This inspection took place on 14, 15 and 21 October 2014. This was an unannounced inspection, which meant that the staff and provider did not know that we would be visiting.
Lindisfarne CLS Nursing provides nursing and personal care for up to 56 service users. The home is arranged over two floors, both of which cater for people with dementia type illness with the first floor providing services for males only. During our inspection on 14, 15 and 21 October 2014 there were 29 service users at the home, 14 of whom were accommodated on the first floor.
The provider is required to have a registered manager at this home as condition of their registration. 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. Although we found that the provider had appointed an acting manager, when we visited on 14, 15 and 21 October 2014 there was not a registered manager in place nor had CQC received an application for a manager to be registered at this home since November 2013.
At our previous inspection carried out on 9, 10, 22, 24, 29, 30 July and 7 August 2014 we found the home was in breach of the following:
Regulation 9, Care and welfare of service users,
Regulation 11, Safeguarding service users from abuse,
Regulation 12, Cleanliness and infection control,
Regulation 15, Safety and suitability of premises,
Regulation 20, Records.
The provider was issued with a Warning Notice in respect of each of these areas.
At this inspection we found that improvements had not been made to meet these requirements and Lindisfarne CLS Nursing was inadequate in all areas we inspected.
We looked at guidance for providers in dementia care including the following:-
- The National Institute for Care Excellence (NICE) ‘Dementia Supporting people with dementia and their carer’s in health and social care 2006;
- Alzheimer’s Society Fact Sheet 2013. Staying Involved and Active
- The Health and Social Care Act 2008; Code of Practice on the prevention and control of infections and related guidance’ and
- The NICE guidelines ‘Pressure ulcers: prevention and management of pressure ulcers 2014’
The provider had failed to take account of this guidance.
We found peoples care and welfare needs were not properly met at this home. People who had dementia care needs did not have them properly met at the home. For example people who displayed behaviours which challenged staff or other service users because of their dementia type illness were not supported by staff in a consistent or well-planned way. Detailed intervention plans for when people became agitated were not in place and best practice guidelines to help avoid these circumstances were not considered. Medicines that have a sedative effect on people were found to be used in some circumstances without guidance or sufficient agreed practice to safeguard and protect service users’ rights.
Responses, strategies and preventative measures for people who had become sexually disinhibited because of their dementia type illness were not in place at the home. There were no detailed or organised plans in place for people who were likely to display these behaviours placing them and others at risk.
People were at risk of poor nursing care at the home. Nurses did not demonstrate that they had an understanding of peoples nursing care needs or were taking actions to meet them. For example some people had pressure ulcers but nurses on duty did not know this and their care plan records gave inconsistent and contradictory information. Some people at the home had life limiting or multiple illnesses but nursing staff did not know about them; did not know what impact this had on their daily needs; nor did they have packages of care in place to support these needs.
Some people required support with their diet so that they could remain as healthy as possible. Care planning for people who needed support with their diets was not sufficiently detailed or was contradictory. The weight and condition of people with dietary needs was not routinely measured to make sure support was working or not and kitchen staff were not involved in supporting people with these needs. Nursing staff also omitted to make sure peoples’ nutritional support medicine was available and in stock at the home.
We found that peoples’ mental health care needs were not understood or supported at the home. For example if people had been subject to treatment and support under the Mental Health Act 1983 the provider did not carry out an assessment of their mental health needs or demonstrate their best interests, rights or care and welfare were protected at the home. Staff were not aware of which people in the home were subject to detention under this Act.
Staff recruitment procedures at the home were not safe. Recruitment records at the home did not demonstrate that service users were protected from those who were unsuitable to work with vulnerable people. For example thorough background checks, including those to make sure applicants had not been legally barred from working with vulnerable adults or children had not been carried out; nurses legal status (registration with professional bodies); and if people from abroad were eligible to work were not checked.
Staff deployment was inconsistent or inaccurate, for example some staff were recorded on the homes rota as working there but in practice were regularly working at another home. We found that the and the provider also failed to regularly assess the needs of service users in relation to overall staffing levels and monitor the services provided. For example we found one nurse and two care staff were allocated to look after 29 service users who had both nursing needs and displayed challenging behaviour. Key staff were also inappropriately organised at the home. For example the home required deployment of nurses who had both mental health and general nursing qualifications all times but the staff rota did not ensure staff with these skills were on duty.
Staff training records had not been compiled and ordered. The provider could not demonstrate the level of training staff had received or how this met the needs of the home or service users. Training in key areas such as how to support people with behaviours that challenge staff or other service users, could not be demonstrated.
The provider did not take measures to safeguard service users who were likely to harm themselves or place themselves in situations which may cause them serious injury or risk of death. For example we found two serious incidents had taken place where the provider had failed to put in measures to reduce the likelihood of harm. We made a safeguarding alert to Durham County Council during the inspection as we were concerned about the provider failing to protect one person’s health.
We found that people were not protected from the risk of infection. Furniture, equipment and surroundings of bedrooms and communal areas were not properly cleaned and there was poor odour control. We found that in a significant number of areas of the home appropriate standards of cleanliness and hygiene were not maintained. This demonstrated that cleaning had not been carried out effectively other procedures used at the home placed service users at risk of infection.
There was a lack of adequate maintenance to the home which meant that service users were not protected against the risk of unsuitable or unsafe premises. For example mobility aids were insecure, furniture was in danger of falling on people, windows did not work properly and refurbishment work had not been completed. One person’s bedroom fire door did not close properly putting them at risk if there was a fire. Combustible materials were being stored in the stair well emergency exit which could have become blocked in the event of a fire. Fire evacuation plans were unsafe and neither the nurse in charge nor care staff knew what to do in an emergency.
The provider did not effectively assess and monitor the quality of the home to make sure it was safe, effective and meeting the homes ‘Statement of Purpose’. The home had a ‘Quality Assurance Policy’ but both the acting manager and area manager could find ‘nothing in place.’ Other areas of monitoring such as the frequency of accidents and incidents and the measures to reduce risks to people living at the home could also not be found. An annual plan to ensure a quality service and residents and relatives surveys were not carried out.
Complaints at the home had not been handled properly. For example responses to complaints by a relative had not been made and this was not recorded in the homes complaints file.
Other monitoring of the home had not taken place. For example, at the July 2014 inspection we made the provider aware that the ambient room temperature of the home were excessive. At this inspection we found the home to be again excessively warm however no monitoring had taken place and no remedial action had been taken to ensure the ambient temperature of the home remained in line within Health and Safety guidelines.
We found that the provider failed to make improvements to the quality and safety of services for people at the home. The provider did not take action following a CQC inspection on 9, 10, 22, 24, 29, 30 July and 7 August 2014 where the home was found to be in breach of five regulations and people using the service were found to be at risk despite Warning Notices being issued. The provider did not act in a timely fashion to achieve compliance, meet service users’ needs and adequately protect them from receiving poor care. Although the provider had taken steps to appoint an acting manager and area manager, approximately five weeks before this inspection, their impact on the service was limited and we found the provider remained in breach of regulations which warranted further enforcement action to be considered.
The provider did not have key policies in place which would support staff to take effective measures to care for people being accommodated at the home at the home. For example the homes response to incidents where staff were required to restrain service users for their own safety were not supported by clear policy and procedural guidance.
We found there were multiple of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We are taking action in line with our enforcement policy outside of this inspection process.