Firgrove Nursing Home

Firgrove Nursing Home is a residential care home providing nursing care to seven people with a range of complex health needs at the time of inspection, including some people living with dementia. The service can support up to 35 people

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

The service did not have a manager employed. Day to day management of the service was undertaken by the acting manager who knew people well. Individual risks were assessed and managed to keep people safe.

Processes were in place for assessing and monitoring the quality of the services provided and ensuring that records were accurate and complete. The environment was clean and enhanced infection control processes were in place to keep people safe.

People told us that they felt safe and said there were enough staff to look after them. People received their medicines safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

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

Rating at last inspection and update

The last rating for this service was requires improvement (published 17 September 2020). A breach of regulation was found in relation to infection prevention and control and in governance.

At this inspection we found improvements had been made and the provider was no longer in breach of regulations.

Why we inspected

This was a targeted inspection to check if improvements had been made to address the concerns highlighted at the last inspection.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to coronavirus and other infection outbreaks effectively.

We undertook this targeted inspection to check on a specific concern we had about how risks to people were managed and the providers processes for monitoring the service. The overall rating for the service has not changed following this targeted inspection and remains requires improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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

Firgrove Nursing Home is a residential care home providing nursing care to seven people with a range of complex health needs at the time of inspection, including some people living with dementia. The service can support up to 35 people.

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

At the time of this focused inspection, due to the risk of COVID-19, people were being supported in their rooms which presented some barriers to being able to talk with people to obtain their views about the home.

Infection prevention and control procedures had been adopted but were not always applied safely. Personal protective equipment was not always used safely and a mobile hoist was moved from one person’s room to another without being cleaned in between. The registered nurse on duty failed to wash or sanitise their hands diligently when administering medicines to people. This put people at risk of infection and cross-contamination. Staff wore disposable masks, with disposable aprons and gloves when providing personal care to people.

A system of audits had been established but these were not effective in identifying the issues found at this inspection or in monitoring and measuring the care provided to drive improvement.

New staff were recruited safely and checks were made on their suitability to work in a care setting. Four staff were self-isolating due to the risk of COVID-19, but staffing levels were sufficient to meet people’s needs. Agency staff would be engaged to make up any short falls in the number of staff on duty.

A new manager had been recruited and commenced their employment at the home in early July 2020. They were in the process of registering with the Commission.

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

Rating at last inspection (and update)

The last rating for this service was Inadequate, report published 23 March 2020.

Enforcement action was not taken due to the outbreak of COVID-19 when the decision was taken to postpone or suspend any enforcement proposals.

At this inspection not enough improvement had been made and the provider was still in breach of two regulations.

This service has been in Special Measures since March 2020. During this inspection the provider demonstrated that some improvements have been made. The service is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is no longer in Special Measures.

Why we inspected

We undertook this focused inspection to check whether improvements had been made and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has changed from Inadequate to Requires Improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Firgrove Nursing Home on our website at www.cqc.org.uk.

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to infection prevention and control and in governance.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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

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

New staff were not always recruited safely. The provider told us an agency had vetted the suitability of two care staff. The provider had not checked the vetting was thorough and satisfactory. The local authority had undertaken investigations relating to 30 safeguarding incidents. Incidents of potential abuse had not been notified to CQC nor were safeguarding referrals made to the local authority by the provider. Some aspects of medicines were not managed safely.

Staff had not completed all the training they required to undertake their roles and responsibilities safely. Systems for supporting staff in their roles had not always been available since the last registered manager left the home.

A robust system of audits had not been established to identify any issues or to drive improvement. The quality of care and the service overall was not monitored or measured. The outcomes of accidents and incidents were not always recorded in detail to prevent similar events from reoccurring or mitigating risks. Medicine audits had not identified the issues we found at the inspection. Notifications which the provider was required to inform CQC about by law had not been received. Frequent changes to the management of the home and staff turnover had a negative impact on the running of the home and on staff retention and morale. People and their relatives were unsure who was in overall charge of the home.

Staff did not demonstrate an understanding of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. We have made a recommendation that training should be identified and implemented. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; but the policies and systems in the service did not always support this practice.

Staffing levels were sufficient to meets people’s needs. There were mixed responses from people and their relatives about the numbers of staff on duty and how they were deployed to ensure people received help from staff when they needed it.

The home was clean, although soap dispensers were empty in two parts of the home and there was no hand cleanser. This put people at potential risk of infection. Lessons were not learned if things went wrong because the recording of incidents and accidents was not completed to a standard sufficient to identify any emerging themes or outcomes.

Because of the high turnover of staff, the consistency of care could not be sustained. However, care was personalised to meet people’s needs. People and their relatives felt staff were kind and caring. People felt the home was safe and that staff treated them with dignity and respect.

People found the choices of food on offer were acceptable and, with one exception, people’s dietary needs were catered for. People had access to a range of healthcare professionals and services.

Activities were planned in line with people’s preferences and interests. People were complimentary about activities at the home and said these had improved since the new activities co-ordinator came into post. People’s communication needs were identified and met appropriately.

People and their relatives were asked for feedback about the home through surveys. Responses were mixed in relation to how people felt about the home.

Rating at last inspection and update

The last rating of this service was Requires Improvement (report published 1 August 2019). Following three breaches of regulations at the last inspection, the provider completed an action plan to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received from the local authority and external health care professionals visiting the home. We liaised with the local authority about a number of safeguarding concerns that had been raised and ongoing issues at the service relating to the standards of care. A decision was made for us to inspect and examine those risks.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Firgrove Nursing Home on our website at www.cqc.or.uk.

Enforcement

We have identified breaches of regulations in relation to safe care and treatment, staff training and supervision, governance and notifications. Please see the action we have told the provider to take at the end of this report. Full information about CQC’s regulatory response to the more serious concerns found during inspection is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within the timeframe, and there is still a rating of Inadequate, for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or varying the conditions of the registration.

The maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as Inadequate for any of the five key questions, it will no longer be in special measures.

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

People’s experience of using this service:

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. The overall rating for this service is ‘Requires improvement’. However, the service remains in 'special measures'. We do this when services have been rated as 'Inadequate' in any key question over two consecutive comprehensive inspections. The ‘Inadequate’ rating does not need to be in the same question at each of these inspections for us to place services in special measures.

Although we found improvements had been made in some areas of practice this was not yet embedded and sustained. We identified a further breach of regulations.

Risks to people were not always effectively assessed and managed to ensure their safety and to protect people from infections. Guidance for staff was not always clear and accurate to reflect the needs of people.

There were not always enough suitable staff to care for people safely. Staff told us that on some occasions they had not followed guidance in care plans to support people to move safely because there were not enough staff on duty. Systems for recruiting staff had improved .Training was provided by suitably qualified people but not all staff had received training or updates in line with good practice. Staff did not all feel supported in their roles.

Previous improvements in personalised care had not been sustained and people were not consistently receiving the social stimulation that they needed.

Whilst there had been some improvements in systems for governance and management oversight these were not yet fully embedded and sustained. The previous breach had not yet been fully addressed.

Staff understood their responsibilities for safeguarding people. Lessons were learned when things went wrong and people were receiving their medicines safely.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were receiving the food and drink they needed and were supported to access health care services.

People and their relatives described staff as kind and caring. One person told us, “The carers are very kind and patient.” A relative told us their relation’s needs were “well met.” Staff involved people in developing care plans and supported people to be as independent as possible.

Staff knew people well and provided care in a personalised way. People and relatives knew how to complain and felt confident that their concerns would be listened to and acted upon.

The provider was taking action to address the concerns of the previous inspection. Some improvements were in place but were not yet embedded and sustained.

Rating at last inspection: Inadequate, the last inspection report was published on 14 February 2019.

Why we inspected: This was a scheduled inspection based on the previous rating of Inadequate. The service was in special measures. Following the last inspection, the provider had submitted an improvement plan on 30 April 2019.

Enforcement: We identified four breaches of regulations.

Follow up: ongoing monitoring

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

Firgrove Nursing Home is a 'care home'. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Firgrove Nursing Home had a registered manager. 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 the time of our inspection the registered manager was also the nominated individual for the service.

We undertook a comprehensive inspection took place on 10 and 11 September 2018 which was unannounced. Following that inspection, we received information of concern in relation to staff recruitment. We undertook a further visit to look into those concerns on 13 December 2018. We announced this visit and we looked at the key questions of Safe and Well Led. This report covers our findings at both visits.

This is the first time Firgrove Nursing Home had been rated Inadequate and the service is therefore in ‘special measures’. Services in special measures 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 significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Following the last comprehensive inspection of the service in September 2017, the overall rating for the service was Requires Improvement with three breaches of regulation. People’s social needs were not being met and people were at risk of social isolation; consent to care and treatment was not always sought and documented in line with legislation; and there was a failure in some systems for monitoring standards and quality. We asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least Good. At this inspection, although some improvements had been made, there remained areas of significant concern. We did not find these inconsistencies had impacted on the safety of people, but these demonstrated shortfalls in quality monitoring and management oversight of some aspects of the service.

Quality monitoring systems were not effective in identifying shortfalls and driving improvement and the registered manager lacked oversight of these processes. Management oversight of recruitment processes was not effective. There was no robust system in place to ensure that required recruitment checks on staff were always made to ensure staff were suitably skilled and qualified to carry out their roles. There was not always sufficient staff deployed in a way to support all people’s needs. Staff training was not always delivered by someone with the appropriate qualifications and competency to do so. Records in relation to maintenance of the building were not well organised to support the registered managers oversight of safety. Care plans lacked information to identify people’s preferences and support their other needs such as access to activities. People had access to some activities, but these were limited and not always person-centred.

People told us they felt safe. One person told us, “I feel safe here, I have no concerns.” Risks to people had been identified and staff understood people well and how to manage risks to help ensure people were safe. People were supported to receive their medicines safely by staff that were trained in administering medicines.

People were protected from avoidable harm. There was a safeguarding policy and staff received training. Staff knew how to recognise the potential signs of abuse and knew what action to take to keep people safe.

People were supported to have maximum choice and control of their lives and staff support them in the least restrictive way possible; the policies and systems in the service support this practice. Staff understood best interest decision making where people lacked capacity in line with the principles of the Mental Capacity Act 2005. Staff sought people’s consent before giving personal or nursing care.

People were supported to maintain their health and had assistance to access health care services when they needed to. Staff supported people by arranging healthcare appointments for them. We saw people had access to services such as tissue viability nursing, a GP and chiropody within the home.

People told us the staff were kind and caring and they were happy with the service they received. We saw positive interactions between people and the staff caring for them. Staff said they enjoyed working at the home and felt supported by the registered manager and deputy manager.

Concerns and complaints were responded to and the provider displayed the complaints policy within the home.

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 have issued a Notice of Decision to impose a Condition on the provider's location to be assured that they have appropriate quality assurance processes in place to assure people's safety and wellbeing.

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. Both the registered manager and the provider were present during the inspection.

At the last inspection undertaken on the 24 and 26 March 2015 we had no concerns and rated the service as 'Good' overall. At this inspection we found three breaches of regulations and further areas of practice that needed to improve.

Staff did not demonstrate a clear understanding of the requirements of the Mental Capacity Act 2005 and their responsibility to seek consent for care and treatment. Some people lacked capacity to make specific decisions, including consent for the use of certain equipment that restricted their movement. Decisions that had been made in their best interest had not been documented and reviewed in line with legislation and guidance. This was a breach of the regulations.

People’s social needs were not being met and this meant that some people were at risk of social isolation. Some organised events were arranged with external performers but these were on an occasional basis. People did not have things to do throughout the day that were suitable for their needs, and relevant to their personal interests. This was a breach of the regulations.

Some management systems had not been effective in providing oversight of shortfalls in practice. This was identified as a breach of the regulations.

People were receiving their medicines safely. However during the administration process medicines were not always stored safely and this was identified as an area of practice that needed to improve.

Some people needed help to move around and staff were using equipment to support them. However, staff were not always using equipment in line with current good practice. This is an area of practice that needs to improve.

People told us they were happy with the food provided at the home. They received the support they needed to have enough to eat and drink and any nutritional needs were assessed and monitored. One person told us, “The food is good here.” People were given a choice at supper time but not for the main meal at lunchtime. Staff said that people were offered alternatives if they did not like the main meal. One person was asleep when their lunchtime meal was brought to them but staff did not offer to reheat the food even though half an hour had passed. This was identified as an area of practice that needs to improve.

People and their relatives told us they felt safe and happy living at Firgrove Nursing Home. One person said, “I feel safe, if not I would tell my family.” A relative said, “The care is very good.” There were enough staff on duty and people did not usually have to wait to have their care needs met. Risks to people had been identified and assessed and care plans were in place detailing how care should be provided. Staff had a clear understanding of their responsibilities to keep people safe and knew how to recognise abuse and what actions to take.

People and their relatives had confidence in the skills of the staff. One person said, “I am very happy with them and trust them completely.” A relative said, “I’ve been very impressed by the care.” Staff had received the support and training they needed to provide care to people safely. They were proactive in supporting people to access the health care services they needed. A visiting health care professional told us that they had confidence in the staff, describing them as “Knowledgeable about people’s needs,” and confirming that they always received appropriate referrals.

People were supported by staff who knew them well and understood their needs. People told us that staff were kind and caring. One person told us, “The carers are wonderful.” Staff spoke to people respectfully and were careful to protect people’s privacy and dignity. One relative told us, “I love the way staff speak to my (relation), they are always refer to people here as Mr or Mrs and I think that makes them more respectful.” People, and where appropriate their relatives, had been included in developing care plans that were person- centred and covered all aspects of their life. Staff were responsive to changes in people’s needs and care plans were amended to reflect this. A relative said, “As things have progressed they have made adjustments to make sure my (relation) remains comfortable.”

There was a visible complaints process and people and their relatives told us they would feel comfortable to raise concerns. The registered manager documented all complaints and actions taken to address the complaint. Quality assurance systems were in place to monitor the standard of care. The registered manager analysed incidents and accidents to look for trends and patterns and used this information together with feedback on the service to drive improvements.

There was clear management and leadership and the values and ethos of the service were embedded within staff practice. The registered manager had good knowledge of the needs of all the people living at the home and worked alongside staff on a regular basis. People and staff spoke highly of the management of the home saying that the manager was easy to talk to and the service was well run. A relative told us, “The communication is good, I would always approach the managers with any issues.”

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

We observed that staff were polite and respectful towards the people living there. People told us that they were listened to and were involved in making choices about their care. They said they were encouraged to be as independent as possible and could decide how and where to spend their time. One person told us 'the staff treat me with respect and address my choices'.

People told us they were well cared for and felt safe. We saw that people had individualised care records and risk assessments in place which helped staff to understand and meet peoples' needs. We noted that in a recent survey a relative had commented 'The home has a lovely atmosphere and it is always a pleasure to visit and my relative is very settled. Also I know that I do not need to worry about her as she is being cared for very well'.

We saw that medication was administered, recorded and stored accurately and safely.

We found that staff were trained and supported through supervision to provide an appropriate standard of care. They were knowledgeable about the people they supported.

All records were kept securely and the records describing peoples' care needs were well organised, detailed and regularly reviewed.