Archived: Hawthorn Green Residential and Nursing Home

At the last inspection on 30 and 31 October and 1 November 2017, we found breaches of regulations relating to the provision of safe care and treatment, maintaining good staffing levels and good governance. Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve. The provider sent us their action plan detailing their planned actions to improve the service. At this inspection we found improvements had not been made in relation to the provision of safe care and treatment or good governance. We found improvements had been made in ensuring safe staffing levels. This is the sixth time the service has been rated Requires Improvement.

Hawthorne Green is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Hawthorne Green provides care and support for up to 90 people who require nursing and personal care. There were 71 people using the service when we visited. There are three floors within the building and each floor consisted of two units. Four of the home’s units are for people who have nursing needs and two of the units are for people with residential care needs, some of whom have early onset dementia.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had been registered with the CQC for one day at the time of our inspection and had been managing the service for approximately one month.

Medicines were not always managed safely. We found one team leader was administering medicines without having the training to do so safely. We found medicines care plans were not always up to date.

The provider did not consistently assess and mitigate risks to people’s safety. We identified some examples of people without clear, written risk management guidelines in place for care staff.

There were enough suitably trained staff scheduled to work during our inspection. The provider conducted safer recruitment practices through appropriate pre-employment checks. However, we found that they did not renew their criminal record checks every three years after appointment as per best practice.

Both permanent and agency staff received an effective induction to the service. Care staff received supervisions and appraisals of their performance, however, we found these were not conducted regularly as some people had not received a supervision in the nine months prior to our inspection.

Care records contained insufficient information about people’s mental health needs and care staff had limited understanding about how to support people with these. People received appropriate support with their physical healthcare needs and care staff assisted them to access external healthcare professionals when needed.

People told us care staff were caring but we observed varying levels of kindness and attentiveness towards people using the service. Care staff had a good understanding of people’s preferences in relation to how they wanted their care delivered. People told us care staff respected their privacy

People told us they felt safe within the home and the provider had an appropriate safeguarding policy and procedure in place which care staff were aware of. However, we found safeguarding investigations were not conducted in a timely way to manage potential risks to people’s safety.

The building was clean and tidy at the time of our inspection and care staff practised good infection control practices. There was a dedicated sluice on each unit for the hygienic removal of disposables such as incontinence pads.

People were supported with their nutritional needs. Care records contained sufficient information about people’s needs and included their likes and dislikes in relation to food. Kitchen staff were aware of people’s needs and people gave good feedback about the food provided.

People using the service and their relatives were involved in decisions about their care and how their needs were met.

Care staff had a good understanding of their responsibilities under the Mental Capacity Act 2005. Mental capacity assessments were completed when needed and we saw these in people’s care files. The provider made applications to the local authority for authorisation where it needed to restrict someone’s liberty for their safety.

People told us they knew how to make complaints and there was a complaints policy and procedure in place.

The provider operated a varied activities programme which included a range of activities both inside and outside the home and people told us they enjoyed these.

The last focused inspection took place on the 4 and 11 October 2016 where we made two recommendations about the staffing levels and person centred care. The service was rated requires improvement.

During the focused inspection on 11 and 12 November 2015 we found two breaches of legal requirements in relation to staffing and complaints. The service was rated requires improvement.

Hawthorn Green Residential and Nursing Home is registered to provide residential and nursing care for up to 90 people. The home is organised into six units. The ground floor has two residential units, the first floor has two nursing units and the second floor has two nursing units specialising in care for people living with dementia. Each unit has 15 rooms with en-suite facilities and spacious communal facilities.

The home is located in Stepney and provides convenient access to local shops and transport links. At the time of the inspection there were 84 people living in the home.

The service had a registered manager in post who was present during the three days we inspected 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.

Sufficient guidance was in place about the actions staff needed to take to make sure risks were safely managed; however these were not always followed. People received their medicines when this was needed and audits were undertaken, however aspects of the management of medicines were not always safe.

Not all staff had received regular supervision and appraisals. Training was available for staff to ensure they had the skills and knowledge to provide effective care for people; however not all staff training was up to date. A review of training had been undertaken to ensure staff completed the required mandatory training.

Feedback about the deployment of staff in the service was varied. Staffing levels were consistently monitored to manage this. The provider was in the process of recruiting new staff.

People gave us mixed feedback about the quality of the food. They were provided with sufficient food and drink and a dietician checked people’s nutritional requirements, however staff did not always ensure that people’s meal times were a good experience.

Routine visits were carried out by health practitioners to offer advice and treatment for people to meet their healthcare needs.

People and their relatives told us staff were kind and caring and their privacy was respected, however aspects of their personal care were not always fully met in a timely way. Advocacy and befriending services were accessible to ensure people had their views heard.

Systems were in place to monitor complaints and the information was accessible to ensure people understood how to raise any concerns.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The service was meeting these requirements.

People were supported to maintain positive relationships with their relatives and friends. They were provided with opportunities to participate in a programme of activities. People’s cultural and spiritual needs were met and their care plans were person centred but some information need to be recorded more accurately.

People’s feedback was sought about the quality of care. Checks were carried out and audits undertaken but these had not identified the issues we found. Staff spoke positively about the management of the home. The provider worked with external stakeholders to deliver integrated care.

We made one recommendation about the safe storage of medicines. We found three breaches of regulation in relation to safe care and treatment, staff supervision and good governance. You can see what action we asked the provider to take at the back of the full version of this report.

We undertook this comprehensive inspection to check that they had followed their plan and to confirm that they now met the legal requirements in relation to the breaches found.

There was a manager at the service, they were in the process of applying for the position of registered manager at the service. 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 home was arranged over four floors, with two units each on the ground, first and second floor. Each unit had 15 bedrooms, each with an en-suite toilet and washbasin. The third floor housed the kitchen, staff and laundry room. There were two residential units on the ground floor, two nursing units on the first floor and two nursing units for people with advanced dementia on the third floor.

At our previous inspection we found that there were not always enough staff at the service to meet people’s needs. We also found that complaints were not managed effectively. People using the service and relatives were not adequately supported to feedback their concerns about the quality of care. At this inspection, we found that improvements had been made in both areas.

Although we received mixed feedback from people using the service and relatives about staffing levels, we found that the provider had undertaken steps in response to the concerns found at the previous inspection.

Staff rotas and discussions with the management team showed that the reliance on agency staff who were unfamiliar with peoples’ support needs had reduced from the last inspection. There was good management oversight on the progress on any pending vacancies. A recruitment tracker was in place and monitored on a weekly basis to pick up any gaps and follow up on any issues that were holding up pending applications. The provider was piloting a formal staffing tool and had completed dependency questionnaires for each person to ascertain the level of support required.

A complaints form and a suggestions box was available for people and visitors to provide feedback. The complaints form was available in other languages. A complaints officer at head office monitored all the complaints that had been received and ensured timescales for responding to complaints were being adhered to. We looked over the complaints that had been received since the beginning of the year and saw that the majority of them had been responded to and resolved.

People told us they felt safe living at the home and we found that where concerns had been raised, the provider had investigated and acted upon recommendations made.

People we spoke with told us they were treated kindly and with dignity and respect and that staff observed their right to privacy. Relatives were mainly happy with the way that staff treated their loved ones. Staff demonstrated a caring attitude towards people, however on occasion we did see instances where staff could have acted in a more caring manner. People were happy with the quality of the food served and that there had been an improvement with the recent appointment of a new chef.

Where people did not have the capacity to understand decisions related to their care and treatment, best interests meetings were held which helped to ensure their rights were protected. The provider sought legal authorisation where people needed to be deprived of their liberty in order to keep them safe.

Medicines in the home were managed appropriately. Staff had received training in medicines administration and asked for people’s consent when supporting them with medicines. Medicines were stored safely and records completed accurately. Regular audits were completed which helped to ensure medicines management was safe.

Regular checks on equipment such as hoists, slings, beds, wheelchairs and assisted baths were carried out. Care records included risk assessments that were individual to people’s support needs.

Care plans included identified strengths, agreed outcomes and planned care tasks and were reviewed on a monthly basis. We found that care plan reviews were not always reflective of people’s current support needs.

New staff completed an induction when they started and thereafter received ongoing training which helped them to provide appropriate support to people. There was good management oversight with regards to compliance against training, which training had expired, when it was due to be renewed and when it had been completed.

People using the service and their relatives told us their healthcare needs were managed appropriately. We spoke with two visiting health professionals who gave us positive feedback about the provider and how they were kept informed about people’s current health needs.

Quality assurance audits at the home were thorough and covered a number of areas including medicines, care plans, ongoing monitoring of changes to people’s health and analysis of any incidents and accidents.

We have made two recommendations in relation to staffing and person centred care.

The provider had addressed the concerns we raised at the previous inspection about the provision of social activities. One person told us, "I like the activities here. I sometimes play games. I don't get bored." Another person told us, "the activities lady comes has a chat with me. Asks if I want to go out of my room." A family member commented, "there wasn't enough activities in the past but it appears there is more to do now." The majority of staff had completed training on meaningful activities and how to match activities to an individual's needs and preferences.

We spoke with staff, including the registered manager and the nurse lead for end of life care. People coming to the end of their life and their families were involved in planning and decisions about their care and death. All clinical staff had completed training in end of life care.

We saw that people who used the service were encouraged to give consent. We saw staff asking permission and waiting for a response. People and their relatives were involved in the assessment and care planning process.

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People were given opportunities to take part in activities. However, we found the service provided limited meaningful activities especially during weekends.

During our visit we walked around the entire building including a selection of people's rooms. We saw all areas, including bathrooms and toilets, were clean and tidy. Furniture and carpets were in a good state of repair and cleanliness, as were things like wheelchairs and hoists. A family member told us, "I think the home is very clean."

Staff and relatives told us they thought there were enough staff to meet people's needs.

The home responded appropriately to concerns and complaints. There were regular staff meetings, monthly audit checks, service user surveys and relatives' meetings which were conducted in order to seek ways to improve the service.

During the inspection we asked people using the service about their day to day experience of living at the home. People described the staff as friendly and helpful. One person said, "I am quite happy here" and another person said "I am fairly settled. There is no real bother."

The provider was able to demonstrate that the nursing staff worked closely with people's healthcare professionals, specialist palliative care nurses, the person and their family members to determine people's care when they were dying. The home enabled people's relatives to stay overnight at the home so they could remain with their family member at this time. We were told the home was introducing advanced care planning, although this was not yet in place.

We found that the home's records were secure and provided accurate information for staff about people's wishes, needs and care.