Archived: Langford/Kennet

Langford and Kennet are two eight bedded units that are managed as one service and provide complex nursing care for people with neuro degenerative or previous brain injury.

Langford and Kennet are one of six adult social care locations at Glenside, which also has a hospital that is registered separately with CQC. 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.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. Some of the systems are managed centrally for all services; for example, maintenance, systems to manage and review accidents and incidents, and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site, also facilities such as the hydrotherapy pool are shared by people in all services.

One adult social care location (Pembroke Lodge) is currently closed as there were ongoing issues with the provision of heating and hot water.

The hospital is also currently closed due to flooding, caused by a major water leak. People from the hospital were transferred at short notice to some of the adult social care (ASC) locations. Works to repair the fabric of the hospital building are currently underway. As Langford and Kennet were temporarily accommodating people from the hospital we reviewed aspects of these peoples care and support in line with the expectations of their inpatient status. The Langford area is being used to accommodate people under the ASC registration and the Kennet area for those people previously accommodated in the hospital

The provider notified us of the temporary arrangements for hospital patients while refurbishments take place. However, Langford and Kennet will not be correctly registered with CQC if these arrangements become long-term. The provider will need to submit applications to CQC to register appropriately if the closure of the hospital continues.

At this inspection we found that people were placed at risk due to management shortfalls. We found systemic overarching poor management systems and that the required improvements were not prioritised. There had been sudden and continuing persistent changes of senior management. There was a lack of regulatory response from the provider. There were issues with poor recruitment procedures, and a lack of investment in equipment and maintenance of the property. The morale of the staff was low, and they were reluctant to give feedback because of fear of reprisals. This had an impact on the care people received.

People’s experience of using this service:

The service was rated Requires Improvement at the comprehensive inspection dated July 2018. The rating for the focussed inspection undertaken on the 7 November 2019 remained the same.

For people receiving adult social care we found:

• Staffing levels had improved since the last inspection.

• Information about pain management was not always clear.

• Three out of eight people living at Langford had a history of epilepsy seizures, however, epilepsy management training was non-compulsory.

• Environmental risk assessments relating to fire safety, infection control, maintenance or temperature check were out-of-date.

• There were no logs of maintenance work requested by staff or carried out in the service. We saw there were areas requiring urgent maintenance and potentially posing a threat to people’s health and safety.

• When agency staff were used, the service did not always ensure they were qualified and knowledgeable enough to lead a shift.

• The unit manager was not supported by the provider to ensure they could focus on making improvements. This included an ineffective maintenance function, and not having recruitment support from a human resources team.

• The service did not have a registered manager in post. The service was being managed by an interim manager.

For the hospital patients we found:

• There was little evidence to show how standards of cleanliness and hygiene were maintained. There was no process, checklist, or audits completed within the organisation relating to infection control. Safety systems were not implemented to protect patients effectively from communicable diseases or to maintain infection control and hygiene. Staff didn’t always decontaminate their hands immediately before and after every episode of direct contact.

• The maintenance of facilities and premises did not keep people safe.

• The clinical care for the people who were hospital patients was not safe. Staff were not able to identify and respond appropriately to changing risks to people who use services. National Early Warning Scores (NEWS) was not in use.

• There were not comprehensive risk assessments carried out for people who use services and risk management plans were not developed in line with national guidance. We reviewed several sets of patient notes and found that the management of risks was not being properly identified or monitored.

• Nursing assessments and documentation were not in keeping with standards for nursing. People’s individual care records, including clinical data, were not written and managed in a way that kept people safe. Information needed to deliver safe care and treatment was not available to relevant staff in a timely and accessible way. Care plans were not always updated as the provider required.

• Medicines were overall safely managed.

• Staff told us that staff were very negative about the provider and this caused friction among staff.

Also, as patients from the hospital had been transferred to other wards, not necessarily their speciality, staff felt there were unrealistic expectations placed on them for patient needs outside their scope of experience.

• Staff told us they had no confidence in senior management as there was no communication, however, the newly appointed CEO was perceived as someone who would listen to the staff.

• Staff were concerned that the hospital (which was closed due to a flood) would not re-open and their jobs would be at risk.

Whilst we saw that some improvements had been made these were not sufficient and additional areas of concern were identified. As a result the rating from this inspection is now inadequate .

Rating at last inspection: This service was rated Requires Improvement at the comprehensive inspection published on 30 August 2018.

Why we inspected:

This inspection was brought forward due to information of risk or concern. Since the inspection visit in October 2018 we received ongoing whistleblowing concerns. After the last inspection CQC requested assurances from the provider about the action they would take to improve the service. To date, these assurances have not been forthcoming. We did not inspect the key questions Effective, Caring and Responsive because ongoing monitoring did not raise any information about risks or concerns in these areas.

Enforcement:

Following the focus inspection in November 2018 we imposed a condition on the providers registration. The provider was required to submit monthly improvement action plans to CQC from February 2019. These have not been received We also issued four warning notices following the focus inspection at Glenside Hospital in November 2018.

Follow up:

This service is now rated as Inadequate and placed on special measures. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe and the rating of inadequate is repeated for any key question or overall, we will take action in line with our enforcement procedures. This will be to begin the process of preventing the provider from operating this service. This process will lead to cancelling the provider’s registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, urgent enforcement action will be escalated. Where necessary, another inspection will be conducted within the next six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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. We will have contact with the provider and registered manager following this report being published to discuss how they will make changes to ensure the service improves their rating to at least Good.

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

Langford and Kennet are two eight bedded units that are managed as one service and provide complex nursing care for people with neuro degenerative or previous brain injury. It is one of six adult social care locations and a hospital registered separately with CQC that are on the same site.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately, some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are also shared across the whole site.

The hospital is currently closed due to flooding, caused by a major water leak. People from the hospital were transferred at short notice to some of the adult social care (ASC) locations on the same site. Works to repair the fabric of the hospital building are currently underway. As Langford and Kennet were temporarily accommodating people from the hospital we reviewed aspects of these peoples care and support in line with the expectations of their inpatient status.

People’s experience of using this service:

People were not safeguarded from abuse and were placed at risk of harm.

Medicines were not safely managed. Medicines Administration Records (MAR) were confusing which increased the risk of errors. Care plans lacked detail on how to administer medicines safely to prevent Percutaneous Endoscopic Gastrostomy (PEG) blockages. One person received their medicine ‘covertly’ (without them knowing). The decision to give the medicine in this way had not been reviewed. Medicine that was out of date was observed being administered. Following the inspection, we received concerns about the management of one person’s medicine which would have left the person at risk of harm.

There were concerns about the competencies of some staff to manage the complex care needs of people living at Langford and Kennet. There were concerns about the medical cover provided to people who should have been accommodated in the hospital.

The service was not well led. The management had not taken action in response to events that had or could cause harm to people. There have been persistent changes of senior managers. There was a lack of regulatory response from the provider.

Rating at last inspection:

The overall rating was changed to Inadequate at the focus inspection dated March 2019.

Why we inspected:

This inspection was brought forward due to information of risk or concern; following the last inspection, in March 2019. After the inspections in August & November 2018 and March 2019, CQC requested assurances from the provider about the action they would take to improve the service. The responses provided by the provider did not give assurances that the service would improve.

Enforcement: Following the last inspection we imposed a condition on the providers registration to submit monthly improvement action plans to CQC. The action plans provided did not give assurances that the service would improve.

Follow up: This service has been placed in special measures. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

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.

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

The team inspected the service against two of the five questions we ask about services: is the service well led and safe. This is because the service was not meeting some legal requirements.

No risks, concerns or significant improvement were identified in the remaining Effective, Caring and Responsive through our ongoing monitoring or during our inspection activity so we did not inspect them. The ratings from the previous comprehensive inspection for these Key Questions were included in calculating the overall rating in this inspection.

Langford and Kennett provide nursing care for up to 16 adults with progressive neurological conditions. Langford and Kennett is one of six adult social care locations at Glenside which also has a hospital that is registered separately with CQC. The location of Glenside Manor Healthcare Services is not close to facilities and people may find community links difficult to maintain. 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.

Each of the services is registered with CQC separately. This means each service has its own inspection report. The ratings for each service may be different because of the specific needs of the people living in each service. While each of the services are registered separately some of the systems are managed centrally for example maintenance, systems to manage and review accidents and incidents and the systems for ordering and managing medicines. Physiotherapy and occupational staff cover the whole site. Facilities such as the hydrotherapy pool are shared across the whole site.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the previous inspection dated 11 and 12 July 2018 we found breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We asked the provider following the inspection to tell us how they were going to meet Regulation 12 and 17. The provider failed to report on the actions to meet Health and Social Care Act 2008, its associated regulations, or any other relevant legislation on how regulations were to be met At this focused inspection we found continued breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The CQC following the inspection formally requested under Section 64 of the Health and Social Care Act 2008 to be provided with specified information and documentation by 16 November 2018. We received some of the information requested but not all.

Quality assurance systems were inadequate. Audits were not robust and did not provide an accurate assessment of the quality of care delivered. Action plans were not developed to drive improvements. The CQC was not notified of accidents and incidents reportable under the Care Quality Commission (Registration) Regulations 2009: Regulation 18.

The CQC received whistleblowing concerns about staff not being able to speak sufficient English. These staff were referred to as “agency staff” and were working without appropriate checks. We found there were some staff working across the site without the appropriate disclosure and barring checks or references in place. A whistleblower told us during the inspection that one staff had been working at the home without disclosure and barring checks. Relatives also expressed concerns about staff not able to speak or understand English.

Recruitment procedures did not ensure the staff employed at the home were suitable to work with vulnerable adults. There were staff employed through a recruitment agency and referred to as “agency staff” because of their terms and conditions. The HR assistant was not able to show that agency staff recruited were suitable to work with adults at risk.

New staff did not always have an induction to prepare them for the role they were employed to carry out. We were not able to verify that new staff had an appropriate induction before starting work. We were informed that not all staff had received an induction or mandatory training due to the level of the English they spoke and understood. Staff responsible for training were not able to sign new staff as competent due to their English speaking skills being poor.

The staff were not trained to deliver care to people that were fully ventilated or with tracheostomies. The training matrix provided under Section 64 of the Health and Social Care Act 2008 listed that 75 percent of staff had attended tracheostomy training and ventilator training was not attended by staff. Whistleblowers told us the training was not adequate and did not provide them with the confidence needed to deliver safe care and treatment. A relative told us about their concern with staff not having sufficient understanding of English to deliver adequate care to people.

Whistleblowers told us senior managers were unaware of staff working and accommodated within Glenside Manor. We received concerns about staff known as “agency staff” as they were not directly employed by the provider but introduced to the provider by recruitment agencies. There were a number of staff on site whose identity could not be confirmed by the most senior staff on duty. The list of agency staff provided on the first day of the inspection was not up to date as we met another 11 agency staff during our inspection that were not on the list.

The CQC received whistleblowing concerns about the competency of the staff undertaking maintenance checks of systems and equipment. The CQC following the inspection requested proof of the competency of these staff from the provider. The documentation provided under Section 64 of the Health and Social Care Act 2008did not give CQC reassurances that staff undertaking maintenance checks were skilled or competent.

The information received from relatives about raising concerns was not consistent with the complaints log.

Staff morale was poor and staff told us they feared about their jobs as they had witnessed other staff being dismissed almost daily. The staff survey provided under Section 64 of the Health and Social Care Act 2008 indicated that 13 of the 38 staff responding would recommend the home.

The overall rating for this service is ‘Requires improvement’. However, we are placing the service in 'special measures'. This means that it has been placed into 'Special measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action. Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

We inspected Langford and Kennet on the 11 and 12 June 2018. The inspection was unannounced on the 11 July 2018 and the provider was aware of the inspection visit on 12 July 2018.

Langford and Kennet 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. It is one of seven adult social care locations situated on one site, known as Glenside. The site also contains a hospital, which is registered with us separately.

At Langford and Kennet complex nursing care can be provided for up to 16 people with neuro-degenerative or previous brain injury. At the time of the inspection, there were 16 people using the service. Eight people were living at Langford and eight people were living at Kennet.

A manager was in post and in the process of becoming registered with CQC. 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.

This is the second consecutive time the service has been rated Requires Improvement.

Quality assurance and audit systems were not robust and did not cover all areas of care provided. The local improvement plan had identified shortfalls and all actions identified for improvement were met. For example, in October the action plan to develop person centred care plans and “ME” documents were met. However, during this inspection we found that some actions identified as met in the improvement plan remained unmet.

Audits were not used to assess all areas of service delivery. For example, when we asked about infection control audits we were told they were not necessary. This was because the issues were already known and actions were documented on meeting minutes. Although risk assessments detailed how risks were mitigated, the risk scores were misleading. Assessments and monitoring of risk may not be promoted due to low scoring for people at greatest risk. This meant that the provider may not have been alerted to emerging risks.

The staff used an online system for reporting accidents and incidents. Although safeguarding referrals were made for reportable abuse the provider had not notified CQC of all incidents. The manager reported to CQC in retrospect all incidents that affect the health, safety and welfare of people who use services.

Medicine systems were not managed safely and people were not having their medicines as prescribed. One relative said one person had not received their medicines on time for three consecutive days. We found gaps in the recording of medicines administered, some prescribed medicines were out of stock and there was a lack of clear guidance on administering “when required” medicines. Where medicines were to be administered outside recommended guidance there was a lack of confirmation from a pharmacist about these medicines. For example, medicines to be crushed. Some errors had not being reported. The staff that applied topical creams were not signing the Administration of Topical Medicine charts these were being signed by registered nurses. The manager told us the supplying pharmacist did carried out visits 12 months after the start of the contract. A meeting with them was arranged and this will be raised.

Clinical care plans were detailed. Some care plans were person centred but needed to be further developed. Relatives were invited to reviews. People said the permanent staff knew their preferences and how to meet their needs.

The manager told us how continuous learning was used to drive improvements. For example, introduction of lead roles for staff in their area of interest, such as tissue viability and safeguarding to ensure staff have a point of contact.

Housekeeping staff told us while recruitment of new staff was in progress there had been better deployment of resources to ensure better cleaning regimes. However, we observed there were areas of the property in need of repair and redecoration. For example, the walls behind beds were worn and had chipped paint.

People felt safe because they had confidence in the staff. The staff we spoke with said they had attended safeguarding adults training to help them recognise the signs of abuse and how to report their concerns.

We found staff available to people during the inspection. While relatives said there were improvements, they had raised concerns about the reliance on agency staff. The staff told us there were measures in place to ensure agency staff were not on duty without permanent staff. This promoted continuity of care.

Where possible people made their own decisions and relatives said they were consulted. In Kennett and Langford mental capacity assessments and best interest decisions were in place for all restrictive practice.

People and relatives were positive about the skills of permanent staff. The staff told us the training provided by the organisation was good and there were opportunities for professional qualifications.

People had access to healthcare services as required. Two relatives raised concerns about the lack of physiotherapists which had led their family members to having restricted movements. Staff said the provider had promised that everyone would have physiotherapy but this had not happened. The registered nurses contradicted these comments and told us physiotherapists had visited recently to assess people and a regular physiotherapist was assigned to the home.

When we asked people if staff were kind and caring they said “excellent” and “brilliant”. We found activities to be an area of real strength. The staff were responsive towards people’s Equalities Diversity and Human Rights (EDHR) in relation to their diet and culture.

The complaints procedure was on display and a suggestions box was available for written feedback and suggestions. Staff told us people “tell us first” about their concerns or they were emailed.

We found a breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

Langford/Kennet was registered as an adult social care location in October 2015. Previous to this, the location formed part of the overall site of Glenside. This was the location’s first inspection, as part of the adult social care directorate.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager had a dual role as they were also the registered manager of Newton House, another location on site. The registered manager was available throughout our inspection.

Risks to people’s safety were not always managed effectively. For example, staff had not identified one person had lost weight. They had not undertaken a nutritional assessment or regularly weighed the person. Despite the person being at risk of dehydration, fluid monitoring charts had not been consistently completed. This did not ensure effective monitoring to ensure the person consumed sufficient amounts. There was conflicting information within records regarding the person’s use of thickener for their drinks. This increased the risk of the person choking. The registered manager addressed this after it was brought to their attention.

Each person had a support plan in place. This clearly described the individual’s clinical needs and the support required. The information was comprehensive and detailed. However, other areas including continence and tissue viability contained less detail. One support plan was not an accurate reflection of the person’s needs. Wound care plans had not been written in a timely manner and there was no care plan regarding the person’s recent surgery. Other plans did not detail how people showed they were in pain and there were no pain assessments in place. Staff showed they knew people well but a person centred approach was not demonstrated within support plans. The registered manager was beginning to address this by introducing “getting to know me” meetings. The first meeting took place in October 2016.

People’s rights to privacy, dignity, choice and independence were promoted. However, this was not so for one person, as staff had not supported them to discreetly cover their catheter bag. Another person was upset that their bedroom door was always left wide open. This was addressed with the registered manager during the inspection and a satisfactory compromise was reached.

There were systems in place to assess, monitor and mitigate risks relating to the health, safety and welfare of people. A traffic light system was used, which identified any shortfall and its level of risk. Records showed further checks were completed to ensure compliance. However, audits had not identified the shortfalls which were raised during this inspection.

Staff knew people well and positive relationships had been built. Staff showed a clear understanding of people’s needs and showed skill whilst communicating with those who did not use verbal speech. There was a clear ethos regarding improving people’s quality of life, which was adopted throughout the staff team.

Safe recruitment processes were in place and there were sufficient numbers of staff to support people effectively. All new staff received a detailed induction when starting at the service. This was regularly reviewed and enabled each staff member to be clear of their roles and responsibilities. Staff received a range of training deemed mandatory by the provider and felt well supported. One to one meetings with the manager were regularly held. This enabled staff to discuss their work and any concerns they might have. Staff received annual appraisals. Records showed they appraised themselves but the discussions or the action plan for the following year were not always documented. There were regular staff meetings and handovers of information. Staff showed they were aware of people’s needs and established relationships had been built.

There was an open approach to complaints and clear processes were in place. Records showed any complaints were properly investigated and a satisfactory outcome was reached. People and their relatives knew how to make a complaint. There were systems to encourage feedback such as meetings and satisfaction surveys. The surveys had recently been adapted to meet people’s needs more effectively.

During our inspection we found two breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.