Nicholas House

Nicholas House is a care home providing personal care to 13 people. The service provides care to adults, some of whom may live with dementia. The service can support up to 30 people. The building has three floors, and each person had their own bedroom. There were shared facilities such as bathrooms and showers, lounge and dining areas as well as staff stations and offices.

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

The prevention and management of trips, slips and falls had improved. Actions were taken to mitigate risks including regular updates of the risk assessments, care plans, working with the physiotherapist, reporting of accidents and incidents, and completion of follow up investigations. Infection prevention and control had improved, however further action was required to ensure correct use of personal protective equipment . There were sufficient staff deployed and personnel files contained the information required by the regulation. Although service users received their medicines, improvement was required to the documentation, for example ‘as required’ protocols and guidance for high risk medicines.

There was positive feedback about the home manager. Oversight of the service at local and trustee level had improved with the changes in the management team. Auditing of care documentation was taking place, and there was evidence of follow up by the management team. There were related action plans, with the actions being tracked for progress on each one. The home manager understood the duty of candour process and had applied it to notifiable safety incidents, for example serious injuries. Statutory notifications required by law were being submitted without delay.

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 inadequate (published 31 July 2021) and there were multiple breaches of regulations. 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 were made and the provider was no longer in breach of some regulations.

This service has been in Special Measures since 11 March 2020. During this inspection the provider demonstrated that improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

This was a planned inspection based on the previous rating.

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.

We carried out an unannounced comprehensive inspection of this service on 18 May 2021 and 19 May 2021. Breaches of legal requirements were found. We issued a warning notice and the provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance, duty of candour and notifying CQC of certain events.

We undertook this focused inspection to check they had complied with the warning notice and followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions Safe and Well-led which contain those breaches of regulations.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from inadequate to requires improvement. 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 Nicholas House 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.

Nicolas House is a residential care home that is registered to provide care for up to 30 people, this includes people living with dementia. Accommodation is situated on three floors with two lounges and a conservatory. There are specialist baths and wet rooms. The home also offers respite provision and day care facilities for non-residents. At the time of our inspection 16 people were using the service.

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

People's relatives expressed concerns about the falls their family members had experienced at the service, comments included, “I really don’t know how mum falls so often, although she does have high blood pressure. I do get a phone call each time she has fallen. In my opinion the home needs to keep regular observations during the night with mum’s high risks of falls." Another relative felt their family member was safe in the home but stated, “[Family member] has had several falls which has rendered her quite disabled. She broke her hip and was admitted into hospital following one fall.”

We found people were placed at significant risk of harm because the provider demonstrated a lack of knowledge and understanding of how to assess, monitor and manage risks. Records showed people who had been identified at risk of falls, continued to sustain injuries, some of which resulted in fractures. Action taken by management and staff when people fell, were not in line with the provider’s prevention and management of falls policy. As a result of this, people remained at significant risk of harm.

People and relatives told us staff wore personal protective equipment (PPE). However, one person commented, “When assisting with bathing the carers are in full kit, but they are not always completely masked.”

We observed staff did not always wear PPE in line with government guidelines and best practice.

We found quality assurance systems and processes in place to identify and assess risks to people’s welfare and safety, remained ineffective. For example, care plans were not regularly reviewed and updated when people had sustained injuries; audits and monitoring systems failed to identify risks; records were not fit for purpose, inaccurate and partially completed. Audits failed to pick up on the issues we had picked up during our visit. There was no scrutiny at board level to identify these issues and ensure senior managers were accountable and well supported to meet their statutory duties.

The provider did not always notify The Care Quality Commission (CQC) when incidents that affected people happened and failed to work in accordance with the Duty of Candour. This is about provider being open and transparent when things go wrong.

People and relatives said they felt safe from abuse and medicines were administered safely. We have made recommendations in relation to the provider's safeguarding and medicines policies.

Rating at last inspection and update: The last rating for this service was inadequate (published 1 May 2020) and the service was placed in special measures. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection not, enough improvement had been made and the provider was still in breach of Regulations.

Why we inspected:

We carried out an unannounced comprehensive inspection of this service on 9 January 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment, good governance, staffing and fit and proper persons employed.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained the same. This is based on the findings at this inspection.

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.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to

hold providers to account where it is necessary for us to do so.

We have identified continued breaches in relation to, safe care and treatment and good governance.

Please see the action we have told the provider to take at the end of this report.

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

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

We found the following examples of good practice.

On entering the home, there was clear signage for staff and visitors. There was a foyer which was self contained. Staff could use the washing facilities within this area and put on person protective equipment.

All staff had their temperature taken prior to commencing their shift. The service had registered for testing of residents and staff. To date no positive results had been returned.

People were supported to see their family and friends as a safe process had been set up. All visitors needed to book a time and were supported to see their relative at a safe distance in the garden.

The service was able to use the environment to enable them to isolate people who had returned from hospital or who may experience COVID -19 symptoms in the future.

People’s clothes were laundered in line with best practice and the service had laundry shoots to enable minimal handling by staff. The staff had access to additional safety measures should any person experience symptoms. For instance, special laundry bags were available.

Additional cleaning of frequently touched areas was carried out.

We observed staff followed correct guidance and were wearing appropriate personal protective equipment (PPE).

Further information is in the detailed findings below.

Nicolas House is a residential care home that is registered to provide care for up to 30 people, this includes people living with dementia. Accommodation is situated on three floors with two lounges and a conservatory. There are specialist baths and wet rooms. The home also offers respite provision and day care facilities for non-residents. At the time of our inspection, 25 people were using the service.

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

During this inspection, we checked to see if the provider had addressed the concerns found at our previous visit on 12 February 2019. We found the provider had not made the improvements they told us they would, and there were multiple repeated breaches of the regulations.

People were placed at significant risk of harm. Risk management plans to reduce identified risk of harm to people’s health and welfare, did not provide staff with enough information to reduce or mitigate those risks. Unsafe recruitment practices placed people at risk of being cared for by staff who were not suitable. The provider did not take prompt action to address poor staffing levels. People were placed at potential risk of harm as the service did not act on recommendations to prevent fire. The provider did carry out necessary checks to ensure staff were competent to administer medicines safely. We have made a recommendation about this.

The assessment of people’s needs and choices and delivering of care was not in line with standards, guidance and the law. The provider could not be assured staffs' working practices would prevent discrimination and protect people's human rights. Staff were not appropriately inducted, trained and supported. The service did not always make effective use of health and social care professionals to support people to achieve good health outcomes. As a result of this we could not establish if people received effective oral hygiene care.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.

Peoples’ care needs, and preferences were not always considered and regularly reviewed to make sure they were still relevant. The provider did not maintain a record of all complaints, outcomes and actions taken in response to complaints.

The management team lacked an understanding of equality, diversity and human rights. We have made a recommendation about this. There were no systems in place to communicate how feedback received had led to improvements. We have made a recommendation about this. There were ineffective quality assurance systems in place which did not improve the quality of the service and protect the welfare and safety of people.

People and relatives were happy with the service provided and spoke positively about the caring nature of staff. Staff said they were supported and described the management of the service as open and approachable.

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 6 March 2019) and there were breaches 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 not, enough improvement had been made and the provider was still in breach of regulations.

Why we inspected:

This was a planned inspection based on the previous rating.

Enforcement

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to person-centred care, need for consent, safe care and treatment, receiving and acting on complaints, good governance, staffing and fit and proper persons employed.

Please see the action we have told the provider to take at the end of this report.

We have issued the provider with a warning notice for staffing.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. This means we will keep the service under review and, if we do not propose to cancel the provider's registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions 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.

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

Nicholas House is a residential care home in south Buckinghamshire. At the time of the inspection 19 older people, some of whom were living with dementia, lived at the home.

People’s experience of using this service:

People and their relatives gave us positive feedback about the care and support they received. Comments included “Neither of us could speak highly enough about the staff we met during our visits,” “Nicholas House is a first class residential home and I would highly recommend it,'' “During this period we always felt she was very well looked after, treated with dignity, and in very safe hands,” “We visit frequently and there is always a very open, calm and friendly welcome for us when the front door is opened at Nicholas House” and “The staff were incredibly sensitive and caring in the last few weeks of her life. Really, we feel so much gratitude for the amazing staff.”

There was a lack of good governance at the home. There was a lack of formal quality assurance processes in place. Records relating to people’s care and treatment lacked details on how to minimise risks to them.

Environmental risks were not always assessed within the timescales recommended by national guidance.

The service did not ensure there was a robust recruitment process in place for new staff. New staff had started to work unsupervised without a full criminal record check by the Disclosure and Barring Service (DBS) being carried out. This placed people at risk of unsuitable staff supporting them.

People were cared for by staff who felt supported. However, records did not demonstrate staff were given appropriate opportunities to discuss their performance. We have made a recommendation about this in the report.

Staff were unsure if they had completed training in supporting people who required end of life care. We found there was mixed understanding from staff about what end of life care was. We have made a recommendation about this in the report.

We found the home to be light, clean and consideration had been given to the environment so people living with dementia were easily able to find their way around the home.

People were supported to receive their prescribed medicines on time.

People were supported by staff who demonstrated compassion and were kind. People’s dignity and privacy was maintained.

People were supported to maintain important relationships with family and friends.

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.

People were supported to engage in meaningful activities both within the home and the local community. The home had forged links with local schools and other care homes.

Rating at last inspection:

The previous inspection was carried out on 9 June 2016 (Published on 7 July 2016). The service was rated Good at the time.

Why we inspected:

The inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Follow up:

We will continue to monitor the service to ensure that people receive safe, compassionate, high quality care. Inspections will be carried out to enable us to have an overview of the service, we will use information we receive to inform future inspections.

We identified breaches of the Health and Social Care Act (Regulated Activities) Regulations 2014. Details of action we have asked the provider to take can be found at the end of this report.

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

At our most recent inspection on 24 February 2014 we found the service was meeting the requirements of the regulations in place at the time.

Nicholas House is registered to provide care for up to thirty older people. Twenty seven people were being cared for at the time of our visit.

The service had two registered managers. 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.

We received positive feedback on the quality of the service from people who lived in Nicholas House and their relatives. “Staff are superb” and “The whole service is wonderful and caring,” were some typical comments made to us.

There were safeguarding procedures in place and staff received training on safeguarding vulnerable people. This meant staff had the skills and knowledge to recognise and respond to any safeguarding concerns.

Risks to people were identified and managed well at the service so that people could be as independent as possible. A range of detailed risk assessments were in place to reduce the likelihood of injury or harm to people during the provision of their care.

We found staffing levels were adequate to meet people’s needs effectively. The staff team worked well together and were committed to ensure people were kept safe and their needs were met appropriately. The senior management team gave additional support when required. “No issues with staffing numbers” was one relative’s assessment.

Staff had been subject to a robust recruitment process. This made sure people were supported by staff that were suitable to work with them.

Staff received appropriate support through induction and supervision. All the staff we spoke with said they felt able to speak with the senior management team or senior staff at any time they needed to. There were also some team meetings held to discuss issues and to support staff.

We looked at summary records of training for all staff. We found there was an on-going training programme to ensure staff gained and maintained the skills they required to ensure safe ways of working.

Care plans were in place to document people's needs and their preferences for how they wished to be supported. These were subject to review to take account of changes in people's needs over time. We found the format for care plans was very concise, clear and sufficiently comprehensive to ensure people were protected by accurate and up to date records of their care.

Medicines were administered in line with safe practice. Staff who assisted people with their medicines received appropriate training to enable them to do so safely.

The service was managed effectively. The registered managers and provider, together with the service’s management team, regularly checked quality of care at the service through audits and by giving people the opportunity to comment on the service they received and observed.

We spoke with six people who lived at Nicholas House and with two visiting relatives. We also spoke with six staff including the registered managers.

We found that people were cared for appropriately and that care plans were specific and detailed to the individuals' needs.

People's nutritional needs were met. Where necessary, people were supported to eat and drink.

Staffing levels were sufficient and people were supported by appropriately trained and managed staff.

The provider took account of the views and comments made by people and their relatives and produced action plans to provide solutions.

Records were generally kept safely and appropriately. They were comprehensive and informative.

Personalised care plans were in place which described specific needs and outlined how these were met, for example, one person liked to rise and breakfast early, and this was denoted in the care plan. Risk assessments were written specifically to the individual for example a falls assessment for a person with reduced mobility. All documentation we looked at was up to date and appropriately reviewed.

People told us they felt well-cared for. We spoke with a visiting healthcare professional who said the care was good, the people who lived there appeared to be happy, and it was a calm environment.

Staff told us they felt supported and spoke positively of the new managers. They felt able to raise concerns, and were sure these would be dealt with quickly and appropriately.

We found there were adequate systems in place to supervise and appraise staff. Training had been provided to ensure staff had the skills and knowledge required to meet people's needs. Further training had been planned in response to staff requests.

There was a complaints policy and procedure, and this was made known to people. We saw the complaints file, and read some compliment cards. People told us they knew how to make a complaint, and were sure it would be "properly addressed".