Archived: Rapkyns Nursing Home

Rapkyns Nursing Home provides nursing and personal care for up to 60 people living with a learning disability, physical disability or complex health condition.

Accommodation is provided in two buildings on the same site and comprises the main building, called Rapkyns Nursing Home, and a smaller building, called Sycamore Lodge. At the time of this inspection, there were no service users living at the Rapkyns Nursing Home building so this inspection is only about what we found for people living in Sycamore Lodge. Sycamore Lodge is a service that provides residential care and support for up to 10 people with a learning disability and autism, with some behaviours that may challenge others. At the time of our inspection, six people were living at the service. Accommodation is provided on one level. Communal areas include a lounge area and dining room, with access to gardens and grounds. All rooms have en-suite facilities.

Rapkyns Nursing Home is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation in relation to incidents that occurred between 2016 and 2018. The investigation is on-going, and no conclusions have yet been reached.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the guidance CQC follows to make assessments and judgements about services providing support to people with a learning disability and/or autistic people.

The service was not able to demonstrate how they were meeting some of the underpinning principles of Right support, right care, right culture.

Right support:

• Model of care and setting maximises people’s choice, control and

Independence

Right care:

• Care is person-centred and promotes people’s dignity, privacy and human

Rights

Right culture:

• Ethos, values, attitudes and behaviours of leaders and care staff ensure people

using services lead confident, inclusive and empowered lives

For example; Meals are cooked in another building and arrive at Sycamore lodge in heated boxes. People cannot be involved in the preparation of their meals or enjoy the anticipation of meals which comes with the smell of food cooking. The service is isolated from access to ordinary community activities such as shops, public transport and entertainment venues. People cannot easily access the local shop or pub; these activities need the use of a vehicle which must be planned which does not allow for spontaneity. This is particularly important where people make choices in the moment and have difficulty understanding the passage of time.

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

We found that the service was not always constantly safe and well led. People were not always supported consistently by people who knew them well and there was a high reliance on agency staff.

Improvements had been made since the last inspection, although these had not yet been fully embedded into practice as the service is still reliant on high levels of agency staff. People spoke confidently about the manager and were positive in their feedback. Staff had an enthusiastic and caring approach to their work, which was observed at inspection. Care plans and risk assessments had been updated and reflected people’s needs, giving detail on health needs and guidance for staff to follow.

Positive behaviour support plans were now in place with staff aware of the content and incidents of behaviours that pose a risk to an individual or others had reduced.

Incidents and accidents were being audited by the manager and actions taken to follow up on concerns.

People were treated in a kind and caring way by staff. People's dignity was maintained by staff who supported people in a sensitive way.

People had been protected from abuse and staff knew their role in reporting concerns. There were enough staff deployed on each shift to keep people safe and infection control measures were effective.

The provider had been submitting a monthly report to CQC as part of the conditions imposed on this location.

Some relatives felt that the provider could do more to engage them and seek their views.

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 (16 June 2020).

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 improvements had been made and the provider was no longer in breach of regulations 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 relating to quality monitoring, the effectiveness of audits.

Why we inspected

This was a planned inspection based on the previous rating. We also followed up on action we told the provider to take 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.

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.

Rapkyns Nursing Home provides nursing and personal care for up to 60 people living with a learning disability, physical disability or complex health condition. Accommodation is provided in two buildings on the same site and comprises the main building, called Rapkyns Nursing Home, and a smaller building, called Sycamore Lodge. At the time of this inspection, Rapkyns Nursing Home was empty, so this inspection is only about what we found for people living in Sycamore Lodge.

Sycamore Lodge is a service that provides residential care and support for up to 10 people with a learning disability and autism, with some behaviours that may challenge others. At the time of our inspection, six people were living at the service. Accommodation is provided on one level. Communal areas include a lounge area and dining room, with access to gardens and grounds. All rooms have en-suite facilities.

Rapkyns Nursing Home is owned and operated by the provider Sussex Healthcare. Services operated by the provider had been subject to a period of increased monitoring and support by local authority commissioners. As a result of concerns raised, the provider is currently subject to a police investigation in relation to incidents that occurred between 2016 and 2018. The investigation is on-going, and no conclusions have yet been reached.

Rapkyns Nursing Home has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Rapkyns Nursing Home was designed, built and registered before the guidance was published. However, the provider has not developed or adapted Rapkyns Nursing Home in response to changes in best practice guidance. Had the provider applied to register Rapkyns Nursing Home today, the application would be unlikely to be granted. The model of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or autism should be operated to meet their needs.

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

Some areas of support were not consistently safe. There were some concerns around the management of behaviours that may challenge others. Not all risks were managed safely such as with one person’s choking risk, and some ‘as required’ medicines did not have clear guidance for their use. Some people were at risk of dehydration and required their fluid levels to be monitored; we found this was not being done effectively.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. We found some improvements were needed around mental capacity assessments and establishing whether people had capacity to make certain decisions for themselves. We have made a recommendation about this in the main body of the report.

Some support was not person centred, such as with activities, and care plans were not always consistent and personalised. There had been work started to improve care plans, but this was a work in progress, and more was needed to be done.

There had been an improvement in auditing and quality monitoring, but this needed more time to rectify all the issues identified in the audits and in this inspection. The provider had been submitting a monthly report to CQC as part of the conditions imposed on this location, and this had been a useful tool in improving standards.

People had been protected from abuse and staff knew their role in reporting concerns. There were enough staff deployed on each shift to keep people safe and infection control measures were effective.

Staff were trained to carry out their roles and had regular and effective supervision from the manager. People had enough to eat to maintain good health and were able to access snacks through the day. The building was designed to meet people’s needs and people could access outside spaces.

People were treated in a kind and caring way by staff who knew their needs well. People were being supported by key workers to be as involved in their care as they were able to be. People’s dignity was maintained by staff who supported people in a sensitive way.

There had been no recorded complaints in the service but there was a process to manage these and staff and relatives felt confident that any complaints would be resolved openly and swiftly. Nobody was receiving end of life care but there were plans available to people and their families to consider their choices and wishes, should the time come.

The manager had been working with the provider to make lots of positive changes in the service and there was a vision for an open culture that empowered people. More work was needed to implement this strategy though. The provider had been sharing information openly with partner agencies and understood their role under the duty of candour to report any incidents in a transparent manner.

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

Rating at last inspection

The last rating for this service, following our inspection on 25 June 2019, was Inadequate (published 20 January 2020).

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 some improvements have been made and the service is no longer in special measures, However, the provider was still in breach of regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

We also imposed conditions on the location due to repeated and significant concerns about the safety of care at Rapkyns Nursing Home. The conditions mean the provider must send to the CQC a monthly report relating to how service users’ needs at Rapkyns Nursing Home have been assessed and monitored in relation to: the management of epilepsy/seizure treatment, constipation, pain management, choking, hydration, medicine management and the management of behaviours that may challenge.

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.

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.

Rapkyns Nursing Home provides nursing and personal care for up to 60 people living with a learning disability, physical disability or complex health condition. Accommodation is provided in two buildings on the same site and comprises the main building, Rapkyns Nursing Home, and a smaller building, Sycamore Lodge. At the time of this inspection, Rapkyns Nursing Home was empty, so this inspection is solely about what we found at Sycamore Lodge. Sycamore Lodge is a service that provides residential care and support for up to 10 people with a learning disability and/or autism, with some challenging behaviours. At the time of our inspection, six people were living at the service. Accommodation is provided on one level. Communal areas include a lounge area and dining room, with access to gardens and grounds. All rooms have en-suite facilities.

The provider and its associated locations have been subject to a period of increased monitoring and support by commissioners. Investigations are ongoing by the local authority, police and partner agencies at some of the provider's locations, including Rapkyns Nursing Home. However, the police investigation is ongoing and no conclusions have been reached. Our inspection did not examine specific incidents and safeguarding allegations which have formed part of these investigations. We have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

At the previous inspection in July 2018 we found six breaches of regulations in relation to the safe management of risks, person centred care, consent, staff training, failure to display ratings and governance. At this inspection we found four breaches continued and one new breach of regulation was found.

Rapkyns Nursing Home has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Rapkyns Nursing Home was designed, built and registered before the guidance was published. However, the provider has not developed or adapted Rapkyns Nursing Home in response to changes in best practice guidance. Had the provider applied to register Rapkyns Nursing Home today, the application would be unlikely to be granted. The model of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or autism should be operated to meet their needs.

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

The service didn’t always apply the principles and values of Registering the Right Support and other best practice guidance. These ensure that people who use the service can live as full a life as possible and achieve the best possible outcomes that include control, choice and independence.

The outcomes for people did not fully reflect the principles and values of Registering the Right Support for the following reasons. There were identifying signs, intercom, cameras, to indicate it was a care home. Staff wore clothing that suggested they were care staff when coming and going with people. Some people were not treated with dignity and other people were not being supported to be as independent as they could be with communication.

Some people were at risk because aspects of their care were not managed safely. Staff did not have consistent guidance or knowledge around supporting people with their individual needs. An incident had not been reported immediately when a person had been found with unexplained bruising. Medicine management had deteriorated since our last inspection, and medicines were not always managed safely. Lessons had not always been learned from or embedded into practice. Risks found at this inspection had been identified to the provider following inspections of some of their other services.

Staff did not have all of the required training to carry out their role such as positive behaviour training. Peoples health needs had not always been managed well. There were inconsistencies in the management of constipation, epilepsy, hydration and pain management.

Staff did not always address people in a dignified way, people’s information was discussed in front of other people and individuals. Some people’s communication needs were not met in a personalised way.

Care plans were inconsistent, and some information was missing. Activities were not always structured to support people with their anxieties.

Leadership at the service was not effective. The manager was not present during our visit, a senior support worker was in charge of the shift but lacked knowledge about people. The previous inspection rated the well led domain as 'Requires Improvement'. At this inspection the rating has reduced to Inadequate. Some of the breaches from the last inspection remain. Auditing and oversight had been ineffective in identifying the concerns we found at this inspection. When areas of improvement had been identified action had not always been taken in a timely way to make improvements.

We observed some interactions which were caring and kind. Staff engaged with people at a pace they preferred, and some staff understood people very well. Some staff had a good rapport with people and were relaxed and used humour effectively. People told us they enjoyed the food, although not all people were offered appropriate communication aids to make choices. People went out throughout our inspection to do various activities and the provider was trying to improve personalised engagement.

Rating at last inspection and update

The last rating for this service was requires improvement (published 12 February 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection sufficient improvement had not been made and the provider was still in breach of regulations.

This service has been rated requires improvement for the last three consecutive inspections and has deteriorated to inadequate in the Safe and Well led domains at this inspection.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement:

We imposed conditions on the provider's registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider's services and actions to improve, and to inform our inspections.

Follow up

The overall rating for this service is ‘Inadequate’ and the service is therefore 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 this 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 to varying the conditions of the 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.

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

The provider and its associated locations have been subject to a period of increased monitoring and support by commissioners. Investigations are ongoing by the local authority, police and partner agencies at some of the provider’s locations. Our inspection did not examine specific incidents and safeguarding allegations which have formed part of these investigations. We have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

Rapkyns Nursing Home provides nursing and personal care for up to 60 people living with a learning disability, physical disability or complex health condition. Accommodation is provided in two buildings on the same site and comprises the main building, Rapkyns Nursing Home, and a smaller building, Sycamore Lodge. At the time of this inspection, Rapkyns Nursing Home was empty, so this inspection is solely about what we found at Sycamore Lodge. Sycamore Lodge is a home that provides residential care and support for up to 10 people with a learning disability and/or autism, with some challenging behaviours. At the time of our inspection, nine people were living at the home. Accommodation is provided on one level. Communal areas include a lounge area and dining room, with access to gardens and grounds. All rooms have en-suite facilities. For the purpose of this report we have referred to the home as Sycamore lodge.

We carried out an unannounced comprehensive inspection at Rapkyns Nursing Home in June/July 2017 and a focused inspection in December 2017, where it was awarded a rating of ‘Requires Improvement’ in all domains and overall. Whilst much of the evidence resulting in breaches of regulations related to the main building at Rapkyns Nursing Home rather than Sycamore Lodge, the registration covers both locations/buildings, and therefore the rating applies to both. As a result of this inspection, the overall rating for Rapkyns Nursing Home (and the service known as Sycamore Lodge) remains at ‘Requires Improvement’.

The last manager at Rapkyns Nursing Home de-registered with the Commission in August 2017. A new manager took over in August 2017 and at our inspection in December 2017, we were informed they had commenced the registration process. However, the manager currently in post at Sycamore Lodge commenced the process of registering with the Commission in May 2018. Therefore, there has been no registered manager since August 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered person’. 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.

Sycamore Lodge, which comes under the registration of Rapkyns 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. CQC regulates both the premises and the care provided and both were looked at during this inspection.

Sycamore Lodge has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Sycamore Lodge was designed, built and registered before the guidance was published. However, the provider has not developed or adapted Sycamore Lodge in response to changes in best practice guidance. Had the provider applied to register Sycamore Lodge today, the application would be unlikely to be granted. The model of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or autism should be operated to meet their needs.

At the last inspection, we found people did not receive safe care and treatment. At this inspection, we found that whilst some risks to people were managed safely, this was still an area that requires improvement. Risks to some people had not always been identified and assessed safely and care plans had not provided consistent information in relation to people’s risks or guidance for staff. Medicines in the main were managed safely, but we have made a recommendation in relation to the safe administration and management of topical creams.

At the last inspection, we found that staff had not always received appropriate support, training, supervision and appraisal as was needed to carry out their roles. At this inspection we found that insufficient improvements had been made and this regulation was still not met. Staff completed a range of training that was considered by the provider to be mandatory to the role. Not all staff had completed the training as required. Staff received regular supervision from the manager with annual appraisals.

Everyone living at Sycamore Lodge was subject to Deprivation of Liberty Safeguards, although some were awaiting authorisation from the local authority. Capacity assessments had been completed as required. However, when decisions needed to be made in people’s best interests, these were not always taken in line with the code of practice under the Mental Capacity Act 2005. Some people were subject to forms of physical restraint for which the process in making this decision had not been followed.

People’s nutritional requirements had been assessed, but some people’s needs had not been fully documented or assessed. This is an area for improvement. The lunchtime meal for people living at Sycamore Lodge was prepared at another of the provider’s locations nearby and transported over to the home in a heated trolley. People enjoyed the lunch provided.

At the last inspection, we found that people did not receive personalised care that met their needs and preferences. This continues to be an area for concern. Some care plans did not document people’s personal histories or preferences, so care and support could not be delivered in a person-centred way. Outings into the community were limited. People’s communication needs had not been assessed in a way that ensured staff communicated with people in a way that they understood. Information was not presented in an accessible format.

At the last inspection, we found that systems had not been developed to monitor the quality of the care delivered or the service overall, to drive continuous improvement. At this inspection, this is still an area of concern. Some of the provider's audits had identified the same issues we found at inspection, but other concerns had not been addressed. After the inspection, we were sent an action plan which identified what actions the provider said had been, or were to be, taken in response to the concerns we fed back following inspection.

Providers of services registered with the Commission are required to display the rating of the service at the location and on their website, if they have one. According to the provider’s website, Sycamore Lodge was awarded a rating of ‘Good’ at the last inspection. This was not correct. Sycamore Lodge comes under the registration of Rapkyns Nursing Home, which was awarded a rating of Requires Improvement at the last inspection. The rating for Sycamore Lodge is, therefore, 'Requires Improvement' and not as stated by the provider.

Relatives had mixed views about the management of the home. The manager had plans to involve relatives more with the production of a newsletter and the introduction of coffee mornings.

We observed instances where staff were kind and caring with people and one occasion where the staff member did not know how to respond to one person’s needs. Care plans did not always document detailed information about people’s preferences, so agency staff would not necessarily have known how to care for people in line with their preferences. People were encouraged to make choices, but work was still to be done to make sure communication systems were implemented that were responsive to people’s needs. People were treated with dignity and respect.

Premises were managed safely, with testing and servicing of equipment being completed as required. Staff had an understanding about keeping people safe and the majority of staff had completed training in safeguarding adults at risk. Staffing levels were sufficient to meet people’s needs. Safe recruitment systems ensured that potential new staff had all the necessary checks completed before they commenced employment. Staff completed training in infection control; the home was clean and smelled fresh.

People received support from a range of healthcare professionals and services. Work was in progress to develop strategies in relation to providing a more holistic approach to people’s care and support. Complaints were managed in line with the provider’s policy.

We found breaches of regulations and areas in need of improvement. We are considering our regulatory response to these breaches of legal requirements and will publish our action when this is complete. As a result of this inspection, the service remains as 'Requires Improvement'.

We imposed conditions on the provider’s registration. The conditions are therefore imposed at each service operated by the provider. CQC imposed the conditions due to repeated and significant concerns about the quality and safety of care at a number of services operated by the provider. The conditions mean that the provider must send to the CQC, monthly information about incidents and accidents, unplanned hospital admissions and staffing. We will use this information to help us review and monitor the provider’s services and actions to improve, and to inform our inspections.

We undertook a comprehensive inspection of Rapkyns Nursing Home in July 2017 where we identified three breaches of legal requirements and judged the service to be 'Requires Improvement' in all domains. The breaches of legal requirements related to gaps in staff training, supervision and appraisal, a lack of personalised care and ineffective quality monitoring systems. The provider submitted an action plan which detailed the steps that would be taken to achieve compliance.

We brought forward this focussed inspection of Rapkyns Nursing Home due to an increase in concerns raised by partner agencies about risk and quality at the service highlighted by routine monitoring visits and safeguarding alerts raised. At this inspection we focussed on the ‘Safe’ and ‘Well-Led’ domains only and checked whether improvements planned by the provider to meet legal requirements in these areas had been undertaken.

The service had been the subject of multiple safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation. Our inspection did not examine specific incidents and safeguarding allegations which have formed part of these investigations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection.

At this inspection the team inspected the service against two of the five questions we ask about services: is the service safe and is the service well led. We were unable to improve the ratings for these Key Questions as we found a continued breach of Regulations. We also identified new risks to people living at the home regarding their care and treatment. Therefore the service remains at ‘Requires Improvement’ in these areas and overall.

Rapkyns Nursing Home is a care home that provides both nursing and residential care for up to 60 people. 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.

Rapkyns Nursing Home accommodated people across two separate units. Rapkyns Nursing Home supported people living with Huntington’s Disease. Sycamore Lodge provided care to younger people with a learning disability and/or autism. At the time of this inspection there were 30 people living in Rapkyns Nursing Home and nine people resided at Sycamore Lodge. People had access to communal areas within the home and Sycamore Lodge bedrooms were complete with en-suite facilities. Sycamore Lodge was adapted to meet the need of people who also had complex physical needs and was fitted with overhead hoisting equipment throughout.

Sycamore Lodge has not been operated and developed in line with the values that underpin the Registering the Right Support and other best practice guidance. Sycamore Lodge was designed, built and registered before this guidance was published. However the provider has not developed or adapted Sycamore Lodge in response to changes in best practice guidance. Had the provider applied to register Sycamore Lodge today, the application would be unlikely to be granted. The model of care provided is not in keeping with the cultural and professional changes to how services for people with a learning disability and/or Autism should be operated to meet their needs.

These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service should be able to live as ordinary a life as any citizen, but this was not always the case for people. Sycamore Lodge is geographically isolated on a campus within the provider's own care village setting. Most people’s social engagement and activities took place either at Sycamore Lodge or at another service operated by the provider with other people who were receiving care by the same provider. People had limited contact with specialist health and social care support in the community due to specialist staff (physiotherapy, speech and language) that were employed by the provider.

There was a manager in post at Rapkyns Nursing Home who had commenced their role at the end of August 2017. At the time of the inspection, they had not yet submitted their application to become the registered manager. Since the inspection, in December 2017, they have submitted their application form. 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. There was a separate unit manager in post at Sycamore Lodge.

At the last inspection we found, risks posed to people were assessed and managed safely. However, at this inspection we found inconsistencies within care records which may increase the potential risk of a person not receiving the correct care and treatment. This included gaps within the guidance for staff who supported people with their continence needs, moving and transferring guidance and those at risk of malnutrition.

At the last inspection medicines were managed safely yet some medicine records would benefit from further development. At this inspection we found inconsistencies and gaps in medicines guidance available for staff in Rapkyns Nursing Home. This included a lack of guidance for staff when applying prescribed topical creams to people with various skin conditions and for people receiving medicines for constipation.

At this inspection there were sufficient staff deployed on each shift, however consideration was needed from the provider regarding how staff were deployed in the upstairs of the nursing home to ensure all people, who received their care in their rooms and beds, had their needs met consistently and safely.

The layout and environment of the Rapkyns Nursing Home did not always lend itself to meet the needs of people with complex physical mobility needs. Due to the narrow layout to some parts of the building we observed on one occasion a staff member manoeuvring a person's wheelchair incorrectly when a person was in it. Staff also referred to the difficulties they had when transferring people when supporting people with their personal care as some of the bedrooms and communal bathrooms were too small for the moving and handling equipment they used.

Accidents and incidents were recorded; however there were inconsistencies within the records regarding the action staff had taken at the time to minimise further risks on behalf of people including informing the West Sussex Adults Safeguarding team to ensure people were consistently protected from harm.

At the last inspection we found systems to assess and monitor the service were in place, but they were not effective. Shortly after the inspection the provider wrote to us to inform us of the action they were taking. At this inspection we continued to find they were not sufficiently robust as they had not ensured a delivery of consistent, high quality care across the service or pro-actively identified all the issues we found during the inspection. This included a lack of analysis and monitoring when people experienced falls to drive improvements to how people were supported by staff to ensure risks of harm to people were reduced.

Environmental risks such as hoist equipment, wheelchairs and legionella checks were managed effectively through prompt and regular servicing. Staff employed by the home underwent a thorough safe recruitment process and told us they were happy with the support they were now receiving from the new manager. People and their relatives were invited to provide their views on the care and treatment received formally through surveys.

At the last comprehensive inspection in June and July 2017 we identified three breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider wrote to us to inform us of the action they were taking. At this focused inspection we found further improvement was needed and we identified new risks to people living at the home. We identified three breaches of the Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The inspection was bought forward as we had been made aware that following the identification of risks relating to people's care, the service had been subject to a period of increased monitoring and support by commissioners. The service has been the subject of 11 safeguarding investigations by the local authority and partner agencies. As a result of concerns raised, the provider is currently subject to a police investigation. Our inspection did not examine specific incidents and safeguarding allegations which have formed part of these investigations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection. Between May and August 2017, we have inspected a number of Sussex Health Care locations in relation to concerns about variation in quality and safety across their services and will report on what we find.

Rapkyns Nursing Home provides nursing and personal care for up to 60 people who are living with a learning disability, physical disability or complex health condition. The home also specialises in supporting and treating people living with Huntington’s disease. Accommodation is provided in two buildings on the same site, Rapkyns Nursing Home and Sycamore Lodge. Young adults and older people reside at the home.

At the time of the inspection there were 35 people living in the main building (two of whom were in hospital during our inspection) and nine people living in Sycamore Lodge.

We carried out an unannounced comprehensive inspection of this service on 16 May 2016 where it was awarded a rating of ‘Good’ in all domains and overall. As a result of this inspection, the overall rating of this service has changed from ‘Good’ to ‘Requires Improvement’.

On the first day of our inspection, a registered manager was in post. When we returned for the second day of inspection, the registered manager had resigned their post and interim arrangements had been put in place for the management of the service. A new manager had been recruited, but had not taken up their 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.

Whilst systems were in place to assess, monitor and improve the quality of the service, these were not always effective, as they had not identified the breaches of regulation we found at the time of our inspection. The lack of supervision for some staff meant that staff may not always have understood what was expected of them. Staff did not always keep clear records relating to people’s fluid intake where this was needed and there was a lack of guidance for staff on one person’s specialised footwear. There was evidence of improvements having been made in accurate record keeping, but further work was still needed.

There were gaps in training for some staff who had not completed all the mandatory training including, moving and handling, safeguarding vulnerable adults and mental capacity. Some staff had not completed all the required training to ensure they carried out their roles effectively. Supervisions had not been held regularly or in line with the provider’s guidelines. Some staff had not received supervision at all in 2017 or had an annual appraisal within the last 12 months. This put people at risk of receiving care from staff whose competency had not been assessed recently.

People did not always receive personalised care that was in line with their preferences, although these were recorded in their care plans. Staff had not been deployed in such a way as to ensure, for example, that people were able to get up at the time they wanted because other people with healthcare appointments took priority. Activities had not been organised in line with people’s interests. Care plans documented the activities that people enjoyed which had been organised by staff, rather than activities that were tailored to meet people’s needs or preferences. There was a lack of mental stimulation for people who had little or no communication. Staff provided care in a task-orientated way; it was not individualised or person-centred.

On the first day of our inspection, the registered manager demonstrated understanding of her responsibilities to protect people from abuse and to provide safe care. They ensured systems were used to monitor and to ensure that appropriate action was taken when incidents and safeguarding situations occurred. Additional training had been provided to staff as a result of safeguarding investigations in relation to personal care. Staff were able to explain the correct procedures that should be followed if they thought someone was being harmed or abused. Senior management shared learning from safeguarding situations that had occurred at other locations operated by the provider to ensure learning and practice improved across the organisation.

Risks to people’s health and wellbeing were being managed safely for the majority of people living at the home. Moving and handling risk assessments were reviewed regularly and changes implemented where necessary. These risk assessments described the number of staff needed and what equipment was needed for each movement and we saw that this was being followed. We observed one person was at risk of trapping their fingers in their wheelchair and that this had not been noticed by staff. This was discussed with the acting manager who assured us that a referral for a new wheelchair would be made. For people who had behaviours that posed risk to themselves and others, assessments and care plans detailed how behaviour may present, the warning signs, triggers and how to support the person safely. Staff who supported these people understood how to provide safe care whilst not restricting their freedom.

Except for one observed instance, people with swallowing difficulties were supported to eat safely. Staff were able to explain the support people needed to eat safely and this corresponded with the contents of their care plans and assessments. They were also able to explain signs of choking and what they should do if this occurred including emergency first aid. We did observe one instance when one person was not positioned to eat in line with the recommendations of the speech and language therapist. We fed this back to the registered manager and we received assurance that was acted upon.

People who could not have food and drink orally received safe care. The care plans, monitoring charts and information in people’s rooms was accurate and reflected the care we observed people receiving. Staff were knowledgeable about supporting people in this area and had received training.

There were sufficient numbers of staff to keep people safe and the use of staff was generally effective. The registered manager demonstrated understanding of assessing that staffing levels were sufficient to provide safe care. Where possible, regular agency or bank staff were used to cover vacancies. There was a high usage of agency staff at weekends.

In the main, safe medicine procedures were followed. Staff checked the instructions on people’s Medication Administration Records (MAR) corresponded with the medicine directions on labels before administering to people and signed the MAR only after people had taken their medicines. Medicines were stored safely. The majority of medicine records were accurate and legible. However, we did note that some MAR would benefit from expansion when codes were used in order that they clearly explained why a medicine had or had not been given.

Registered nurses had completed training in addition to the mandatory training on offer, in areas such as palliative care, enteral pumps, catheter care, PEG management and venepuncture. Staff had also completed training on specific health conditions, such as Huntington’s disease. Staff meetings were organised with separate meetings taking place for nurses and care staff.

The service operated within the principles of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards and put this into practice. Staff had completed training in this area and mental capacity assessments had been completed for people where required. People’s capacity to make decisions independently was documented and managed appropriately.

People and a relative were positive about the food on offer. The chef understood people’s dietary needs which were documented appropriately. Specialist diets were catered for, including for people who received nutrition through PEG feeding. People told us they had choices within the menu on offer or could select an alternative if they wished.

People had access to a range of healthcare professionals and services. Care plans provided detailed information to staff about how they should support people with their various health and medical conditions. People’s healthcare appointments were documented and guidance provided to staff with any actions that needed to be addressed.

People were supported by kind and caring staff who were prompt in helping people when they needed. People’s likes and dislikes recorded in their care plans were put into practice, aside from personalised activities which we referenced earlier in this section. For example, one person liked to have a thin sheet or blanket covering them all the time and this was in place. People were supported to stay in touch with their families and their spiritual and cultural beliefs were catered for. They were treated with dignity and respect and had the privacy they needed.

Peop

Rapkyns Nursing Home provides nursing and personal care for up to 60 people who are living with a learning disability or physical disability. Rapkyns Nursing Home provides accommodation in two buildings on the same site, Rapkyns Nursing Home and Sycamore Lodge. At the time of our inspection, there were 37 people living at Rapkyns Nursing Home and ten people living in Sycamore Lodge. Rapkyns Nursing Home specialised in supporting and treating people who have Huntington’s Disease. The provider and staff were engaged with wider Huntington’s Disease links and research. The aim of which was to improve the lives of people using their service but also to find treatment solutions to help others living with the disease.

There was no registered manager in place at the time of the inspection. However, a new manager had been appointed in March 2016 and had begun the process of applying for registration.. 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.

People living at the service had their own bedroom and en-suite bathroom. In both buildings, there was a communal lounge and separate dining room on the ground floor where people could socialise and eat their meals if they wish. The buildings shared transport for access to the community and offers the use of specialist baths, spa pool and physiotherapy. The service had weekly GP visits, 24-hour nurse support, a multi-sensory room and a social and recreational activities programme. The service could accommodate relatives who wished to visit their family.

Risk assessments and care plans contained information on people's preferred routines, likes, dislikes and medical histories. However, we identified six risk assessments and care plans that did not include guidance for health conditions, which had been identified. This meant that people were at risk of not receiving the care and treatment they needed. We brought this to the managers attention at the time of our visit. The manager reviewed and updated these risk assessments and care plans before our visit concluded. We were satisfied that people were not at risk from receiving treatment.

Staff worked closely with community health professionals and therapists to maximise people's well-being. People felt safe at Rapkyns Nursing Home and had positive and caring relationships with the staff who supported them.

People were protected against avoidable harm and abuse. Good systems were in place for reporting accidents and incidents and the service was responsive to people's individual needs.

Staff enjoyed working at the service and felt well supported in their roles. They had access to a wide range of training, which equipped them to deliver their roles effectively. Staff completed an induction course based on nationally recognised standards and spent time working with experienced staff before they were allowed to support people unsupervised. This ensured they had the appropriate knowledge and skills to support people effectively. Records showed that the training, which the provider had assessed as mandatory was up to date. Staff told us that they felt supported and received training to enable them to understand about the needs of the people they care for. People and their relatives felt the staff had the skills and knowledge to support people well.

There were sufficient numbers of staff on duty to keep people safe and to meet people's needs. We saw that staff recruited had the right values, and skills to work with people who used the service. Staff rotas showed that the staffing levels remained at the levels required to ensure all peoples needs were met and helped to keep people safe.

Policies and procedures were in place to ensure the safe ordering, administration, storage and disposal of medicines. Medicines were managed, stored, given to people as prescribed and disposed of safely. Nurses had completed safe management of medicines training and had their competency assessed annually. The nurses were able to tell us about people's different medicines and why they were prescribed, together with any potential side effects.

People who used the service expressed satisfaction with their care and felt confident that staff understood their needs. Staff were kind and caring. People who lived at the service were allocated key workers and we observed trusting friendships between people who lived in the service and staff members. A key worker is a named member of staff responsible for ensuring people's care needs were met.

The Care Quality Commission monitors the operation of the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. The members of the management team and nurses we spoke with had a full and up to date understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). These safeguards protect the rights of adults by ensuring that if there are restrictions on their freedom and liberty these are assessed by appropriately trained professionals. We found that appropriate DoLS applications had been made, and staff were acting in accordance with DoLS authorisations.

The service placed a strong emphasis on meeting people's emotional well-being through the provision of meaningful social activities and opportunities. People were offered a wide range of both group and individual activities, which met their needs and preferences. Visiting was unrestricted and people's relatives felt included in the care of their loved ones.

People were provided with a variety of meals and the menu catered for any specialist dietary needs or preferences. Mealtimes were often viewed as a social occasion, but equally any choice to dine alone was fully respected.

People were supported to maintain a healthy balanced diet through the provision of nutritious food and drink by staff who understood their dietary preferences. We observed communal mealtimes where people ate together. Where people had been identified to be at risk of choking staff supported them discreetly to minimise such risks, while protecting them from harm and promoting their dignity

We looked at care records and found good standards of person centred care planning. Care plans represented people's needs, preferences and life stories to enable staff to fully understand people's needs and wishes. The service was responsive to people's individual needs. The good level of person centred care meant that people could lead independent lifestyles, maintain relationships and be fully involved in the local community.

The service had robust systems in place for monitoring the quality of care and support. The auditing systems showed that the manager was responsive to the needs of people who lived at the service.