Archived: Nuffield Care Centre

This inspection site visit took place on 31 January 2018 and was unannounced.

There was a registered manager in post on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 21 July 2017 we asked the provider to take action to make improvements in relation to people’s safety, staffing levels and training, the requirements of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), the involvement of people in their care, how people were respected, activities and the leadership at the service. We found that these actions had not been completed.

The lack of strong and effective leadership has had an impact across all five key questions that we ask. There had been continued breaches of regulation over two inspections and despite action plans being sent to us to say that the required improvements had been made we found that this was not the case.

There were not sufficient staff to meet the needs of people. People were left waiting for care and at times left isolated due to the lack of available staff. Nurses were often providing personal care to people to support care staff which meant that their nursing duties were not being carried out appropriately.

Staff were not always following good infection control practice. Sluice and medicine rooms were not always clean and waste was not disposed of appropriately. There were some areas in the service that required cleaning and equipment needed updating which was putting people at risk. We did see some good examples of staff washing their hands and using protective equipment when attending to people’s personal care. Paperwork relating to people’s care was disjointed and staff did not always know where to locate the care records for people.

People who were at risk of dehydration were not being prompted enough to drink and staff were not effectively monitoring this. Records of when cream was being applied to people’s skin were not completed appropriately and it was not clear if the cream had been applied or not. Other records were not always being completed appropriately including when how often people required repositioning in bed. This had been raised as a concern by the Coroner in relation to the death of a person using the service.

There were aspects to the management of medicines that were not safe. Reviews of people’s medicines relating to their mental health and dementia were not taking place. Charts were not being routinely used to assess whether people were in pain particularly those that were unable to communicate verbally. Body maps were not being used to show staff where creams needed to be applied.

The premises and equipment was not always in good order. Chemicals were not being stored in a safe way and equipment in areas of the service needed updating or replacing.

Not all staff had received supervisions and nurse competency had not always been assessed. Staff were not up date with their mandatory and clinical training. Staff had not ensured that decisions for people had been undertaken in their best interests although decision specific Mental Capacity Assessments (MCA) had taken place.

Staff were not effectively informed about people which impacted on how care was provided. There were a high number of agency staff at the service that did not know people’s needs. People did not always have access to appropriate health care professionals in relation to their ongoing care. The environment was not appropriate for the needs of people living at the service particularly those living with dementia.

There were mixed responses from people about the caring nature of staff. We found that people were left isolated without meaningful interactions from staff. People did not have choices around when they wanted to get up. Staff did not always have time to support people in a meaningful way. However when staff did interact with people this was done in a caring and respectful way.

People told us that they were bored. We found that there were insufficient meaningful activities for people to participate in. Actions from complaints responses were not always actioned to show that lessons had been learned.

Quality assurance was not always robust and there was a lack of leadership at the service. The issues we identified on the inspection had not been recognised through the registered managers and providers monitoring of the service. Where people had raised ideas about improvements this was not always followed. There were aspects to the quality assurance that were effective in relation to audits of care plans, health and safety and medicines.

There were aspects to the medicines and risks to care that were being managed well. Risks to people’s mobility and those that were nutritionally at risk were managed in a safe way. Accidents and incidents were recorded and action taken. There were appropriate plans in place in the event of an emergency. There was a robust recruitment process in place to ensure only suitable staff were employed.

People told us that they liked the food at the service. There were occasions where people did have the input from health care professionals where needed including GP and Speech and Language Therapists (SaLT). People’s needs were assessed prior to moving in to ensure that the service was appropriate for them. Care and support was planned and delivered in line with current evidence based guidance.

People were able to personalise their rooms and visitors were welcomed to the service any time they wanted. Care plans were detailed in relation to people’s individual needs including mobility and nutritional needs. Wound care management was detailed with appropriate guidance for how to dress the wound. People were supported at the end of their life to have a comfortable, dignified and pain-free death.

Staff told us that they felt supported and could go to the registered manager when they needed.

Services that provide health and social care to people are required to inform the Care Quality Commission (CQC) of important events that happen in the service. Staff had informed the CQC of significant events.

The overall rating for this service is ‘Inadequate’ and has been placed into ‘special measures.’

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. 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.

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.

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.

This service was previously registered under a different legal entity and was last inspected on 31 May 2016 where the overall rating was Requires Improvement. This is the first inspection under the new legal entity. Despite the change in registration the provider and registered manager have remained the same.

There was a registered manager in post that supported us on the day of the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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 people said they felt safe living in the service there were not always enough staff deployed to meet people’s needs, particularly in the afternoon.. People sometimes had to wait to receive the care they required and told us that staffing levels were too low.

The requirements of the Mental Capacity Act 2005 (MCA) were not always followed correctly and not all staff understood their responsibilities under the MCA. People had applications made to deprive them of their liberty when they had capacity to make this decision.

Staff did not have up to date training in all key areas and supervisions were not always being completed by the registered manager. This meant that staff may not be aware of, or follow best practice.

The mealtime experience for people could be improved. Feedback we received was mixed with some people saying the food was not as good as it could be whilst others were happy with the quality of food provided.

People, relatives and staff told us that activities were limited and could be better. The activity co-ordinator had left recently and staff did not always have the time to spend with people to provide meaningful activities.

The provider did not have robust quality assurance processes in place. Quality assurance systems had failed to identify the issues seen on the day of the inspection. Some safety checks had not been completed and where an audit had been completed there was limited or no information about what steps had been taken to address areas of concern or set timescales for improvements. There were breaches in regulations that had not been met from the previous inspection.

Safe recruitment procedures were in place and staff had the required checks made before they started employment in the service. Staff knew about what should be referred as a safeguarding concern and were able to describe what constituted abuse. We identified one concern that had not been recognised as a safeguarding matter and asked for this to be referred to the local authority straight away.

Riske to people were identified to help keep them safe from avoidable harm. People had risks assessments in place that were up to date and relevant. Where people had specific health risks these had been identified and action taken to minimise the chance of avoidable harm. Medicines were administered when people needed them and recording of this was good. The storage and disposal of medicines was safe.

People were supported to attend healthcare appointments with other care professionals such as opticians, dentists and their GP.

People described staff as caring and kind. We saw staff engage positively with people on the day of the inspection. Relatives told us they could visit their loved on when they wished and had been involved in planning of care where appropriate.

Before people moved into the service they had an assessment of their needs to ensure care could be provided. Care plans were detailed and reviewed regularly to ensure staff had the most up to date picture of people’s needs. There had been one complaint since the last inspection which had been responded to in line with the provider’s complaint policy. People felt able to raise any concerns they may have with the registered manager.

The registered manager was described positively and staff felt supported by her. Notifications to the CQC had been submitted appropriately.