The inspection took place on 20 March 2018, 21 March 2018, and 26 March 2018 and was unannounced. Furzehatt is a care home. 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.
Furzehatt Residential and Nursing Home is divided into two units. The residential and nursing unit are situated within the same building and divided by a reception area at the main entrance. The nursing unit provides nursing care for a maximum of 32 people and the residential unit supports a maximum of 29 people. At the time of the inspection 28 people were being supported on the nursing unit and 18 people within the residential part of the service.
There was a management structure in place. The service had a registered manager. 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.
At the last inspection on the 14 and 15 April 2016, we rated the service as Good overall. At this inspection we rated the service as Requires Improvement. This is because systems were not always in place to keep people safe, this included, medicines, risk management, and incident reporting. Staff were not always provided with sufficient information to meet people’s needs consistently and safely. Quality Audits had not been effective in identifying concerns we found at this inspection. The quality of care across the service was not always consistent.
Prior to the inspection we had received concerns from the local authority safeguarding team, regarding people’s care at the service. A safeguarding meeting had taken place with the local authority prior to the inspection and we were told a number of safeguarding investigations in relation to these areas of concern were on-going and therefore not concluded at the time of the inspection. We did not look at these specific investigations as part of the inspection, however, we did use this information to inform us about how we needed to conduct the inspection and areas of care we needed to consider and review.
The local authority had also informed us prior to the inspection, that due to the high number of concerns received, they had met with the provider and requested an improvement plan and assurances about people’s safety. Due to the concerns the local authority had agreed a suspension on all residential and nursing placements, whilst investigations were ongoing and improvements made. At the inspection the registered manager confirmed these suspension arrangements, and that they also would not admit any privately funded people during this time.
The Care Quality Commission had also spoken to the registered manager and written to the registered provider on two occasions since the last inspection about concerns raised by relatives about people’s care and medicine issues in the home. The registered manager and registered provider had responded to requests for information about these concerns at the time and had provided us with assurances about people’s safety. However, despite these assurances issues relating to people’s safety were found during this inspection.
During this inspection we found inconsistencies in systems and the quality of care provided across the service. When concerns we found related to a particular part of the service, we have reported on this by referring to either the nursing or residential unit. This information can be found within the full version of the report.
At this inspection we found people were not always safe. People did not always receive medicines in a way they were prescribed and staff did not always have guidance to follow to help them decide when certain medicines needed to be given. Systems were in place to report medicines incidents, however, staff were not in all cases clear about the type of medicines incident they should report. Some incidents relating to medicines such as a missed dose, or refusal by a person to take medicines had not been documented as an incident. This meant the service did not in all cases have an oversight of medicines incidents to enable them to review if appropriate action had been taken and to consider patterns and lessons learned. The medicines related concerns found during the inspection had not in all cases been picked up as part of the homes medicines audits and other quality assurance
We saw a number of good examples of risks to people being identified, reported and well managed. However, the quality of information relating to risks associated with people’s care was not consistent across the service. For example, when risks had been identified staff did not always have the information they needed to help ensure the risk was managed consistently and in a way the person needed and preferred.
Systems were in place for staff to report and escalate incidents. However, these had not in all cases been followed by staff to ensure people’s health and well-being was protected. For example, during the inspection one person’s health had deteriorated and medicines prescribed to the person had failed to be delivered by the pharmacist. The person’s health deteriorated significantly over a twenty four hour period resulting in the need for an emergency hospital admission. Staff had failed to effectively escalate this incident and to ensure the person’s health needs were met in a timely manner. This incident was reported to the registered manager at the time of the inspection.
People did have access to a range of healthcare services. However, care plans did not in all cases provide staff with sufficient information about how people’s specific healthcare needs should be met. This meant there was a risk of people’s healthcare needs not being met consistently by the service. Systems were in place to monitor people’s health, such as food and fluid charts, skin monitoring and repositioning charts and weight monitoring forms.
A programme of audits was in place. These checks were undertaken by the registered manager, staff and the registered provider, and included audits of medicines, records and the environment. However, these checks had not identified concerns found during our inspection, particularly in relation to medicines, risk management, incidents and care planning. For example, checks and audits were in place to review medicines and although the registered manager and provider had assured us improvements had been made to the medicine management systems, medicines errors and inconsistencies were still found.
Following the inspection we took immediate action to ensure people were safe. We told the provider to provide assurances that people were safe in relation to medicines, management of risk and the escalation of incidents. The provider sent us assurances within the timescale requested, this included a plan to review care plans and risk assessments, to provide updated medicines training for staff on the residential unit and to provide training on incidents and the escalation of concerns. This action satisfied us that immediate concerns relating to people’s safety had been addressed.
People’s care plans were not in all cases personalised, and did not always provide staff with sufficient information about people’s routines and how they chose and preferred to be supported. Although people’s plans of care were reviewed at regular intervals or if needs changed, information was not in all cases updated to reflect these reviews and changes. This meant staff did not always have access to clear and accurate information about people’s needs.
Staff undertook a range of training and said they felt supported by their colleagues and management. However, some staff on the residential unit said some training was not in-depth enough to reflect the complexity of people’s needs, such as supporting people living with dementia. Following the inspection the provider sent an action plan to address immediate concerns we had found relating to people’s safety and management of risk. The plan included an action to provide staff with additional training in relation to caring for people with dementia and associated behaviours.
People, relatives and staff spoke positively about the registered manager. Comments included; “The manager is approachable, they always stop and say hello”, and “If I have any concerns I speak to the manager and they would usually sort it”. However, some staff and visiting healthcare professionals said the management and quality of care was at times inconsistent across the service. Comments included, “Roles and responsibilities are not always clear at weekends and evenings”, and “Systems and processes between the residential and nursing unit are so different, which isn’t helpful if you have to work between the two”. Two visiting health care professionals said staff worked hard and wanted to meet people’s needs effectively. However, they said care was sometimes inconsistent, “Some people received good care, and other aspects of care could be neglectful, I think this is about the management of the home”.
We received mixed views from people and staff about staffing levels and how staff were organised. Some said staff were available in sufficient numbers to meet people’s needs and to keep them safe, comments included, “ There are always staff around and they are always quick to help me if needed” whilst others said they did not always feel there were enough staff particularly when people wandered and needed close supervision. One person said, “I don’t want to stay in the lounge sometimes as I feel vulnerable and I get worried about others when staff are not around”.
People were supported by staff who cared and respected their privacy and dignity. We saw staff responding promptly and with compassion when people were distressed or felt unwell. Staff wer