The Chiswick Nursing Centre

The Chiswick Nursing Centre is a residential care home providing personal and nursing care to up to 146 people. The service provides support to older people, people living with dementia and younger people with physical disabilities. At the time of our inspection there were 139 people using the service.

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

People told us they felt safe living in the service and felt well respected by staff. A family member told us, “I’m very pleased with the home, the staff are absolutely lovely.”

The service had delivered an action plan to improve how it managed medicines, and this was now carried out safely. There were suitable processes for managing risks and protecting people from avoidable harm. Staff understood their responsibilities to report suspected abuse and the provider worked with the local authority to safeguard people and investigate reported concerns.

The service ensured there were enough staff on duty to meet people’s needs. People told us staff responded promptly to call bells and there were systems of regular checks to ensure people’s wellbeing. Where incidents had taken place the provider ensured people’s needs were reviewed to prevent a recurrence.

The service had worked with local health agencies to respond to and contain outbreaks. There were suitable infection control measures to protect people from infectious disease which at times exceeded national requirements.

The service was continuously improving and developing, through participating in research and redesigning areas of the building to promote a more stimulating and pleasant environment. Staff told us they felt well supported by their managers and colleagues and described the home as a good place to work. There were good systems of communication and audit to ensure that standards were maintained and areas for development identified.

People’s family members told us the service communicated well with them and kept them updated on their relative’s wellbeing. People felt confident raising concerns or queries with managers and that these were acted on appropriately.

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.

For more information, please read the detailed findings section of this report. If you are reading this as a separate summary, the full report can be found on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 22 June 2022).

Why we inspected

We carried out an unannounced focussed inspection of this service on 17 March 2022. A breach of legal requirements was found in relation to the safe management of medicines. We issued a warning notice requiring the provider to make improvements.

We undertook this focused inspection to check if the provider had made improvements and if they were now meeting the legal requirements. This report only covers our findings in relation to the key questions Safe and well-led.

For those key questions not inspected, we used the ratings awarded at the last comprehensive inspection to calculate the overall rating.

At this inspection we found improvements had been made and the provider was now meeting this regulation.

The overall rating for the service has changed from requires improvement to good. This is based on the findings at this inspection.

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

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.

Follow up

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

The Chiswick Nursing Centre is registered to provide accommodation for up to 146 people with nursing care needs and at the time of the inspection 123 people were residing at the service. The premises were purpose built and accommodated people on four separate suites. A fifth suite was not currently in use.

The service supported older people with physical frailties and/or people living with dementia, and younger adults with disabilities. People were provided with an en-suite bedroom and shared communal facilities which included lounges, dining areas, a passenger lift and gardens.

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

People’s medicines were not always rigorously managed to ensure they received their medicines in a safe and consistent way.

People were protected from avoidable harm and abuse by staff with suitable safeguarding knowledge and skills to promote their safety and wellbeing.

People were supported by sufficient staff with appropriate backgrounds and experience to meet their needs.

People were provided with a clean and hygienic environment.

People’s care needs were assessed and their care plans were devised in partnership with them and their representatives, where possible. Risks to people’s safety were identified and guidance was developed to mitigate these risks.

People were supported to access care and treatment from external health and social care professionals. Staff worked well with local professionals to make sure people received safe and smoothly delivered care and support.

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 and their representatives told us staff were caring and compassionate, and treated them with respect. Relatives told us staff kept them informed about their family member's needs.

People were offered a range of social activities to provide enjoyment and fulfilment.

People and their representatives views were sought and listened to. People were satisfied their complaints were taken seriously.

The provider had processes in place to continuously monitor and improve the quality of the service, although this was not sufficiently robust for the management of medicines.

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 11 February 2022) and there were breaches of regulation. At this inspection we found the provider remained in breach of regulations. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

We carried out an unannounced focused inspection of this service on 4 February 2021. A breach of legal requirements was found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safe care and treatment.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met the legal requirement. This report only covers our findings in relation to the Key Questions Safe which contains the requirement and Well-Led.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating. The overall rating for the service has remained requires improvement. This is based on the findings at this 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 COVID-19 and other infection outbreaks effectively.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary to do so.

We have identified one repeated breach of regulation in relation to the safe management of medicines and have issued a Warning Notice. We have made a recommendation in relation to the robustness of the provider's quality monitoring system for medicines.

You can see what action we told the provider to take at the end of the full version 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 the progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

The Chiswick Nursing Centre is registered to provide accommodation for up to 146 people with nursing care needs and at the time of the inspection 120 people were using the service. The premises were purpose-built and accommodated people on five separate units. The service supported older people with physical frailties and/or people living with dementia, and younger adults with disabilities. People were provided with an en-suite bedroom and shared communal facilities which included lounges, dining areas, a passenger lift and gardens.

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

People did not always receive their medicine safely, for example how staff ensured medicine administration practices did not place people at the risk of cross contamination.

People were not always properly protected from the risk of infection by the provider's infection control and prevention measures.

People were protected from the risk of abuse. Their concerns and complaints were responded to.

People and their relatives told us staff were noticeably busier due to the impact of the pandemic.

Staff told us they felt well supported and appreciated for their commitment by the provider.

People and their relatives thought the service was well managed and they felt the management team were approachable.

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

The last rating for this service was requires improvement (published 1 April 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 enough improvement had not been made and the provider was still in breach of regulations.

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 and Well-led which contain those requirements.

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 requires improvement. This is based on the findings at this inspection.

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

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.

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 discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary to do so.

We have identified one repeated breach of regulation in relation to the safe management of medicines.

Follow up

We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service. We may inspect again if we receive any further information.

The Chiswick Nursing Centre is registered to provide accommodation for up to 146 people with nursing care needs and at the time of the inspection 142 people were using the service. The service occupied purpose-built premises and accommodated people on five separate units. The service supported older people with physical frailties and/or people living with dementia, and younger adults with disabilities. People were provided with an en-suite bedroom and shared communal facilities which included lounges, dining areas, a passenger lift and gardens.

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

The management of people’s medicines was not always sufficiently robust in order to make sure people consistently received their medicines in a safe manner.

People were protected from avoidable harm and abuse by staff who had received relevant training and understood how to report safeguarding concerns.

People’s care needs were assessed and individual care plans were developed in consultation with people and their representatives, where possible. Risks to people’s care and support were identified and addressed. Care planning was in place to meet people’s end of life care needs. However, we received some negative comments about the quality of care, including palliative care.

People were supported to access external healthcare support from applicable professionals, for example podiatrists, dentists and NHS specialist nurses.

People mainly felt there were sufficient staff deployed to meet their needs, although some people thought staffing could be increased at mealtimes and night time. Staff received training, supervision and support to carry out their roles and duties.

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 and their representatives told us staff were kind and caring and spoke with them in a respectful way. People’s representatives felt staff kept them informed about their relatives needs, including significant changes to their health and welfare. We also received feedback about occasions when people's representatives felt staff were not supportive and did not inform them of important changes that impacted on people's safety and welfare.

People were supported to take part in activities and entertainments that offered social stimulation. This included activities designed for people living with dementia.

People and their representatives were invited to participate in meetings about how the service was managed.

People and their representatives were given information about how to make complaints or comments about the quality of the service. Complaints were managed in line with the provider’s complaints procedure.

The provider had systems in place to monitor the quality of the service and make any required improvements, although this was not rigorous enough in relation to the management of medicines.

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 was good (published 19 September 2017).

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have found a breach in relation to safe care and treatment. Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and 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.

The Chiswick Nursing Centre is a 146 bedded care home with nursing and provides care, accommodation and support for older people and younger adults, people who are living with dementia, people with mental health needs, people with complex neurological conditions, people with physical disabilities and people with learning disabilities. At the time of our inspection 141 people were living in the home.

There was a registered manager in post at the time of our 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.

People’s risks were managed and care plans contained appropriate and detailed risk assessments which were updated regularly when people’s needs changed. The service had a robust recruitment process and staff had the necessary checks to ensure they were suitable to work with people using the service. Recruitment was ongoing with the aim to reduce the number of agency workers.

People who required support with their medicines received them safely from staff who had completed in-depth training in the safe handling and administration of medicines, which was refreshed annually. Staff completed appropriate records when they administered medicines and these were regularly checked to minimise medicines errors.

The majority of people who used the service and their relatives told us they felt safe using the service and all staff had a good understanding of how to protect people from abuse. Staff were confident that any concerns would be investigated and dealt with. All staff had received training in safeguarding adults from abuse and had a good understanding of how to identify and report any concerns. One person felt they were at risk in relation to fire evacuation procedures because of their poor mobility. The provider had consistently reassured them that there was a plan in place to manage any emergency and their potential evacuation.

Staff demonstrated a good understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff were aware of the importance of asking people for consent and the need to have best interests meetings in relation to decisions where people did not have the capacity to consent to their care. The provider was aware when people had restrictions placed upon them and notified the local authority responsible for assessment and DoLS authorisations.

Staff were aware of people’s dietary needs and food preferences and provided support to those who required it during mealtimes. If people had questions or concerns about their food the provider met with them to discuss their preferences and to find alternative options.

Registered nurses and care assistants told us they contacted other health and social care professionals, such as occupational therapists, psychiatrists and speech and language therapists, if they had any concerns about people’s health. We saw evidence of these referrals in people’s care records. People had regular access to a GP who visited at least three times a week, was available for emergency ‘house calls’ on a daily basis and was also available outside of normal surgery hours.

There was a comprehensive induction and training programme in place to support staff in meeting people’s needs effectively. New staff shadowed more experienced staff and had their competency signed off by senior staff before they started to deliver personal care or support people with their medicines independently. Staff received regular supervision from management and told us they felt supported and were happy with their input during the supervision they received.

The majority of people who used the service and their relatives told us staff were kind and compassionate and knew how to provide the care and support they required. People were spoken with and treated in a respectful and kind way and staff respected their privacy and dignity, and promoted their independence.

The provider was in the initial stages of working towards accreditation in the Gold Standards Framework, which is a framework to help deliver a gold standard of care for all people as they near the end of their lives.

People were involved in planning how they were cared for and supported. An initial assessment was completed from which care plans and detailed risk assessments were developed. Care records were person centred and developed to meet people’s individual needs and reviewed regularly or if there were any significant changes. People using the service and their relatives were actively encouraged to express their views and were involved in making decisions about their care and whether any changes could be made to it.

People were encouraged to take part in a range of activities and events to increase their well-being and reduce social isolation. There was evidence that people’s cultural needs were considered when discussing this and making sure these needs were met. Improvements were in the process of being implemented to create a more dementia friendly environment in the suite for people living with dementia.

People using the service and their relatives knew how to make a complaint and were able to share their views and opinions about the service they received. The provider listened to all complaints and met with people to discuss their concerns. There were also meetings and surveys in place to allow people using the service and their relatives the opportunity to feedback about the care and treatment they received.

There were effective quality assurance systems in place to monitor the quality of the service provided and understand the experiences of people who used the service. The registered manager and senior management team followed a daily, weekly, monthly, quarterly and annual cycle of quality assurance activities and learning took place from the result of the audits. The registered manager was fully aware of their registration requirements regarding notifiable incidents and kept us updated with the progress of incidents and investigations.

The service promoted an open and honest culture and staff spoke highly of the atmosphere at the service and the support they received from management. Staff were confident they could raise issues or concerns at any time, knowing they would be listened to and acted upon.

Overall, there had been significant improvements, noticed by both staff and people and/ or their relatives. Two relatives we spoke with described how their relative's condition had improved, which they felt was down to the care provided and the "detailed" approach of staff. One person described nursing staff as "superb," whilst another stated staff had a "lovely attitude". People felt able to raise concerns and had confidence in them being dealt with. Staff were also positive about recent changes and felt it was an enjoyable place to work.

The provider had done all that was practicably possible to ensure that people and/ or their relatives had been involved in developing their care plans and had consented to it. People and/ or their relatives had signed their care plan, risk assessments and any care specific consent forms. Where people lacked capacity, staff had acted in accordance with the law. People received care in line with their individual care plan and we found no discrepancies in the recording of observations.

Most people we spoke with were complimentary about the service and felt that their needs were being met. There were now systems in place to monitor the quality of service provided and to enable people to provide feedback. Whilst we observed that there had been improvements made, we continued to find examples of where care was not being delivered in line with people's care plan and where gaps in recording meant that we could not be assured that people were getting the care they needed when they needed it.

Most staff had received Mental Capacity Act 2005 training, but they were unable to demonstrate how they would apply what they had learnt in practice. Staff continued to sign people's consent forms and care plans "in the person's best interest" and there was a lack of documentary evidence to show that staff had acted in accordance with the law where people lacked capacity.

Most people we spoke with were satisfied with the care provided. However, the Care Quality Commission had been contacted by relatives who were concerned about the care being provided. We found that the provider was not meeting the Warning Notice and that care was still not being delivered in a way that ensured people's safety and welfare. Whilst new systems and observational tools had been put in place, staff continued to record their observations retrospectively and documents were not being fully completed.

There were consent policies in place, but these were not being followed. Staff had little understanding of the Mental Capacity Act 2005 and how it linked to consent. Where people lacked capacity to consent, the provider had not acted in accordance with legal requirements.

The necessary improvements had been made in relation to medicines management and staffing levels. On the day of our inspection we saw no evidence of a system to monitor the quality of service provided. We requested additional documentary evidence from the provider, which we did not receive.

There were insufficient staff to meet people's needs. People we spoke with were complimentary about the staff describing them as "caring" and "kind", but felt that they were "overstretched". People told us that staff took a long time to answer their call bells, particularly at night and whilst they got their medication on time the delivery of care was sometimes "erratic". There were no systems in place to monitor the hours that staff were working and we were told there were occasions when staff were sleeping at night.

Care was not delivered in a way that ensured people's safety. There were inadequate systems in place to ensure that staff responded appropriately if a person's condition deteriorated and there was no allocated time for a formal handover between shifts. In people's care records, we found care notes and observations were not being completed contemporaneously. Most staff told us that they completed them at the end of their shift and so we could not be assured that they were accurate. People were not always protected against the risks associated with the unsafe management of medicines. We found discrepancies in people's medication records, which meant that they may have not been given the prescribed dosage.

The provider told us that care plans had been reviewed in collaboration with people who use the service or their relatives. We spoke with relatives who confirmed that they had been involved in developing their relative's care plan. However, one relative told us that staff were not following the care plan. In addition, the provider had not used alternative means of communication to support those with communication difficulties to make decisions about their care.

People's nutritional needs were met and staff were aware of those with particular dietary requirements. Most people confirmed that they were given a choice of food and were supported to drink sufficient amounts. People who use the service told us that they felt safe living at the home and told us that staff were gentle when delivering care. Staff were able to demonstrate awareness around the importance of meeting people's needs. Staff we spoke with felt that there were enough staff each shift to ensure people were well cared for.