Aldergrove Manor Nursing Home

Aldergrove Manor Nursing Home is a residential care home providing personal and nursing care to older people, and younger adults some of whom may have dementia or physical disabilities. The service can support up to 70 people. At the time of the inspection there were 61 people living at the home.

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

The providers systems for ensuring staffing levels at the home were adequate had not been followed to ensure there was enough staff.

We have made a recommendation about assessing the required staffing levels for the home.

The systems for checking medicines administration had not been used effectively to ensure people had enough medicines in stock and medicines administration records required improvement. Medicines were not consistently available for people and medicines administration records required improvement.

Daily charts checks had not been completed to ensure documentation was accurately completed. Care plan evaluations had not consistently been completed to ensure peoples care plans were accurate.

People’s risks and plans for mitigation were not always clearly documented. Staff understood how to keep people safe, they knew how to minimise risks to their safety and could recognise and report any concerns. Staff followed the current guidance for infection prevention control and there was a system in place to learn when things went wrong.

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.

People, relatives and staff had their views sought about the service and these were used to make improvements. The registered manager ensured any incidents were reported to the appropriate agencies.

There was a learning culture in the home and the registered manager ensured staff were fully briefed on any changes made. The registered manager worked with other agencies to seek advice and make improvements to people’s care.

Rating at last inspection

The last rating for this service was good [published 9 June 2021].

Why we inspected

We received concerns in relation to staffing, medicines management, risks management and governance of the home. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

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 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 and well led key sections of this full report.

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

Enforcement and Recommendations

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 monitor the service and will take further action if needed.

We have identified breaches in relation to the governance arrangements in the home at this inspection.

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.

Aldergrove Manor Nursing Home is a residential care home providing personal and nursing care people, some of whom may have dementia or learning disabilities. The service can support up to 70 people. At the time of the inspection there were 62 people living at the home.

Aldergrove Manor accommodates 70 people across two floors, each of which has separate adapted facilities. The ground floor accommodates people receiving nursing care and upstairs specialises in providing care to people living with dementia.

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

People and relatives told us they felt people were safe. Staff knew how to identify signs of potential abuse and report any concerns. The management team had reported concerns to the local authority and notified us of any incidents, as required by law. Risk’s to people’s health, well-being and safety were assessed and managed and any changes were recorded to ensure staff provided people with safe, consistent support. There were enough staff to meet people’s needs and respond to any incidents and staff had been recruited safely. People received their medicines as prescribed and systems used to manage medicines were safe. Where incidents had taken place the management team had reviewed them and shared any learning or improvements with the staff team. Infection control procedures were in place to protect people from the risks of cross infection.

People, relatives and staff felt the home was well managed. The acting manager had been in post since November 2020, as the registered manager had taken a leave of absence. People and relatives told us they found the acting manager to be approachable and accessible. Staff we spoke with felt well supported in their roles and felt the home provided a good standard of care. The management team conducted quality audits to ensure people’s experience of care was positive and took action where required. Staff at the home worked in partnership with local agencies, to ensure people’s individual needs were met. Relatives had been supported to visit their loved ones throughout the pandemic and spoke positively about the support provided by the management and staff teams.

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 24 January 2018).

Why we inspected

The inspection was prompted in part by notification of a specific incident. Following which a person who used the service died. This incident is subject to a criminal investigation. As a result, this inspection did not examine the circumstances of the incident.

The information CQC received about the incident indicated concerns about the management and staff knowledge of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). This inspection examined those risks.

We undertook a focused inspection to review the key questions of safe and well-led only.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

We found no evidence during this inspection that people were at risk of harm from this concern. Please see the safe and well-led sections of this full report.

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 remained good. This is based on the findings at this inspection.

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

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.

We found the following examples of good practice.

• People were supported by a cohort of staff who had been allocated specifically to work on the designated setting. The designated setting was accessed via an entry that was used solely by the staff cohort.

• Staff had access to a separate self-contained area to enable them to get changed into their uniform prior to entering the corridor where people who had tested positive for COVID-19 resided.

• Staff handovers and break times had been adapted to ensure social distancing guidelines could be complied with.

• The manager had implemented regular welfare calls to staff working on the designated setting to ensure they felt supported and were not isolated.

• Staff risk assessments had been undertaken to identify staff who were at disproportionate risk of COVID-19. Those who were assessed as lowest risk had been allocated to work on the designated setting.

We were assured that this service met good infection prevention and control guidelines as a designated care setting.

Aldergrove Manor is registered to provide accommodation with nursing and personal care for up to 70 people including older people, people living with dementia, as well as people with physical disabilities and younger adults. On the days of the inspection there were 61 people living at the home. The home is divided into two units. The downstairs unit accommodated people who had specific nursing needs with the first floor unit catering for people who were living with dementia.

There was a registered manager in post. 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 legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

People and their relatives were confident they felt safe living at the home. Staff were trained in safeguarding and knew how to identify signs of possible harm and how to report and escalate any concerns. Risks to people were assessed, managed and reviewed and clear guidance was available to staff about how to reduce the risk of harm. Staffing levels were planned in order to meet people’s care and support needs as well as allow staff time to spend and talk with people. People received their medicines as prescribed, where required these were regularly reviewed. Staff offered people pain relieving medicines when required and systems used to manage medicines were safe.

People received support from staff who were trained and knowledgeable within their roles. Staff received regular training and competency checks to ensure they were able to meet people’s needs. New staff were given a period of induction at the home, which enabled them to work alongside more experienced staff. People were asked for their consent before care was provided and where people had their rights restricted this process had been completed lawfully. People were happy with the food and drink provided and where people had specific dietary needs staff were aware of them. Staff took action to ensure people receive sufficient amounts of food and drink to maintain their health. People were supported to access healthcare professionals when required and the staff team had developed effective working relationships with other agencies to ensure people’s healthcare needs were met.

People were supported by staff who were friendly and compassionate. Staff offered reassurance to people when they became distressed or anxious. People were supported to make decisions about their daily lives and staff encouraged people to maintain their independence where possible. People were supported by staff who recognised the importance of people’s dignity being maintained and who were sensitive when providing support. Staff protected people’s privacy and care at the end of people’s lives was planned and delivered sensitively in accordance with people’s individual wishes.

People and their relatives had been involved in the planning and review of their care and support. Staff provided support in accordance with people’s care plans, which reflected their life histories, personalities, interests and care needs. People were supported by staff to participate in activities that they enjoyed. People and their relatives knew how to make a complaint if they were unhappy about the service they received and the provider had a system in place to manage and investigate complaints.

People spoke positively about life at Aldergrove Manor and felt that the home was well managed. People, relatives and staff knew who the registered manager was and found them to be approachable. People, relatives and staff had been invited to give feedback about the home and action was taken to make improvements and implement ideas where possible. The registered manager and senior staff team carried out checks to ensure the quality of care being provided. The provider also carried out audits on the service and any actions identified were used to drive improvements. The registered manager was keen to develop and improve the service people received and welcomed input and support from other external agencies in an effort to enhance and improve the lives of people living at Aldergrove Manor.