We carried out an unannounced comprehensive inspection of this service on 14 and 15 April 2015 2015. Breaches of legal requirements were found in relation to staffing and records. Following the inspection, the provider wrote to us to say what they would do to meet these legal requirements. The provider informed us the final date by which they would have fully completed their action plan to ensure they met regulatory requirements was 18 October 2015.
In November 2015 the Care Quality Commission received information of concern about the effectiveness of infection control processes at the service. We undertook an unannounced comprehensive inspection of the service on 7, 8 and 9 December 2015. As part of the inspection we included infection control and checked to see if the provider had completed their action plan in relation to the previously identified breaches of regulatory requirements.
Quinta Nursing Home is registered to provide nursing care for up to 41 older people some of whom are living with dementia. At the time of the inspection there were 37 people living at the service.
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.
The service did not have a registered manager in post as required for this location; the provider had informed us on 7 September 2015 that the service was being run by the deputy manager. The provider intended that the deputy manager would become the manager of the location and submit an application to become the 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. We have asked the provider to ensure the previous registered manager submits an application to de-register as the registered manager of Quinta Nursing Home as required.
Most people told us staffing levels were still not sufficient to meet their needs. There had been a small increase in the number of care staff for people on each staff shift but there was still no system in place to demonstrate the adequacy of the staffing levels provided. There was a lack of sufficient staff to provide people’s care at the times it was needed for example, in the morning or at lunchtime. As a result records demonstrated some people were awoken at 05:30 and people who required support to eat their meal at lunchtime did not always receive timely support. There was a high use of agency staff and a high staff turnover which resulted in people receiving inconsistency in their care. Agency nurses were regularly in charge of the service at night, this meant the service at night was not always being run by nurses who were sufficiently familiar with the service and people’s needs. There was an insufficient level of management currently provided to ensure the service was well managed to ensure peoples’ safely.
Staff were receiving supervisions and staff appraisals had commenced. However, the provider was unable to demonstrate that all staff had completed the care industry standard induction requirements. Staff had still not all completed ongoing training to ensure they kept their knowledge and skills up to date. Staff still did not receive robust moving and handling training with an assessed practical element to ensure they could move people safely. The competency of nurses to carry out their role effectively had not been assessed. People were cared for by staff who had received insufficient training and induction into their role.
People’s records still did not always contain all of the required information to enable staff to provide people’s care safely and effectively.
The provider had not ensured people were protected from the risk of acquiring an infection. They had not ensured preventative measures were in place and robustly implemented, such as; thorough monitoring of staff practices to ensure they had followed infection control guidance. Regular and thorough cleaning of the service or the analysis of two incidents where people had acquired an infection were not in place to prevent a reoccurrence or spread of the infection.
Environmental risks to people had not been managed safely. Required checks in relation to water safety had not always been completed and where defects had been found they had not always been acted upon promptly to ensure people’s safety.
Staff had not ensured people could always reach their call bell or that they had a drink within reach. Staff had not always ensured people could access assistance as required for their safety and comfort. This meant people were at risk of not being able to access staff as required.
Most people told us the staff were good. Many staff were observed to interact positively with people; however, there was inconsistency in staff practice. People did not all experience positive relationships with staff. People were not all supported to make choices and not everyone had their privacy and dignity upheld. Not all staff knocked on people’s bedroom doors before entering. Not all staff ensured conversations with people about personal care were held in private. Staff did not always protect people’s dignity and privacy when providing their personal care. Staff did not consistently respect the fact they were working in peoples’ home and refrain from the use of mobile phones at work. Not all staff treated people with compassion.
Staff had not all received training on the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLs). As a result not all staff understood their role or responsibilities. There was a lack of evidence to demonstrate that where people lacked the capacity to make a decision an MCA assessment had been undertaken and a best interest decision made on their behalf. DoLs applications had been made for three people but there was no associated MCA assessment to demonstrate how the decision to make each application had been reached. The building was not secure for people who were subject to DoLs and mobile to ensure their safety. There were no door codes on the inside of the front door, so if people were mobile and wished to leave the building they could do so, which could place them at risk.
Since the last inspection only three areas of the service had been audited, in relation to infection control, medicine administration records and staff files. These audits had not identified all of the issues we found at this inspection which required action or improvement. Following completion of the audits there was a lack of resulting robust action plans to ensure improvements were made to the service for people and to ensure their safety.
The provider had not ensured that all of the required information was available for each member of staff in relation to their safe recruitment. The interim manager had completed an audit on 3 December 2015 and was aware of these discrepancies. However, there was no action plan in place yet to ensure to ensure this was addressed for people in order to demonstrate the suitability of staff for their role.
People and staff were generally supportive of the interim manager. People did not consistently provide positive feedback about the provider. Since the provider had terminated the registered manager’s contract in August 2015 there had been a lack of sufficient management for the service. The interim manager lacked the support of a deputy manager to enable them to carry out their role effectively.
Staff spoken with were not aware that the provider had a set of values. We requested a copy of the provider’s values but these were not provided. Staff behaviour was not always consistent with their duty of care towards people. Staff had taken unauthorised leave which resulted in some shifts not being adequately staffed. The staff rota was not managed at a local level to ensure an effective organisation of staff shifts so that the staff roster was operated smoothly and efficiently for people.
People’s relatives had been encouraged to participate in reviews of their care. However, their involvement was not always evident from people’s care records. Some people’s care records had not been reviewed as regularly as required by the provider. Staff received a verbal handover between shifts and a written handover sheet. However, this did not contain all of the information staff needed in order to provide people’s care safely and effectively.
Staff were focused on the practical delivery of people’s care. There were a range of activities available to people, however, these were not based on people’s assessed needs and interests.
People received their medicines safely. Medicines had been stored safely. People’s medicines were administered to them by staff who sought their consent prior to administration.
People told us they felt safe. Most staff had completed safeguarding training and understood their role and responsibilities. Safeguarding alerts had been made to the relevant agency as required. Staff had access to relevant safeguarding guidance.
People told us they were satisfied with the food available, which looked and smelt appetising. Staff knew who had specific dietary requirements and these were met. The risks to people from weight loss had been assessed. People were supported to access health care services in response to their assessed needs.
There was a complaints process and people’s complaints had been responded to.
We found two continuing and three new breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.