Archived: Francis Court

Francis Court is a residential care home providing personal and nursing care for up to 87 people in purpose-built accommodation. The service provides support to older people, many of whom have dementia, and younger people with disabilities. At the time of our inspection there were 50 people using the service.

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

There were insufficient staff to support people’s needs. Sometimes people had to wait longer then they should expect for support from staff. People told us staff answered call bells quickly but would sometimes come back later to deliver care. This had a negative impact on people’s quality of life, but this had not been identified by the provider’s quality monitoring systems which only measured the response time for call bells.

People’s need for social stimulation was not consistently supported. People did not always have enough to occupy them, and staff were not spending quality time with people. The provider’s system for monitoring quality had identified this shortfall but improvements had not yet been made.

People who were receiving care at the end of life had not always received the support they needed. Shortfalls had been identified following a complaint and the registered manager had implemented additional training for staff and amended systems to address these concerns. These improvements were not yet fully embedded and sustained in practice.

Since the last inspection improvements had been made in the assessment and management of risks and the administration of medicines. Care records were being maintained consistently and reflected the care provided to people.

People told us they felt safe and staff were kind and caring. One person said, “They are all so kind.” A relative said, “The care assistants are very good, genuinely caring and supportive.” Staff demonstrated a clear understanding of their responsibilities for safeguarding people and knew when to report concerns.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

People, relatives and staff spoke highly of the management of the service. One staff member said, “It has been a difficult time, but we have been well supported.” The registered manager was open and transparent about challenges the service had faced and demonstrated the improvements that had been made since the last inspection.

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 12 February 2020) and there were 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 we found the provider remained in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe, Responsive and Well-led which contain those requirements.

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 COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating. The overall rating for the service has remained requires improvement based on the findings of this inspection. We have found evidence that the provider needs to make improvements. Please see the Safe, Responsive and Well led sections of this full report. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Francis Court on our website at www.cqc.org.uk

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to monitor the service and will take further action if needed.

We have identified breaches in relation to staffing, personalised care and monitoring and improving the quality of the service at this inspection. Please see the action we have told the provider to take at the end of this report.

Follow up

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 continue to monitor information we receive about the service, which will help inform when we next inspect.

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

Risks to people’s safety were not always monitored and managed effectively. Some people were at risk of choking, care plans did not provide clear guidance for staff. This meant people were at risk of not receiving food and drink appropriate for their needs. Some people were at risk of falling, incident monitoring was not consistent and care plans were not always reviewed to ensure that risks were mitigated. Shortfalls in administration of medicines did not support good practice.

There were enough staff to care for people safely, but the deployment of staff was not effective in ensuring that people’s needs were met. Some people had to wait longer then they should expect for the support they needed. People’s social needs were not consistently met. Staff did not always follow good practice with regard to infection control procedures.

There were continued concerns about the accuracy of records and the system for governance was not robust and had not identified all the shortfalls that we found. However, the provider had already identified similar themes and had an action plan to make improvements. A new manager had been in post since October 2019 and staff spoke positively about the leadership of the home.

People told us they felt safe living at Frances Court. One person commented, “The care is very good really.” Staff understood their responsibilities for safeguarding people and knew how to report concerns.

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 27 June 2019). The provider completed an action plan after the last inspection to show what they would do, and by when, to improve. At this inspection not enough improvement had been made and sustained and the provider was in breach of three regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last two consecutive inspections.

Why we inspected

We received concerns in relation to the management of medicines and people’s nursing care needs. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only. The ratings from the previous comprehensive inspection for those Key Questions not looked at on this occasion were used in calculating the overall rating at this inspection.

The overall rating for the service has remained as Requires Improvement. This is based on the findings at this inspection. You can see what action we have asked the provider to take at the end of this full report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Francis Court on our website at www.cqc.org.uk.

Enforcement

We identified one continued breach of regulation in relation to maintaining accurate records and ensuring the quality and safety of the services provided. We also identified new breaches of regulation in relation to safe care and treatment and staffing. Following the inspection, the operations support manager sent us an action plan. This provided clear details of immediate actions they were taking with timescales to address all the concerns we had raised. This gave us further confidence that improvements in management and oversight of the home were in progress, but not yet embedded and sustained.

Please see the action we have told the provider to take at the end of this report.

Follow up

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.

People’s experience of using this service:

People told us they felt safe and the feedback they gave us about staff and the care they received was consistently positive. Despite people’s positive experiences, we found shortfalls in how some nutritional risks were monitored and responded to. Records relating to topical creams were not accurate and checks had not proactively identified or addressed this. There was also an ongoing issue with doors in certain parts of the service that had not been addressed, which could affect fire safety. There was a governance framework in place but it had not robustly addressed every issue we identified. Care plans did not always accurately reflect care delivery, so we made a recommendation about care planning.

People spoke positively about the activities on offer, which were varied and catered to a variety of needs and interests. There were systems to involve people and ask for their feedback. People were encouraged to be independent and staff provided care in a dignified manner, respectful of people’s privacy.

People were satisfied with the food that was prepared for them and the kitchen responded to people’s dietary requirements when preparing meals. Staff sought input from healthcare professionals when where required and people benefitted from input from trained nursing staff at the service. Staff had received the right training and support for their roles and there were sufficient numbers of staff at the service to meet people’s needs.

End of life care was planned for sensitively and the provider was in the process of implementing improvements in this area. There was an ongoing plan to improve the service and people had been involved in this. People spoke positively about how the service was run and felt confident in the management team. People knew how to raise a complaint and individual complaints were documented and responded to in line with the provider’s policy.

Rating at last inspection: Good (Published 9 December 2016)

Why we inspected: This inspection was due in line with our policies, we brought it forward slightly due to an increase in safeguarding concerns shared with CQC.

Enforcement: Action we told provider to take (refer to end of full report)

Follow up: We will continue to monitor the service and respond to any concerns. We will request an action plan from the provider and return to inspect in line with our policies.

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

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 and associated Regulations about how the service is run.

We saw that regular meetings took place and people were encouraged to ask questions, discuss suggestions and address problems or concerns with management. However, we identified concerns in relation to feedback being acted upon by the provider. People, relatives and staff told us that they were not always satisfied with the service provided and that communication was not always good. Although some staff spoke positively of the culture and how they all worked together as a team, feedback from other staff was mixed and indicated that there was a lack of cohesion and a negative culture in the service. We have identified these as areas of practice that need improvement.

People were happy and relaxed with staff. They said they felt safe and there were sufficient staff to support them. One person told us, “The relaxed atmosphere makes me feel safe”. When staff were recruited, their employment history was checked and references obtained. Checks were also undertaken to ensure new staff were safe to work within the care sector. Staff were knowledgeable and trained in safeguarding and what action they should take if they suspected abuse was taking place.

Medicines were managed safely and in accordance with current regulations and guidance. There were systems in place to ensure that medicines had been stored, administered, audited and reviewed appropriately.

People were being supported to make decisions in their best interests. The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS).

Accidents and incidents were recorded appropriately and steps taken to minimise the risk of similar events happening in the future. Risks associated with the environment and equipment had been identified and managed. Emergency procedures were in place in the event of fire and people knew what to do, as did the staff.

Staff had received essential training and there were opportunities for additional training specific to the needs of the service, caring for people with dementia and palliative (end of life care). Staff had received supervision meetings, and formal personal development plans, such as annual appraisals had been implemented. One member of staff told us, “Since [the registered manager] has been in post I get regular training. I wanted training around moving and handling and I got it, and I wanted to do an NVQ (National Vocational Qualification) and I’m on it”.

People were encouraged and supported to eat and drink well. There was a daily choice of meals and people were able to give feedback and have choice in what they ate and drank. One person told us, “The carers have to mash my food and the chef knows that I like parsnips, so he does them for me”. Special dietary requirements were met, and people’s weight was monitored, with their permission. Health care was accessible for people and appointments were made for regular check-ups as needed.

People chose how to spend their day and they took part in activities in the service and the community. People told us they enjoyed the activities, which included singing, exercises, films, arts and crafts and themed events, such as reminiscence sessions. One person told us, “Sometimes there are quizzes and there have been outings”. People were also encouraged to stay in touch with their families and receive visitors.

People felt well looked after and supported. We observed friendly and genuine relationships had developed between people and staff. One person told us, “They are all friendly and caring and know what they are doing”. Care plans described people’s needs and preferences and they were encouraged to be as independent as possible.

Staff were asked for their opinions on the service and whether they were happy in their work. They felt supported within their roles, describing an ‘open door’ management approach, where managers were always available to discuss suggestions and address problems or concerns. The provider undertook quality assurance reviews to measure and monitor the standard of the service and drive improvement.

This summary is based on our observations during the inspection, discussions with 11 people, four relatives, the interim manager, deputy manager, clinical lead, four nurses, five carers, four agency carers, two activities coordinators and one hostess. We also reviewed records relating to the management of the service, ten staff recruitment files, four staff training files and six people's care and health records. As some people could not talk with us about their experiences of living at the service we spent time observing how they were cared for and treated by staff. We observed interactions between staff and people who lived at the service for four hours during the morning and lunchtime period.

If you wish to see the evidence supporting our summary please read the full report.

Is the service safe?

There were enough suitably qualified and experienced staff on duty to meet people's needs. Staff that we spoke with told us that there were enough staff and that they were able to spend social time with people. We observed that staff responded quickly to meet people's needs and ensure their safety. Since our last visit the service had recruited more staff and reduced their reliance on agency staff. Where the service used agency staff, they checked to ensure that the individuals had the necessary skills and experience to support people living at the service.

We looked at recruitment processes. We found that the service had not always obtained references before new staff started to work at the service. Other checks, such as criminal records checks had been completed appropriately. The interim manager had since taken over responsibility for the process. We noted that for the next intake of new staff, the return of references was being monitored. Confirmed start dates had only been given to those staff that had all checks and information returned.

CQC monitors the operation of the Deprivation of Liberty Safeguards which applies to care homes. Since our last visit one application had been made. The interim manager and staff that we spoke with demonstrated knowledge of their responsibilities in respect of this.

Is the service effective?

We found that people's care plans were detailed and that they had been reviewed on at least a monthly basis. This ensured that the care provided was in line with their individual needs and preferences.

As many of the people living at the service were unable to speak directly of their experience, we spent time observing the care and support that they received. Staff demonstrated skill and experience when supporting people. One person told us, 'Staff are extremely good and helpful'. Another said, 'They look after you here alright'.

Staff had received training to meet the needs of people living at the service. Staff that we spoke with told us that they felt supported and were able to deliver good care. Since our last visit a system of appraisals had been introduced and staff received appropriate professional development. One member of staff told us, 'The manager has involved us and advised us how we could do it better'. Another said, 'I am happy. My job really helps people. It's a very nice home'.

Is the service caring?

People were supported by kind and attentive staff. We saw that staff were patient and gave encouragement when supporting people. We spoke with 11 people. They were all satisfied with the care that they received. They told us they were able to do things at their own pace and were not rushed. Our observations confirmed this. One person told us, 'They are very good. In many ways it is a delightful place'. Another said, 'They're very kind to you'.

Is the service responsive?

People told us that they were able to raise suggestions or concerns and that they were regularly consulted about changes in the service. Relatives told us that they were kept informed and updated if there were any issues or concerns regarding the health of their family member. One relative said, 'We get a good update over the phone'. We found that the service listened and responded to questions and feedback received from people, their representatives and from staff. One relative told us, 'Things have changed so drastically. It's (the service) going up and up!'

Is the service well-led?

Since our last visit the manager had left and there was no registered manager in post. The service was being managed by an interim manager. A representative of the provider informed us that a candidate had been identified and that they would inform the Commission as soon as the new manager's appointment was confirmed.

Since our last visit improvements had been made in the way the service selected and inducted agency staff and in the professional development that staff received. A service improvement plan was in place. People, their relatives and the staff that we spoke with were very positive about the changes and improvements that had taken place in the service. One member of staff said, 'It's much better than a year ago. Everybody knows their responsibilities. It is more organised'. Another told us, 'There has been a great improvement. When I first started it was very chaotic but now it feels calm'.

Systems were in place to make sure that staff learnt from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve.

We spoke with nine people who used the service. They told us that they were happy with the care and support that they received at Francis Court. One told us, “It’s very good, the people are nice”. Another said “I am very well cared for. I have no concerns”. We observed that staff had a good rapport with the people they were supporting. They were available and responded quickly to meet their needs. We also spoke with three relatives who were visiting the home on the day of our visit. They were equally complimentary. One said, “The carers are lovely” and, “It’s personal, the carers take time with them”. Some people mentioned that they were often cared for by new members of staff. They said that this could be frustrating as new staff were not always aware of how people preferred to be supported.

We spoke with the new manager, two representatives of the provider and 15 members of staff, including eight permanent staff and seven employed through agencies. Some permanent staff told us that they felt frustrated and demoralised by the instability in the staff team. One said, “We have the numbers of staff needed but having new agency makes our work more difficult”. Others spoke more positively. One said, “They’re getting things on track and things have improved”. Another told us, “It’s definitely picking up, the vibe is lifting slightly”.

We looked at the processes, procedures and records held by the service relating to the use and management of medicines. We found that there were appropriate arrangements in place to manage medicines.

The home used a significant number of agency staff in order to maintain their staffing level. Many of the agency staff worked in the home on a regular basis, which provided continuity for the people they were supporting. We found, however, that the provider did not check the skills and experience of agency staff before they came to work in the home. This meant that they could not ensure there were enough suitably qualified and experienced staff available to meet the needs of people living in the home. We also found that agency staff were not always given a suitable induction to the home. This meant that they were not adequately supported to fulfil the tasks expected of them and had the potential to impact on the care that people received. One relative said, “If they can only get the staff settled, that’ll be the thing”.

We spoke individually with 10 of the 46 people who lived at the home. They all told us that they had received good care and were treated well by the staff who supported them. One person said "I am really happy here" and another said "I have no complaints at all."

We looked at a range of records which related to people's care. We found that each person had an individual plan of care and staff recorded daily how this care had been delivered. We saw that where people's needs had changed, their care plan had been quickly updated and new guidelines to support them had been put in place.

We found that people were safeguarded from harm because staff now understood their roles and responsibilities in this area. Increased staffing levels and recent training also meant that staff were better equipped to manage people's anxieties and de-escalated challenging behaviour.

We found improvements in the way people's medicines were managed with evidence that there were now appropriate systems in place to handle people's medicines in a safe and person centred way.

Staffing levels had been increased and were now allocated to work according to people's needs. This meant that there were now sufficient staff on duty to support people safely. Staff told us that the extra staff meant that people now had the time to deliver the care that was required.

Staff reported that the new management team were now effectively supporting them. We saw evidence of an induction and training programme in place which provided them with the mandatory and specialist training needed. Staff had received regular recorded supervision sessions and attended staff meetings which they told us made them feel more valued and listened to.

You can see our judgements on the front page of this report.

Since our last inspection, we have liaised closely with our health and social care colleagues to ensure the safety of the people who used the service. We have also been in constant contact with the provider who took immediate steps to improve the quality of care provided. This action included implementing a new management team at the home and increasing staffing levels. The purpose of this inspection was to assess whether the action taken by the provider had reduced the serious risks previously identified in October 2013.

This inspection was carried out by three Inspectors, one of whom was a pharmacist Inspector for the Commission. Our inspection was also supported by a specialist nurse advisor who was able to give us an independent view about the nursing care provided at Francis Court. We found that the quality of care at Francis Court had been significantly improved and that there was no longer evidence of a major risk to people's health and well-being.

We found that the interim manager was knowledgeable about people's needs and in control of the daily running of the home. They closely monitored the direct care and support provided to people by permanent and agency care staff. This meant that the risk associated with the use of temporary staff was lowered because agency staff were supported by someone who understood the needs of the people who used the service. The interim manager was supported by a new clinical lead and a team of senior staff from Care UK. This provided sufficient management cover to the service and enabled change to be effected quickly.

We found that staffing levels had been significantly increased, with the number of registered nurses who worked on each shift having doubled. This meant that there were now sufficient staff to meet the complex needs of people which ensured that they were properly supported. The home was still heavily reliant on the use of agency staff, although it was evident that many of these staff now regularly worked in the home. We found evidence of an active recruitment drive and nine new staff members were undertaking induction training at the time of this inspection. We also saw that existing staff had completed key training since our last inspection. This meant that the provider had taken appropriate steps to increase staffing levels and competencies at Francis Court.

We found that significant improvements had been made to the way medicines were managed by the home. The increased number of nursing staff meant that people now received their medicines in a more timely way and that medication records were now better maintained. We also identified that medication guidelines had been reviewed with appropriate medical professionals as necessary. This ensured that people were better protected by the medication systems in place. We found some areas of medication could be further improved, but there was no longer the serious risk of harm which had previously been identified.

We talked to people and their relatives about the care they had received. We observed care practice during the eight hour inspection and looked at the care records of twelve of the seventeen people who had received nursing care at Francis Court. We found that each person now had a plan of care which reflected their current support needs. We also found evidence that information about the care provided was now being recorded most of the time. There were still risks associated with the fact that not all staff were able to access all of the information necessary to support people effectively. This risk however, had been reduced by the increased management presence in the home.

Across these three days, we spoke individually to ten people who used the service, two relatives and 15 members of staff. We spoke with representatives from the senior management team over the course of our inspections, including the company's chief executive. We also had contact with various health and social care professionals who were involved in supporting people at the service.

We found serious shortfalls in the way that people received their care, medicines and were protected by the home. We identified that the home had failed to provide a system of care planning which allowed all staff to have access to accurate and up to date information about people's care needs. This meant that people were at risk of receiving inappropriate and unsafe care and treatment because staff lacked the information to support them properly.

We found that staff did not have a detailed understanding of the needs of the people they cared for and that nursing staff had failed to effectively monitor their specialist needs. This meant the people who were at risk of skin damage, malnutrition and dehydration had not received the nursing care that they required. People with diabetes were placed at risk because staff were unaware of the need to monitor their food and drink. Where people had fallen and suffered injury, there was no evidence that they had received the appropriate medical treatment.

The management of medicines was chaotic with insufficient nursing staff on duty to administer medicines in a timely way. People who required occasional medication were placed at risk because staff did not have access appropriate guidelines that outlined when medicines, such as those for pain or anxiety, should be administered.

We found that people, especially those who lived on the first floor of the home, were not adequately safeguarded from harm. This was because there were insufficient, skilled and experienced staff to manage people's challenging needs and aggression towards each other. The registered manager had failed to recognise when incidents between people amounted to abuse and as such had not taken steps to report and safeguard these people from harm.

Records were not accurately maintained and key documents, including care plans and accident records were either not available or incomplete.

We observed that staff had a good rapport with people who used the service and their visitors, which promoted a relaxed atmosphere. We saw interactions between staff and people which were sensitive and respectful. A person told us 'All the staff are so helpful and kind to me I can't fault them, I just wish there was more of them to help the ones that shout out a lot' a relative told us 'Mum is very happy here, much better and safer than other places she has stayed in we have always found the staff to be really helpful'.

There were not always sufficient numbers of qualified staff to meet the needs of people who used the service which meant that people were placed at risk of inappropriate care. Staff told us: 'This is the best week of staffing we have had in months, there is actually three nurses on duty which means we can provide much better care as we can support the care staff better' and 'There have been days when you are the only experienced member of care staff on duty as its new or agency staff.'

Staff did not always receive appropriate professional development or support in order to help ensure they could deliver consistent appropriate care and support.

People told us that they felt well cared for and that there were enough staff on duty to meet their needs. 'It's very nice here. The carers are good' said one person. Another person told us 'This home is as good as you'll get in every respect'.

People told us that staff understood their needs and provided appropriate care and support. One person said 'Carers are very caring and very well trained.' We observed that staff were responsive when people asked for assistance and offered people choices about how their care was provided.

People felt safe and good arrangements were in place to safeguard people. Sufficient numbers of staff with the relevant training, skills and experience were employed to meet peoples' needs. The service took account of peoples' views in how the service was provided. The service monitored the quality and safety of the service provided and took action where needed.