Archived: Kettlewell House Nursing Home

The inspection took place on 30 November 2016 and was unannounced.

There was a registered manager 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. The registered manager assisted us with our inspection.

We carried out this fully comprehensive inspection to see what action the provider had taken in response to the shortfalls we had previously identified. We found during this inspection that the provider had made the improvements needed and was now meeting the regulations.

People were safe because there were enough staff on duty to meet their needs. Risks to people had been assessed and measures implemented to reduce these risks. There were plans in place to ensure that people would continue to receive their care in the event of an emergency. The provider made appropriate checks on staff before they started work, which helped to ensure only suitable applicants were employed and staff understood safeguarding procedures.

People were supported by staff that had the skills and experience needed to provide effective care. Staff had induction training when they started work and on-going refresher training in core areas. They had access to regular supervision, which provided opportunities to discuss their performance and training needs.

Staff knew the needs of the people they supported and provided care in a consistent way. Staff monitored people’s healthcare needs and took appropriate action if they became unwell. People medicines were stored safety and administration practices for medicines were robust.

The registered manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). People’s best interests had been considered when decisions that affected them were made and applications for DoLS authorisations had been submitted where restrictions were imposed upon people to keep them safe.

People enjoyed the food provided and could have alternatives to the menu if they wished. People’s nutritional needs had been assessed and staff were knowledgeable on people’s individual likes and dislikes in relation to food. Information contained in people’s care plans helped staff to ensure that people received the care they required.

People had positive relationships with the staff who supported them. Relatives said that staff were kind and caring. The atmosphere in the home was calm and relaxed and staff spoke to people in a respectful manner. Staff understood the importance of supporting people to remain independent as well as treating them with respect and allowing them their own privacy.

The registered manager provided good leadership. Relatives told us the service was well run and that the registered manager was open and approachable. They said the registered manager had always resolved any concerns they had. Staff told us the registered manager provided good leadership and they felt supported by her. They said they worked well as a team to ensure people received the care they needed.

The provider had an effective quality assurance system to ensure that key areas of the service were monitored effectively. Where suggestions had been made these were used to develop and improve the level of care that was provided to people.

The home had a registered manager. 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.

People said they felt safe living at the home. People said: “Yes I do feel safe living here” and “its home from home”. However, we found areas where the provider needed to make improvements.

Staff and the registered manager had a basic understanding of safeguarding people, but the registered manager did not always make referrals to the local authority safeguarding team when they should have done.

Risk assessment and management activities were not as detailed as they should have been. Some risk assessments had been incorrectly completed, and appropriate risk management plans were not always in place. Although incidents and accidents were recorded, they were not always well analysed to see if there was any link between them, and what action needed to be taken to stop the incident from happening again. Risks to the environment and routine maintenance were all well managed.

Recruitment practices were not robust. The provider did not ensure they completed all of the pre-employment checks for staff and volunteers before they began work. Staff were not well supported with training, supervision and appraisals. Most of the training was via e-learning and was not always effective. People told us there were enough staff on duty to meet there needs and that staff were helpful and kind.

Management of people’s medicines was not always safe. Some records did not include a photograph of the person, and referrals to people’s GP was not always made when it should have been. Medicines were handled and stored safely.

People told us they were well looked after, and staff were kind and caring. The registered manager had a very detailed understanding of people using the service and supported staff to meet people’s needs. Staff tried to relieve people’s distress in a caring way, but the provider did not give enough support to staff to enable them to meet the more specific needs of people with dementia. People’s care plans contained basic information about people’s needs and preferences but it was not clear how often they were updated.

Complaints were investigated but the outcome of investigations were not recorded. There was no evidence of learning from the outcome of complaints or incidents and accidents. Feedback from people was asked for by the provider, but they did not always act when areas of improvement were identified. Staff were given little opportunity to provide feedback in a formal way.

The registered manager had not notified CQC of some incidents as they are required to by law. Quality monitoring was understood by the manager and provider but it was not always completed effectively. Although action had been taken to address some issues raised, the registered manager did not have an action plan in place to ensure continuing quality improvement. Feedback about the manager and staff was positive from all of the people we spoke with.

We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, people were not properly protected from the risk of abuse, treatment was not provided with the consent of the relevant person, appropriate risk assessments and management plans were not detailed enough, and staff did not receive appropriate training, supervision and appraisal, and pre-employment checks were not fully completed. You can see what action we told the provider to take at the back of the full version of the report.

Below is a summary of what we found. The summary is based on our review of records, observations during the inspection, speaking with people and their relatives who used the service and speaking with staff who supported the people who used the service.

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

We found people expressed their views and were involved in making decisions about their care, treatment and support. They experienced effective, safe and appropriate care. These were a few of the quotes people used to describe the care and support they received. 'I can't fault the place and the girls are very good.' 'We do have choice here'. 'The staff are tolerant and very patient'. 'I am so happy my relative is here'.

We observed the lunchtime meal and saw the food was laid out on people's plates in an appetising way. People we spoke with told us, 'the food is very good and they got enough food and drink'. We saw that people were encouraged to make choices about their meal even though the menu displayed had not offered any choice. We saw two different protein choices (fish cake and fried fish) had been provided by the cook.

Generally, people had their medicines at the times they needed them from staff qualified to do so. On the day of our visit we saw medicines being administered late. We were told this was because there was a medical emergency which the registered nurse had to deal with before they were able to commence the administration of medicines.

People and their relatives spoke highly of the care they received and the cleanliness of the service. We observed the service had a number of domestic staff on duty carrying out cleaning throughout the service. We noted the staff wore suitable protective clothing including gloves. We saw the laundry was clean, well-appointed with receiving area(soiled and used laundry) and clean area (for clean laundry). Laundry and domestic staff were knowledgeable about infection control. We saw the service had appointed a company experienced in waste disposal and waste was collected on a regular basis.

The service had appropriate systems in place to effectively assess and monitor the quality of the service.

The five questions we ask about services and what we found.

Is the service safe?

People who used the service told us they were treated with respect and dignity. For example, one person said, 'When I am being assisted with my care needs, the carers informed me of what they were going to do before undertaking the task'.

We observed the service had a system in place to ensure that people's risk assessments were kept under regular review. Any trends identified were dealt with to minimise risks relating to people's health, welfare and safety.

All seven members of staff spoken to were able to describe what measures the service had in place to promote people's safety and how they would protect people if they felt their human rights were being breached.

The service had processes in place to ensure that staff who administered medicines had suitable training to enable them to handle medicines safely, securely and appropriately.

We saw documented evidence that the service used a range of quality monitoring tools such as review of risk assessments, care plans reviews, staff supervision and appraisals. They also used a yearly clients and staff satisfaction surveys to measure the quality of care and support people received from the service. People told us they felt safe with the staff.

Is the service effective?

We found that people's care plans provided detailed information on how they wished to be supported with their care needs. For example, resident X needed the help of two members of staff to mobilise safely. We observed that people's daily care record sheets included the date and what help and support was offered to the person. Care staff spoken with told us they used the daily record sheet to highlight any changes to the person's care to ensure continuity of care. We saw that these were appropriately maintained to ensure if required a new member of staff would be able to deliver care safely and effectively.

Care staff told us they had regular supervisions and appraisals to ensure they are competent to deliver effective care to people who used the service. We saw documented evidence of staff appraisals which had been carried out by the registered manager and or the supervisor. We saw records of staff training which demonstrated care staff had regular and appropriate training to enable them to meet the care needs of people who used the service.

We found that people's health care needs were kept under regular review. They had access to health care professionals such as the GP, dentist, optician and chiropodist. This meant that people were supported to keep healthy and well.

Is the service caring?

People told us that care staff spoke to them in a kind and respectful manner. One person said, 'The staff all of them demonstrates a genuine affection, care and concern to me'. All four members of care staff spoken with were knowledgeable about people's care needs including their preferences and personal histories. It was evident that people were listened to and care staff responded to them in a positive and caring way. One person said, 'I feel I receive excellent care'.

Is the service responsive?

The six people we spoke with told us they were supported to express their views and be actively involved in making decisions about their care, treatment and support. In the care plans and daily record sheets we looked at we saw evidence which reflected that people received individual care as laid out in their care plans. We saw planned activities advertised which was age related and suitable for people at the service.

We were told by a senior member of staff that the service had not received any complaints since the last inspection. People we spoke with all said they knew how to make a complaint, but have never done so. They said they discussed their care needs with the member of care staff and they worked well together so there was never any need to complain.

Is the service well led?

Staff spoken with said that they felt supported by the management team and were in regular contact with the registered manager and or deputy manager. They were able to raise questions relating to the delivery and implementation of best practice on the spot. They told us they have had one to one supervisions and yearly appraisals. This meant that staff felt supported and well-led.

We found that the service had quality assurance systems in place. Staff practice had been regularly observed. The outcomes from these were discussed and used to improve the care provided. Staff spoken with said that they were provided with adequate training. This enabled them to perform their roles and to be accountable for their actions.

People spoken with told us the registered manager is always available in the home. They said either the registered manager or the deputy manager made regular visits to the lounge and their bedrooms to check if they are happy with the care and if the care workers were performing satisfactory. This ensured people received agreed and effective care.

The service had arrangements in place to monitor complaints, accidents and incidents. This meant that lessons were learnt from mistakes, incidents and complaints investigations to ensure improvements with the service delivery was maintained.

Relatives and people we spoke with told us they were given information about the service. This meant they understood the choices available to them before they moved in. We asked if people felt respected and one relative told us 'Yes they do respect my family member, and me.' A person who used the service told us 'I feel respected by staff.'

We saw that assessments of people's needs had been carried out. Care was provided that met those needs. Relatives told us they had been involved in the planning of care.

The provider had systems in place to ensure people were protected from unsafe premises.

We saw that the provider carried out appropriate checks when employing staff. This ensured staff were of good character and had the necessary skills and experience to do the job.

The provider had an effective system in place for dealing with complaints. People we spoke to said they knew how to make a formal complaint.

One person told us 'It's very pleasant here; they do all they can to make life comfortable.' Another said 'Staff ask if I want to do things. I can choose to stay in my room if I want.' People were seen to interact well with staff laughing and joking with them.

Relatives told us their permission had been asked for around decisions to the care and treatment being given. One person said 'Mum is in a good place, the key worker would contact me if her care needed changing.' Another told us of issues they had raised with staff, but went on to say 'Overall they do a good job here.'

We saw that people and relatives had been involved in the planning of care. We noted that some risks had not been identified to protect people from harm.

We saw that the provider had some systems in place to monitor and check building safety and maintenance. Not all checks were up to date when we visited.

People who used the service, relatives and staff told us they felt there were enough staff. All the staff we spoke to said they felt supported to do their job.

People told us they had the opportunity to express their views about the service, and that the provider took action where needed.