Archived: Westbury House Nursing Home

We undertook an unannounced focused inspection of Westbury House Nursing Home on 31 May and 6 June 2016 as a result of concerns raised during previous inspections in March and April 2016. We inspected the service against three of the five questions we ask about services: is the service Safe, Effective and Well led. This inspection was completed as we had increasing concerns regarding the care provided to people living at the home. These included concerns regarding the lack of appropriate reporting of incidents which had posed a significant threat to people’s health and wellbeing and risk assessments not being appropriately detailed to manage risks to people’s safety. Concerns also included insufficient staffing levels to be able to meet people’s need safely and staff not being in receipt of the most up to date and appropriate training to be able to meet people’s individual needs. We were also concerned that the home was not appropriately well led by a visible registered manager.

We carried out an unannounced comprehensive inspection of this service on 22, 23 March and 4 April 2016 where eight regulatory breaches were identified. Following these inspections the provider wrote to us to say what they would do to meet these legal requirements. During the inspections we checked whether the provider had completed their action plan to address the concerns we had found. The provider had made inadequate improvements to address the original concerns; and at these inspections additional concerns were also raised. At this inspection we found that the provider continued to be in breach of Regulations and had not made necessary improvements to ensure people’s safety and welfare.

As a result of our inspection on 31 May 2016 we wrote a letter to the provider to highlight our concerns and to request written confirmation that sufficient numbers of suitably trained staff would be deployed to ensure people’s safety by 2 June 2016. The provider met and spoke with the Care Quality Commission (CQC) on 2 June 2016. Following this meeting the provider submitted a staffing plan on 3 June 2016 showing the staffing levels which would be deployed in order to meet people’s needs safely.

We revisited the home on 6 June where it was identified that our concerns had not been appropriately addressed. We were not assured that people were receiving safe and effective care from sufficient numbers of suitably trained staff. As a result action was taken by the CQC to ensure people’s safety, health and welfare.

Westbury House Nursing Home provided accommodation and nursing care for up to 35 older people who had physical disabilities and neurological related diseases and disorders. These included Huntingdon’s disease and acquired brain injuries as a result of illness or accident. This also included people who required care on a short term basis referred to as ‘respite’ care. At the time of our inspection 31 people were using the service.

Westbury House is a large four storey period building set in expansive grounds on the outskirts of West Meon. West Meon is a small village situated between the towns of Winchester and Petersfield in Hampshire. The house comprised of two units where both residential and nursing care was provided. A wing of the house separated by a locked door was used as living accommodation for those with the most complex behavioural needs for their own and other people’s safety.

This report will refer to the two units collectively as ‘the home’ throughout this report unless individually specified.

The home had 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.

At previous inspections in March and April 2016 we had identified that the registered manager was regularly absent from the service. They were not in day to day control of the service providing consistent managerial support for staff. During our inspections in May and June 2016 neither the provider or the registered manager were present at the home.

Our inspection of 21 and 22 March and 4 April found a number of breaches of the Health and Social Care Act 2008 and associated regulations.

These breaches were across a number of regulatory areas. Safeguarding concerns were not appropriately reported or investigated therefore external agencies could not assure themselves that appropriate action was being taken to address the identified concerns. People’s risk assessments were not completed fully or identified as necessary where required to ensure staff knew how to give safe care. There were insufficient numbers of suitably qualified and experienced staff deployed to meet people’s needs. Communication between people using the service and staff was not always clear due to a lack of English language known and English language skills training provided to staff from non-English speaking countries. Recruitment procedures were not robust and did not fully and accurately determine that people were suitable for their role of providing safe care. People were at risk of infection due to insufficient cleaning practices and Medicines were not always appropriately secured placing people at risk of accessing medicines not prescribed to them.

People at risk of weight loss had not been appropriately identified and steps taken to ensure they were appropriately referred to healthcare professionals so the reason for this weight loss could be addressed. The provider had not complied with the requirements of the Mental Capacity Act 2005 (MCA). There was a lack of documented processes to identify when someone should be receiving care in their best interests. Staff had not received specialist training in areas such as Huntingdon’s disease and motor neurone disease to be able to effectively meet the needs of the people they were supporting. People were not always involved in their care planning therefore care was not always provided in the way people wanted or needed.

The registered manager had not appropriately recorded notifications to the CQC advising us of serious incidents and allegations as part of their regulatory function to enable us to monitor the safety of the service. There were no regular checks or a system of quality monitoring in place to ensure that improvements could be made to the quality of the service provided to people.

As a result of the concerns identified on 8 April 2016 we wrote an urgent letter to the provider advising them they would no longer be able to admit or readmit people to Westbury House without our prior consent. This was to ensure that we could check that appropriate care planning and support documentation was in place prior to people’s moving into the home.

Prior to our inspection on 28 May 2016 the local authority supported Westbury House by providing three additional members of staff to support the current staff working at the home. This included one nurse and two members of care staff for both the day and the night shift. This was to ensure that there were sufficient numbers of staff to meet people’s needs.

During our inspection on 31 May we focused our attention on a number of people who had been identified at risk of not receiving safe and effective care and treatment. As a result a number of concerns were identified.

Despite our letter to the provider on 8 April stating that they were not able to provide care to people without our prior authority one person had been readmitted to Westbury House on three separate occasions without CQC written permission. Another person had also been admitted since 8 April again without CQC written permission. This was in direct breach of our Notice of Decision to restrict admissions.

During our inspection on 31 May we could not see that people were being supported to maintain their independence. One person we had previously identified on 4 April as not being supported to leave the home to visit friends when requested were still not having their needs met. This person expressed their desire to leave the home however we could not see that provisions had been made to support them with their choice to leave the home.

There was insufficient equipment available to meet people’s needs safely. Those who required additional support with their moving and handling needs which required the provision of equipment had not always had their needs met.

We could not see that people had always consented to receive care from Westbury House Nursing Home. Not all the people living at the home had provided written consent to live at the home. No action had been taken to identify whether or not their placement at the home was as a result of a best interest decision when people were unable to make their own decisions.

People who were losing weight had not received appropriate referrals to healthcare professionals to ensure their needs in relation to their weight loss were appropriately assessed. No specific guidance had been provided to staff on how to make sure that people’s nutritional and hydration needs were being met.

The provider did not ensure that people who were at risk of dehydration had effective care plans in place which provided the appropriate guidance to staff as to how much fluid a person should be consuming in a day to ensure their on-going health and welfare.

People living with diabetes and at risk of suffering hyperglycaemic or hypoglycaemic episodes did not have their conditions managed effectively. This led to people being at risk of suffering a diabetic coma which if untreated could lead to a serious deterioration in a person’s health eventually resulting in death.

Staff were not always provided with sufficient guidance to maintain and support people’s health and wellbeing nee

Westbury House Nursing Home provides accommodation and nursing care for up to 35 older people. The home provides accommodation and nursing care for up to 35 people over the age of 18 who have physical disabilities and neurological related diseases and disorders such as Huntingdon’s Disease and acquired brain injuries. At the time of our inspection 33 people were using the service.

The service had a registered manager. 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 in June 2015, we found the home to be ‘Good’ overall. Improvements were required in infection control.

During our visit on 21 and 22 March 2016 we were concerned about the safety of people using the service. Following this visit we wrote a letter to the provider to highlight our concerns and to request an urgent action plan to ensure people’s safety by 31 March 2016. We revisited the home on 4 April to check whether the actions set out in the action plan, and confirmed as completed by the provider had been carried out and to gather evidence in this respect. The provider was unable to provide all of the required evidence on 4 April 2016 and requested until the 6 April to be able to provide this. We found much of the evidence was dated after our visit on 4 April 2016 and therefore contradicted the provider’s action plan dated 31 March 2016 which stated that actions had already been taken.

People were not protected from abuse, because safeguarding concerns were not appropriately reported or investigated.

Risks to people were not identified and mitigated to ensure people’s safety. Care plans included risk assessment tools to assess people’s individual risks; however, not all identified risks had been appropriately mitigated.

The dependency tool used to identify appropriate staffing numbers did not identify the required ratio between nurses and care workers for day and night shifts to ensure people's needs were met. It was not possible to determine staffing levels in the home because we were given conflicting information by the provider.

Not all staff were suitably qualified to meet people’s needs because they did not have a standard of English which meant they could be understood by people using the service.

Recruitment and induction practices were not safe. We found that staff had gaps in their employment history, references from friends and girlfriends and one person had a criminal record which had not been risk assessed. This meant it was not possible for the provider to determine their suitability for employment because staff pre-employment checks were not complete.

People were not protected by the prevention and control of infection. During our inspection we observed a lack of effective cleaning practices throughout the home. Carpets were frayed and dirty and smelt urine, floors were visibly soiled, walls and floor coverings indicated visible stains and discolouring with dirt and grime. We found bathrooms to be grubby, bath hoists showed signs of rust and were not clean.

Medicines were stored safely in locked medicines trolleys and a locked cabinet attached to the wall. Whilst observing a medicines round we noted that the nurse left the keys on top of the medicines trolley when unattended. There was a risk that people who were independently mobile would be able to access the medicines in the absence of the nurse. There was no clear procedure for ensuring that people admitted to the home for respite care received their medicines safely and consistently.

The provider had not taken steps to ensure that people received sufficient nutrition to sustain good health. One person’s condition meant they were at high risk of weight loss. The provider only took action to address this after we raised concerns during our inspection

The chef showed us a four week rolling menu for main meal choices. There were two choices available each day; one of the choices did not always include a vegetarian option. No options were provided for breakfast of supper on the menu. Staff told us that people were not offered a hot breakfast.

The provider did not comply with the requirements of the Mental Capacity Act 2005 (MCA). Mental capacity assessments had been carried out, which were decision specific, however, the provider demonstrated a lack of understanding of other elements of the MCA. For example, where it had been determined, by assessment, that the person lacked capacity for a decision, a best interest decision making process had not been recorded. This meant there was no outcome for the person and therefore the provider may not have been acting in the person’s best interests.

People can only be deprived of their liberty to receive care and treatment when this is in their best interests and legally authorised under the MCA. The application for this in care homes is called the Deprivation of Liberty Safeguards (DoLS). We found that there were some applications appropriately in place which legally deprived people of their liberty.

Staff had received training in relation to key areas such as fire safety and moving and handling. No trained nurses had received training in specialist areas such as Huntingdon’s disease, motor neurone disease, Parkinson’s disease or multiple sclerosis. These areas are identified in the provider’s statement of purpose as areas where they have a particular speciality.

People and their relatives felt that staff were kind and compassionate and treated them with respect. However, we observed staff supporting people without any interaction. Rooms were dirty and lacked personalisation.

People had not signed their care plan and there was no evidence they had been involved or consulted in their development. Care plans were divided into main sections to address need, however people’s individual plans of care were not always accurate and did not appropriately address the need in a person centred way.

Activities were planned and organised by the activities co-ordinator. The activities co-ordinator explained that each session was planned ‘as it comes’ tailored to those who attended sessions.

The registered manager was not familiar with CQC reporting requirements. During the inspection we found evidence of serious incidents and allegations which should have been notified to CQC. This meant that CQC were unable to monitor incidents in the home or check the appropriateness of actions taken by the provider as a result.

Although the provider carried out regular checks there was no system of quality monitoring involving audits and related action plans in order to strive for continual improvements in the service.

The atmosphere in the home was not open and empowering. Staff were not encouraged to question practice or be involved in the development of the service.

During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The overall rating for this service is ‘Inadequate’ and the service is therefore in 'Special measures'.

The service 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

We carried out a follow up inspection of this home on 20 and 21 October 2014.This inspection was carried out to inform enforcement action we had proposed to take against the provider and to review the progress made on their action plan.

At the time of our visit 32 people lived at the home. As part of our inspection process we spoke with; the registered manager, the clinical lead, the deputy manager, 15 people who lived at the home, seven members of staff including care staff, domiciliary staff and registered nurses, three relatives or visitors and three health and social care professionals.

A team of three Inspectors, two Experts by Experience and a Specialist Advisor in the use of the Mental Capacity Act 2005 visited the home over the two days of the inspection. We observed people in the home as they were supported with activities of daily living. We reviewed a total of 14 care records during this inspection.

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the five questions we always ask; Is the service safe, effective, caring, responsive and well led?

This is a summary of what we found-

Is the service safe?

Since our previous inspection additional staff had been employed to support the needs of people. Staffing levels were consistent however did not always reflect the numbers we had been told were required to meet the needs of people. The provider had identified a new method to assess people's needs to ensure there were adequate numbers of staff available in the home. This had not been fully implemented at the time of our inspection. The provider told us this would be in place by November 2014.

For people who were unable to consent to their care and treatment we found the provider had made some improvements to this, however further work was required to ensure the Mental Capacity Act 2005 was applied consistently where appropriate. We found for some people decision specific mental capacity assessments had been completed, however best interests decision making processes and recording had not been consistently applied.

The provider had introduced a new format of record keeping and this work was in progress. We found some care records lacked consistency and were incomplete. The provider told us effective care records would be in place by January 2015.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which apply to care homes. The registered manager showed us several applications which had been made to the local authority since our last inspection. We saw policies and procedures were in place to meet this need.

Is the service effective?

The home delivered care and support for people with complex mental and physical health and social care needs. We found the provider had taken steps since our last inspection to ensure staff identified and developed the skills they required to meet these needs. This was work in progress.

People were cared for by staff who had a good understanding of how to communicate with people. We saw staff were confident to communicate with people and were knowledgeable of their needs.

Is the service caring?

We saw the majority of staff supported people in a kind, dignified and attentive manner. People told us staff were caring and provided the support they required.

Is the service responsive?

The provider had an action plan in place to ensure all people's needs were assessed and their care planned in accordance with their wishes. This work was in progress and was due to be completed in January 2015. Records showed the provider was working with other health and social care professionals to ensure people's needs would be addressed. People told us they were involved in the planning of their care and could request changes to this. We saw activities were available for people to participate in.

Is the service well-led?

Following our inspection in May 2014 the provider had worked to an action plan due to be completed in January 2015. They had informed us monthly of the actions they had completed and any further work they planned. At this inspection we saw not all of the actions stated as completed had been done. For example, action plans had not been completed as the provider told us they would be.

Staff who worked at the home told us their training needs had been identified and appropriate training provided to ensure they had the skills required for their role. This was work in progress. Staff told us they had been able to access training since our last inspection and the provider had encouraged this.

We saw the provider had sought feedback from their staff and people who lived at the home since our last inspection. Records did not always show how any issues had been addressed.

Care plans had not always been reviewed effectively, we saw care records were not always consistent or accurate. We could not be assured the systems the provider had in place to monitor and review all incidents and accidents in the home were effective.

A team which included three Inspectors, two Experts by Experience and two Specialist Advisors visited the home over the three days of the inspection. We reviewed a total of 17 care records during this inspection.

We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; Is the service caring, responsive, safe, effective and well led?

This is a summary of what we found-

Is the service caring?

People told us staff were very caring, but that there were not enough of them and they did not have time to sit with them. We saw staff mostly acted in a calm, dignified and respectful way. Two people we spoke with were positive about the care they received. One said, 'There are good carers around.' Another told us, 'We are well looked after.' This meant people were mostly cared for in a kind and respectful manner.

Is the service responsive?

The provider ensured people were able to access support from other health and social care professionals as was required to monitor and evaluate their medical and social needs.

People had access to a wide range of activities. However, it was not clear these activities were suitable or acceptable for all people who lived at the home. We saw some people had very little interaction with staff or others.

We found, whilst care plan records were in place, these held conflicting information and were not updated effectively to ensure people's needs were clearly identified for staff to support.

Is the service safe?

Staff personal records held all the information required by the Health and Social Care Act. People were cared for by people who had been recruited appropriately. The service had robust procedures in place to support people with the management of their monies and all staff had a good understanding of the processes they should follow if they had any concerns about abuse in the home.

However, people were not always cared for by staff who had a good understanding of how to communicate with people. This meant people were at risk of not having their needs appropriately identified by staff.

For people who were unable to consent to their care we found the provider did not act in accordance with the Mental Capacity Act 2005. We found documentation in place to identify people's ability to consent to care and treatment was not consistent. In some cases conflicting information was held.

CQC monitors the operation of the Deprivation of Liberty Safeguards (DOLS) which applies to care homes. We saw the home had applied for two DOLS since our last inspection and neither of these had been upheld. While no further applications were in place, proper policies and procedures were in place. The registered manager had a good understanding of this process and its application.

Is the service effective?

This home delivers care and support for people with complex health and social needs. Many people at this home were unable to verbally communicate with others. Care plans were not effective in supporting staff to communicate with people. We observed staff did not support effective and supportive communications and interactions with people. We used our Short Observational Framework Inspection (SOFI) tool to observe interactions between people, staff and any visitors. We found staff lacked the skills to effectively interact and communicate with people who had communication difficulties or challenging behaviours.

Is the service well-led?

Staff told us there were not enough members of staff at times to meet the needs of people who lived at the home. We were told a recent turnover of staff meant registered nursing staff on duty during our inspection were new to the home and gaining experience of the people who lived there. The registered manager explained the processes they used to ensure adequate staffing numbers were on duty at any one time. We saw staff did not spend time with people who lived at the home talking to them and interacting. They told us there was no time for this.

Staff working at the home told us they did not have opportunities to express concerns about any issues they had and have them listened to and dealt with appropriately.

During this inspection we looked at the care records of seven people who lived at the home and spoke with four people who lived at the home. We spoke with seven members of staff, and spent time talking to the registered manager (who is also one of the registered providers and is referred to as the manager throughout this report). We also spoke with the other registered provider. We also spoke to two other health and social care professionals who were involved in the care and treatment of people currently living at Westbury House Nursing Home.

At an inspection of the service in November 2011 it had been identified that the service was not meeting the standard relating to notifying CQC about events and incidents affecting the wellbeing of people using the service. We checked the provider's compliance with this standard at this inspection.

We found that the providers were fulfilling their legal obligation to notify CQC about incidents affecting the wellbeing of people living at the home. However, the providers had not informed us, as required, of the outcome of applications made to deprive people of their liberty using the Deprivation of Liberty Safeguards.

We checked the provider's compliance with the essential standards about care and welfare of people and the recruitment of staff because we had received concerning information relating to these two standards. We inspected the essential standard about consenting to care and treatment because we identified concerns regarding this outcome during the inspection process.

We found that the provider had failed to appropriately assess the changing needs of people who used the service. The provider had failed to plan and deliver care that met the individual needs of people using the service, that ensured the safety and welfare of people who used the service and that reflected guidance published by appropriate professional and expert bodies.

We found that recruitment procedures were followed at the home and that appropriate checks were undertaken before staff began work.

We asked to see 17 people's records relating to the Mental Capacity Act 2005, following the inspection, which the providers sent to us. A specialist advisor who had expert experience and knowledge about the Mental Capacity Act (2005) supported us in reviewing this information.

We found that the provider was not acting in accordance with the Mental Capacity Act 2005. Sufficient action had not been taken to support people to make informed decisions. Some decisions were being made on behalf of people who could not consent to care and treatment. However, the provider could not evidence the legal basis for this decision making process.

We found that the maintenance of care records failed to ensure that accurate and consistent information was available about people's care needs.

We looked at how the provider assessed and monitored the quality of the service. We found that the provider did have some formal and informal systems to assess and monitor the quality of the service the systems. However, these were not fully effective, because issues we found with care and welfare, consent to care and treatment and records had not been identified by the provider.

During this inspection we met and spoke with approximately 25 people who lived at the home. We also spent time observing their care and spoke to three relatives who were visiting during our inspection. We spoke to approximately 14 staff including three nurses, a senior care supervisor, an occupational therapy assistant, cleaners and care assistants. We also met two of the administration support team and spent time talking to the registered manager, who is also one of the registered providers and will be referred to as the manager throughout this report, and the other registered provider.

We also spoke to eight other professionals who were involved in the care and treatment of people currently living at Westbury House Nursing Home. This included, doctors, social workers, care coordinators and privately funded professionals.

The majority of the people we spoke to were positive about the care and treatment provided at Westbury House. We found that people's care needs were mostly being met and they had consented to this care. Records did not always reflect this and we have asked the provider to make improvements in this area.

We saw that many improvements had been made in the home since December 2012, including in respect of cooperating with other providers and quality monitoring of the service.

Every body had a plan of care, which provided clear, individualised guidance for staff.

There was consistent information throughout the care plans documents to ensure people received and care and support in a consistent manner. There was evidence that advice and guidance was sought and followed from relevant health and specialist professionals.

Details in the safeguarding policy gave clear guidance about which authority had responsibility for investigating allegations of abuse. Both of the providers demonstrated an understanding about safeguarding vulnerable adults. Members of staff that we had conversations with had a good understanding about safeguarding and the actions they needed to take to safeguard people in the event of suspected abuse occurring.

We found that there were policies and procedures in place to guide staff in understanding the importance of people living at the home giving their consent for care and treatment and to make their own decisions.

There was evidence that best interest decision processes were being followed in the event of people not having the capacity to make a specific decision.

There was evidence that best interest decision processes were being followed in the event of people not having the capacity to make a specific decision.

Every body had a plan of care, but care plans did not consistently provide accurate and up to date information about the care and support people needed or wished for. Some people had signed their agreement to their care plans, but when we spoke with them some were unable to recall their care plans being discussed with them.

Details in the safeguarding policy did not give clear guidance about which authority had responsibility for investigating allegations of abuse. One of the providers told us 'I don't know anything about it,' when we asked them about their understanding about safeguarding vulnerable adults. However most members of staff we spoke with demonstrated a good understanding about safeguarding.

There were processes in place for assessing the quality of the service. However, these were not effective identifying areas for improvement. Audits were in the process of being completed for care planning.

Staff confirmed that they received relevant training and supervision sessions. They had the opportunity to discuss training needs, career progressions and any concerns/issues they had with the provision of care at the home.