All inspections: Firtree House Nursing Home

This was an unannounced inspection which took place on 9 January 2017.

Firtree Nursing Home is registered to provide accommodation for elderly people who require nursing or personal care. The home provides care for up to 35 older people, some of whom are living with dementia and some of whom have specific nursing needs. Accommodation is arranged over two floors. At the time of our visit there were 26 people living at the home.

During our inspection the registered manager was present. 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 found that there were not always enough staff employed to safely meet people’s needs. Whilst on the day of inspection we found that there were sufficient numbers of staff that attended to people promptly our analysis of the staff rota showed that the required number of staff was not always maintained. Feedback from relatives was that this was an issue, particularly at weekends. Agency staff were used regularly to help maintain staffing levels. Not all staff were recruited safely and recruitment checks had not been fully completed.

There were assessments made of risks to people’s health and safety. Whist these identified risks action to reduce the likelihood of harm occurring was not always taken. One person was at risk of developing a pressure sore and had asked to stop using a special mattress that would have helped to reduce one developing.

Not all staff had received relevant training or supervision to help themto do their job well. Training records detailed that most staff had not completed mandatory training despite this needing to be done every year. This resulted in staff not always having the skills and competencies to do their job well. Feedback from healthcare professionals was that staff were not always aware of people’s needs or how to treat specific conditions they may have.

The application of the Mental Capacity Act was not consistently followed and applications that were needed to authorise a deprivation of liberty had been made that were not appropriate. Best interest decisions were not always made with professionals involved in people’s care.

There were mixed views on the quality of food in the home. Whilst people nutritional needs were met there was an inconsistent approach to mealtimes and the types of food that people could safely eat. Where people had specific dietary requirements such as allergies or for those with diabetes these were catered for.

People and relatives told us that staff were kind and caring however these comments were not consistent. Some relatives felt that some staff appeared not to treat people with dignity and respect. We saw that, whilst staff spoke kindly to people, there were occasions when staff missed the opportunity to sit and talk to people.

People were not supported to engage in meaningful activities and spent most of the time sitting watching television. Staff did not spend time sitting and talking with them when they had the chance to.

The care plans we viewed were not always accurate and did not provide staff with detailed information about people’s most up to date needs. People and relatives had made complaints but these had not been responded to or investigated in line with the providers’ complaint policy.

There was a lack of oversight from the provider about the quality of the care people received. Where quality assurance systems had been used they had not been effective as they had not identified the shortfalls we had found. Important notifications about incidents in the home were not submitted to CQC in a timely manner.

Medicines were administered safely. There was safe storage and disposal of medicines by qualified nursing staff who had been trained to give medicines to people. Medicines records were clear and had been completed appropriately. People were protected from harm and safeguarding incidents were reported appropriately to the local authority by the registered manager. Staff knew what to do if they suspected that abuse was occurring.

People had access to other healthcare professionals to help maintain their wellbeing. There were regular visits from the local GP to help ensure that people were treated in a timely manner.

Staff told us that they felt supported by the registered manager and relatives told us that the manager had made improvements in the home.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014.

Firtree Nursing Home is registered to provide accommodation for people who require nursing or personal care. The home provides care for up to 35 older people, some of whom have dementia. Accommodation is arranged over two floors. At the time of our visit 16 people lived there.

There was not 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 manager of the home had submitted their application to the Care Quality Commission to become the registered manager of the home, and had recently had their interview with the CQC.

The inspection took place on 16 December 2015 and was unannounced. At our previous inspection in March 2015 we had identified three concerns. These have since been addressed by the manager.

The manager and staff worked well to keep the environment clean and feeling homely for people. Since our last inspection the main lounge had been redecorated and a new floor had bene put in. It made the room light and airy and a pleasant space to sit in. People were positive about their experiences at the home. One person told us, “It’s a lovely and warm atmosphere here; I feel we are well cared for.” One relative said the home was, “120% better than it was and there was a stable staff team in place that was helping to maintain standards.” They said they were, “Very confident in the manager,” and this gave them, “Peace of mind.”

There was positive feedback about the home and caring nature of staff from people and their relatives. One person said, “Oh definitely they (staff) are caring.” When asked if anything could be improved they said, “No, I’m happy with all the care I receive.”

People were safe at Firtree House Nursing Home. One person said, “I feel very safe, everybody looks after us so well.” There were sufficient staff deployed to meet the needs and preferences of the people that lived there. Staff were available when people at risk of falls were moving around, or when people asked for help. One person said, “Whenever I need something they come straight away.”

Risks of harm to people had been identified and clear plans and guidelines were in place to minimise these risks, without restricting people’s freedom. In the event of an emergency people would be protected because there were clear procedures in place to evacuate the building.

The provider had carried out appropriate recruitment checks to ensure staff were suitable to support people in the home. Staff received training and induction to support the individual needs of people in a safe way. The effectiveness of training for first aid was raised with the manager as some staff knowledge did not match current best practice. The manager arranged for refresher training for all the staff within two days of our inspection to ensure staffs knowledge was current. They were also looking into the training that had been provided previously to ensure it gave staff the knowledge they needed.

People’s medicines were managed in a safe way and staff were trained in the safe administration of medicines. People received their medicines when they needed them.

Where people did not have the capacity to understand or consent to a decision the provider had followed the requirements of the Mental Capacity Act (2005). An appropriate assessment of people’s ability to make decisions for themselves had been completed. People told us that staff did ask their permission before they provided care. One person said, “They always ask my permission, and explain what they are doing. I can always say no, if I wish.”

Where people’s liberty may be restricted to keep them safe, the provider had followed the requirements of the Deprivation of Liberty Safeguards (DoLS) to ensure the person’s rights were protected.

People had enough to eat and drink, and received support from staff where a need had been identified. One person said, “I love the food, its food of our generation. The cook gets to know what we like to eat.” Specialist diets to meet medical or religious or cultural needs were provided where needed.

People were supported to maintain good health as they had access to relevant healthcare professionals when they needed them. When people’s health deteriorated staff responded quickly to help people and made sure they received appropriate treatment. One person said, “If you’re not well they call the doctor straight away, there’s no dilly-dallying here.”

The staff were kind and caring and treated people with dignity and respect. Good interactions were seen throughout the day of our inspection, such as staff holding people’s hands and taking the time to sit and talk with them. People could have visitors from family and friends whenever they wanted.

Care plans gave a good level of detail for staff to reference if they needed to know what support people required. People and relatives had been involved to ensure they reflected what people wanted. People received the care and support as detailed in their care plans. The staff knew the people they cared for as individuals. People had access to activities that met their needs.

People knew how to make a complaint. Documents recorded that complaints had been responded to in accordance with the provider’s policy.

Quality assurance records were kept up to date to show that the provider had checked on important aspects of the management of the home. Accident and incident records were kept, and were analysed and used to improve the care provided to people. Records for checks on health and safety, infection control, and internal medicines audits were all up to date.

People had the opportunity to be involved in how the home was managed. Meetings and surveys were completed and the feedback was reviewed, and used to improve the service.

The manager and staff had made improvements around the home since our last inspection, so that people received a good standard of care. A relative said, “Come here if you want somewhere where staff know people as individuals; it’s clean, it’s homely, and staff are caring.”

This inspection took place on 18 and 20 March 2015 and was unannounced on both days.

Firtree Nursing Home is registered to provide accommodation for elderly people who require nursing or personal care. The home provides care for up to 35 older people, some of whom are living with dementia. Accommodation is arranged over two floors. At the time of our visit there were 23 people living at the home.

At our previous inspections we had identified a number of concerns at the home. During this visit we saw that some improvement had been made, however from what we saw and were told, it was too early to say whether the home would sustain these improvements.

At the time of our visit there was no 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 manager had submitted here application to the CQC to become the new registered manager.

People were generally positive about the permanent staff saying they were kind and caring, but they were concerned about the numbers especially at the weekend when staff did not turn up. The management were looking at ways to manage this.

The provider had plans in place to improve the service and had employed a consultant to put the changes in place. Many of these processes were still being introduced, or had not yet had time to show that they were working.

The management of care and other important records around the home was not consistent. Information such as people’s personal histories, recruitment files, and daily care records had gaps, which could mean that staff would not have the correct information available to give appropriate care.

Where people lacked capacity to understand decisions about their care the provider had not correctly followed the requirements of the Mental Capacity Act 2005. Assessments that we were told would be redone at our visit last July 2014 were not completed correctly to show that were a decision had been made for someone it had been done in their best interests. Where peoples liberty may be being restricted to keep them safe, the provider had contacted the appropriate agencies

People told us they had their medicines when they needed them, and since our last visit the management and storage of medicines had improved. The service needed to improve with regards to staff’s knowledge of people’s special dietary needs.

Staff training had improved. The provider had employed external trainers to provide practical training for staff. Some improvements were required to ensure all staff received training when it was due, and that training had been effective and staff had learnt from it, for example when learning how to use equipment.

We have identified three breaches in the regulations. You can see what action we told the provider to take at the back of the full version of this report.

We carried out an unannounced comprehensive inspection of this service on 07 and 08 July 2014. Breaches of legal requirements were found. As a result we undertook a focused inspection on to follow up on whether action had been taken to deal with the breaches that resulted in two warning notices being issued to the provider.

Comprehensive Inspection of 07 and 08 July 2014.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014, and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This was an unannounced inspection that took place over two days. At our last inspection in February 2014 we found the service had not met the regulations in four areas. These were care and welfare of people who use the service; management of medicines; staffing; and informing CQC when people died. We received an action plan from the provider that told us they would have met the regulations by the beginning of June 2015.

At this visit the service was still not meeting the requirements for two of the four areas we had previously identified. In addition we found the service had not met the required standard of a further three regulations. This meant the service had not met the requirements for the following regulations: consent to care and treatment; care and welfare; safeguarding vulnerable adults; management of medicines; and assessing and monitoring the quality of the service. We saw that the service had improved with regards to staffing, and telling CQC when incidents happened such as when people died.

Firtree Nursing Home provides accommodation and nursing care for up to 35 older people, some of whom are living with dementia. There were 22 people living at the service when we visited. The home is made up of two floors, with access to the upper floor being by stairs or a small passenger lift. Bedrooms are spread across both floors; people with mobility needs live on the ground floor.

At the time of our visit there was no registered manager in post as they had left the service the week prior to our visit. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The newly appointed matron told us they were in the process of sending in their application to the CQC to become the registered manager.

People were at risk because medicines were not managed safely. Staff were seen to carry out appropriate checks before they administered medicines; however we saw staff leaving medicines unattended when preparing them. The system for safe storage and disposal of medicines was not effective, with overflowing sharps bins and large amounts of waste medicines in the locked medicines room.

The service had not taken the correct steps when they made decisions for people who could not make them for themselves. It was not recorded if the decisions had been made in people’s best interest. Staff were not following the requirements of the Mental Capacity Act 2005.

Focused Inspection of 12 and 25 November 2015

After our inspection of 07 and 08 July 2014 the provider wrote to us to say what they would do to meet legal requirements in relation to the warning notices we had issued for Regulation 13 HSCA 2008 (Regulated Activities) Regulations 2010 Management of medicines and Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service provision.

We undertook a focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. We found that the provider had not followed their plan and not taken sufficient action to meet legal requirements.

We identified issues with the disposal, security and record keeping of medicines which could affect people receiving their medicines. The provider was unable to show that people consistently received the right medicine, at the right time, and at the right dose.

The provider had still not implemented checks to ensure people received a good quality of care. The provider was unable to show us that feedback from people had been responded to and actioned. Policies and procedures had been updated but staff had not yet read them, so they would be unaware if they were working in line with them. Maintenance and cleanliness issues were still not identified and corrected by the provider.

The service had not met the requirements of the warning notices that had been issued, or the action plan that they submitted to us. CQC is currently reviewing its enforcement options in relation to the continuing breaches described.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, and to provide a rating for the service under the Care Act 2014, and to pilot a new inspection process being introduced by CQC which looks at the overall quality of the service.

This was an unannounced inspection that took place over two days. At our last inspection in February 2014 we found the service had not met the regulations in four areas. These were care and welfare of people who use the service; management of medicines; staffing; and informing CQC when people died. We received an action plan from the provider that told us they would have met the regulations by the beginning of June 2015.

At this visit the service was still not meeting the requirements for two of the four areas we had previously identified. In addition we found the service had not met the required standard of a further three regulations. This meant the service had not met the requirements for the following regulations: consent to care and treatment; care and welfare; safeguarding vulnerable adults; management of medicines; and assessing and monitoring the quality of the service. We saw that the service had improved with regards to staffing, and telling CQC when incidents happened such as when people died.

Firtree Nursing Home provides accommodation and nursing care for up to 35 older people, some of whom are living with dementia. There were 22 people living at the service when we visited. The home is made up of two floors, with access to the upper floor being by stairs or a small passenger lift. Bedrooms are spread across both floors; people with mobility needs live on the ground floor.

At the time of our visit there was no registered manager in post as they had left the service the week prior to our visit. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider. The newly appointed matron told us they were in the process of sending in their application to the CQC to become the registered manager.

People were at risk because medicines were not managed safely. Staff were seen to carry out appropriate checks before they administered medicines; however we saw staff leaving medicines unattended when preparing them. The system for safe storage and disposal of medicines was not effective, with overflowing sharps bins and large amounts of waste medicines in the locked medicines room.

The service had not taken the correct steps when they made decisions for people who could not make them for themselves. It was not recorded if the decisions had been made in people’s best interest. Staff were not following the requirements of the Mental Capacity Act 2005.

We visited Firtrees Nursing Home to look at the diet and drinks that were available for people who used the service. This was because concerns had been raised with us. We looked at one outcome which related to meeting people's nutritional needs.

People that we spoke with told us they enjoyed their food. One person told us 'We have choices for breakfast lunch and supper.' Another person told us 'I like my porridge in the morning with sugar.' People confirmed with us that the food was good and nicely presented.

We found that staff monitored people's weight and reported any loss or gain to the GP. Special diets were catered for. For example we saw some people had a diabetic diet. The manager told us who those people were and how they would be monitored.

The manager told us that any concerns related to people's nutrition would have a referral to a dietician or speech and language therapist. We saw that a recent referral had been made.

We carried out this responsive inspection because we had received anonymous information regarding a number of practices at the home which potentially placed people at risk of harm and receiving care and treatment that was unsafe. During our visit we met the assistant manager, the provider, three care workers and the administrative officer.

People who used the service told us that. 'Staff are nice and kind but there are not enough of them as they are always busy'.

Relatives that we spoke with told us' Staff are kind and caring '. However, some relatives told us that the standard of care had got worst over the past three to four months due to staff shortages. Two relatives told us that they were disappointed with the poor care their relative received when health deteriorated and they felt there had been significant failure in relation to medical treatment and taking appropriate action.

Care and treatment was not always planned or delivered in a way that was intended to ensure people's safety and welfare and people's care and treatment did not always reflect relevant research and guidance.

People were not always protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Peoples needs were not always met because the provider failed to take appropriate steps to ensure that there were sufficient numbers of suitable qualified, skilled and experienced staff to support people.

The provider did not notify the Care Quality Commission about a number of deaths of people who used the service. .

We spoke with people who used the service and with representatives of people who used the service. Comments included 'I am very happy here, they can't do enough for you', 'The chef is great and food is nutritious, I don't think I have ever eaten so well' and 'The staff are kind and look after me well'. They went onto tell us they were happy with the care and treatment that they or their relatives received and were satisfied that it met their needs.

People who used the service or their representatives told us they or their representatives were involved in developing their plan of care. They were also aware that regular reviews of their care plans took place and they were informed of any changes that were required.

People told us the food was nutritious and they had a choice. They said the food was 'very good'.

People said they felt staffing levels were sufficient, however, they thought there were not enough staff on duty at the weekends.

Representatives of people that we spoke with told us that they were able to express any concerns to the manager or senior staff at any time. They said their concerns were usually addressed fairly quickly. However, they told us they had not been surveyed or asked specifically for their comments about the quality of the service that was provided.

People who used the service and their relatives told us that they were aware of having a care plan in place to meet their needs but had not seen the plan of care and did not know specifically what it contained.

People told us that they received care that met their individual needs and that if they had any concerns they or their relatives were able to speak to the manager straight away and any concerns resolved.

People who used the service told us that they were happy in the home and that 'staff are wonderful and caring'. People told us that they felt safe and secure and that they had no concerns.

Representatives of people who used the service told us, 'the staff knows our relative and their needs really well'.

People who used the service told us that the food 'is really good' and the chef was 'marvelous and is always asking for ideas'.

People told us that they were happy living at Fir Tree House. They felt their wishes and expectations were taken into account when making a choice about living there.

There was good feedback regarding the food and we were told that the chef meets with them frequently to discuss menus.

People felt that there was sufficient staff employed in the home to meet their needs.

Relatives said they were satisfied with the standard of care provided and were kept informed of any changes.

Archived: Firtree House Nursing Home

All Inspections

9 January 2017

During a routine inspection

16 December 2015

During a routine inspection

18 and 20 March 2015

During a routine inspection

12 and 25 November 2014

During an inspection looking at part of the service

Comprehensive Inspection of 07 and 08 July 2014.

Focused Inspection of 12 and 25 November 2015

07 and 08 July 2014

During a routine inspection

7 May 2014

During an inspection in response to concerns

11 February 2014

During an inspection in response to concerns

11 June 2013

During a routine inspection

24 July 2012

During a routine inspection

31 August 2011

During a routine inspection