Harewood Court Nursing Home

Harewood Court Nursing Home is a residential care home providing personal and nursing care to up to 40 people aged 65 and over. At the time of our inspection there were 36 people using the service. The home accommodates people across 2 floors, each of which has separate adapted facilities.

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

The provider assured us there was a sufficient number of staff on each shift, however at times we observed no people in communal areas. Risks around behaviours had not been managed. There was a lack of records in place to record fluid and food intake of people assessed at risk of weight loss. People were protected from abuse and staff understood the principles of safeguarding. There was a clear system in place to respond to incidents.

Preferences and choices were reflected in people’s care plans. Staff completed a wide range of training. People were supported to access healthcare services as needed. People were able to request what they wanted to eat. Staff knew how to respond and deal with any concerns.

There was a positive culture within the service. A number of audits were completed at the service. Satisfaction surveys were completed, and actions were devised in response to any concerns. People had access to appropriate health professionals when needed.

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.

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

Rating at last inspection and update

The last rating for this service was good (published 20 January 2020).

Why we inspected

This inspection was prompted by a review of the information we held about this service.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Harewood Court Nursing Home on our website at www.cqc.org.uk.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.

We were assured that this service met good infection prevention and control guidelines.

Staff were trained on how to keep people safe from the risk of infection. However, during the inspection not all staff wore their PPE in line with government guidance this was discussed with the registered manager at the time of the inspection. Following the inspection, the registered manager confirmed they had spoken to staff and established there was an issue with the fit of the masks. The registered manager removed all defective masks and provided evidence of observing staff wearing masks correctly.

The home was clean and tidy however, cleaning records had not always been completed. This was discussed with the registered manager who took immediate action to address concerns. Following the inspection the registered manager provided evidence of amended daily cleaning schedules which allowed for staff to document when they had wiped down areas throughout the day.

At the time of our inspection the home was allowing visitors and there were protocols in place to reduce the risk of infection.

The provider had appropriate arrangements to test people and staff for COVID- 19 and was following government guidance on testing.

People admitted to the service were supported following government guidelines on managing new admissions during the COVID-19 pandemic.

The home's infection prevention and control policy was up to date and in line with current guidance. The home had a contingency plan in place for when emergencies occurred.

Harewood Court Nursing Home provides nursing and personal care for a maximum of 40 older people, some of whom are living with dementia. At the time of our inspection there were 32 people living at the service.

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

Overall, the provider maintained appropriate staffing levels to ensure people's needs could be met safely. We have made a recommendation that the provider continues to monitor sufficiency of staffing. Robust recruitment procedures ensured suitable staff were employed. People were supported by staff who understood how to identify and report potential abuse. Medicines were managed so people received their medicines as prescribed. People told us they felt safe and risks to people’s health and safety were managed well. When accidents or incidents occurred, learning was identified to reduce the risk of them happening again.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People had the support they needed to maintain a balanced diet and good health. Staff received training and support to give them the knowledge and skills needed to care for people safely and effectively.

Staff promoted positive, caring relationships with the people who lived at the service. They knew how people preferred their care and support to be provided. Staff respected people’s privacy and dignity and promoted independence, equality and diversity. People and their relatives were involved in the planning and delivery of their care.

People had access to a good range of activities and told us they enjoyed these. People's care plans were individualised and supported a person-centred approach. Staff said they read and followed these. People's wishes regarding their end of life care were established, so these could be addressed at the appropriate time. People and relatives were confident to raise issues and concerns. Complaints procedures were effective.

There was positive leadership in the service. People and their relatives spoke highly of the provider and registered manager. They were described as approachable. Audits and monitoring procedures were used effectively to manage the service and to make improvements where needed.

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

Rating at last inspection (and update)

The last rating for this service was requires improvement (published 6 December 2018) with one breach of regulation. 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 regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Harewood Court Nursing Home 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. Harewood Court Nursing Home provides nursing and personal care for a maximum of 40 older people, some of whom are living with dementia.

There was a registered manager in post. A registered manager is a person who has registered with 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 2008 and associated Regulations about how the service is run.

We last inspected this service in August 2017. At that time, we found, improvements had been made to the service following our previous inspections when we had identified a number of concerns. We rated the service Requires improvement. We completed this comprehensive inspection to check whether the improvements had been sustained. We found that not all of them had and there were some shortfalls within the service.

On this inspection, the service has been rated as Requires Improvement. Providers should be aiming to achieve and sustain a rating of 'Good' or 'Outstanding'. Good care is the minimum that people receiving services should expect and deserve to receive; we found systems in place to ensure improvements were made and sustained had not been not fully effective.

We found some concerns relating to the records of management of medicines. Although the provider took swift action at the time of the inspection; quality assurance systems had not ensured on-going improvements around medicines management were sustained.

We received mixed views from people who used the service, relatives and staff about staffing levels. This related to the supervision of communal areas and night staffing sufficiency. We have recommended that the provider reviews the deployment and organisation of staff to ensure there are always sufficient staff at the times they are needed.

People were protected from abuse and told us they felt safe. Staff were recruited safely. Risk assessments contained enough detail to enable staff to keep people safe from harm. Risk assessments were reviewed regularly, and any changes were incorporated into people's care plans.

People lived in an environment that was cleaned daily. The home and equipment were maintained to minimise the risk of cross infection. Health and safety checks were undertaken and there were

appropriate procedures in place in the event of an emergency.

People told us they enjoyed the food at the service. There was a varied menu available to people and specialist diets were catered for. People were supported to maintain their health. They received consistent care and had access to health professionals as required.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice. People were supported to make choices and retain their independence.

Staff felt well supported and received appropriate training which was updated when needed. Staff said they enjoyed working for the service. We were told there was good teamwork and a positive culture within the service.

People we spoke with told us they were happy with the care they received and were complimentary about the staff who supported them. Overall, we saw individualised caring interactions between staff and people who used the service. People were treated with dignity and respect.

People received support from staff that understood their needs and preferences. Care plans were comprehensive to make sure staff had all the information required to support people as they wished. Staff understood how to provide end of life care.

People understood how to complain and these were responded to. People and their relatives had the opportunity to share their feedback.

Staff felt supported by the management team. People, their relatives and staff all spoke highly about the way the service was managed. The registered manager had identified how they wanted to improve the service for people living with dementia and had made positive steps in gaining support to do this.

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

At the last inspection in November/December 2016 we found the provider had breached five regulations associated with the Health and Social Care Act 2008.

At this inspection, we found improvements had been made with regard to these breaches and the provider is now compliant with the regulations.

Harewood Court provides nursing and personal care for up to 40 people. The service is divided into two units with the second floor accommodating people who may be living with dementia.

There was a registered manager in post. 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.

At this inspection, we found medicines were better organised and managed. Medicines were stored correctly and medication administration records (MARs) showed people received their medicines as prescribed. Staff were trained and competent to administer and manage medicines.

Systems for assisting people to make decisions in line with the requirements of the Mental Capacity Act 2005 (MCA) had improved. There were policies and procedures in place in relation to MCA. Staff were trained in the principles of MCA and could describe how people were supported to make decisions. Where people did not have capacity decisions were made in their best interests.

Recruitment was now managed safely. Recruitment procedures were robust enough to ensure staff were suitable and fit to be employed at the service. Staff showed a good understanding of safeguarding vulnerable adults and knew what to do to keep people safe from abuse

Staffing arrangements had improved; we saw staff worked as a team and each unit had a manager. Senior staff had also been trained to administer medication, which meant the nurse on duty each day had more time to attend to people’s nursing needs.

Systems had now been established and were operated effectively to assess, monitor and improve the service. Staff and relatives we spoke with told us the management team led the service well and had driven improvements. A range of checks and audits were undertaken to ensure people's care and the environment of the home were safe and effective.

Overall, staff were trained and supervised appropriately which meant they were able to carry out their role effectively. Staff received support to help them understand how to deliver good care and meet people’s individual needs. We recommended the provider reviews how staff accessed training to ensure all staff were enabled to complete their training in a timely way, as we were told this was completed by staff in their own time.

Support plans covered what was important to people; what their interests were and how they wished to be supported. Staff understood people's individual needs in relation to their care and showed they had developed positive relationships with people. There were systems which ensured risk was well managed. Staff were aware of the risks people faced and what they could do to manage these.

People were provided with the food and drink they liked to eat. There were choices available on the menus and alternatives if people didn't like what was on offer. Nutritional risk was assessed and people’s weight was monitored. Health, care and support needs were assessed and met by prompt and regular contact with health professionals.

There were systems in place to ensure complaints and concerns were fully investigated. We saw the manager and provider had dealt appropriately with any complaints received.

At this inspection in November/December 2016 we found the provider was still in breach of three of these regulations and was in breach of an additional two regulations related to staffing and fit and proper persons employed. The provider had made improvements in some areas; care plans were more informative on people’s care needs and gave guidance for staff on care needs. The certificates to show the home was maintained safely were available and in date. We also saw the current CQC rating for the home was on display.

Harewood Court provides nursing and personal care for up to 40 people. The service is divided into two units with the second floor accommodating people who are living with dementia.

There was a registered manager in post. 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.

Medicines management was not safe and we found some issues we identified at our last inspection in February 2016 had not been addressed. This continued to put people at risk of not receiving their medication as prescribed.

One person told us there were not enough staff and one person said staff did not come when they needed them. They also said they sometimes received their medication late. We found people were not always cared for, or supported by, enough skilled and experienced staff to meet their needs. There was only one nurse on duty at all times; to cover two floors of the home. The registered manager calculated staffing requirements on people’s level of funding and not their individual assessed needs.

Recruitment procedures were in place. However, for one staff member we found their Disclosure and Barring Service (DBS) check had not been checked for their employment at this home. The DBS checks assist employers in making safer recruitment decisions by checking prospective staff members are not barred from working with vulnerable people. For another staff member, their DBS had an error within it which could have affected the validity of the DBS.

The provider’s disciplinary procedures had not always been followed when concerns had been raised about staff member’s fitness and ability to carry out their duties. Systems in place were not robust and records did not clearly show the actions taken in these circumstances to ensure staff’s practice was safe.

Care plans we looked at contained risk assessments associated with people’s care and support needs which staff understood and followed to keep people safe. We saw there was a positive atmosphere in the service and people who used the service had developed good relationships with the staff team. Staff could recognise abuse and knew what action to take to ensure people’s safety.

We found the service was not fully meeting the legal requirements relating to the Mental Capacity Act 2005 (MCA) and these were the same concerns we raised at our inspection in February 2016. Mental capacity assessments were not specific to the decisions being assessed and there was conflicting information within capacity assessments which made it unclear as to whether people had capacity to make their own decisions. Mental capacity assessments undertaken were confusing and contradictory and showed a lack of understanding of the principles of the MCA.

Where people lacked capacity, relatives, staff and other health and social care professionals were not always consulted and involved in making decisions in each person’s ‘best interest’.

Deprivation of Liberty Safeguards (DoLS) records showed two people’s had expired and applications for renewal had not been made until after the expired date. There was a risk people could be being deprived of their liberty illegally.

Overall, we saw staff training was updated regularly. However, records showed some staff had not completed training in MCA and one of these staff had completed a number of the MCA assessments where we saw there were shortfalls. Nursing staff had not all received a check of their competence to administer medication. Staff had regular supervision; however, this was not a two way process of communication between the supervisor and the person being supervised.

People were supported to eat and drink well and to maintain a varied balanced diet of their choice. Culturally appropriate food was provided for people; with a twice weekly Caribbean option on offer.

Overall, people had access to healthcare facilities and support that met their needs. However, we found the instructions of a health professional had been overlooked for a number of months which put the person’s health at risk and for another person the instructions had not been transferred in to the person’s care plan.

People received support from staff who knew them well. People’s dignity and privacy was, in the main, respected. Care records showed people’s needs were identified and responded to in a person centred way. Information was written in a person-centred way. However, daily notes were not completed in detail to show how people spent their day.

There were procedures in place to ensure the provider responded appropriately to any complaints they received and information was displayed about how people could make formal complaints.

People were provided with a range of activity within the home and most people we spoke with said they were satisfied with this. However, we saw there were times when people received no interaction and stimulation and were falling asleep; sometimes in uncomfortable positions.

Staff spoke positively about the registered manager. They said they were approachable and communicated well on the needs of the service and what was expected of staff.

There were systems in place to monitor the quality and safety of the service provided. However, these were not fully effective. Actions to improve the service were sometimes identified but then not followed up and addressed. The audits used had failed to highlight any of the concerns and discrepancies we found at this inspection.

We found shortfalls in the care and service provided to people. We found a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) regulations 2014.

The overall rating for this provider is 'Inadequate'. This means that it has been placed into 'Special

measures' by CQC. The purpose of special measures is to:

• Ensure that providers found to be providing inadequate care significantly improve.

• Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.

• Provide a clear timeframe within which providers must improve the quality of care they provide or we will seek to take further action, for example cancel their registration.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains 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 the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will 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 we will move to close the service by adopting our proposal to vary the provider's registration to remove this location or cancel the provider's 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.

This was an unannounced inspection carried out on 09 February 2016. At the last inspection in April 2015 we found the provider had breached two regulations associated with the Health and Social Care Act 2008. We found the provider did not have systems and processes in place to fully ensure the safety of the premises and assure compliance with national guidance. Where people did not have the capacity to consent, the provider did not always act in accordance with the legal requirements of the MCA 2005. At this inspection we found this was still the case with MCA.

At the time of the inspection there was no registered manager in post. However, there was a manager in post who had overall day to day control of the home. A registered manager is a person who has registered with the Care Quality Commission (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 2008 and associated Regulations about how the service is run.

We looked at a sample of medicines and records for people living at the home as well as systems for the storage, ordering, administering, safekeeping, reviewing and disposing of medicines. We found the provider had not protected people against the risk of not receiving their medication as prescribed.

The gas certificate for the premises had expired on 03 January 2016. We were told by staff they were waiting for the provider to authorise the expenditure. We asked the manager to send us information when the gas check has been completed and a copy of the certificate. The information we requested was sent to us in a timely manner. However, we found the provider had not protected people against the risk of premises and equipment.

There were systems in place to make sure people were not deprived of their liberty unlawfully. However, we found mental capacity assessments were not specific to the decisions being assessed and did not show how decisions were made as required by the Mental Capacity Act 2005.

Care plans did not show how people who used the service would like to be cared for. There were no evidence individuals or their relatives were involved in the care planning process. We found the registered person had not protected people against the risk of not receiving person centred care.

We found the previous CQC inspection rating was not displayed in the home. The manager was unaware this had to be displayed.

We found the quality assurance monitoring systems in place were not robust as shortfalls in the service highlighted in the body of this report had not been identified through the audits carried out by the manager or provider.

We saw staff were patient and caring toward people in their care. People who were able told us they were happy living at Harewood Court and were complimentary about the staff.

We saw people were offered a choice of what to eat and given assistance, if they required it. The food was well presented and looked appetising. People were offered a choice of hot or cold drinks to go with their meal. A person who used the service told us, “The food is nice, very nice.” Another person said, “The food’s good, not bad.”

Robust recruitment procedures were in place and appropriate checks had been undertaken before staff began work. Staff demonstrated a good understanding of protecting vulnerable adults. They told us they were aware of how to detect signs of abuse and were aware of external agencies they could contact. They told us they knew how to contact the local safeguarding authority and the CQC if they had any concerns. They also told us they were aware of the whistle blowing policy and felt able to raise any concerns.

There was a complaints procedure available which enabled people to raise any concerns or complaints about the care or treatment they received.

Breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found during this inspection. You can see what action we told the provider to take at the end of this report.

Breach of the Care Quality Commission (Registration) Regulations 2009. The Care Quality Commission will deal with this outside of the inspection process.

We revisited Harewood Court because we had received further concerns about the number of staff on duty and the standards of care and treatment people received.

During our visit we spoke with three people living at the home, three visitors, 15 members of staff, including the nurses on the day and night shifts and the Registered Manager.

We saw the staff were busy but appeared well organised and supportive of each other. The atmosphere was calm and staff were observed interacting warmly with people. There were no signs that anyone living at the home was in distress or unable to obtain timely support from the staff.

People's needs were assessed but care and treatment was not always delivered in line with their individual care plan. We were unable to establish whether people's wishes were being respected. Records about people who had asked to have a weekly bath or shower were incomplete and we were unable to determine if or when people had received their bath or shower.

Care and treatment was not always delivered in a way which ensured their safety and welfare. There was evidence in people's care records to show that risk assessments had been completed. Where a risk had been identified, there was a plan in place to manage the risk. However, we found; plans which did not reflect the level of risk, delays in addressing the risk, lack of sufficient detail to manage the risk and the absence of records to show the requirements of the risk plan had been followed by staff.

Arrangements in relation to obtaining, recording, handling, administering, storing and the disposal of medicines were not always adequate. One person was left without sufficient medication. Medicines were not kept securely and there were several examples of people's medicine not being accurately recorded.

There were not enough qualified, skilled and experienced staff to meet people's needs. The staff and visitors we spoke with on the day of our visit told us they had no major concerns about the number of staff at the home. However, we found the one nurse on duty was called upon to deal with other issues whilst administering medication. Care staff were predominantly occupied meeting people's essential needs and they had little time to spend with people and engage them in activities which enriched their experience of living at the home.

We visited the home over two consecutive days, observing how people were cared for during the morning, afternoon and evening shifts.

We spoke with the Registered Manager and 12 members of staff. None of the staff we spoke with had observed people who used the service being spoken to or treated inappropriately. They told us that they would report any concerns to a manager and were confident they would be dealt with.

We observed the morning and evening routines and how well the staff were able to meet people's needs. We saw that the staff were fully occupied meeting people's essential needs, assisting people with their personal care and serving breakfast. All but one of the members of staff we spoke with expressed concerns about the number of staff on duty. However, the staff we spoke with were all confident that people's needs had been met and none could recall an occasion when a person had been neglected or harmed.

We found the home was calm and the staff well organised. Requests for assistance were met promptly. Staff spoke warmly and respectfully to people who in the main appeared relaxed and to enjoy the company of the staff.

The visitors we spoke with told us that they were generally happy with the care their relatives received. One said 'I'm quite satisfied that they are doing their best for mum'. Another relative said that the home was 'Better now there are some activities.'

People who used the service had personalised care plans which were regularly reviewed an updated. The staff we spoke with understood the needs of the people they cared for and were involved in decisions about their care needs. The staff were clear about their personal responsibility to keep people safe. They understood how to protect vulnerable adults, the signs of abuse and how to report concerns. The staff had access to supervision and felt they could ask for advice or support from more senior colleagues at any time.

The manager had put in place systems to monitor the quality of the service. Quality information was regularly reviewed. The views of people who used the service and their relatives were used to identify areas for improvement.