Nightingale Care Home

Nightingale Care Home is a residential care home providing accommodation and personal care to up to 47 people. The service provides support to older people, the majority of whom are living with dementia. At the time of our inspection there were 41 people using the service. Nightingale Care Home is an adapted property on two floors with additional wings added.

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

People using the service and relatives gave us positive feedback about the care and support provided. One person who used the service told us, “I feel safe here and it is because of the people. You can get on with the staff, they are more like family. I feel safe with the carers, they put me at my ease and make you feel welcome.” A relative of a person living with advanced dementia praised the kindness and attention to detail of the staff saying, “[The staff] do sensory things like hand massage – they are very good like that. I have no issues. [My relative] is never in pain. Their training is excellent… I am very happy.”

People received safe care and treatment which met their needs. Some staff required further development and support to be confident in their skills and in their spoken English. The provider had plans in place to address this. There were enough staff to meet people’s needs and they were recruited safely. Staff understood about safeguarding people from harm and safeguarding concerns were referred to the local authority and investigated. Risks, including health related risks, were well managed, and records were accurate. The environment was suitable for the people who used the service. The safety of the environment and safety equipment and systems were monitored and satisfactorily maintained. Staff administered medicines safely.

People consented to their care and treatment and records relating to consent were good. People were supported to have maximum choice and control of their lives. Staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

There were robust quality assurance systems in place to monitor the safety and quality of the service. The culture of the service was positive and inclusive, and the management team worked well together to drive the service forward.

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 29 April 2019) and there was a breach of regulation. 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 improvements had been made and the provider was no longer in breach of regulation.

Why we inspected

An external health professional had raised concerns in relation to staff members' spoken English and understanding of their role. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

The overall rating for the service has changed from requires improvement to good based on the findings of this inspection. We found no evidence during this inspection that people were at risk of harm from this concern. However, the provider acknowledged some further development and language work was needed to be undertaken with some staff members. This was already underway before the conclusion of our inspection. Please see the safe and well-led sections of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Nightingale Care Home on our website at

www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

some of whom were living with dementia, at the time of the inspection. The service can support up to 47

people.

Nightingale Care Home is a period building which has been extended and converted to provide

accommodation over two floors. The service has two lounges, dining room, conservatory and secure garden

areas.

We found the following examples of good practice;

¿ The Registered Manager was based from home at the time of the inspection. The service was supported by the Regional Manager to support with the running of the service in the Registered Manager's absence.

¿ Staff were observed to be wearing Personal Protective Equipment (PPE) in line with current government guidelines. The service also had PPE available in different areas of the building ensuring it was accessible at all times to the staff.

¿ Risk assessments were in place for both staff and people who used the service, ensuring that both staff and the people using the service remained safe at all times.

¿ The service appeared clean throughout the visit. Staff informed us that they had been supporting with domestic duties to cover sickness of the domestic team, ensuring the service remained clean at all times.

¿ All staff and people who use the service were receiving COVID-19 testing as per government guidelines.

Further information is in the detailed findings below.

Nightingale Care Home is a residential care home providing personal care to 40 people aged 65 and over, some of whom were living with dementia, at the time of the inspection. The service can support up to 47 people.

Nightingale Care Home is a period building which has been extended and converted to provide accommodation over two floors. The service has two lounges, dining room, conservatory and secure garden areas.

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

People were safe. Safeguarding incidents were identified and reported as required. Actions had been taken to identify and address risks to people. A system was in place to oversee incidents that occurred in the service. The registered manager and staff had a good understanding of people’s individual risks and how these were managed. Additional infection control measures had been taken in response to the covid-19 pandemic. We have signposted the registered manager to guidance regarding isolating following admission to the service and cohorting.

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 (published 29 April 2019)

Why we inspected

We undertook this targeted inspection to follow up on specific concerns which we had received about the service. The inspection was prompted in part due to concerns regarding the management of risk and onward safeguarding referrals in response to incidents that occurred in the service. A decision was made for us to inspect and examine those risks.

The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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 coronavirus and other infection outbreaks effectively.

Follow up

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

People’s experience of using this service: At our last inspection, published 1 June 2018, we rated this service Inadequate overall with breaches of regulation relating to safe care and treatment, staffing, consent, good governance, safeguarding, person centred care, dignity and respect and the employment of fit and proper people. We placed the service into special measures and asked them to provide us with an action plan documenting how they would make the required improvements. At this inspection we found people’s experience had improved significantly but there were still some areas of concern which needed to be fully addressed.

People’s safety was compromised because some risks were not well managed. Procedures relating to choking, pressure care and infection control required improvement to ensure people were safe. Medicines were well managed and there were enough staff to meet people’s needs. Staff understood their responsibility to keep people safe from the risk of abuse and knew how to raise concerns. The service was clean.

Staff received good training but supervision and appraisal needed to be more structured. Some better monitoring of some people’s drinking and eating was needed to ensure that people were not placed at an increased risk of losing weight or not drinking enough. People’s health needs were well monitored and the provider made prompt referrals to healthcare professionals.

Although staff received training relating to consent their understanding of how the Mental Capacity Act 2005 needed to be improved. Records demonstrated that the provider had not always assessed people’s capacity to consent in line with legislation and some records needed review.

The environment had much improved since the last inspection and the service was warm and comfortable. Further improvements were planned to enhance the environment for those people living with dementia.

Staff were patient, kind and caring and relationships between staff and the people they were supporting and caring for, were good. Staff ensured people’s dignity was maintained and managed people’s distress, associated with their healthcare conditions, well.

The registered manager kept care records under review and they reflected people’s current needs. Care was person centred and there were activities to occupy people’s time, although further enhancement to these were planned.

There were good systems in place to monitor the quality and safety of the service. The registered manager and the regional manager constituted a strong team focussed on bringing about the required improvements at the service and remaining person centred. They were honest and open about work which still needed doing and worked well with the local authority quality assurance team. Some relationships with outside professionals were not good which had the potential to affect people’s care but we found a strategy was in place to address this.

There is more information is in the full report below.

Rating at last inspection: Inadequate with the key questions of Safe, Effective and Well-Led being individually rated Inadequate and the other two rated as Requires Improvement (report published 1 June 2018.)

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

Follow up: The rating for this service has improved to Requires Improvement. We will continue to monitor this service and inspect it again in line with our regulatory inspection schedule.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Prior to this inspection we carried out an unannounced focussed inspection of this service on 11 July 2017, we found a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We had been alerted to an incident where, on the advice of a healthcare professional, one person's controlled drugs had been given to another person. This was not in line with the provider's own medication policy. This incident had placed the person at risk of harm and prompted our responsive inspection. We concluded that, not all medicines were managed safely. We also found audits had not identified the errors we found. Some audits could not be located and the registered manager at that time did not have clear oversight of all the issues related to the safe management of medicines.

Previous to the focused inspection we completed an unannounced comprehensive inspection of this service on 16 March 2017 and found the provider to be fully compliant with the Regulations. We rated the key questions is the service safe, effective, caring, responsive and well led as good.

At this inspection we found that insufficient improvements had been made following our previous focused inspection. We identified a continuing breach in the Health and Social Care Act regulations relating to medication and found additional breaches of Regulation.

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.

Nightingale 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. The care home accommodates people in one adapted building. Nightingale care home accommodates 47 people, some were living with dementia. At the time of the inspection there were 31 people living at the home.

A recently appointed manager was in post and had submitted their application to register with 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 previous registered manager continued to work at Nightingale Care Home under the supervision of the new manager. Their role and responsibilities had not yet been agreed at the time of our visit.

Risks to people's health and wellbeing were not appropriately assessed and reviewed. Care plans were not sufficiently detailed to provide an accurate description of people's care and support needs.

Although the provider had systems in place to protect people from harm, we found these were not always effective. The majority of staff were trained in safeguarding adults yet the training was not always implemented in practice whilst supporting people. Staff told us they were aware of their responsibility to keep people safe however, they failed to identify some of the practices within the home which were abusive and breached people's rights to receive safe, respectful and dignified care. At the time of our visit, we requested the manager to complete a safeguarding referral to Norfolk local authority safeguarding team reporting our findings. Following our visit, we also contacted the local authority to share our concerns.

People were supported by staff who had not been safely recruited. The previous registered manager had not completed all the appropriate and standard safety recruitment checks to ensure staff were safe to provide care to people. We found insufficient staffing levels to support people's needs and people did not always receive care and support when required. The manager agreed with our findings at the time of inspection and following our inspection, had reassessed the needs of people, resulting in the staffing levels being increased by an additional 7.5 hours per day. This also meant the service was enabled to be more flexible to meet people’s needs.

Staff had completed training on the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). Applications had been made to the local authority for DoLS however, thorough assessments had not been carried out on people’s mental capacity prior to the applications being made. We found staff lacked understanding about the Mental Capacity Act 2005, Deprivation of Liberty Safeguards, and obtaining consent and carrying out care and support in people's best interests. There were restrictions and interventions being used, imposed on people that did not consider their ability to make individual decisions for themselves, as required under the MCA Code of Practice. At the time of our inspection, the manager agreed with our findings and had started the process of reassessing people’s needs.

We identified gaps in training provided to staff. In spite of staff's best efforts and hard work to provide care in a supportive and friendly way, they lacked experience and training. This had resulted in negative outcomes for people being cared for. Some staff had received an appraisal of their work performance but most had not received regular support and supervision. There was also a lack of team meetings and opportunities for staff to learn and discuss best practice. Resulting in staff feeling unsupported and opportunities missed in identifying inconsistencies in staff knowledge and practice.

We found that people's privacy, dignity and independence were not always respected and promoted. We had to intervene on several occasions to ensure people received safe and appropriate care. Staff did not always engage with people when given the opportunity. People, who used the service, or their representatives, were not always encouraged to contribute to the planning of their care.

People who remained in their bedrooms lacked social stimulation and few opportunities to engage in activities were recorded.

Although processes were in place to deal with people's complaints and concerns if received, we were not satisfied the provider operated an effective accessible system for identifying complaints. There had been no documented complaints since June 2011. We found no evidence the provider sought and acted on feedback from people using the service, those acting on their behalf, staff and other stakeholders, so that they can continually evaluate the service and drive improvement.

There was no shared understanding of the service's vision and values and a culture of task-centred instead of person-centred care was embedded. Systems in the service that were meant to monitor and identify improvements were not effective and records were not always maintained and completed in full. This lack of effective governance led to all people not receiving safe and consistent care. The care plans for people using the service were incomplete or did not contain up to date and regularly reviewed information. This meant staff were not able to perform their duties efficiently.

People were provided with a variety of meals and the menu catered for any specialist dietary needs or preferences. People were supported to maintain a healthy balanced diet through the provision of nutritious food and drink by staff who understood their dietary preferences. We observed communal mealtimes where people ate together.

People's health care needs were assessed, monitored and recorded. Referrals for assessment and treatment were made when needed and people received regular health checks. People's rooms were decorated in line with their personal preferences.

For people who were mobile and able to access the lounge, there was a strong emphasis on meeting people's emotional well-being through the provision of meaningful social activities and opportunities. These people were offered a wide range of individua

This inspection took place on 11 July 2017 and was unannounced.

The service provides accommodation for up to 47 people, some of whom are living with dementia.

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.

This report specifically focuses on the key areas of Safe and Well-Led with regard to how medicines were managed at the service. This included a consideration of the safe ordering, storage, administration, stocktaking, disposal and auditing of medicines.

We had been alerted to an incident where, on the advice of a healthcare professional, one person’s controlled drugs had been given to another person. This was not in line with the provider’s own medication policy. This incident had placed the person at risk of harm and prompted our responsive inspection. At this inspection we concluded that, although some recent improvements in the administration of medicines had taken place, not all medicines were managed safely. In addition we were concerned that a full investigation into this incident had not taken place and lessons learned.

Staff managed people’s regular medicines well and people received their medicines at the correct times. Although medicines were made available to people promptly when newly prescribed, information on some medicines was not available to guide staff. Staff were not clear about how to administer one emergency medicine and had not received the required training.

Medicines were stored appropriately but some recording of the room temperature was missing. This meant we could not be assured that medicines were always stored in a way which ensured they were safe and effective to use. Medicine trollies and the medicine room were well organised.

Drugs stored in the controlled drugs cupboard were mostly well managed but stocks for one medicine did not tally with records. This meant there was a risk that a person had not received the correct dose of their medicine. One medicine had not been administered according to the manufacturer’s instructions which placed the person at risk of harm.

Audits had not identified the errors we found. Some audits could not be located and the registered manager did not have clear oversight of all the issues related to the safe management of medicines. Where errors had taken place, these had not been fully investigated by the registered manager or provider or notified to the Care Quality Commission or the local authority as a safeguarding matter.

We found a breach of regulation related to the management of medicines. You can see the action we took at the back of this report.

The home has had the current registered manager in post since September 2014. 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.

At the last inspection on 5 and 6 April 2016, we asked the provider to take action to make improvements to how they managed risks to people, how they deployed staff around the home and to their assessing and monitoring systems in the home. This action has been taken.

Staff assessed individual risks to people and took action to reduce or remove them. There was adequate servicing and maintenance checks to fire equipment and systems in the home to ensure people’s safety.

There were enough staff available to meet people’s needs and the registered manager took action to make sure there were staff available throughout the home at all times.

Good leadership was in place and the registered manager and provider monitored care and other records to assess the risks to people and ensure that these were reduced as much as possible and to improve the quality of the care provided.

Staff were aware of how to safeguard people from the risk of abuse and they knew how to report concerns to the relevant agencies. People felt safe living at the home and staff supported them in a way that they preferred.

Recruitment checks for new staff members had been made before new staff members started work to make sure they were safe to work within care.

People received their medicines when they needed them, and staff members who administered medicines had been trained to do this safely.

Staff members received other training, which provided them with the skills and knowledge to carry out their roles. Staff received adequate support from the registered manager and senior staff, which they found helpful.

The CQC is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The registered manager had acted on the requirements of the safeguards to ensure that people were protected. Where someone lacked capacity to make their own decisions, the staff were making these for them in their best interests.

People enjoyed their meals and were able to choose what they ate and drank. They received enough food and drink to meet their needs. Staff members contacted health professionals to make sure people received advice and treatment quickly if needed.

Staff were caring, kind, respectful and courteous. Staff members knew people well, what they liked and how they wanted to be treated. They responded to people’s needs well and support was always available. Care plans contained enough information to support individual people with their needs. People were happy living at the home and staff supported them to be as independent as possible.

A complaints procedure was available and people knew how to and who to go to, to make a complaint. The registered manager was supportive and approachable, and people or other staff members could speak with them at any time.

The Nightingale Care Home is a care home that provides accommodation and care for up to 47 older people who are living with dementia. On the day of our inspection, there were 37 people living within the home.

There was a manager working at the home who is registered with us. 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 and associated Regulations about how the service is run.

At this inspection we found three breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.

People did not always receive care in a timely manner to meet their individual needs. The staff had not been deployed effectively to enable them to do this. Risks to some people’s safety were not being mitigated effectively to protect them from the risk of harm.

The main areas of the home were clean but some equipment that people used was not. The principles of the Mental Capacity Act had not always been followed when some decisions had been made on behalf of people who were unable to consent to them.

Some staff were kind, caring and compassionate and they treated people with dignity and respect. However, other staff did not always act in this way.

Most staff had received training on how to provide people with safe and effective care. However, although their competency to provide this had been assessed, some staff provided people with poor care. The environment was not fully designed to promote people’s independence.

Some of the current governance systems in place were not effective at assessing and identifying improvements that were needed to the quality and safety of the care that was being provided. Improvements identified by an external body had not been fully acted on within the time-scales given.

The staff knew how to protect people from the risk of abuse and people received their medicines when they needed them. People received enough food to meet their needs. People were encouraged to participate in activities that complemented their hobbies, interests and that promoted their wellbeing.

There was an open culture where people, relatives and staff could raise concerns that were listened to and acted upon. Staff were happy working in the home.

We have made a recommendation in relation to providing an appropriate environment for people living with dementia.