Archived: Devonia House Nursing Home

In December 2015 the provider made the decision to stop providing nursing care at the service as they were unable to recruit and retain nursing staff. This came into effect from January 2016.

As a result of the unannounced comprehensive inspection in April 2015 the overall rating for this provider was ‘Inadequate’. This meant that it has been placed into ‘Special measures’ by the Care Quality Commission (CQC).

At the unannounced comprehensive inspection in January 2016 we found improvements had not been achieved and the overall rating for the service remained inadequate. At the inspection in January 2016 we identified nine continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and two new breaches. We found people’s care plans did not contain person specific mental capacity assessments and applications for the Deprivation of Liberty Safeguards had not been carried out appropriately. Care plans were not updated on a regular basis and some sections were not completed or were inaccurate. There were not enough staff to provide support to people who used the service and recruitment practices were not safe. The provider had not taken steps to ensure staff received on-going or periodic training, supervision and an appraisal to make sure competence was maintained. The management of medicines did not protect people from the risk of unsafe care or treatment. Risks were not fully assessed for the health and safety of people who used the service. The provider had failed to monitor the quality of the service to identify issues. People were at risk of harm because the provider’s actions did not sufficiently address the on-going failings.

After the comprehensive inspection in January 2016, the provider wrote to us to say what they would do to meet the legal requirements in relation to the 11 breaches of regulation.

We undertook this unannounced focused inspection on 22 and 23 June 2016 to check that the provider had followed their improvement plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Devonia House Nursing Home on our website at www.cqc.org.uk

As a consequence of the inadequate rating for the service, Devon County Council suspended admissions to the service from 27 July 2015 until 13 May 2016. The suspension of placements was lifted by the local authority on 13 May 2016. However an advisory notice remains in place for social care placements, meaning that any social care funded placements to the service had to be agreed by a senior manager within Devon County Council. The service continues to receive considerable support from the local authority ‘quality assurance and improvement team’ and from health and social care professionals. Regular monitoring and support visits had been undertaken by health and social care professionals. We found that despite this support from the local authority the provider was unable to meet the essential requirements and make all of the necessary improvements.

At the time of this inspection the home did not have a registered manager. The service has not had a registered manager since December 2013. However, with the assistance of the local authority, a new manager had been recruited and appointed in January 2016. This manager left the service in March 2016. Another manager was appointed and started working at the service in March 2016 but has since resigned and left the service on 30 June 2016. The provider informed us on that a senior member of the night staff team has been appointed as acting manager temporarily, with responsibility for the day to day running of Devonia House. 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 at the time of the inspection demonstrated that they understood some of the shortfalls at the service and had begun to implement systems and processes to improve the service. However due to the limited time they had managed the service and the difficulties they had experienced the action taken had yet to have a sustained impact upon the overall quality of the service. At times people were exposed to avoidable risk.

People’s health, safety and welfare were put at risk because there were not always sufficient numbers of suitably qualified, skilled and experienced staff on duty at all times. Staff did not receive the training they required to be able to fulfil their role effectively. The provider did not have appropriate arrangements in place to manage medicines safely. People were put at risk as a result of poor practice and a lack of staff training in relation to medicines.

People's nutritional needs were not always monitored. Records relating to people's daily dietary and fluid intake were poor. This meant we could not tell in any detail whether people had sufficient amounts to eat and drink.

People were at risk because accurate records were not consistently maintained. There were gaps in people’s food and fluid charts, weight, bowel and repositioning charts. We could not be assured that people’s care needs were being met.

Systems the provider had in place to monitor and improve the quality of the service had not been embedded and were ineffective.

Some people were happy with the care and support they received. Two health care professionals and two relatives provided positive feedback, especially in relation to staff attitude and caring approach. We witnessed some kind and caring interaction between staff and people who lived at the service.

Some care plans had been improved and contained detailed and personalised information about people’s care needs and preferences. However two people did not have care plans or risk assessments in place to ensure staff provided appropriate and safe care and support.

We found improvement in relation to the Mental Capacity Act 2005, which requires providers to ensure safeguards are in place when someone does not have the capacity to make an informed decision about their care and treatment. Some people’s capacity to consent to care and support had been assessed. Applications had been submitted to the local authority in respect of six people where it had been identified that were being deprived of their liberty. However, we found improvement was still needed to ensure everyone’s rights were protected.

During the inspection we identified seven continuing breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. People were at risk of harm because the provider’s actions did not sufficiently address the on-going failings. There has been on-going evidence of the provider’s failure to sustain full compliance since 2011. We have made these failings clear to the provider and they have had sufficient time to address them.

Due to the concerns found at this inspection, through our legal processes we have told the provider they cannot admit any new service users without the written consent of CQC.

This inspection was conducted in order to check that the provider had complied with the requirements of the warning notices.

During our follow up inspection of this service we used the evidence gathered in relation to the four outcomes we inspected to answer our five key questions; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led?

Below is a summary of what we found.

Is the service safe?

On the day of our inspection the service was safe. We found that the care and support people received had been accurately documented and where specific risks had been identified appropriate action had been taken to address the identified risks.

We found that people who were unable to re-position themselves independently had received appropriate care and the quality of wound care provided by the service had been recently recognised by a medical professional.

Is the service effective?

The service was not effective. At our previous inspection we identified staff had not received appropriate training in relation to manual handling, the Mental Capacity Act and safeguarding of vulnerable adults. During this inspection we observed one example of poor manual handling practice and noted that the identified training needs had not yet been addressed. We discussed this with the acting manager who explained that a number of training courses had been arranged and said 'most of us have now signed up to do our NVQ level3'.

The lack of information technology in the home meant staff were unable to access guidance on current best practice.

We found that procedures for the management of people medications were not sufficiently robust and appropriate audits had not been completed.

Is the service caring?

The service was caring. People who used the service were well cared for by attentive and friendly staff. People and their relatives told us 'the staff are lovely', 'very good and very kind', 'generally I find the staff very helpful' and 'the provider is very kind, he amuses us and is often the extra waiter'.

At our previous inspection we found that the home was cold, people had requested blankets from inspectors. During this inspection people were comfortable and commented positively on how 'homley' the service was.

Is the service responsive?

The service was responsive. People who used the service and their relative told us 'they are looking after us', 'I am happy because I know I could not cope on my own', 'I know mum is well looked after' and 'I think generally it is a bit better than it was, yes I would say that it is improving'.

Since our previous inspection the acting manager had worked to review and update care plans within the home. At the time of inspection the care plans of half of the people who used the service had been updated. We found the updated care plans included sufficient information to effectively direct and inform staff of people care needs. However the care plans were task orientated and lacked information about people's life history, hobbies and interests.

Since our previous inspection the provider had addressed reported issues in relation to meals being served cold by recruiting an additional cook. During our inspection people told 'lunch was nice', 'the food is good' and 'I am surprised how well she (the new cook) is doing'.

Is the service well led?

The service was not well led. An acting manager had been appointed at Devonia House Nursing Home. Low trained nursing levels within the service meant that the acting manager had continued to work full time a nurse on duty in the home and had been unable to focus on managerial responsibilities.

The provider had attempted to recruit additional trained nursing staff to enable the acting manager to focus on their managerial responsibilities. At the time of our inspection this had been unsuccessful. Staff told us 'we really do need more registered staff to allow the manager to focus on the issues'.

We saw evidence that demonstrated the acting manager intended to reintroduce staff supervision but at the time on our inspection no staff supervision meetings had occurred.

Below is a summary of what we found.

Is the service safe?

The service was not safe. We found that assessments had identified people as being at significant risk of malnutrition but the home had failed to seek appropriate support. We found that people who had been identified as at risk of malnutrition had experienced significant weight loss and their food and fluid intake had not adequately monitored.

People who were unable to re-position themselves independently had not received appropriate care in order to protect them from the risks associated with not being re-positioned regularly. We spoke with a relative of a person who required regular re-positioning who was visiting on the day of our inspection. This relative told us that they visited the home for four hours every day and said 'X is never moved while I am here'.

We saw that improvements had been made in relation to premises since our last inspection. A fire risk assessment had been completed in April 2014 and we found that the high priority actions identified in this assessment had been addressed.

Is the service effective?

The service was ineffective. The three care plan we reviewed were disorganised and did not effectively direct, inform and guide staff as to the care needs of people who used the service. A staff member told us 'We don't need care plans we go by the handover'. The care plans did not include sufficient information to enable staff to provide effective pressure area care and when asked staff were unable to find relevant assessment documentation. Staff told us 'we are all just fumbling along here, we have no guidance.'

We found that the information about people's mental capacity recorded within the care plans we reviewed was conflicting and did not comply with the requirements of the Mental Capacity Act.

Is the service caring?

We found that the staff employed by the service were caring and we observed people being supported by staff in a patient, caring and respectful manner. The two relatives of people who used the service that we spoke with had conflicting views of the service, their comments included 'I think it's great, there is a really warm welcoming feel and X tells me she is really happy here' and 'It's not as good as it used to be'. The quality of care provided by Devonia House was adversely affected by the lack of effective management and supervision in the home because decisions in relation to the provision of care had been taken at an inappropriate level.

A recent decision by the provider to reduce staffing levels without having completed an assessment of the care needs of people who used the service exposed people to the risk of unsafe and inappropriate care. The provider explained these staffing changes had been made as he could no longer afford the previous staffing levels. Staff members told us 'we are short of staff', 'none of us think it's a good idea', 'one carer and one nurse only at night, we have to work together to do hoists and can't answer bells' and 'we used to have a sleeper (sleep in member of night staff) back along, I think that was safer'.

Is the service responsive?

The service was not responsive. We found that the home had received a number of thank you cards from relatives of people who used the service. Comments received included 'you made us feel part of the family' and 'thanks for your tender loving care'. However, we found that the service had failed to adequately address issues raised by people who used the service during residents meetings. For example we saw that people had raised an issue in relation to food being served cold at the most recent residents' meeting and on the day of our inspection people told us their lunch was cold.

In addition the service had failed to respond effectively to address issues identified in previous CQC inspection reports. For example we found that outdated policy documentation identified during our inspection on the 21 February 2014 had not been appropriately reviewed and updated.

Is the service well led?

There was no effective leadership at Devonia House. At the time of our inspection the provider did not have a registered manager in post and was not employing anyone to manage the registered activities at the Devonia House Nursing Home. The provider did not manage the day to day operation of the home and had no clinical background or experience.

At the time of the inspection the post of manager was being advertised, however, the provider explained that he had been unable to recruit an appropriate manager as he was unable to provide a sufficient salary to attract suitable candidates.

The lack of effective management and leadership within the home exposed people who used the service to the risks associated with decisions that impacted on the quality of care being taken at inappropriate levels. There were no effective systems in place to provide staff with appropriate supervision or ensure their training needs were met.

When we visted we found that the registered manager had left and the home was being managed by an acting manager.

The standard of care provided ensured people's dignity. People were satisfied with the service they received. Comments included "I am very happy with the care and the help I get is good" and 'I have never been refused anything I have asked for' .

The home was clean, fresh and people were protected from the risk of infection because appropriate guidance had been followed. The nursing home was 'homely' and well furnished. However, fire safety and water safety checks were not completed and not all recommendations from external agencies had been followed. This meant that some risk within the premises was not managed.

Recruitment procedures at the home protected people. There was a programme of staff supervision and support, although not well established. Training was disorganised with no established arrangements in place to ensure staff maintained knowledge, skills and their personal and professional development. The newly recruited acting manager was arranging additional training.

The quality of the service was not adequately reviewed and people's health, safety and welfare could not be assured. Professional advice was not always taken. Some staff roles were unclear and this increased the potential for risk.

We saw that people received a high standard of care. Nursing staff were knowledgeable about people's needs and each person had an assessment of their needs and a plan of how their care would be delivered. Health care needs were monitored to promote people's health and external advice sought as appropriate.

People had the equipment they needed for their comfort and safety. Staff were provided in sufficient numbers to meet people's needs. Training, staff supervision and support had been increased and was ensuring a skilled and knowledgeable staff. Staff were recruited using the checks in place to ensure they were suitable for the work.

Records were complete and kept in a confidential way. Each person was having their care reviewed and a new care planning system was being introduced for people's safety.

The registered manager was knowledgeable about how to ensure people's safety and improve the home. They were working toward more effective arrangements, such as reviewed policies, procedures and staff practice.

The arrangements for cleanliness and hygiene were not sufficient to protect people or staff at the home.

We did not find that there was a concerning level of pressure sores at Devonia House as we had been informed. Staff were aware of those people at increased risk of pressure damage and we saw that some care workers were designated to provide fluids and help people change position to reduce any risk. However, we found short falls in records of assessment and care planning. These increased risk from inappropriate care because information was absent, out of date or difficult to find. One person had no care plan or risk assessments in place although they had been at the home for five days.

Personal information was not held confidentially. We found records relating to a deceased person, in a corridor where people passed by.

Health care professionals told us, "They do a good job with wound care. They do what is asked of them" and "They mostly follow advice". People using the service and their family told us, "They do their best"; "I am improving since I've been here. I would like the laundry to improve", "They could improve the number of hoists (although there were four hoists at the home) and people that operate them" and "It's always pretty good. The food is good. The main staff are pretty good and the new manager is really nice. The owners are ever so kind."

People's comments included, "I never see anything but kindness" and "It's the personal touch they do best"; "Everybody is very kind", "They seem to do all they can to help" and "Most staff know what they are doing." A community nurse said she had no concerns about the care provided.

Although staff had received no training in consent to treatment people were offered choice and their decisions were respected. Family and health care professionals were involved in decisions on some people's behalf where necessary.

Assessment and care planning of people's needs was minimal but sufficient to ensure health needs were met. There was little or no information as to how social needs would be met but the acting manager was trying hard to increase activities and social interaction at the home.

People received a nutritious and healthy diet that was to their liking. People's health was monitored and steps taken should there be any concerns. External advice was sought as necessary.

New equipment had been provided but overall not sufficient that so people sometimes had to wait for care. Also, the lack of some equipment checks posed a potential risk to people.

Staff recruitment procedure was not always followed. Staff training was not well planned. Staff were not supported in their role.

People's views were sought but not in a way that guaranteed improvement to the service.

We found that people's views were being sought through one to one meetings and feedback questionnaires. There was evidence of more discussion and agreement about the care people received.

There was improved equipment providing more choices for people and a safer environment. There was a training budget; training schedule and staff training in progress and formal staff supervision was improved. People's needs were being met, but some people felt there were not enough staff - we saw that care staff had some kitchen duties and non care staff guided and prompted people to the toilet/bathroom, which could pose risk.

Other improvements included: complaints management, maintenance management, activities for people, the safe use of chemicals for cleaning and the safeguarding of vulnerable adults. People were happy with the home and staff were enthusiastic and supportive about the improvements at the home.

We also used the visit to look at the progress that had been made on the non-compliances we identified during our last visit in June 2012. At the time of the visit the dates agreed for completion for the compliance actions had not yet passed.

People who used the service told us 'I am listened to by the staff and they usually follow up what has been asked'. Other people using the service told us 'All OK. Can't find any fault here'. They also told us 'the staff are all really lovely' and there was 'marvellous food'.

A relative told us there were 'absolutely lovely staff', and their relative was very well cared for.

A visiting GP told us that the standard of care here was "excellent". They also told us that they thought it was "well run, and things got fed back to them".

We saw improvements had taken place since our last visit, and comments from the people we spoke to were positive. The registered manager still has a number of actions to complete before the home is compliant with the regulations that we checked, but we could see that progress was being made.