Benoni Nursing Home Limited

Benoni provides accommodation with nursing and personal care for up 25 people. There were 22 predominantly older people using the service at the time of our inspection.

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

Medicine systems and processes were in place. People received their medicines safely and as prescribed.

People were provided with the equipment they had been assessed as needing to meet their needs. For example, pressure relieving mattresses. These were correctly set for the person using them.

Staff were recruited safely in sufficient numbers to ensure people’s needs were met. Two nurses were on duty each day supported by six care workers. One nurse and two care workers were on duty at night.

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. Any restrictive practices were regularly reviewed to ensure they remained the least restrictive option and were proportionate and necessary.

There were systems and processes in place to monitor the Mental Capacity Act, and associated Deprivation of Liberty Safeguards assessments and records.

People told us, “Staff are good at what they do, they encourage you to get well and are proactive on your behalf with health care professionals,” “There is nowhere better. I feel comfortable and peaceful and that’s what I want” and “The staff are very caring”.

Relatives told us, “I can’t fault the place. They provide good care for [Person’s name] and they do a good job. I visit most weeks and they are always very chatty and offer me tea and even a meal if I want it,” and “I give the home ‘full marks’. The staff are very good, I visit twice a week and as a family we are very pleased Mum is getting the care she needs”.

Staff had received appropriate training and support to enable them to carry out their roles safely.

The food provided by the service was enjoyed by people. However, meals were not a social event. People were provided with their drinks and food at the seat in which they sat for most of the day. We have made a recommendation about this in the Effective section of this report.

There were activities provided for people. People’s views on activities were mixed. Activities were not always relevant and meaningful to all the people living at the service. We have made a recommendation about this in the Responsive section of this report.

People received care and support that was individual to their needs and wishes. Care plans were regularly reviewed and updated and were an accurate reflection of people’s needs and wishes.

Risk assessments provided staff with sufficient guidance and direction to provide person-centred care and support.

Audits were carried out regularly to monitor the service provided. Actions from these audits were being acted upon to further improve the service.

We observed many kind and caring interactions between staff and people. Staff spent time chatting with people as they moved around the service.

A complaints process and procedure was available to people. The manager told us there were no on-going complaints at the time of this inspection.

People were supported to access healthcare services, staff recognised changes in people's health, and sought professional advice appropriately.

Rating at last inspection and update:

At the last inspection the service was rated as requires improvement (report published 3 October 2018) and we issued requirement notices and imposed a condition on the providers registration of the service which required the service to report to CQC each month on areas of concern identified at that inspection. 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 improvements had been made and the provider was no longer in breach of regulation. Conditions applied after the previous inspection in October 2018 were met.

Why we inspected: This inspection was carried out to ensure improvements required at the last inspection had been made.

Follow up: We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

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

This unannounced comprehensive inspection took place on 11 September 2018. The last inspection took place on 11 July 2017 and was focused on reviewing the warning notice issued due to the concerns found at the April/May 2017 inspection. Those concerns were about the auditing of medicines, fire risk management, the provision of hot water and infection control issues. At the July 2017 Inspection we found the provider had taken appropriate action to address the issues raised in the warning notice. However, the rating remained as Requires Improvement as we needed to see the changes sustained over time and would review the outstanding breaches at this comprehensive inspection.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection.

A registered manager is a person who has registered with the 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 service is required to have a registered manager and at the time of the inspection there was no registered manager in post. There was an acting manager at the service who had not applied to become the registered manager at the time of this inspection. The acting managers position was under review by the provider.

People received their medicines as prescribed. Systems and processes relating to the administration and storage of medicines helped ensure medicines were managed safely. Medicine audits were carried out monthly. The service had increased the areas that were covered by this audit since the last inspection and it was now more robust. Any issues that arose from the regular audits were being addressed by the nurses.

The premises were regularly maintained. There were no unpleasant odours at the service. The service was registered for dementia care, and we had raised concerns with the provider, at previous inspections, that there was no pictorial signage to support people who were living with dementia and who may require additional support with recognising their surroundings. At the last inspection we were given assurances that the provider had ordered new signage for people’s bedroom doors which would help people to recognise their own rooms. At this inspection new signage had still not arrived despite the providers repeated assurances it would be arriving soon.

We had previously identified concerns with the supply of hot water to some rooms. Some rooms did not have any hot water, one room had no water. We also identified that the provider was not carrying out regular Legionella tests. At this inspection we found the hot water supply was regularly checked to ensure the temperature was safe for people to use. All rooms had a working water supply. Legionella checks were recorded regularly.

Equipment and services used at Benoni were regularly checked by competent people to ensure they were safe to use. The service carried out regular health and safety audits. The service was due to have a fire risk assessment carried out by an external agency, we were assured this had been booked to take place in the coming weeks following this inspection. The provider had taken advice from a fire assessment and was planning to have a sprinkler system installed. Emergency fire evacuation equipment was evident on all landings and in people’s rooms. All people had personal emergency action plans in place.

People's rights were not always protected because staff did not always act in accordance with the Mental Capacity Act 2005. The principles of the Deprivation of Liberty Safeguards (DoLS) were not entirely well understood and applied correctly. There was a DoLS authorisation in place for one person at the service which was not recorded in the person’s care plan and the acting manager was unaware of this being in place. Consent forms signed by inappropriate people on behalf of people who lacked capacity remained in care files since 2013 despite recent care plan reviews having been carried out. The service was in the process of collecting copies of the legal documentation to evidence which people living at the service, had appointed lasting powers of attorneys in place. Some information held in people’s care plans led the reader to believe legal powers were held by family members when the service had no evidence of this.

The manager did not have robust effective processes in place to monitor all aspects of care and support provided. For example, when catheters needed changing, DoLS authorisations needed reviewing and any dressings that may need renewing. The nursing staff held their own handwritten lists which helped them to provide good care, however this did not ensure people always received care in a timely manner. One person had required their catheter to be changed on a specific date and this had not taken place.

This has led to repeated breaches of Regulation 11 and Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.

We spent time in the communal areas of the service. Staff knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect. People were well cared for.

All the people we spoke with told us they felt safe using the service and were happy with the care and support they received. Comments included, “There is nowhere better than here” and “I like it here they (staff) are very nice.”

A relative told us, “The girls (staff) are really lovely here”. They felt welcomed and were always offered a cup of tea when they arrived. Relatives were able to join their family members for a meal if they wished. The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes. The service had a relaxed and comfortable atmosphere.

All but two people’s care plans had been fully reviewed. The ones that had been reviewed were well organised and contained accurate and up to date information. Care planning was reviewed regularly and people’s changing needs were recorded. Daily notes were completed by staff. Risks in relation to people’s daily lives were identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible. Monitoring records completed by staff were regularly checked by nursing staff to ensure people received appropriate care and support.

The service had identified the minimum numbers of staff required to meet people’s needs and these were being met. The service had no staff vacancies at the time of this inspection.

Meals were well presented and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy. People’s weight was regularly checked to ensure they had sufficient intake.

People had access to activities at Benoni. An activity co-ordinator was in post four days a week. People were also supported to go out in to the community and to attend appointments,

Technology used to help improve the delivery of effective care was limited. For example, alarmed pressure mats were used, if appropriate, to alert staff that a person was moving around. This meant staff could support them in a timely manner.

People were supported by staff who knew how to recognise abuse and how to respond to concerns. The service held appropriate policies that had been recently updated to support staff with current guidance.

The acting manager was supported by the provider and a team of motivated staff. The staff team felt valued and morale was good. Staff were happy working at the service. They told us they felt well supported and could ask for support when needed. They told us, “I love working here it has such a lovely atmosphere and everyone is so supportive” and “If I have any problems or concerns I can go to management, he listens and is helpful.”

Supervision and appraisals were offered to staff. A training programme was in place and staff were offered updates when needed. Staff comments included, “We had a very interesting fire training session involving a 13- stone dummy that we had to safely evacuate from the building, it was excellent and built our confidence.”

Staff told us they felt the service had improved recently and they felt well supported. They told us,“It (the service) has improved from when I started. People are really coming first in every aspect. The management have really promoted this. Management are really aware that change is needed. People are being consulted more about what they want,” “Staffing levels are better” and “The nurses help with practical aspects of care and it promotes working as a team more.”

Despite the service being rated as Requires Improvement for the previous three inspections, this inspection showed improvements had been made in many areas such as staffing levels and the support and safe recruitment of staff, monitoring and recording of care provided, medicines management and management of the premises. However, there was still further work required to meet the requirements of the regulations but the provider and staff are committed to continuous improvement of Benoni and will strive to obtain a Good overall rating.

We fo

This unannounced comprehensive inspection took place on 24 April 2018. The last comprehensive inspection took place on 28 April and 3 May 2017when the service was not meeting the legal requirements. There were four breaches of the regulations. The service was rated as Requires Improvement that time. A warning notice was issued regarding the management of medicines, fire risk management, the provision of hot water and infection control issues. Statutory requirements were issued for the other breaches of the regulations related to staffing levels, the management of risk, lack of effective quality assurance processes and the poor condition of the premises. We carried out a focused inspection on 11 July 2017 to review the actions taken by the provider to address the issues in the warning notice. At that time the provider was found to have addressed the conditions of the warning notice, however the rating remained as Requires Improvement as we needed to see the changes sustained over time and review the outstanding breaches at the next comprehensive inspection.

At this inspection we found the service had taken action to address the breaches of the regulations and improvements were noted. However, some concerns remained and the service has continued to be rated as Requires Improvement.

People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is required to have 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 and associated Regulations about how the service is run. There was a registered manager in post, however they told us and the provider confirmed, that they were stepping down from their post. The provider had begun to put plans in place for the on-going management of the service.

We spent time in the communal areas of the service. Staff were kind and respectful in their approach. They knew people well and had an understanding of their needs and preferences. People were treated with kindness, compassion and respect. The service was comfortable and appeared clean with no odours. People’s bedrooms were personalised to reflect their individual tastes. People told us, “Its the little things the staff do that makes a difference," "The staff are always dropping in to see if I'm alright” and "The staff are very nice people and very caring."

Staffing levels had been increased since the last inspection. People’s needs were being met and call bells were answered quickly. There were no staffing vacancies at the time of this inspection.

People received their medicines as prescribed. Systems and processes relating to the administration and storage of medicines helped ensure medicines were managed safely. However, the audit currently carried out was not detailed enough to capture all aspects of medicines management. The provider told us they were in the process of addressing this and templates were shown to inspectors of the new audit to be used in the future.

People and relatives told us, “The safety of the home is very good. There are always plenty of staff about,” “The staff made sure we are safe” and “I always get my tablets when I should and that makes me feel safe.”

The premises had been improved since the last inspection. The condition of floor covering was improved and areas of damaged paintwork had been redecorated. The service was registered for dementia care however, as seen at the last inspection there continued to be very little pictorial signage at the service to support people who may require additional support with recognising their surroundings. The numbers on some people’s bedroom doors had come off and names were displayed in a small typed format which was not easy for people to read and recognise as their own room. One toilet just displayed a number on it.

The premises were regularly checked and maintained by the provider. Equipment used at Benoni, such as hoists, stand aids, stair lifts and passenger lifts were regularly checked by competent people to ensure they were safe to use. There was a new maintenance person working at the service. However, one person who was independent at cleaning their own teeth, did not have any cold water running from the tap in their sink. We were told this must have only just happened as the provider was unaware of the issue and staff had not reported it. We were assured this would be addressed immediately. There were no regular Legionella checks being carried out at the service. We have made a recommendation about this in the Effective section of this report.

Care plans had been changed to a new format since the last inspection. They were organised and contained accurate and up to date information. Care planning was now reviewed regularly and people’s changing needs were recorded. However, daily notes were not always completed by staff each day. Records relating to the care people had received were not always completed in a chronological way. This meant it was not always easy to find information in the order in which it took place. Risks in relation to people’s daily lives were now clearly identified, assessed and planned to minimise the risk of harm whilst helping people to be as independent as possible.

At the last inspection the service was found to be not entirely meeting the requirements of the Mental Capacity Act 2005, including the associated Deprivation of Liberty Safeguards (DoLS). At this inspection we found that whilst the registered manager had applied appropriately for people to have potentially restrictive care plans, there was not a robust system in place to monitor any agreed authorisations. There was no evidence of capacity assessments having been carried out or the best interest process having been used prior to DoLS applications being made. This meant it could not be ensured that the decision was in the person’s best interests and the least restrictive option available. Family members had been asked to consent on behalf of a relative, before the service had clarity on which power of attorney was held and what legal powers the family member held.

The service had infection control processes in place and staff used aprons and gloves appropriately. Liquid soap was now used from sealed replacement cartridges and no longer a reservoir that was regularly topped up.

Meals were appetising and people were offered a choice in line with their dietary requirements and preferences. Where necessary staff monitored what people ate to help ensure they stayed healthy.

People had access to activities. An activity co-ordinator was in post. People were supported to go out and supported by staff to attend appointments, have coffee or visit local attractions. People in their rooms were provided with regular one to one activity to help ensure they would not feel isolated.

The use of technology in the delivery of care was limited. Alarmed mats and cushions were used to help improve the delivery of effective care, and people had access to call bells.

Recruitment processes were not entirely robust. Whilst the service carried out Disclosure and Barring checks and requested two references, three new staff had only had one reference received prior to them starting work at Benoni. One staff member’s only reference, from their previous employer, was not positive. This meant inappropriate staff could be recruited to work with vulnerable people.

Staff were supported by a system of induction, training, some supervision and staff meetings. Appraisals had not taken place but there was a clear plan to address this in the near future.

The service held appropriate policies. However, some required review to ensure they provided staff with current guidance. Mandatory training was provided to all staff with regular updates provided.

The registered manager was supported by the provider and a team of motivated and long standing staff. The staff team were happy working at the service and told us morale was good. Staff told us, “I am happy here” and “We all work together, it can be difficult when we are short due to sickness though”

There were some quality assurance systems in place to monitor the standards of the care provided. Audits were carried out by the registered manager. This meant the service was seeking people’s views and experiences in order to improve the service provided.

Many improvements had been put in place at Benoni since the last comprehensive inspection. However, the registered manager had not identified the concerns found at this inspection.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) 2014. You can see the action we have told the provider to take at the end of this report.

There was a registered manager at the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

This unannounced focused inspection took place on 11 July 2017. The last comprehensive inspection took place on 28 April and 3 May 2017. We identified four breaches of the regulations at that inspection. The breaches related to staffing levels, the management of risk, lack of effective quality assurance processes and the poor condition of the premises. A warning notice was issued regarding the management of medicines, fire risk management, the provision of hot water and infection control issues. Statutory requirements were issued for the other breaches of the regulations. The provider sent the Care Quality Commission an action plan detailing how the service would meet the requirements of the regulations. We carried out this focused inspection to check on the action taken by the service to meet the requirements of the warning notice. The action taken to address the requirements will be reviewed at a comprehensive inspection at a later date.

This report only covers our finding in relation to “Is the service Safe”. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Benoni Nursing Home on our website at www.cqc.org.uk.

During this inspection we checked the services medicines systems. The management of prescribed medicines at Benoni had improved. Handwritten entries on the medicine management record were always signed by two staff to help ensure the risk of errors was reduced. Where people were prescribed pain relieving patches records were being kept consistently of where the patch was sited to help ensure it was always a different position on the person’s body.

However, we still found some errors. Staff were required to count medicines at each medicine round to ensure all were accounted for. The records for one medicine did not tally with the stock held. One person was on a prescribed medicine, which was monitored by a regular blood test. The result of this blood test led to frequent changes in the dose of the medicine. The records relating to this medicine did not show the person had received the correct dose of this medicine, according to advice from the GP. Prescribed creams continued to not be dated when opened. Regular medicine audits were now being carried out and showed some improvement in errors. However, the audits were not being entirely effective in identifying issues found at this inspection.

Although action had been taken to address the concerns in the warning notice about the safe management of medicines further improvements are required and the service remained in breach of the requirements of the regulations.

The service had now followed their own recommendation from the last infection control audit in 2016 which stated ‘liquid soap must not be topped up’ and that sealed cartridges of liquid soap should be used. We found new sealed cartridge soap dispensers were in place.

The maintenance person had been replaced at the service since the last inspection. Work had been carried out to ensure that hot water was available in all outlets at a safe temperature. Further work was planned to provide constant hot water to a staff toilet where it was found to be cold on the day of this inspection.

A large fan, without a guard, that was found in regular use at the top of the stairs at the last inspection had now been removed.

A Fire and Rescue Service report carried out in July 2016 had requested action to be taken to ensure the service was safe. This had not been done at the last inspection. A further inspection was requested in June 2017 which required the service to take specific actions. At this inspection we found an external fire service professional had been commissioned to carry out all the required improvements to Benoni to ensure it met the necessary fire service requirements. The service had carried out a fire risk assessment and regular drills and fire training were now in place for all staff.

The service will have the outstanding requirements reviewed at the next comprehensive inspection. At this inspection we found a continued breach of Regulation 17 of the Health and Social care act 2008 (Regulated activities) 2014.

Benoni is a nursing home which offers care and support for up to 25 predominantly older people with physical health needs, some of whom have a form of dementia. At the time of the inspection there were 25 people living at the service. Bedrooms were arranged over three floors. There was a communal lounge and a dining area on the ground floor. A lift assisted people to access the upper floors.

The service did not have a registered manager in post; however, the current manager had made an application to become registered with CQC. 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.

There were not sufficient staff available to meet people’s needs. We heard call bells ringing frequently throughout the day and observed lengthy periods when staff were unable to attend to people who had called them. For example, one person told us, ““I’ve asked for the commode over half an hour ago and I’m still waiting.”

People who used the service and staff who worked at Benoni all commented there were not enough staff to meet people’s needs. Comments included, “The staff are all very nice. But I do think they are understaffed. They are running around covering what they have to do but you won’t find many have time to stand and chat with you”, “The staff are very nice but very very busy” and “They are always short staffed it appears. Call bells are ringing all morning on and off.”

We had concerns with the way medicines were managed by the service. We found incidents when medicines had been signed as being given which were not in stock. For example, a person was prescribed one dose of a medicine which had been signed as being administered twice. Management told us this had taken place because the staff member had not referred to the medicine administration records while administering medicines. This meant the MARs records were not an accurate reflection of the medicines people had received.

Handwritten entries had not been signed by a member of staff or witnessed by a second member of staff. The strength of one medicine for a person had been crossed out and a handwritten amendment had been added. There was no authorisation or explanation for this change and the amendment was not double signed as a checking mechanism. This meant there was a potential risk of errors and people might not receive their medicines safely.

Where people were prescribed pain relieving patches we saw body maps were included with prescribing information. However, these were not consistently being used to indicate where patches had been placed. This meant there was a risk that concurrent patches could be placed on the same site which is not medically recommended.

Carpets in communal areas throughout the ground floor were badly stained and in need of replacement. We saw there were maintenance issues throughout the service. For example, there was damage to wood work around the walls in one person’s room, in another room a double electric plug socket was broken but still being used. We saw a rusty wall mounted corner unit in a bathroom and brown water stains on the ceiling in the lounge and two people’s bedrooms.

Care plans were personalised to the individual but did not consistently give clear details about each person’s specific needs For example, there was a lack of clear guidance about diabetes management recorded in care plans.

Details recorded in care plans about how people liked to be supported were not always consistent with what people told us. For example, one person said they would like to be able to be more mobile during the day. We looked at the care records for this person where it was recorded “Likes to stay in bed watching tv, has problems sitting out in chair – slides off.” This meant care plans did not always accurately and consistently reflect people’s choices.

Care plans were generally reviewed monthly or as people’s needs changed. We saw some care plan reviews had fallen behind the service time frame for review. People had not signed their care plan to state they consented to the contents.

Risks were not consistently identified, assessed and monitored for any changes. For example, we found one room had water at a temperature above what would be considered safe. There was no risk assessment in place for this.

People living at the service did not have access to sufficient meaningful activities to occupy their time. The service offered some activities such as music for health and armchair exercises on a monthly basis, however, people told us there were not regular activities offered. There was an activity board outside the lounge but this did not record any activities as planned for the week. There were no activities offered to people during the two day inspection. We observed people spent time in the communal lounge reading or watching television or in their rooms.

Staff were clear on how to report any concerns they may have regarding the safeguarding of people at the service.

Staff had recently been supported with supervision and appraisals. Staff said they felt supported by the manager. Comments included, “[Name] will fight your corner. She is supportive.”

Staff had attended mandatory training such as safeguarding, infection control and first aid. Nurses received clinical training for example about tissue viability. Some training specifically for nurses such as medication administration updates were required. Fire warden training had also been identified as being required.

The service was not entirely meeting the requirements of the Mental Capacity Act 2005, including the associated Deprivation of Liberty Safeguards. Where it was recorded that people living at the service did not have capacity to make their own decisions, it was not evidenced how staff came to this conclusion. We found people did not have mental capacity assessments in place and people had not routinely signed their consent to their care package. We found there was confusion about the correct process to follow when a person was unable to provide their consent. In some cases family members had signed in place of their relative without having the legal authorisation to do this. The manager told us they were aware that systems required further work in this area.

We had concerns about aspects of infection control management. The service had not followed the guidelines of their policy and procedure regarding replacement of liquid hand-wash that required the use of replacement sealed liquid soap cartridges. Staff told us they did not use single use cartridges and regularly topped up soap dispensers. This meant there was a risk of bacteria developing within soap dispensers and posed an infection risk.

Benoni did not have appropriate systems in place to assess, monitor and improve the quality of the service. Quality assurance audits were out of date. We found the fire safety regulations highlighted in a fire safety inspection in July 2014 had not been fully met.

We identified breaches of the regulations. You can see what action we have told the provider 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.

Accommodation was decorated, furnished and maintained to a satisfactory standard, although some areas were in need of upgrading. When we inspected the home was clean and odour free. A satisfactory system was generally in place regarding staff recruitment checks. Staffing levels and staff training standards were satisfactory. Quality assurance systems were satisfactory.

We saw people's privacy and dignity being respected and staff being helpful. We saw that residents were spoken with in an adult, attentive, respectful, and caring way. We saw and heard staff greeting people in passing, 'hello Mr *' or 'hello sir'.

Staff confirmed the training they had done and also confirmed that they were supervised. Staff said that they enjoyed working at Benoni Nursing Home.