Archived: Murrayfield Care Home

Murrayfield Care Home is a residential service providing nursing and personal care for up to 74 people, some of whom are living with dementia. At the time of our inspection there were 57 people using the service. The home is purpose built, consisting of individual bedrooms and communal spaces spread over three floors with an accessible rear garden.

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

People and relatives told us they felt safe with the care and support they or their relative received. However, despite the positive feedback received we found concerns with infection control and management oversight and other issues with staff recruitment, training and support and person-centred care.

The provider had systems in place to monitor the quality and safety of the service, however they did not identify some of the issues we found during the inspection.

Not all procedures in place to keep people safe from risk of infection and COVID-19 were being followed.

We observed positive interactions between people and staff. However, some people, relatives and staff told us more activities needed to be offered.

We have made a recommendation around activity provision.

We have made a recommendation around staff training and support.

We made a recommendation around safeguarding adults.

People were supported by staff who had been assessed as safe to work with vulnerable adults and understood their responsibilities to report any concerns.

Staff told us they felt supported and people were supported by staff who knew them well.

We observed there was enough staff to keep people safe. However, some people, relatives and staff told us the service was short staffed.

People’s care was regularly reviewed by the service; however, people and their relatives were not always involved in the process.

The provider had systems in place to assess risks to people before undertaking their care and support. However, we found a couple of examples where peoples health risks were not sufficiently documented.

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.

People received their medicines safely and as prescribed.

People had access to a balanced and healthy diet and were satisfied with the food on offer.

People and their relatives spoke positively of the service and the management team.

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 20 March 2020) and there were breaches of regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found the provider remained in breach of regulations.

At our last inspection we recommended the provider seek and implement national guidance on the provision of dementia friendly environment. At this inspection we found the provider acted on the recommendation and improvements were made.

The last rating for this service was requires improvement (published 20 March 2020). The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 6 and 7 February 2020. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve person centred care and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions safe, effective, responsive and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained the same. This is based on the findings at this 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 COVID-19 and other infection outbreaks effectively.

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

Enforcement and Recommendations

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 and will take further action if needed. We have identified breaches in relation to safe care and treatment and good governance at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Murrayfield Care Home is a nursing home providing personal and nursing care and accommodation for older people, some of whom may be living with dementia. The home can support up to 74 people. At the time of the inspection there were 69 people living at the home.

Murrayfield care home is a large purpose built care home set in a residential area of Enfield, North London. Bedrooms are located across three floors with an accessible rear garden. The home provides a combination of nursing and residential care.

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

People told us they felt safe living at Murrayfield Care Home. Relatives also confirmed that they believed their relative was safe and appropriately cared for. Staff knew how to recognise abuse and report their concerns to safeguard people from potential abuse.

Throughout the inspection we observed and identified continued issues in relation to people’s experiences of dementia care, poor staff engagement with people and people not always being stimulated or involved in activities that promoted their well-being. This was especially apparent on the second floor of the home where most people were living with dementia.

Management oversight processes in place monitored the quality of care people received and where issues were identified these were addressed with details of actions taken so that further improvements and learning could be implemented. However, although the registered manager and senior managers were aware of some issues around people’s dining experience specifically on the second floor, additional issues that we found in relation to poor staff engagement and activity provisions had not been identified.

We have made a recommendation about the provision of dementia friendly environments.

Risk assessments were in place for people which assessed risks associated with their health and care needs with clear management strategies in place for staff to follow to keep people safe.

Policies and systems in place supported the safe management and administration of medicines.

Staff received the appropriate training and support to meet people’s needs effectively.

People’s health and care needs were comprehensively addressed and where required access to health and care specialists was promptly arranged to meet people’s changing needs.

People were supported to maintain a healthy and balanced diet. People told us that they were offered a choice of what they wanted to eat. Where people had specialist dietary requirements these were catered for.

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.

We observed that people did receive good care across other areas of the home, with care staff demonstrating kind and caring qualities when supporting people.

People were involved in making day to day decisions about how they were supported. Relatives also confirmed that they were always involved in every aspect of care provision relating to their family member.

People and relatives knew who to speak with if they had issues or concerns to raised and were confident these would be addressed appropriately.

Care plans were comprehensive and person-centred detailing people’s health and care support needs and how they wished to be supported.

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 18 February 2018). We had identified breaches of regulations around person-centred care and good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve. However, at this inspection improvements had not been made or sustained and the provider was still in continued breach of regulations for these reasons. The service has consecutively been rated Requires Improvement specifically under the key question of Responsive over the last four inspections and has been rated Requires Improvement overall four times since 2015.

Enforcement

We have identified breaches of regulations in relation to person centred care provisions and the governance arrangements of the service at this inspection. Please see the action we have told the provider to take at the end of this report.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We last inspected the service on 21 November 2017 and was rated ‘Good’ overall with the key question of responsive rated as ‘Requires Improvement’. This was because we found that further improvements needed to be implemented in the provision of meaningful activities, staff understanding of person centred care and the timely completion of daily records in response to people’s needs.

At this inspection we found that the service had not made the required improvements in areas such as the provision of meaningful activities and the timely completion of daily records in response to people’s needs. We also found that the provider implemented management and staffing structure within the home may affect the safe and effective management of the home.

This means that the service is no longer rated ‘Good’ and has been rated as ‘Requires Improvement’.

Murrayfield Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Murrayfield Care Home accommodates up to 74 people. Within the building there were three floors, each of which had separate adapted facilities. Lifts were available within the home giving people access to all areas of the home. One of the units specialises in providing nursing care to people and the two other floors specialised in providing care and support to people living with dementia and physical health needs. At the time of this inspection there were 72 people living at the home.

A registered manager was in post at the time of this inspection. 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.

Activities provision within the home did not always stimulate or engage people. Where scheduled activities were organised and facilitated by designated activities co-ordinators, people were seen to enjoy these. However, very little meaningful activity was initiated and delivered by care staff in the absence of activity co-ordinators.

Monitoring charts and records were not consistently and comprehensively completed by care staff to ensure people received care and support that was responsive to their needs.

End of life preferences and wishes were not always clearly documented within people's care plans.

Quality assurance processes in place allowed the registered manager and the provider to oversee the quality of care provision, identify issues, learn and implement improvements where required. However, where actions were identified, which were similar to those identified as part of this inspection, these had not been actioned effectively and improvements had not been made.

We found that the management and staffing structure implemented by the provider did not always support the effective management and running of the home.

Staffing levels were determined based on individual people’s levels of need. We saw that there were sufficient number of staff available around the home at the time of the inspection.

People and their relatives told us that they felt safe living at Murrayfield Care Home. All staff demonstrated a good understanding of safeguarding people from abuse and the actions they would take to report their concerns.

People’s care plans contained detailed risk assessments people’s identified risks associated with their health and social care needs. Further information was also documented to guide staff on how to support people to be safe and free from harm.

Staff told us and records confirmed that they felt supported in their role and received regular supervisions and annual appraisals.

Recruitment processes ensured that only those staff assessed as safe to work with vulnerable adults were recruited.

People received their medicines safely, on time and as prescribed. Medicine policies and processes in place supported this.

Accidents and incidents were recorded, reviewed and analysed to ensure that where things had gone wrong improvements and further learning were considered and implemented.

Staff received an induction when they first started work at the home with regular on-going training which enabled them to deliver effective care and support.

People’s needs and preferences were assessed prior to their admission Murrayfield Care Home so that the home could confirm that these could be effectively met.

People had access to a variety of snacks, drinks and regular meals which helped them to maintain a healthy and balanced diet. Where people had specialist diets and support needs in relation to their dietary intake this was appropriately catered for.

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

People had access to a variety of health care professionals to ensure they were able to maintain a healthy lifestyle. The home worked effectively within as well as with other healthcare professionals so that people had access to specialist and relevant services which addressed and met their identified health and care needs.

We observed positive and caring interactions between people and staff. Staff knew the people they supported well and treated them with dignity and respect at all times.

People were supported to be involved in all aspects of the delivery of their care and support where possible. Relatives also confirmed that the home always involved them in every aspect of their relative’s care.

Care plans were detailed and person centred which gave specific information and guidance to staff on how to meet people’s identified needs and wishes.

People and relatives knew who to speak with if they had any concerns or complaints to raise and were confident that their concerns would be dealt with appropriately.

At this inspection we found a breach of Regulation 9 and 17 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 found that people were not supported by care staff in a person centred way. Care was not delivered in a way which was appropriate, met people's needs and reflected their preferences. The provider did not ensure that appropriate activities were organised and provided to people, which encouraged autonomy, independence and involvement within the community. People were not supported by care staff with dignity and respect. Care staff did not put person centred care into practice or provide care that ensured people were treated with dignity and respect. Care staff did not interact with people unless they requested attention.

The provider was not protecting people and was not doing all that was reasonably practicable to mitigate identified risks associated with people's care and support needs. The provider failed to ensure that people were appropriately supported with their nutritional and hydration needs in order to maintain their health and well-being. The provider did not ensure that all areas of the home and equipment used by the service were clean, suitable for the purpose for which they were to be used and properly maintained.

Quality assurance audits that were being completed were not effective as they did not highlight concerns and issues around the home which had been identified on inspection. Where issues were identified there were no action plans in place on how these issues were to be addressed and resolved and there was also a lack of evidence that staff were supported to fulfil their roles and responsibilities through regular supervisions and appraisals.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve each of the key questions to at least good. During this inspection we found that the service had made appropriate improvements to the issues that we identified and were also able to evidence sustainability of improvements that had previously been made.

Murrayfield Care Home is a ‘care home’ providing nursing care. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Murrayfield Care Home accommodates up to 74 people in one purpose built building. Within the building there were three floors, each of which had separate adapted facilities. One of the units specialises in providing nursing care to people and the two other floors specialised in providing care and support to people living with dementia and physical health needs. At the time of this inspection there were 73 people using the service.

A registered manager was in post at the time of this inspection. 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 service had made significant improvements in the fabric and condition of the home. The home was clean and improvements had been made to food preparation areas and other specific areas around the home. However, we did note that sluice rooms had not been kept locked and secure where required.

The service had implemented a number of checks to ensure the appropriate completion of fluid intake charts and to ensure people were appropriately hydrated. However, the effectiveness of these checks were inconsistent across the home because charts had not always been checked appropriately.

Some care staff were able to demonstrate a basic understanding of safeguarding and the steps they would take to report any concerns but this remained inconsistent with some care staff unable to demonstrate a clear understanding of safeguarding and whistleblowing.

Care plans contained appropriate documentation confirming consent to care had been obtained and care staff were clearly able to explain their understanding of the MCA and DoLS and how this impacted on the care and support that they delivered.

We observed positive and caring interactions between people and care staff. However, further improvements needed to be made especially around people’s mealtime experiences.

Significant improvements had been made to people’s care plans. Care plans were detailed and person centred and also contained a life history booklet about the person which gave detailed background information about the person, their likes and dislikes and information about their interests.

During this inspection we observed that although improvements had been implemented to ensure a daily schedule of activities was delivered, outside of this schedule, care staff did not always take the initiative to deliver any additional activities or interaction.

Improved systems were in place to monitor and check the quality of care provided. We received consistently positive feedback from people, relatives and staff regarding the management structure in place and the support they received.

The service had policies and procedures in place to ensure the safe management and administration of medicines. Previously the service had encountered significant issues with medicines which had resulted in enforcement action. However, during this inspection the service demonstrated that they had successfully sustained the improvements in the way that medicines were administered and managed.

People’s care plans identified and assessed risks associated with their health, care and medical needs and appropriate guidance was available to care staff in order to reduce or mitigate the risk in order to keep people safe and free from harm.

Records seen confirmed that staff received regular supervisions and annual appraisals as well as regular training to enable them to deliver safe and effective care.

We received mix feedback from people and relatives about staffing levels within the home. However, during both days of the inspection we observed appropriate staffing levels to be in place. Staff did not seem to be rushed and people’s needs were met appropriately.

Appropriate recruitment processes and checks were in place to ensure that only staff safe to work with vulnerable people were recruited.

Procedures and policies relating to safeguarding people from harm were in place and accessible to staff. Where safeguarding concerns were raised, the service was able to demonstrate the actions they took and the improvements made to ensure lessons were learnt.

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.

The senior management team were accessible to people, relatives and staff who spoke positively about them and felt confident about raising concerns.

There was a registered manager in post. However, the registered manager was not available on both days of the inspection and the inspection process was supported by the deputy manager and the provider’s area 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. However, one week after the inspection we learnt that the registered manager had left their position and that the home did not have a registered manager in place.

At our last inspection in September 2015, we found that some aspects of medicines management were not safe. The provider was also found to be in breach of Regulations 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which related to the lack of documentation to show how staff were supported effectively through supervisions and appraisals. There was also no documentation to show that the service had completed any quality assurance audits

Due to the serious nature of the breach of Regulation 12, relating to unsafe medicine management, we had taken enforcement action against the provider. We issued a warning notice to the provider detailing the issues we found and requiring them to become compliant within a specified timescale. An unannounced focused inspection took place in December 2015 to check that this significant breach of legal requirements had been addressed. During the focused inspection, it was found that all legal requirements for the safe management of medicines had been met.

During this inspection we found that, although the service had made some improvements in relation to previous issues that we had identified, a range of other serious concerns were found in relation to the care and support that people received.

Care staff did not understand what person centred care was or how to support people living with dementia even though specific dementia awareness training had been delivered recently within the home. Care plans did not always have a life history booklet completed about the person and significant details about the person were not always recorded in the care plan.

Scheduled activities did not always take place. Very little interaction, activity or stimulation was noted to be initiated by care staff on duty and people were seen to be taken to the lounge and positioned to watch television throughout the day. Care staff did not appear to be caring and responsive to people’s mental and emotional well-being.

Over both days of the inspection, we observed people experiencing a poor mealtime and dining experience, which did not promote well-being and independence. There were no menus available for people to know what their meal was going to be on the day. People who required assistance with their meals were seen to be left waiting for prolonged periods of time before they were supported. Care staff were noted to have poor awareness of what was on the menu and on occasions did not offer people any choice of what they would like to eat.

Risks associated with people’s care and support needs had been identified and these had been assessed, giving staff instructions and directions on how to safely manage those risks. However, where records were needed to be kept in relation to monitoring fluid intake, these had not been completed to ensure that this area was safely monitored and that people were protected from the identified risks. Care staff were also unable to tell us which people’s fluid intakes were being monitored.

Poor standards of cleanliness were noted in various areas of the home. The service had a housekeeping team in place where cleaning schedules were followed. However, these were observed to be ineffective as specific areas were observed to be extremely dirty. This included certain food preparation areas, bathrooms and shower rooms.

On the first day of the inspection we found a number of chemicals, one without a sealed lid, loose medicated creams and mouthwashes in the communal bathroom areas which were easily accessible to people to pick up and possibly consume. This is of particular concern where people are living with dementia.

Although people and relatives confirmed that people felt safe at the home and with the care and support that they received, care staff that we spoke to were unable to explain to us what was meant by the term ‘safeguarding.’ Care staff could not describe the various types of abuse and were unable tell us the actions that they would take if abuse was suspected. Care staff were also unable to explain their understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS) and how this affected the care and support that people received.

At the inspection in September 2015 we identified that there was gaps in information confirming training that care staff had completed. During this inspection, we saw records confirming that all staff had received the appropriate training required to fulfil the requirements of their role. However, this training was not effective as care staff were unable to tell us about what safeguarding, whistleblowing and MCA meant.

Care plans that we looked at did not include information to show that people had consented to their care. Where a person was unable to consent to their care, there was no documentation that relatives or other people involved in the person’s care and support had been asked to consent on their behalf.

Safe medicine management systems and process were in place to ensure that people received their medicines safely and as per their needs and requirements. The service had ensured that issues identified at the inspection in September 2015 were addressed and the improvements made were sustained.

Care staff told us that they received regular supervision and felt supported in their role. However, we were unable to evidence and check during the inspection to confirm this. Completed supervision and appraisal forms were not available or contained within care staff personnel files.

People and relatives had mixed views about the quality of the food that was provided at the home. Some people and relatives told us that the food was of good quality and some told us that the food was not very good and very little choice was offered. On the second day of the inspection, we sampled the food that was offered to people and found it to be appetising and appropriately presented.

People, relatives, care staff and external health care professionals were positive about the management structure that was in place and the way in which the home was managed. They told us that the registered manager and deputy manager were always available to deal with any queries or complaints.

During the inspection in September 2015 we found that although the service carried out medicine audits, there was a lack of evidence to show that other areas of the home or service provision had been checked to ensure management had oversight of the home and the service that it provided. This included areas such as housekeeping, infection control, care plan and care staff file audits. During this inspection, we found that although a number of systems had been in place to monitor service provision, these were not always effective and did not highlight the issues that we had identified during this inspection.

The provider demonstrated safe recruitment processes were in place to ensure that each person employed at the service was safe to work with vulnerable adults. This included criminal record checks, identification verification, visa verification and reference requests confirming staff conduct in previous employment.

At this inspection we found breaches of Regulation 9, 10, 12, 14, 15, 17, 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to people not receiving person centred care as well as poor use of fluid intake charts so as to minimise risks associated with poor fluid intake. Breaches were noted in relation to poor mealtime experiences, the cleanliness of the home and the risks associated with leaving chemicals and medicines within easy access of people especially those living with dementia, ineffective quality audit systems and care staff’s poor understanding of key areas such as safeguarding and MCA 2005. You can see what action we told the provider to take at the back of the full version of the report.

Our inspection of 30 August 2013 found that care plans did not provide clear and detailed information about people's care and the risks associated with meeting their needs. At this inspection one person said, 'I am well looked after here.' We looked at three care plans and found that they provided information about people's needs and how these should be met. For example, a pain assessment had been carried out and staff knew how to identify when a person needed pain relieving medication.

Our inspection of 30 August 2013 found that care plan audits had not been carried out. The provider wrote to us and told us that they would carry out monthly care plan audits. At this inspection staff told us that care plan audits had been carried out and where issues had been identified these had been addressed. We looked at care plan audits that had been carried out between October 2013 and February 2013 and found that these identified where information about people's preferences and choices had not been included in their care plans. The manager had checked to make sure that this had been addressed.

The care plans that we looked at did not provide clear and detailed information for staff about how people's needs would be met. Care plans were not personalised as they did not provide information about meeting each individual's needs, rather they used the same phrases that were repeated in each person's care plan.

The manager informed us that she had only been at the home for the past two weeks and had not carried out any care plan audits. She told us that the last audits would have been carried out in June 2013 by the previous manager. We asked to see these, but the manager was unable to locate them. We looked at seven care plans and found that they did not always contain complete information about people's care and treatment and the risks associated with supporting their needs. Regular audits of the quality of care plans were not being carried out to ensure people's safety.

People told us that they liked their meals. A person said, 'the food is nice.' We asked people about the variety of food and, a person told us, 'I can choose something different if I don't like what is on the menu." People were provided with a choice of suitable and nutritious food and drink.

There were effective recruitment and selection processes in place. Staff told us that they had been through a detailed recruitment process that included completing an application form, interviews and references being taken up from their former employers. People's personal records including their care plans were accurate, and had been reviewed and updated at regular intervals. Care records gave an explanation of how people's needs were to be met. This meant that care records supported staff to provide safe and appropriate care to people who use the service.