We carried out an unannounced comprehensive inspection of this service on 7 January 2015 and 2 February 2015. Breaches of 10 legal requirements were found and we issued warning notices for breaches in care and welfare, meeting nutritional needs and consent to care and treatment. The provider was required to meet the regulations by 13 March 2015.
As a result we undertook an unannounced focussed inspection on 24 March 2015 to follow up whether action had been taken to deal with the breach.
You can read a summary of our findings from the two inspections below.
Comprehensive Inspection 7 January 2015 and 2 February 2015
The inspection took place on 7 January 2015 and 2 February 2015 and was unannounced.
Chandlers Ford Christian Nursing Home provides accommodation and nursing care for up to 45 older people. The home is located in the centre of Chandlers Ford behind the Methodist church and close to local shops and amenities. The home is located on the ground and basement floors of a large purpose built building. The first and second floors are flats with separate access.
Chandlers Ford Christian Nursing Home had a registered manager in post on the day of the inspection. The registered manager left two days after our first visit. The provider told us a relief 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 last inspection on 9 July 2014, we asked the provider to take action to make improvements in respect of acting in accordance with the Mental Capacity Act 2005 (MCA), care and welfare and meeting nutritional needs. This was because the provider had not acted in accordance with the requirements of the MCA, did not always provide care in line with people’s needs and had not protected people from the risks of inadequate food and hydration. The provider submitted an action plan which stated that the home would be compliant by 30 August 2014. We found that the provider had not carried out the required improvements.
During our first visit on 7 January 2015 we were so concerned about the management of medicines that we asked a specialist pharmacist inspector to visit the home. They visited on 2 February 2015 and identified improvements in the management of medicines since our last visit.
Medicines were not stored or managed safely. When we visited the home on 7 January 2105 we found large quantities of prescription medicines stacked up in the hairdressing salon. The door was wedged open. Labels indicated that some medicines had been stored unsafely in the room since the beginning of December 2014. We found the treatment room to be open and unlocked and medicines were stored in unlocked cupboards in the room. There was a risk that people, staff or visitors to the home would take the medicines inappropriately. Action had been taken to address these issues by the time of our second visit on 2 February 2015.
Staff understood about safeguarding and when to report a concern and people told us they felt safe. However, people’s individual risks were not clearly assessed, documented, reviewed and changed in response to their changing needs.
There were not sufficient numbers of staff to keep people safe and meet their needs. Staffing levels had recently been reduced from seven to five care workers per day shift. Staff were rushed and task focussed, spending minimal amounts of time with people and only to perform a function such as supporting a person to drink. Call bells were ringing constantly and continued for long periods. People told us they waited a long time for call bells to be answered and their meals were served late.
People were at risk of choking because they were not supported to eat food which was suitable to their needs.
Although food and fluid monitoring charts were in place for some people, details recorded were not sufficient to support staff in ensuring people had eaten and drunk enough to meet their needs.
People did not receive support to eat sufficient quantities of food to meet their needs. Support from staff was inconsistent, sporadic and provided by various members of staff with long gaps in between of no support. This was not a pleasant mealtime experience for people.
Staff had not received sufficient training to meet people’s needs. Not all staff had completed essential training. There was no clinical training specifically to improve competencies for nurses. Supervision meetings had not been carried out in line with policy and two members of staff said they had not had a supervision meeting in the last year.
There was evidence that advice had been sought from health professionals such as GPs, occupational therapists, speech and language therapists and psychiatrists, however we found that advice was not transferred to care plans and care was not delivered in the recommended way.
The provider was not acting in accordance with the requirements of the Mental Capacity Act 2005 (MCA). The MCA is a law that protects and supports people who do not have the ability to make decisions for themselves. This meant that the service was not obtaining valid consent for treatment and care in relation to people whose mental capacity was in doubt.
The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. These safeguards protect the rights of people using services by ensuring that if there are any restrictions to their freedom and liberty, these have been agreed by the local authority as being required to protect the person from harm. The registered manager did not understand when a DoLS application should be made and was not aware of a recent Supreme Court Judgement which widened and clarified the definition of a deprivation of liberty. As a result appropriate applications had not been made.
Although staff were kind and caring they were not able to provide personalised support in line with people’s individual needs because the written and verbal handover information was inaccurate and lacking in detail. People were not involved or consulted in their care planning.
Staff were unable to respond appropriately to people’s needs due to a lack of detailed and accurate care plans, risk assessments, daily records and shift handovers. Care plans were not in place in relation to people’s specific risks and needs such as pressure ulcers, continence, pain and behaviours which may challenge others. There were no care plans in place in relation to specific conditions such dementia, diabetes and osteoporosis.
Staff morale was low and staff were not actively involved in developing the service. The home was not well organised, care was not provided in a consistent way, staff didn’t feel listened to and we found errors in people’s medicines and care plans which should have been detected through routine audits. Some aspects of the service were unsafe, such as the storage of medicines in the hairdressing salon for up to a month. Staff training was not up to date and staff competencies had not been checked. People said they didn’t know who the registered manager was, but they would like to know.
During our inspection we found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. You can see what action we asked the provider to take at the back of the full version of the report.
Focussed inspection 24 March 2015
Following our inspection on 7 January 2015 and 2 February 2015, the provider was served three warning notices in relation to care and welfare, meeting nutritional needs and consent to care and treatment. These required the service to be compliant by 13 March 2015. We undertook this unannounced inspection to check that the breaches of regulations had been addressed.
We found that regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, continued to be breached. People did not receive personalised care that was responsive to their needs. Risks in relation to dysphagia (difficulty swallowing) had not been appropriately addressed and assessed. It had taken 10 weeks for one person to be referred to a speech and language therapist even though they had severe difficulty swallowing.
There was no care plan in place for a person with a urinary tract infection and staff had not appropriately delivered care to meet their needs. Staff continued to give one person showers even though a relative had stated they preferred baths. It was not clear whether topical medicines were being appropriately administered in line with the care plans because the records were incomplete and inconsistent and care staff instead of nurses made decisions about whether people required cream.
Improvements were noted in respect of the handover process and specific care planning to address the risks of acquiring pressure ulcers. Pain assessment tools meant that nurses were better able to ascertain whether people were in pain and administer analgesia appropriately.
Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, continued to be breached. The provider was not acting in accordance with the requirements of the Mental Capacity Act 2005 (MCA) as people’s capacity to make specific decisions was not appropriately and consistently assessed and acted upon.
Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, was being met. Detailed records were kept in the kitchen about people’s individual dietary requirements and the chef was knowledgeable about these. People were served a meal in line with their required consistency and support was offered where appropriate.
Additionally we identified a continued breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We observed staff members to be providing care in a manner which was not kind and caring and was not in line with the required support identified in the person’s care plan.
As a result of this inspection we met with the provider and asked them to produce an action plan showing how they would achieve compliance within four weeks. The provider agreed to provide us with weekly updates demonstrating progress. The provider agreed to voluntarily stop new admissions until they met the requirements.