Archived: Lands House

The inspection took place on 20 and 25 January 2016 and was an unannounced inspection. On the date of the inspection there were 16 people living in the home. Lands House Nursing Home provides accommodation and nursing care for up to 30 people at any one time. The home is located in Rastrick, Brighouse with accommodation spread over two floors. The client group was mainly older people, some of whom were living with dementia.

A registered manager was not required as the provider was a single individual who also undertook management duties within the home. Following the previous inspection, the home had appointed a nursing manager in November 2015 to provide nursing oversight of the service. Sadly they had died unexpectedly in early January 2016. At the time of the inspection, there was no nursing oversight of the home, with only two registered nurses available to work days. Due to shortages of nursing staff the clinical lead was unable to work any supernumerary time allocated to nursing management duties.

People and their relatives told us that the service was safe and it provided good, effective care. They said staff were kind and caring and treated people well. They said that they felt safe from abuse in the company of staff.

At the last inspection in July 2015 we found seven breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found some improvements had been made, for example to care planning documentation and the management of nutrition. We found interactions between staff and people who used the service were improved.

However there was insufficient improvement made in a number of other areas, including the management of risk and the evaluation and improvement of nursing care. Concerns remained about the management teams understanding of a number of key topics including the Mental Capacity Act and safeguarding.

We found some aspects of the medicine management system had been improved. For example the administration of Warfarin was better managed and for boxed medication, there were no gaps on Medication Administration Records (MAR) demonstrating people were regularly receiving their medicines. However there was a lack of appropriate procedures and care planning to support the safe and consistent administration of medicines. We found two people did not receive the medicines at the times they needed them.

Staffing levels were sufficient to ensure safe care. Requests for care and support were responded to promptly by staff.

At this inspection we found there was better recording of incidents which had occurred within the service. However we were concerned that the management team were not correctly identifying incidents as safeguarding and referring onto the local authority. We found risks to one person were not appropriately managed and risks assessments put in place were not robust enough to provide us with assurance that further incidents would not occur.

The home was not complying with the legal requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Where DoLS were in place the conditions were not being complied with and the management team had a lack of understanding of the correct processes to follow.

Improvements had been made to the way the service managed risks associated with poor nutrition.

There was a lack of systems in place to provide nursing staff with proper and worthwhile clinical supervision. There were some gaps in the training records which showed some nurses had not received their mandatory training.

We observed staff were kind and caring and treated people well. People were listened to and their choices respected with regards to daily life within the home.

Since the previous inspection care records had been improved. In most cases, they demonstrated a better assessment of people’s individual needs. However further improvements were needed to some records to ensure they accurately reflected people’s care and support needs. The provider acknowledged this process was not yet fully complete.

Records showed that people were involved in a number of activities to help keep them occupied.

A range of audits were undertaken by the service and we saw evidence these were used to improve a number of aspects of service delivery. Regular meetings with staff groups had also been used as a mechanism to improve the service. However the provider acknowledged that further improvements were required, however these were not formalised into a structured action or improvement plan.

There was a lack of systems in place to assess, monitor and improve the quality of nursing care within the home. We were concerned that audits of nursing care plans and investigation into nursing incidents were being completed by the provider who was not a registered nurse.

We were concerned that some issues we found at the previous inspection such as not working within the legal framework of the Mental Capacity Act (MCA) and a failure to manage risks appropriately were still present. This showed a lack of action taken to fully address these areas based on our feedback.

Overall, we found significant shortfalls still remained in the care and service provided to people. We identified six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At the last comprehensive inspection this provider was placed into special measures by CQC. This inspection found that there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

We used the information to answer the five key questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well led?

This is a summary of what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

Is the service safe-

Our observations of care, examination of care plans and discussions with staff demonstrated to us that the provider was delivering a safe service which was sympathetic to people's individual needs.

Each person's care file had risk assessments in place which covered areas of potential risk such as mobility, falls, pressure sores and nutrition.

We found people were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

One person we spoke with said the home was 'a bit dated'. We found the premises were safe; however, there were many areas in which it required refurbishment or decoration. We saw some redecoration had taken place and there was a planned maintenance and refurbishment programme in place.

The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Whilst no applications had been submitted, proper policies and procedures were in place. Relevant staff had been trained to understand when an application should be made, and how to submit one.

Is the service effective '

People had an individual care plan which set out their care needs. We saw wherever possible people had been involved in the assessment of their health and care needs and had contributed to developing and reviewing their care plans.

We saw staff received appropriate support by way of a programme of one to one supervision and annual appraisals to enable them to understand and meet the needs of the people who used the service. Staff also confirmed the management of the service was responsive to their training needs as discussed at either supervision or appraisal meetings.

Is the service caring '

The staff we spoke with demonstrated a good knowledge of people's needs and were able to explain how individuals preferred their care and support to be delivered.

During our visit we saw a number of positive interactions between people and the staff. We asked people if they liked living at the home and they told us that they did. One person with limited verbal communication indicated to us that they were happy with the care they received.

One relative told us "They always have time to help my [relative]; they'll do anything for you and always appear friendly." Another visitor told us their relative looked well cared for and was alert; they said the staff were 'friendly and jolly'.

Is the service responsive '

We spoke with two people who used the service and two relatives. They said that they thought there was always enough staff on duty although there were times when staff were not evident. We observed there were times throughout the day when the competing demands on staffs' time meant that although they were able to meet people's need they were not always able to do this in a timely way.

Wherever possible people who used the service and/or their relatives were involved in discussions about their care and the risk factors associated with this. Individual choices and decisions were documented in the care plans and reviewed on a regular basis.

The input of other health care professionals involved in people's care and treatment was recorded in their care plans. This helped to make sure people received appropriate and safe care and treatment.

Is the service well led '

During this inspection we checked to make sure the provider had taken action to address the shortfalls identified during the inspection in March 2014. We found the provider had taken appropriate action to make sure accurate and up to date records were maintained to protect people against the risks of receiving inappropriate or unsafe care.

We saw there was a quality assurance monitoring system in place that was designed to continually monitor and identify shortfalls in the service and any non-compliance with the essential standards of quality and safety.

The owner/manager was in day to day charge of the home and told us this gave them plenty of opportunities to monitor the quality of the services provided by speaking to people who used the service and their relatives. In addition, we saw people were involved in reviewing their care plans on a regular basis and were given the opportunity to complete a survey questionnaire once a year.

The provider had a complaints procedure in place and we saw evidence that action was taken in response to people's comments, concerns or complaints.

The staff we spoke with told us they were well supported by the management team.

On the 17 March, we spoke with the provider, the assistant manager, a senior carer, two care assistants, the laundry assistant and the maintenance person. We also spoke with three people who used the service and one relative. Following our inspection we also spoke with two nurses who worked at the service.

When we returned on 24 March, we spoke with the provider, assistant manager and the clinical lead nurse. Due to the focussed nature of our visit we did not speak to people who used the service.

As part of our inspection on 17 March we looked in the communal areas of the home and 15 bedrooms. During our visit we also looked at a selection of records kept by the service, including four people's care records.

We saw the home's communal areas, bathrooms and toilets were all clean. The home was generally free from odours. The manager showed us records which demonstrated there was a cleaning schedule that was being monitored.

We found the home had been inspected by the Food Standards Agency in November 2013 and had scored a five star rating.

We saw parts of the premises were not well maintained and remained in need of renovation and refurbishment. Repair work had been completed in two bedrooms where equipment had damaged the walls. We also saw repairs were in progress to the first floor landing ceiling which had been damaged as a result of a storm.

We saw the easy chairs in the communal areas and in the bedrooms we looked at were visibly clean and we did not detect any unpleasant odours.

We spoke with the provider about staffing levels at the home. They said since our last inspection the cook's hours had been increased. They told us the cook used to finish work at 2.30pm but they now worked until 5.30pm. They also told us they were planning to increase the care staff from three to four each afternoon.

When we looked at peoples' care records we found a number of examples where the provider had not maintained accurate and detailed records.

We noted in three of the files we looked at there was no evidence people had been offered or had received baths or showers. For example, in two people's records we could see no documented record of them being offered or having received a bath or shower during February.

When we looked at the duty rota for the service we found that it did not provide an accurate reflection of the staff who were working.

During our visit we also spoke with a relative of a person who used the service. They said, 'We have no problems what-so-ever. It's clean. Everyone is so caring. I'd give them 100 out of 100.'

Respecting and involving people who use services

Cleanliness and infection control

Safety and suitability of the premises

Staffing

Records

We said that improvements were needed and judged the areas of non-compliance had a moderate impact on people who lived at the home.

On this visit we inspected the same outcomes and found that some improvements had been made. We found that sufficient improvements had been made with regard to respecting people who used the service. However, there was little evidence that people had been involved in planning or reviewing their care and support.

We saw some improvements in relation to cleanliness and infection control, safety of the premises, staffing and records but further improvements were needed to achieve compliance. In view of the improvements, we have judged that the non-compliance in these areas was of minor impact to the people who lived at the home.

During our visit we spoke with five people who lived at the home. They all expressed a general satisfaction with the service they received and spoke highly of the the kindness and attentiveness of the staff.

We saw that staff treated people with respect and demonstrated a caring approach.

'I worry about the person sitting next to me as they keep falling asleep and I worry that they are going to fall out of the chair.'

'I really enjoy working here and enjoy finding out about the people who live here.'

'When I visit I find the staff helpful.'

We found that there were some practices in the home that showed a lack of respect for people. There were care plans in place and evidence that people's health and care needs were being met.

When we looked around the home we found it was dirty, infection control measures were poor and the environment was poorly maintained. There were not enough domestic staff to keep it clean.

Some of the care records were poor leaving people at risk of not receiving the care they needed.

The provider and staff were aware of their responsibilities regarding protecting people from abuse. Staff told us they knew how to raise concerns. There were enough qualified, skilled and experienced staff to meet people's needs.

The provider had quality assurance systems in place to ensure the quality of the service being delivered was meeting people's needs.