Ersham House Nursing Home

Ersham House Nursing Home is a care home with nursing and accommodates up to 40 people in a purpose-built building. The service supports adults whose primary needs are nursing care. Some people also live with additional mental health disorders, and dementia. At the time of our inspection there were 22 people living at the service

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

The providers’ quality assurance and governance systems had improved under the consistent leadership of the registered manager, who came into post after the last inspection in September 2022. Whilst there had been improvements, there were still areas of care delivery, and documentation that needed to be improved and embedded into everyday practice. This relates to food and fluid records, oral health, and the updating of the mental capacity assessments.

There were suitably trained staff deployed, but the numbers of staff on duty had not always ensured peoples’ needs were met consistently. Staffing levels had the potential to impact on safe outcomes for people’s health and well-being, such as remaining in bed in their bedroom as staff had not time to hoist them and being assisted with meals that were no longer hot.

During the inspection process, the provider had reviewed staffing levels and increased the number of staff deployed.

All staff had received training to recognise signs of abuse or risk and understood what to do to support people safely. “One person said, "Very safe here, staff very vigilant." Another said, "The staff make sure we are all safe." Risk of harm to people had been reviewed and risk mitigated as good practice guidelines for the management of medicines, pressure care management, and nutrition had been followed. 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.

Infection control audits and cleaning schedules were in place, and the premises were clean and hygienic. The provider ensured that when things went wrong, accidents were recorded, and lessons were learned.

The home now had an effective management team which provided good leadership for staff and communicated effectively with people, relatives, and professionals. Staff were positive about their roles and felt valued for the work they did. People told us, "The staff are very kind and respectful," and "They are all nice, I know the manager and can talk to her if I have a problem."

The views of people who lived at the home, their relatives and staff were encouraged and acted upon by the management team. People told us, "Staff are very kind, they look after me very well," and "I think the staff are lovely." Relatives said, "I have total faith my (relative) is safe. Things have improved and the staff are polite and thoughtful,"

People and their relatives felt able to raise any concerns they had and were confident these would receive an appropriate response. One visitor said, “Very much improved, I feel listened to now.”

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 September 2022)

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 regulations.

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At our last inspection we recommended that the provider consider current guidance regarding health and well-being decisions made on peoples’ behalf when they lack capacity to make their own decisions. At this inspection they had reviewed their mental capacity assessments and had made improvements.

The service remains rated requires improvement. This service has been rated requires improvement for the last four consecutive inspections.

Why we inspected

This inspection was prompted by a review of the information we held about this service and review the rating, and to follow up on action we told the provider to take at the last 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.

We conducted an unannounced focused inspection of this service on 18 August 2022. 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, and good governance at this inspection.

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.

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 remained Requires Improvement but have met the breaches of regulation. 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 Ersham House 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.

About the service

Ersham House Nursing Home is a care home with nursing and accommodates up to 40 people in a purpose-built building. The service supports adults whose primary needs are nursing care. Some people also live with additional mental health disorders, and dementia. They have recently removed the service user bands, learning disabilities and autistic spectrum disorder, and people who misuse drugs and alcohol as the service is not suitable to provide this support. At the time of our inspection there were 23 people living at the service

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

The providers’ quality assurance and governance systems had not consistently identified the shortfalls found at this inspection. The improvements seen at the last inspection had not been sustained sufficiently to the meet breaches of regulation. There was a lack of clear and accurate records regarding some people's care and support. For example, oral care, nutrition support, lymphedema and diabetes. There was a lack of oversight by the provider and management team. The leadership within the service had been impacted on due to the changes with the management of the home.

Risk of harm to people had not always been mitigated as good practice guidelines for the management of medicines, pressure care management, and nutrition had not been followed. There was a lack of guidance for peoples’ specific needs, such as lymphedema. This meant that people's safety and welfare had not been maintained at all times. Whilst Infection control audits and cleaning schedules were in place, not all areas of the home were clean, and there were potential cross infection risks. COVID 19 guidance was not being consistently followed. There were not enough suitably trained and experienced staff deployed to meet people’s individual needs, and the rota in the premises was not accurate and up to date.

We have made a recommendation about the mental capacity assessments for people who live at Ersham House Nursing Home.

Following the inspection, the provider informed us they had made changes to improve medicines management, records, care planning, cleanliness, personal emergency evacuation plans and governance,

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 (25 March 2022) 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 we found the provider remained in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about cleanliness of the service, infection control, care delivery and staffing. A decision was made for us to inspect and examine those risks.

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.

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 Requires Improvement. This is the third time the service has been rated Requires Improvement.

We have found evidence that the provider needs to make improvements. Please see the relevant key question, safe and well-led sections of this full report.

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 continued breaches in relation to safe care and treatment, staffing and good governance at this inspection.

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

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

Ersham House Nursing Home is a care home with nursing and accommodates up to 40 people in a purpose-built building. The service supports adults whose primary needs are nursing care. Some people also live with additional mental health disorders, and dementia. At the time of our inspection there were 22 people living at the service.

People’s experience of using this service:

People told us they ere comfortable living at Ersham House. comments included: "Nice friendly staff," "The staff try hard to make us happy, the food is nice and my room comfortable."

The providers’ governance systems had improved and were being used to improve the service. There had been improvements made, but there were still areas that needed to be further improved to ensure peoples safety. For example, there was a lack of clear and accurate daily records regarding some people's care and support. Food and fluid charts were inconsistently completed which meant that staff would not be able to monitor their health and well-being effectively.

There had been improvements to the management of risk. However, there were environmental areas that needed to be risk assessed to keep people safe. Such as using unlocked rooms for storage of flammables. Risk of harm to people had not always been mitigated as there was information missing in respect of peoples’ specific diabetic needs and some pressure relieving equipment was not set correctly. This meant that people's safety and welfare had not been maintained at all times. Not all staff had received an appropriate induction, training, or had their competencies checked to enable them to perform their roles effectively.

We observed medicines being given safely to people by appropriately trained staff, who had been assessed as competent. Safe recruitment practices had been followed before staff started working at the service.

The home was clean with dedicated housekeepers. One person told us, "They keep my room nice and clean."

People's dietary needs were assessed, and people were provided with a choice of cooked meals each day. Feedback about the food was positive and people said they enjoyed the meals most of the time. People’s health needs were met with involvement from a variety of health and social care professionals. 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.

Staff were caring in their approach to the people they supported and we saw people were treated with respect and dignity. People and visitors to the service were consistent in their views that staff were kind, caring and supportive. One health professional said, “The home atmosphere is much more positive, and people seem to be content.” People were relaxed, comfortable and happy in the company of staff and engaged with them in a positive way.

People confirmed they were involved in their care planning. End of life care planning and documentation guided staff in providing care at this important stage of people’s lives.

Complaints made by people were taken seriously and investigated. Resident and family meetings were recommencing.

The registered manager and staff team were committed to continuously improve and had plans to develop the service and improve their care delivery to a good standard. Feedback from staff about the leadership was positive, “It’s a good place to work, communication is good, and we share information. We all feel we can contribute, and we work as a team.”

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 (11 June 2021) there were five 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 we found improvements had been made and the provider had met three of the five breaches of regulation.

Why we inspected

This inspection was prompted by our data insight that assesses potential risks at services, concerns raised and based on the previous rating. This enabled us to review the previous ratings. We also used this opportunity to look at the breaches of Regulation 9, 10, 12, 17 and 19. As a result, we undertook a comprehensive inspection to review all the key questions.

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. This included checking the provider was meeting COVID-19 vaccination requirements.

You can see what action we have asked the provider to take at the end of this full report.

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

This was a targeted inspection that considered the management of medicines. Based on our inspection we found that areas of medicine management were not safe. Risk of harm to people had not always been mitigated as good practice guidelines for the management of medicines had not been followed.

Following the inspection we received an action plan and confirmation of involvement of the medicine optimisation in care homes (MOCH) team to mitigate risk.

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 12 June 2021).

Why we inspected:

The inspection was prompted in part due to concerns received about the management of medicines. A decision was made for us to inspect and examine those risks.

Enforcement:

We have identified a continued breach of Regulation in relation to safe care and treatment regarding the management of medicines.

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.

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

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.

People’s experience of using this service:

The providers’ governance systems had not consistently identified the shortfalls found at this inspection. There was a lack of clear and accurate records regarding some people's care and support. For example, oral care, communication needs and daily records. Management of behaviours that challenge were not always documented clearly and lacked details to manage them effectively. There was a lack of oversight by the provider. The leadership within the service had been impacted on as there had been no registered manager for 11 months and several short-term managers.

Risk of harm to people had not always been mitigated as good practice guidelines for the management of medicines, continence and pressure care management had not been followed. There was a lack of guidance and analysis in managing some people’s behaviours that challenge and there was no evidence of what strategies worked and what staff could try next time. This meant that people's safety and welfare had not been maintained at all times. Infection control audits and cleaning schedules were not in place and there were areas of the premises that were not clean and were a potential cross infection risk. There were not enough staff deployed to meet people’s individual needs, and the rota in the premises was not accurate and up to date.

Staff had not received an appropriate induction, training, or had their competencies checked and support to enable them to perform their roles effectively. People told us, “Pretty good I reckon,” and “I know the staff get training, I have no worries or complaints.” However, staff confirmed that they had not an induction and no practical training in moving and handling or infection control. The mealtime experience needed to be improved to ensure people received a balanced and nutritious diet.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

We have made a recommendation about the mental capacity assessments for people who live at Ersham House

People's care was not person-centred. The care was health orientated and not designed to ensure that people's independence was encouraged and maintained. People were not encouraged to be involved in activities and there were no planned activities in house to encourage people to come out of their rooms and meet other people.

People, their belongings and personal rooms were not always treated with respect and dignity. However, we did see some lovely interactions between staff and the people they supported.

Whilst there were areas of care planning and assessing risk to people that needed to be improved, there were also systems to monitor people's safety and promote their health, these included health risk assessments and care plans. End of life care was planned for and people could state their preferences.

The provider had ensured staff were recruited safely.

There were COVID-19 policies in place for visiting that was in line with government guidance. Families told us that they were welcomed into the home and that staff supported them with the lateral flow test and PPE.

Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.

Following the inspection the provider has appointed a new manager who has shared a comprehensive action plan with CQC.

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

Rating at last inspection:

This service was registered on the 26/03/2020 and this is the first inspection rating all five key questions to give an overall rating.

Why we inspected:

This inspection was prompted in part due to information of risk and concern. CQC received concerns in respect of staffing levels (high use of agency staff) lack of leadership and poor care delivery. The concerns raised were looked at during this inspection and have been reflected in the 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.

Enforcement:

We found five breaches in relation to safe care and treatment, staffing levels, dignity and respect, person centred care and good governance at this inspection.

Follow up:

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

We undertook this targeted inspection to follow up on specific concerns, which we had received about the service. The concerns were about peoples’ safety and well-being.

We inspected using our targeted methodology developed during the COVID-19 pandemic to examine those specific risks and to ensure people were safe.

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

People told us, “Very good here, I had a fall and wasn’t safe to live at home, but I am safe here,” and “I feel safe and looked after.” A relative said, “I am very happy with the care, it’s not easy at the moment, but I’m kept informed and I know my relative is safe.”

Quality assurance systems had been introduced in March 2020 and were continuing to be developed and improved. There had been three managers in post since March 2020. This meant that systems had not had the opportunity to be fully embedded in to practice and further time was needed.

People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible. Staff understood the risks associated with the people they supported. Risk assessments provided guidance for staff about individual and environmental risks to their health and well-being. People received their medicines safely, when they needed them, supported by individual care plans and risk assessments. There were enough staff to meet people's needs. The provider used a dependency tool to determine staffing levels. Staffing levels were regularly reviewed following falls or changes in a person's health condition. Safe recruitment practices had been followed before staff started working at the service.

We were sent the COVID-19 infection procedures and policies prior to the inspection. These reflected current guidance and we were told it was updated regularly. All staff were aware of the government guidance and confirmed that they received updates daily. Staff were all wearing protective personal equipment (PPE).

Staff told us that they felt well supported by the management team and received regular supervision and wellbeing meetings. They felt that improvements to the service had been made and were still being implemented.

Rating at last inspection:

This service was registered on the 26/03/2020 and this is the first inspection.

Why we inspected:

The inspection was prompted due to concerns received about staffing, and peoples’ safety and well-being. A decision was made for us to inspect and examine those risks. We found no evidence during this inspection that people were at risk of harm from these concerns.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspection 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.

CQC have introduced targeted inspections to follow up on a Warning Notice or other 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.

Follow up

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