We inspected Ersham House Nursing Home on the 29 and 31 August 2017 and the inspection was unannounced. Ersham House Nursing Home provides accommodation and personal care, including nursing care, for up to 40 people. People had needs such as poor mobility, diabetes, as well as those living with various stages of dementia. The service also had a contract with the local authority to provide care and support for up to seven people to prevent unnecessary hospital admissions. There were 26 people living at the service on the days of our inspection.An acting manager was in post but they were not yet registered with the commission. 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 and associated Regulations about how the service is run. The registered manager left the service at the end of October 2016. A previous acting manager had been in post from October 2016 to April 2017. The current acting manager took over in May 2017 and had been in post four months at the time of the inspection and told us they would submit an application to become the registered manager.
At the last inspection undertaken on 28 and 29 February 2017, we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. These breaches were in relation to; Regulation 9, people were at risk of social isolation. Regulation 11, people's care plans did not reflect their basic rights to consent and decision making. Regulation 12, evidence was not available to show that care was provided in a safe way and Regulation 17; effective systems were not in place to monitor the quality and safety of the service.
We asked the provider to take action to meet regulations 9 and 12. We took enforcement action against the provider and told them to meet Regulation 11 by 14 June 2017 and Regulation 17 by 14 July 2017. The provider sent us a report of the actions they were taking to comply with Regulations 9 and 12 and they told us they would be meeting these Regulations by 31 July 2017.
At this inspection we found the provider had made some improvements to the service and standards of care. Another activity coordinator had been recruited and staff no longer referred to people in an inappropriate manner. Prescribed fluid thickener was not left in easy reach of people. Staffing levels had increased and a dependency tool was now in place to assess what staffing levels were needed to meet people’s needs. However, many improvements had not been made and we found continuing breaches of regulations from the last inspection. We also found new breaches of regulation.
The overall rating for this service is 'Inadequate' and the service is therefore in '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. 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.
Prior to our inspection, we received information of concern from an anonymous source that the consistency of people’s pureed food was not in line with their assessed need as determined by Speech and Language Therapists (SALT). This is to ensure people who have swallowing difficulties do not choke. During the inspection, we observed a staff member pushing aside lumps within people’s pureed food and a member of the kitchen team advised that the blender provided was not fit for purpose.
People did not consistently receive safe care and treatment. The management of catheter care was ineffective and placed people at risk. There was a lack of guidance for registered nursing staff to follow. Nursing staff did not consistently have oversight of people’s air mattresses settings and a number of air mattresses were set at the incorrect setting which placed people at risk of their skin breaking down. Nursing staff regularly checked people’s blood sugars, but diabetic care plans and risk assessments were not in place to ensure consistent safe care.
The principles of the Mental Capacity Act (MCA) 2005 were still not consistently applied in practice. Where people had bed rails, the provider could not evidence whether they had consented to the use of bed rails or whether they were implemented in people’s best interests when people did not have capacity to consent. Relatives were signing consent forms without the appropriate authority to do so. People raised concerns about the restrictions imposed on their freedom. One person told us, “I certainly feel restricted from how I was living before. I’ve been here about five months. I’d like to go out in a taxi on my own and go shopping, then get a taxi back. I can’t see why I can’t; I did do it before I came here without any problems.”
The management of medicines was not always safe as people did not always receive their medicines on time. Protocols for the use of ‘as required’ PRN medicines were not in place and pain assessment tools had not been implemented. Medicines were not always administered in line with best practice guidelines or the prescriber’s instructions.
People's healthcare needs were met but communication with relatives was not consistently responsive. Healthcare advice had not consistently been followed by care staff. Staffing levels had increased since the last inspection in February 2017 but the deployment of staff was ineffective. People were left without staff supervision and engagement from staff. Restrictions on staffing levels meant people could not freely sit outside or access the garden. People remained at risk of social isolation. The provision of activities was not consistently meaningful and accessible to people with varying needs and preferences.
Safeguarding policies and procedures were in place but systems to ensure people were protected from harm or abuse were not consistently robust.
The provider continued to fail to maintain accurate, complete and contemporaneous records. People's daily monitoring charts were incomplete and included unexplained gaps and omissions. Staff had not all received up to date training or training to meet people's individual needs.
Whilst the quality assurance process identified and addressed some shortfalls, it remained ineffective. The provider lacked strategic oversight of the service. The management team were dedicated to making the necessary improvements, but these were not yet embedded or sustained. Shortfalls identified at the last inspection in February 2017 had not been addressed and the provider had failed to act on recommendations made at the last inspection. The lunchtime experience was not consistently positive for some people; this was because some people were having their meals sitting in the armchairs that they had spent most of the day sitting in. This didn't help people to orientate or know that it was time for their meal, nor did it aid their digestion or independent eating. We have identified this as an area of practice that needs improvement.
Staff spoke highly of the people they supported. People’s right to privacy was respected and people spoke highly of the staff. One person told us, “The staff are very caring, they cuddle me and talk to me and cheer me up because I get very tearful, because of my legs.” Advanced care plans were in place for people to discuss their wishes surrounding end of life care. However, these were not consistently completed. We have identified this as an area of practice that needs improvement.
People spoke highly of the food provided and for those who enjoyed group activities, a range of activities were on offer. These included arts and craft, card games and puzzles. Staff recruitment practice was safe.
During our inspection we found a number breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the registered providers to take at the back of the full version of the report. 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.