts for people were not being completed as per their care plan. Hence we could not be sure when people were being repositioned sufficiently often enough to reduce the likelihood of pressure sores. We could not be sure from the records one person whether a pressure sore they had developed was being cared for properly.

We were not confident that medicines were being managed properly. This was because medicines had not been correctly booked into the service. Also we found that a medicine had been signed for in the Medication Administration Record (MAR) to state that it had been administered when in fact it had not.

People were not always being protected from abuse. On the day of our inspection the service did not have any sterile dressings, which meant that one person’s dressing change due that day was not done. The Clinical Lead did raise this as a matter of safeguard at the time with the relevant authorities and ordered a new supply which was with the service the next day.

The premise was not secure. One person had tried to leave the service and actions regarding security had been taken downstairs, but the window restrictors upstairs were ineffective and meant that people would be at significant risk of falling if they tried to leave the building that way.

The service had no processes in place to check that equipment such as the suction machine and syringe drivers were being checked as in good order and fit for use.

Although staff considered there were enough staff on duty. The management were not aware of how many people at the service required nursing care and there were no completed dependency assessments of people’s needs being carried out to determine number of staff required to be on duty.

The service had emergency plans in place and monitored accidents that occurred to determine any correcting action that could be taken. The service had a system in place for recruitment. However we could not be assured that an on-going training and development plan had been organised for nurses to continue to keep up to date with their practice. The new manager and clinical lead had been in post for four months and had not commenced any supervision or appraisals for staff. However, we understood from the clinical lead that they had reviewed the situation and were in the process of implementing a programme of planned supervision in the near future.

The meals we saw on the days of our inspection were appetising and we saw staff supporting people with their meals. We saw staff being carrying towards people and some staff knew people well. People told us they had good relationships with the staff. However, there was no robust system in place to ensure the catering team were aware of people’s dietary needs, in particular people with diabetes.

People told us they enjoyed the activities provided, but when staff were on holiday, others did their best but they could become bored with the lack of activities.

The service worked with other professionals but we were surprised to see the level of support that the service required from other professional nurses as the service is registered for nursing care and does employ qualified nursing staff.

The care plans lacked detail with regard to the mental capacity of people and how care was to be provided. We were informed by the clinical lead that they were being reviewed and saw this was in process.

The quality of recording was not always adequate. Records failed to demonstrate that people were receiving the care they needed. There was inadequate management oversight of the service. The manager and clinical lead had been unaware of the concerns identified during our inspection until these were outlined during feedback. Although the manager was not present during our inspection, we could see no evidence they were aware of or had taken action to address these short-falls in the service provision. Some areas of the service were audited periodically but there was no service improvement plan in place to address any shortfalls identified. Although the provider was present most days at the service they did not carry out or record monitoring visits to the service.

The auditing of the service was lacking in detail and action. Although medication audits were in place they were not followed up from one month to the next. Hence, instead of being an auditing process for safety and improvement, the documents we saw were stand-alone documents.

The overall rating for this service is 'Inadequate' and the service is therefore in 'Special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

We spoke with one relative who was positive about the service their relative received. They commented, "Overall, I am very happy with the care, I have no issues, good care and nice staff who treat my relative well'.

We found that people who used the service experienced care and support that met their individual needs and protected their rights. Where people did not have the capacity to consent to care, the provider had not always acted in accordance with legal requirements set by the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS).

We found that people who used the service, staff and visitors were protected against the risks of unsafe or unsuitable premises. We found that there were effective recruitment and selection processes in place and that there was enough qualified, skilled and experienced staff on duty.

We did not speak with people who used the service on this occasion. We gathered evidence by looking at records and speaking with staff to ascertain what improvements had been made to ensure the service was protecting people from the risks associated with infection control, administration of medication and maintaining accurate and appropriate records.

We made two visits to the service, because the registered manager was unavailable on the first day of our inspection. We found that the provider had made the improvements we had asked them to make; however we identified further areas of concern in relation to cleanliness and infection control, out of date policies and procedures and failing to notify the Commission of events that affected the welfare, health and safety of people using the service.

People spoken with told us that they were happy with the service they received and that the staff were polite and treated them well.