Archived: Clinton House Nursing Home

The service is required to have a registered manager and there was one in place. However, the registered manager had been on maternity leave since August 2016. A temporary manager had covered the role for the first six weeks and another manager had been appointed nine days before our 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.

We carried out this unannounced comprehensive inspection of Clinton House Nursing Home on 1 November 2016. We brought forward the planned comprehensive inspection due to concerns that had been raised with us. These concerns related to the premises and equipment, the quality of the food, lack of activities, poor care practices, staff working without the relevant recruitment checks, staff training and medicines. At this inspection we also checked to see if the service had made the required improvements identified at the inspection of 7 April 2016.

In April 2016 we found the premises and equipment were not properly maintained. We found there was hot water at 50 degrees centigrade coming from two taps in bathrooms used by people who lived at the service. At a previous inspection in February 2016 we had also found water that was too hot coming from a different tap used by people living at the service. At this inspection we found another two taps with water coming from them that was too hot. This posed an on-going risk of people scalding themselves that had not been adequately addressed by the provider, despite being asked to rectify these issues at two previous inspections.

We also found at this inspection that there was no hot water coming from sinks in the laundry room for staff to wash their hands. There were several toilets and bathrooms, used by people living at the service, with no soap or paper towels. This meant people, visitors and staff were unable to wash their hands effectively after using the toilet.

At the inspections in April 2016 we had concerns about poor recording and missing records, of the information given to staff when they started a shift. We had raised the same concerns at previous inspections in February 2016 and October 2015. This meant it was difficult to establish what information had been provided for staff at each shift change to ensure they had the right information to meet people’s needs. At this inspection we were able to see records of daily handover meetings. The information in these records was basic, although staff told us they were given detailed verbal handovers. However, on the day of the inspection an agency worker asked repeatedly during the morning if they could have a handover as they did not know what peoples’ needs were. This meant the system for providing staff with information about people’s needs at each shift was still not robust.

The care we saw provided to people during the inspection was often task orientated rather than in response to each person’s individual needs. Care plans did not always give staff guidance about how to provide the appropriate care to meet people’s needs. People were not always referred to appropriate healthcare professionals in a timely manner. This mean relevant treatment to help people was delayed. The high reliance of the service on bank and agency workers meant that people did not always receive care from staff who knew and understood their needs. There were gaps in staff training and supervision which meant staff were not fully trained or supported in their role.

Recruitment practices were not safe. Relevant employment checks, including Disclosure and Barring Service (DBS), were not completed before new staff started to care for people. The failure to complete necessary checks before allowing staff to provide care exposed people to unnecessary risk and did not protect people from the potential risk of harm from being supported by staff who were not suitable for the role. There were not always enough staff on duty to adequately meet people’s needs. Staffing levels were frequently lower that the level assessed by the service as being the number of staff needed to meet people’s needs. People did not always receive assistance in a timely manner. The call bell system was faulty and difficult for new staff to understand, which could cause delays in people receiving help.

The management of medicines was not robust. One person had not been given one of their prescribed medicines for three days. Records as to why this omission had occurred stated that the medicine was ‘out of stock’. However, it came to light on the day of the inspection that this medicine had ‘gone missing’. This meant that the person had missed three doses of their prescribed medicine and 17 tablets of Mirtazapine were unaccounted for. Records to explain this incident were inaccurate. Some people had been prescribed creams and these had not been dated upon opening and not always recorded when applied. We found creams in people’s rooms that belonged to other people. This demonstrated that prescribed creams were being shared between people.

Risks were not always identified and detailed assessments of how risks could be minimised put in place. On the day of the inspection one person nearly fell out of their wheelchair while sitting unattended. We had to intervene and ask staff to assist as they had not noticed. Records for this person showed that they were at risk of falls. However, no risk assessment had been completed to give guidance for staff or to assess the risk of them being left unattended in their wheelchair. This meant staff did not have accurate information to help ensure people were not at risk of harm.

We found management and staff were not working within the principles of the MCA. Staff were not clear on who was authorised to consent on behalf of people. The service did not fully understand DoLS legislation and how it should be applied.

The provider has overall responsibility for the quality of management in the service and the delivery of care to people using the service. The provider has repeatedly not achieved this at Clinton House Nursing Home and has been rated as Requires Improvement since the first rated inspection carried out in December 2014. The Care Quality Commission has carried out six inspections (including this one) of the service since December 2014. At each inspection there have been breaches of the regulations.

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.

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.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. 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 this inspection the Care Quality Commission received information of concern relating to people not always having their care needs met. Concerns had also been raised about staffing levels and some aspects of the premises at Clinton House. We carried out this focused inspection to check on the actions taken by the service to meet the requirements of the regulations and to follow up on the information of concern received.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clinton House on our website at www.cqc.org.uk

Clinton House is a care home which offers care and support for up to 46 predominantly older people. At the time of the inspection there were 30 people living at the service. Some of these people were living with dementia. The building is a detached house over two floors with a recently added extension on the ground floor comprising of five new en suite rooms. Clinton House is part of the Morleigh Group of homes.

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. The registered manager for Clinton House was working at a different service in the Morleigh Group. The manager working at Clinton House at the time of this inspection was the registered manager from another service in the group. This manager was in the process of applying to be the registered manager for Clinton House.

At the February 2016 inspection we found prescribed creams were not always dated when started and not always stored safely. A recent external pharmacy audit highlighted concerns which remained since the last audit which produced actions that needed to be taken a year before. Medicines for disposal were not stored in accordance with the advice given in January 2016. Out of date blood bottles and needles had not been disposed of. The medicine policy used at the service needed to be reviewed.

At this inspection the manager was unaware of any outstanding actions relating to the external pharmacy audit. The pharmacist told us they were unaware of any actions that had been taken by the service since the last Medicine Advice Visit in January 2016. We found prescribed creams were mostly dated upon opening and were stored safely. All items stored in the medicines room were regularly checked to help ensure any item which was out of date was removed. The medicine policy had been fully reviewed since the last inspection.

At the February 2016 inspection we found hot water recorded at 50 degrees centigrade coming from a tap in a toilet used by people who lived at the service. Hot water at this temperature risks scalding people. There were incontinence odours at the service. Equipment had been left in corridors which posed a risk to people using the corridors. Inspection of the premises and equipment used at the service was not reviewed effectively in order to identify any defects or faults.

At this inspection we again found there was hot water recorded at 50 degrees centigrade coming from two taps on the first floor, which were used by people who lived at the service. This continued to pose a scald risk to people using the hot water. Checks were regularly carried out on pressure relieving mattresses. However, some of these records contained errors. There were no incontinence odours at the service at this inspection. There was no unused or inappropriate equipment found in corridors at the service.

At the February 2016 people’s food and drink intake was mostly recorded but not monitored. This meant action was not always taken to address any reduction in a person’s intake. Guidance provided for staff about people’s needs was not always accurate.

At this inspection we found staff were effectively recording what people ate and drank. The total amount of food and drink taken by a person was totalled each 24 hours. However, these amounts were not always accurate.

At the February 2016 inspection a written complaint made to the new manager, three weeks before the inspection, had not been investigated, responded to or recorded in the complaints record. At this inspection we found that complaint had been fully responded to and resolved. There had been another concern raised to the service and the local authority, since our last inspection. A full investigation had been carried out regarding this concern.

At the February 2016 inspection we found moving and handling slings and net pants, used by people to secure their continence products were unnamed and shared communally. People were being weighed openly in the lounge in front of other people that used the service. We also saw uncovered hot food given to a person then left for 25 minutes before staff arrived to support the person with eating their meal. These examples of poor practice did not protect people’s dignity.

At this inspection we were told new moving and handling slings had been purchased, named and allocated to each person who required such equipment. We found numbered slings in corridors and lounge areas which indicated some were continuing to be shared. Staff told us people were no longer being weighed in the communal lounge, and this was now taking place in private. People who chose to eat in their rooms were supported as necessary by staff who delivered the food.

At the last inspection we found guidance in care plans was being followed by staff. However, some guidance was not clear. We also found people’s confidential care records were not held securely at the service. Handover records for shift changes that had taken place since 25 January 2016 were not found. The handover records we saw were often not dated. This meant it was difficult to establish what information had been shared by staff at shift handovers.

At this inspection we found guidance provided for staff in care plans, about people’s needs, had been improved since the last inspection. However, we did identify two people whose needs had not always been effectively met by the service. People’s confidential care records were found to be securely stored at this inspection. We identified some instances of poor communication between the staff shifts. As found at the last inspection handovers sheets had not been dated and did not contain sufficient information to inform each shift.

The service had notified the Care Quality Commission prior to this inspection that they were having difficulty covering nursing shifts at the service. We were told there were six care staff on in the mornings with five in the afternoons and two at night. Each shift was supported by one nurse. We checked the staffing rotas held at the service at this inspection. The staff rotas were not always accurate.

The provider had made some improvements since the last inspection. However, we found continuing concerns remained.

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.

This report only covers our findings in relation to these topics. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Clinton House on our website at www.cqc.org.uk

Clinton House is a care home which offers care and support for up to 46 predominantly older people. At the time of the inspection there were 30 people living at the service. Some of these people were living with dementia. The building is a detached house over two floors with a

recently added extension on the ground floor comprising of five new en suite rooms.

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. The service did not have a registered manager in post. The manager who was previously applying to be the registered manager at our last inspection had been moved to another service in the group. However, there was a new manager in post at this inspection, who had now applied to become the registered manager. The new manager present at this inspection had been in post since November 2015.

At the last inspection we found medicines storage, recording and administration was not entirely safe. Care plans did not always provide staff with clear guidance on how to respond to risks and help reduce them. Accidents and incidents that took place in the service were not always recorded by staff in people’s records. The safeguarding adults policy did not contain the contact details of the local authority or the Care Quality Commission to assist people in raising any concerns they may have.

At this inspection we found some improvements had been made to the recording and administration of medicines. There were no gaps in the Medicine Administration Records (MAR) or handwritten entries of the MAR. Medicines that required stricter controls were recorded accurately and the records balanced with the stocks held. The cold storage of medicines was being monitored daily and was within safe limits. However, creams were not always recorded when started and not always stored safely. A recent external pharmacy audit highlighted concerns which remained since the last audit which produced actions that needed to be taken a year before. Medicines for disposal were not stored in accordance with advice given in January 2016. Out of date blood bottles and needles were found.

Accidents and incidents were recorded by staff in people’s records and these incidents were audited by the new manager. Care plans showed that where a risk had been identified there was guidance for staff on how to support people appropriately in order to minimize risk and keep people safe. The safeguarding adults policy had been reviewed and updated appropriately. However, we found hot water recorded at 50 degrees centigrade coming from a tap in a toilet used by people who lived at the service. Hot water at this temperature risks scalding people.

At the last inspection we found incontinence odours were present at the service. People’s care records were not stored securely. Equipment was found lying in corridors such as TV’s, parts of a bed rail, a mattress pump unnamed continence products and a broken call bell. This posed a risk to people using the corridors. Complaints made about the service were not always recorded and responded to in line with the complaint policy.

At this inspection we found some incontinence odours remained. This was mainly due to staff not disposing of bed pans and pads effectively. Unnamed continence products for communal use had been removed from bathrooms and toilets. Equipment left in corridors was reduced but some remained. Sharp scissors were found in a bag, in a corridor continuously used by a person living at the service who was confused. The premises and equipment used at the service was not reviewed effectively in order to identify any defects or faults. People’s food and drink intake was recorded but not monitored. This meant action was not always taken to address any reduction in a person’s intake. Guidance provided for staff about people’s needs was not always accurate. A written complaint made to the new manager three weeks before this inspection had not been investigated, responded to or recorded in the complaints record.

At the last inspection we found that moving and handling slings and net pants, used by people to secure their continence products were unnamed and shared communally. At this inspection we found this practice had continued. In addition, we saw that people were being weighed openly in front of other people that used the service in a communal lounge. We also saw uncovered hot food given to a person and then left for 25 minutes before staff arrived to support the person with eating their meal. These examples of poor practice did not protect people’s dignity.

At the last inspection we found people’s care needs were not always met. People were not always re positioned according to the guidance in their care plans. At this inspection we found guidance in care plans was being followed by staff. However, some guidance was not clear. For example, one care plan stated ‘turn regularly.’ This did not provide specific directions to staff about how often to help each person to move to ensure people would not be at risk from pressure damage to their skin. Another care plan stated a person ‘disliked baths’ and then later in the same care plan it stated they liked baths twice a week.

At the last inspection we found people’s confidential care records were not held securely at the service. At this inspection we found this concern remained. The service had fitted a lock to the door of the office where care plans were stored, however, this door was propped open throughout the inspection and was regularly unattended.

At the last inspection ‘Taster’ days were offered to potential new staff who had not done care work before to give them a clear idea of the role before applying. There were no processes or safeguards in place to ensure the people who did ‘taster’ days would respect people’s right to privacy. This meant there was a potential risk of a breach of confidentiality when the person who had done the ‘taster’ day left the service. At this inspection people attending ‘taster’ days were required to sign a confidentiality agreement. People were strictly supervised and shadowed an experienced member of staff during their shift. During this inspection we saw a person was having a ‘taster’ day and they confirmed they had signed a code of confidentiality document and were always under supervision.

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.

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, their relatives, the staff supporting them and from looking at records. If you want to see the evidence to support our summary please read the full report.

Is the service safe?

People were treated with dignity and respect by staff. We spoke with four people living in the home and they told us they felt safe living there. We found care plans were informative and personalised to the individual, reflected people’s needs and were regularly reviewed.

There were enough staff on duty to meet the needs of the people living at the home. One visitor we spoke with told us they had previously raised concerns about staffing levels, but felt the levels had increased.

Incidents and accidents were recorded and learning from these events was used to change practice to reduce the risk of harm to people.

People who used the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Staff understood the signs of abuse and how to raise concerns with the right person when those signs were noticed.

Clinton House had policies and procedures in relation to the Mental Capacity Act 2005 (MCA) and the associated Deprivation of Liberty Safeguards (DOLS). There was evidence the home considered the impact of any restrictions put in place for people that might need to be authorised under the Deprivation of Liberty Safeguards.

Is the service effective?

During our inspection we observed staff caring for people. It was clear from our observations and from speaking with staff, and relatives of people who used the service, that staff had a good understanding of people’s needs.

People’s health and care needs were assessed and mobility and equipment needs had been identified in where required. Staff we spoke with and observed showed they had good knowledge of the people they supported.

We spoke with two visitors and they confirmed they were able to visit the home whenever they wished and the home kept them informed of any changes to their relative. One visitor told us: “They [the home] keep in touch with us”.

Is the service caring?

People’s individual care plans recorded their choices and preferred routines for assistance with their personal care and daily living. We saw staff provided support in accordance with people’s wishes.

We spoke with four care staff, four people who used the service, two visitors and observed staff interaction throughout our inspection. People we spoke with told us staff were caring and attentive to their needs. People told us: “they [staff] will do anything I want” and “staff are friendly”. We observed staff responding to people in a kind and caring manner.

Is the service responsive?

The home provided some regular group activities such as karaoke, nail and beauty sessions and a visiting hairdresser. The manager told us a new and more individualised activity programme was being developed. Most people we spoke with did not express a view about the activities on offer. One person told us: “there is not enough to do, but there is not a lot I can do now, staff put me where I like to be to watch outside”.

Clinton House gave clear information to people about how to complain. We looked at the home’s complaints policy and saw a copy of the complaints procedure in the entrance hall of the home. Visitors told us they knew how to complain and when they had raised any concerns these had been listened to and acted upon.

Is the service well-led?

The home worked with external health professionals to ensure people’s health needs were met. This included community nurses and GPs.

The provider had not fully implemented an effective system to regularly assess and monitor the quality of service that people received. The provider did not have a system in place to ask people who used the service for their views about their care and treatment.

As a result we were not assured that the quality of the service provided to people was continuingly improving. We have asked the provider to tell us what actions they intend to take to meet the requirements of the law in relation to quality assurance.

Some of the people who lived at Clinton House Nursing Home had a form of dementia and therefore could not always tell us about their experiences. To help us to understand the experiences people had we used our SOFI (Short Observational Framework for Inspection) tool. The SOFI tool allowed us to spend time watching what was happening in a service and helped us to record how people spent their time, the type of support they got and whether they had positive experiences.

We saw people’s privacy and dignity was not always being maintained. People we spoke with told us the staff were “very nice” and; “I find it very nice indeed”. When asked how long they waited for their bell to be answered one person said “they [the staff] will come eventually, depends what they are doing”. We did overhear some staff talking about people’s health and wellbeing in earshot of other people who used the service.

We saw care plans were detailed and generally gave direction as to the care and support people needed. They had been regularly reviewed, but we found some care plans did not reflect the care and support that people currently needed. We saw they were not always developed and reviewed with the person who was using the service and /or their relatives, where appropriate.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

On the day of the inspection there were enough staff to meet people’s needs. We saw staff had the time to maintain a person’s independence, for example, by explaining where the toilet was, when they asked, instead of taking them to it.

People were cared for by staff who were adequately supported to deliver care and treatment safely and to an appropriate standard.

This was a planned inspection bought forward due to three safeguarding concerns being raised with Adult Care, Health & Well-being (formerly Adult Social Care) since May 2013.The concerns included staff access to the kitchen after 5 pm, small meals, cold meals and drinks for people who were being looked after in their rooms, poor language skills of people whose first language was not English, poor staffing levels and issues around security of the home.

We saw care plans were detailed and gave direction as to the care and support people needed. They had been regularly reviewed.

We saw there was food available to make snacks for people, once the kitchen staff had left at 6 pm. Most people told us they liked the meals they were offered and the portion sizes were adequate for them.

We saw staff were always busy. We were told they were currently only just managing to meet people’s needs. Support systems in place such as one to one meetings were not being used consistently due to lack of time.

Care plans and associated documentation were in place. They were detailed enough to direct and guide staff of the action they needed to take in order to meet people’s assessed care needs. People's records were personalised, and showed choices were made by people in respect of their daily lives.

People were protected against the risks associated with medicines because the provider had appropriate arrangements in place to manage medicines.

People were protected from unsafe or unsuitable equipment. The home had sufficient and appropriate equipment to meet people's assessed needs.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.