Archived: Nightingale House

People’s experience of using this service:

• People were supported by caring staff that knew them well. Their needs were captured in person centred care plans and the care they received was aligned with preferences in care plans.

• People’s needs were regularly reviewed and a thorough assessment process undertaken when new people moved in. The service had just re-written all its care planning documents to better capture how people’s needs affected their day to day living.

• Staff knew how to spot and report any safeguarding concerns and risks were fully assessed and positively managed.

• People were given choice and control in their lives, and this looked different for different people.

• Staff had a good insight into Korsakoff’s syndrome and how this might affect people’s behaviours and changing preferences and opinions.

• People’s health needs were actively monitored and supported, and timely referrals made to relevant health care services.

• Medicines were managed safely and staff were trained and competency tested before administering medicines.

• Staff had a basic understanding of the Mental Capacity Act 2005 and asked people for consent.

• People said they felt safe and relatives told us people were happy and well looked after.

• Quality assurance systems had improved and were now more robust.

Rating at last inspection: At the last inspection in February 2018 the service was rated requires improvement. The report was published in April 2018.

Why we inspected: This was a planned inspection based on our schedule. We did not have any concerns prior to inspecting this service.

Follow up: We will continue to monitor the service through notifications and maintaining contact with the service. We will inspect the service according to our planned schedule, or sooner if we are made aware of concerns.

Nightingale House has been rated requires improvement at two previous inspections. The registered manager and staff are working hard to better understand and implement the improvements required. In January 2016 improvements were required in all five key questions; in November 2016 improvements were required in four key questions. At this inspection improvements were required in two key questions.

Nightingale House 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 home is registered to provide care and accommodation for up to 27 people who have an alcohol related brain damage such as Korsakoff's and/or mental health needs. The home is registered to provide care for 24 people in the main house and three people in a house adjacent to the home known as The Porch House. At the time of the inspection 21 people were living at the main house and no one was living in The Porch House. Nightingale House provides accommodation on the lower-ground, ground and first floors. The home can accommodate people with limited mobility on the ground floor, but people unable to use the stairs would not be able to use the dining room situated on the lower ground floor.

The home has a registered manager who has managed the home for many years. 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.

People told us they were safe living at Nightingale House. They described the staff as “pleasant”, “nice” and “very accommodating”. One person said, “On the whole they [staff] are really very good.” Staff were observed to be caring in their interactions with people and they spoke positively about their relationship with people. No-one we spoke with had any complaints about the home.

Staff had been provided with safeguarding training in January and December 2017 and were aware of people’s vulnerability due to their circumstances. People’s care plans had been rewritten in an easier to access format and these plans included information about risks to people’s health, safety and well-being. However, some further detail about how living with Korsakoff’s Syndrome and other mental health conditions affected people’s day to day lives was required. Staff had received training in supporting people with these specific care needs and knew people well. Where people were unable to consent to receive care and support, best interest decisions had been made on their behalf. Due to people’s vulnerability and to ensure their safety, people were restricted from leaving the home without the support of staff or a family member. Authorisation for these restrictions had been applied for. Some people told us they no longer wished to live at Nightingale House. Records showed people’s continued residence at the home had been reviewed annually by each person’s commissioning authority to ensure it remained in their best interest to do so.

The home continued to support people with managing their money. Records of money received and spent were recorded for each person. Staff said people had access to their money whenever they needed it but most people required support to budget effectively.

Some people told us they would like more to do during the day. Staff said they encouraged people to be involved in day to day activities, as well as planned events both in and out of the home. Since the home had created the games room, staff said people were engaging more with each other. We asked the home to seek guidance about how to promote people’s involvement in meaningful engagement and social activities.

There were sufficient numbers of staff employed at the home and records showed staff had been recruited safely. Staff told us staffing levels were flexible dependent upon planned events both in and out of the home.

People received their medicines safely and as prescribed from staff who had received training in safe medication practices. People saw a number of health care professionals such as GPs, dentists and opticians to support their health and well-being.

People told us they enjoyed the food provided by the home and said they could have drinks and snacks whenever they wished. Staff continued to prepare drinks for people, although people were encouraged to make their own, most people preferred staff to do this for them.

Since the last inspection and their work with the local authority’s quality assurance and improvement team, the home had developed a service improvement plan. This plan highlighted the areas the home had identified as requiring improvement and what actions have been taken to ensure these improvements are made. Regular meetings continued where staff and people were invited to share their views about promoting people’s independence and improving the home. Questionnaires seeking feedback from people and care professionals in January 2018 provided a positive response.

We have made three recommendations for improvement. Care plans require more detail about how people’s mental health care needs affect their day to day lives and how staff should provide support. The home has been asked to seek guidance about providing more person-centred engagement for people and to review the availability of staff.

Nightingale House is registered to provide care and accommodation for up to 27 people who have an alcohol related brain damage such as Korsakoff's and/or mental health needs. The home is registered to provide care for 24 people in the main house and 3 people in a house adjacent to the home known as The Porch House. At the time of the inspection 21 people were living at the main house and two of these people were living in The Porch House.

The home had a registered manager 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.

The home was previously inspected in January 2016 and was rated requires improvement in all five key questions. We identified the home was in breach of a number of regulations of the Health and Social Care Act 2008 Regulated Activity Regulations 2014. Improvements were necessary in a number of areas: how the home documented and managed people’s care needs and risks to their health and safety; gaining people’s consent to their care and not depriving people of their liberty without proper authorisation, as well as maintaining the cleanliness of the home and reducing the risk of cross infection. We issued the home with two warning notices relating to the improvements required.

Following that inspection, the registered manager sent us information about how the home was going to make improvements. They have also been working closely with Devon County Council’s quality assessment and improvement team (QAIT) and had consulted with another provider of a similar service to discuss and share good practice.

At this inspection we found improvements had been made to meet the requirements of the warning notices. However, some further improvements in documentation relating to risk assessment and care planning; staff training as well as supporting people’s independence and involvement with their hobbies and interests were still required. We made a number of recommendations in relation to these issues.

The home had been working with QAIT to review how risks to people’s health and well-being were assessed and how people’s care and support needs were recorded. However, this process had not yet been completed and not everyone’s assessments, management plans and care plans had been rewritten to better reflect their individual needs. Care plans required further information about how staff supported people at times when they became distressed and anxious as well as how to encourage and support people with their independence and personal goals. We found documentation to be lengthy and cumbersome to use. The registered manager agreed staff would benefit from more easily accessible information and confirmed the assessments and care plan documents would be further reviewed and simplified.

While we recognise the manager had made progress to ensure that changes needed were taking place, improvements in the way the home supported people to take risks and promote their independence and choice were not yet fully established and some people still felt overly restricted. This is a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the previous inspection we found people were not being routinely assessed in respect of their mental capacity. Also some people told us they wished to live more independently rather than in a group care home. Following that inspection everyone living at the home had had their capacity to make decisions about their care and support assessed. For those people whose liberty was restricted to maintain their safety, applications for legal authorisation had been submitted to the local authority. People had also been assessed by their commissioning authority to review whether continuing to live at Nightingale House was in their best interest: all of the assessments concluded that remaining at the home was in people’s best interests.

Although the registered manager told us staff had received training in supporting people with mental health conditions and in particular alcohol related brain damage, we heard staff use language to describe people’s mental health needs in a way that was not always respectful. For example, we heard staff refer to people as “kicking off” and “playing up” when talking about people’s well-being, and care records referred to one person as being “nasty, snappy and difficult”. There was also a description of one person “choosing” to self-neglect, rather than this being a consequence of their mental health needs. The registered manager said they would address this with staff.

People told us they felt safe and were well supported by staff. One person said, “I’m treated like a human being, the staff are nice” and another person said, “Everything is fine.” We observed staff to be caring in their interactions with people and people spoke positively about the staff. They described the staff as “nice” and “respectful”. On the first day of the inspection, it was a person’s birthday and a staff member had made a cake and everyone sang ‘Happy Birthday’ to them and shared the cake. Staff were observed to be chatting warmly with people. There were pleasant and kind interactions with lots of laughter. The atmosphere in the home was relaxed and friendly.

At the previous inspection people told us there was not enough to do during the day and people were seen to be left in the lounge for long periods with little stimulation or interaction. At this inspection we received mixed views from people about the opportunity to be involved in social events or meaningful activity. Some people told us there was little to do but watch television and they were bored. Other people told us there were regular planned activities and they could be as involved as they wished. The home had previously implemented overly restrictive practices such as people not being allowed to use the kitchen, or locking some people’s bedroom doors, rather than individualised risk management strategies. At this inspection, and immediately following the inspection, changes were implemented to reduce these restrictive practices and move towards support that was more reflective of people’s individual abilities and level of risk.

The home had increased the number of staff on duty during the day and early evening since the previous inspection. Staff had been safely recruited to ensure they were safe to work with people who were vulnerable due to their mental health needs and their reliance upon staff.

Many of the people living at the home were unable to manage their own finances. Where they did not have a Court of Protection officer appointed or a family member to support them with their finances, the home undertook this responsibility. Although some people were supported to manage their own money others told us they didn’t know how to obtain money. We discussed this with the staff and the registered manager as the system in use meant some people had to ask for money rather than be supported to manage their own money independently. Individual records were maintained of each person’s income and expenditure. Receipts were obtained to enable an audit of people’s finances.

The home managed people’s medicines safely and people received their medicines as prescribed.

Since the previous inspection the home had improved its monitoring of the cleanliness of the environment. We found the home to be clean, tidy and free from offensive odours. Cleaning audits and room checks were made to ensure all areas of the home remained clean and staff had received training in infection control.

QAIT had also supported the home with introducing quality monitoring systems to enable them to review care practices, evidence the support provided to staff and monitor the quality of the service. The registered manager was recording observations of staff interaction with people and was undertaking formal supervisions with staff. We saw from records and heard from staff, that the registered manager had invited staff to reflect upon how people were being supported and had discussed further changes to the home’s practices.

You can see what action we told the provider to take at the back of the full version of the report.

Nightingale House is registered to provide care and accommodation for up to 27 people who have an alcohol related brain injury such as Korsakoff’s and / or mental health needs. On the day of the inspection 25 people were living at the care home.

The service had a registered manager 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.

Stoke

People told us staff were kind and caring, and most people told us they were treated with dignity and respect. We found staff did not always have time to talk with people, promote their independence and social activities were limited.

People’s involvement in the community and social life were not promoted, and some people told us they were bored. People felt staff were competent; however, people were not supported by staff that had the knowledge, skills, experience and training to carry out their role and deliver personalised care. People were protected by safe recruitment procedures.

People were supported to eat and drink enough and maintain a balanced diet. Mealtimes were at set times throughout the day and people told us they did not have a choice of meals. Drinks were also at set times throughout the day and served in the dining room.

Some people felt safe living at Nightingale House, some people felt restricted. The registered manager understood their safeguarding responsibilities.

People were protected from risks but to the extent their independence and freedom was affected. Where staff felt there were risks, risk assessments did not identify these. We found blanket rules in place for everyone rather than individual assessments of people’s needs.

People’s mental capacity was not always being assessed and regularly reviewed which meant care being provided by staff may not always be in line with people’s wishes. People who may be subject to Deprivation of Liberty applications (DoLS) had not been assessed. Staff did not understand how the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) protected people to ensure their freedom was supported and respected.

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People did not always have care plans in place which addressed their individual health and social care needs. People were not involved in the creation of their care plan and ongoing reviews of their care. Therefore care plans may not have reflected people’s needs, wishes and preferences about what care they needed and how they wanted staff to provide it.

People’s end of life wishes were not documented and communicated. This meant people’s end of life wishes were not known to staff.

People who were living with short term memory difficulties due to their previous alcohol use were not always appropriately supported in an individual way. People’s care plans did not address people’s cognitive and memory needs or demonstrate how they would like to be supported. People were not always protected by effective infection control procedures.

People knew about the complaints procedure. Staff felt the registered manager was supportive. Staff felt confident about whistleblowing and told us the registered manager would take action to address any concerns.

The registered manager did not have effective systems and processes in place to ensure people received a high quality of care and people’s needs were being met.

People’s medicines were managed safely.

People’s confidential and personal information was stored securely and the registered manager and staff were mindful of the importance of confidentiality when speaking about people’s care and support needs in front of others.

We found 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 the report.

We spoke with four people who told us they felt supported by staff and that they were able to be involved in their care. One person said 'They don't ever force anything on me.'

We saw that there were appropriate restrictions and routines placed upon people. Records clearly showed the reasons for these decisions and restrictions.

People had access to health and social care services. People we spoke with said they were happy living at the home. One person said 'I'd rather be in my own home but my doctor says I need to put my feet up here and get looked after.'

The home was clean, tidy and free from offensive odours. There were systems in place to ensure that people living at the home, staff and visitors were protected from the risk of infection.

There were suitably skilled staff on duty. The staff we spoke with and people who lived at the home thought there were enough staff on duty. One person said 'There is always someone floating around.

The majority of records were well maintained. Care records and maintenance records were clear, easy to use and kept under review.

People we spoke with said they were happy living at the home. One person said 'I am well cared for.' People explained that staff 'Sorted out doctor, dentist and hospital appointments and took them wherever they had to be.'

Staff were knowledgeable about the care and support needs of people in the home. Care records were well written, up to date and clearly reflected the complex needs of people at the home.

Staff felt supported by management and had received training and education to care for vulnerable people. They also knew how to recognise and report any allegations of abuse.

Medications were well managed at the home although the storage of controlled drugs could be improved to meet current storage legislation.

People living at the home, their relatives and staff had opportunities to feedback their views about the service and the provider had systems in place to regularly monitor and assess the quality of the service.