Fulford Care & Nursing Home

Fulford Care and Nursing Home is a residential care home providing personal and nursing care to up to 74 people. The service provides support to people living with a range of care needs including Parkinson’s disease, age related frailties and dementia. At the time of our inspection there were 60 people using the service.

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

Quality assurance systems remained ineffective in monitoring the quality and safety of medicine administration. The provider’s auditing of medicines was not robust enough to continually identify and address concerns around the storage, administration and risks to people in relation to medicines. Where internal processes had highlighted areas for improvements, necessary improvements were not always addressed and sustained.

The management structure had been under a recent review and there had been a shortage of office and senior clinical staff. Deputy managers covered the duties of these staff which impacted managerial oversight of the quality and safety of the service.

People, their relatives and staff told us there were times of staff shortages. There were enough staff to meet people’s needs, however, we observed staff were not always deployed effectively. A relative told us, “Mum said sometimes she has to wait for the toilet. Sometimes she can get a bit annoyed but it's not their fault, her walking isn't that brilliant now.”

People’s support and associated health risks were mostly assessed. Care planning considered people’s health needs and provided clear guidance to staff in how to support people, for example, with moving and positioning equipment and eating and drinking. Checks of the environment were completed, staff were trained and followed hygiene practices to keep people safe from the spread of infection.

People were protected from risk of abuse; staff received training and knew how to recognise and respond to safeguarding concerns. People and their relatives told us they would feel comfortable to speak with management or staff if they had concerns of safety. A person said, “I couldn’t have stayed by myself in my house any longer. I came here determined to settle in, and the atmosphere is safe and caring. It really is very nice here; I can have visitors anytime.”

People, their relatives and staff were invited to share their feedback with the management team. Staff morale had improved since our last inspection. We saw examples of where people and staff had voiced their opinion and had been listened to by the management team.

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.

People had access to healthcare services and staff supported them to attend appointments. Professional guidance had been recorded in people’s care documentation and staff were further informed of changes at staff handover.

We expect health and social care providers to guarantee autistic people and people with a learning disability the choices, dignity, independence and good access to local communities that most people take for granted. Right support, right care, right culture is the statutory guidance which supports CQC to make assessments and judgements about services providing support to people with a learning disability and/or autistic people. We considered this guidance as there were people using the service who have a learning disability and or who are autistic.

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 1 October 2021) and there were breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. The service remains rated requires improvement. This service has now been rated requires improvement for the last 2 consecutive inspections.

At this inspection we found the provider remained in breach of regulations.

Why we inspected

We carried out an unannounced comprehensive inspection of this service on 30 June, 5 July and 9 July 2021. Breaches of legal requirements were found. The provider completed an action plan after the last inspection to show what they would do and by when to improve safeguarding, staffing, safe care and treatment and good governance.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

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 comprehensive inspection to calculate the overall rating. The overall rating for the service remains requires improvement. This is based on the findings at this inspection.

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

Enforcement

We have identified breaches in relation to medicines, staffing and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Fulford Nursing Care Home is a residential care home registered to provide nursing and residential care for up to 74 people with a range of care needs including Parkinson’s, frailty of age, specific health conditions and people living with dementia. At the time of our inspection, 65 people were living at the service. Accommodation was over three floors and divided into five designated units. The floors were accessible by a lift and stairway.

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

Systems had failed to identify that people were not always protected from avoidable harm. People did not always receive safe support in relation to their medicines. Staffing levels were not effective in meeting people's care needs in a timely and person centred way.

Aspects of leadership and governance were not effective in identifying some of the concerns found. Medicine audits failed to identify some significant shortfalls in the management and administration of medicines. Care provided was not always recorded accurately within people’s care records. There was an apparent discord between staff and the management team which was impacting on people’s wellbeing.

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

The last rating for this service was good (Published 1 November 2018).

Why we inspected

We received concerns in relation to staffing levels and the management of medicines. As a result, we undertook a focused inspection to review the key questions of safe and well-led only.

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.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection.

You can see what action we have asked the provider to take at the end of this full report.

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

Enforcement

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to keeping people safe, medicines, the deployment of staff, and the way the service was managed.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We found the following examples of good practice.

The registered manager had a pre booking system for visitors and was able to facilitate three visits for different people each day. This spacing allowed the visiting room to be effectively cleaned between visits.

The registered manager had recruited additional housekeeping staff to support an increase in cleaning schedules and purchased a fogging machine to enable quick sanitising of rooms and bathrooms between use. The provider had purchased three additional uniforms for staff to ensure they had a clean uniform to wear every shift.

The registered manager had purchased two tablet devices for people to use and invested in technology to improve connectivity within the home. This meant that residents could use their personal devices to contact relatives wherever they were around the home.

Staff were using an electronic care management system to minimise use of paper records. The system was also used to provide staff with policy updates and changes in practice in a timely way.

Further information is in the detailed findings below.

The inspection was brought forward as we had been made aware of safeguarding issues communicated to us directly and received from the local safeguarding authority. Our inspection does not examine specific incidents and safeguarding allegations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection.

At our last comprehensive inspection on 5 and 6 October 2017 the overall rating of the service was, 'Requires Improvement'. This summary rating was the result of us rating the key question's 'safe', 'effective', 'caring', 'responsive' and well-led as, 'Requires Improvement'. At our last inspection we found breaches of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The provider had failed to ensure that care and treatment was provided safely. Staff were not always deployed to meet people's care and support needs. Staff did not receive supervision and appraisal necessary to enable them to carry out their duties. Consent to treatment was not always obtained from people. Where people were unable to give consent because they lacked capacity, staff did not act in accordance with the Mental Capacity 2005 Act. People were not involved in the assessment of their needs and preferences. Care and treatment was not designed to make sure it met peoples’ needs. Systems were not effective in monitoring and managing risks. Records relating to the care and treatment of people were not kept securely.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions to at least good. At this inspection we found significant improvements had been made and maintained, resulting in the overall rating of the service changed to, 'Good'.

At this inspection we have rated the key question 'well led' as 'Requires Improvement'. We found although there were significant improvements in the care planning, further work was still needed to ensure they were accurate and fully completed. We also found that the new systems introduced since the last inspection required more time to be embedded and sustained. Although necessary provision had been made to ensure that medicines were managed safely, we found due to the technology being used, medication was delayed. The provider had identified this themselves through their quality monitoring processes. This had impacted how relatives felt their loved one’s needs were being met. We have recommended the registered provider ensures care records and information relating to people's care is contemporaneous.

Fulford Care and Nursing Home is registered to provide nursing care and residential care for up to 74 people with a range of care needs, including frailty of old age, specific health conditions and people living in the early stages of dementia. At the time of our inspection, 67 people were accommodated at the home. Fulford Care and Nursing Home is divided into five areas, over three floors. The five areas are called Magnus and Harold, on the ground floor. First floor: Godwin and Edmund. Second floor: William. The floors are accessible by a lift and stairway.

Fulford Care and Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection.

Since the last inspection, the registered manager had left employment and another registered manager was in post. 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 2008 and associated Regulations about how the service is run.

There were systems, processes and practices to safeguard people from situations in which they may experience abuse. Risks to people's safety had been assessed, monitored and managed so they were supported to stay safe while their freedom was respected. Suitable arrangements had been made to ensure that sufficient numbers of suitable staff were deployed in the service to support people to stay safe and meet their needs. Background checks had been completed before care staff had been appointed. People were protected by the prevention and control of infection and lessons had been learnt when things had gone wrong.

Suitable arrangements had been made to obtain consent to care and treatment in line with legislation and guidance. Care staff had been supported to deliver care in line with current best practice guidance. People enjoyed their meals and were supported to eat and drink enough to maintain a balanced diet. In addition, people had been enabled to receive coordinated and person-centred care when they used or moved between different services. As part of this people had been supported to live healthier lives by having suitable access to healthcare services so that they received on-going healthcare support. Furthermore, people had benefited from the accommodation being adapted, designed and decorated in a way that met their needs and expectations.

People were treated with kindness, respect and compassion and they were given emotional support when needed. They were also supported to express their views and be actively involved in making decisions about their care as far as possible. Confidential information was kept private.

People received personalised care that was responsive to their needs. People's concerns and complaints were listened and responded to in order to improve the quality of care. Suitable provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.

There was a positive culture in the service that was open, inclusive and focused upon achieving good outcomes for people. People benefited from there being a management framework to ensure that staff understood their responsibilities so that risks and regulatory requirements were met. The views of people who lived in the service, relatives and staff had been gathered and acted on to shape any improvements that were made. Quality checks had been completed to ensure people benefited from the service being able to quickly put problems right and to innovate so that people consistently received safe care. Good team work was promoted and staff were supported to speak out if they had any concerns about people not being treated in the right way. The management team worked in partnership with other agencies to support the development of joined-up care.

This inspection was the first inspection since a change of provider in December 2016. The inspection was planned because we had been made aware of a number of safeguarding issues communicated to us directly and received from the local safeguarding authority. Our inspection does not examine specific incidents and safeguarding allegations. However, we used the information of concern raised by partner agencies to plan what areas we would inspect and to judge the safety and quality of the service at the time of the inspection.

Fulford Care and Nursing Home is registered to provide nursing care and residential care for up to 74 people with a range of care needs, including frailty of old age, specific health conditions and people living in the early stages of dementia. At the time of our inspection, 50 people were accommodated at the home. Fulford Care and Nursing Home is divided into four units, Magnus, Harold, Edmund and Godwine. Communal facilities include the main lounge on the ground floor and a smaller lounge on the first floor. There is a large dining room located in a converted barn and a ground floor conservatory. All rooms have profiling beds and are en-suite. People have access to gardens surrounding the home.

A registered manager was 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 2008 and associated Regulations about how the service is run.

People’s risks were not identified, assessed or managed safely. Risk assessments provided incomplete information about people’s risks and insufficient information and guidance for staff on how to mitigate risks. Daily records in relation to completion of fluid intake or repositioning charts for people, had not always been completed fully. Personal emergency evacuation plans were not in place for everyone living at the home. Some aspects of medicines management were unsafe. The medicines trolley was left unlocked and/or unattended when medicines were administered to people. Medicine profiles for people were out of date, although staff were in the process of taking new photos of people.

Staff were not deployed in such a way as to ensure people’s needs were met promptly. Many people were still in bed or sat in their rooms in their nightwear at 11am awaiting personal care. A medicines round which had begun at 8.30am was not completed until 11.15am. There was mixed feedback about the staffing levels, with some relatives and staff expressing concern about the high usage of agency staff.

Staff had not received regular supervision meetings or appraisals of their work. Competency assessments for nursing staff had been completed in some cases, but information was scant and did not cover all clinical competencies. Staff completed a survey in July 2017 which indicated they were unhappy with the level of support they received at that time.

Assessments of people’s capacity, in line with the legal requirements of the Mental Capacity Act 2005 (MCA), had not always been completed. Some people had been deemed to lack capacity, but had no capacity assessments in place to corroborate this. People’s consent to care and treatment had not been formally recorded, nor was it clear how people’s particular communication needs had been assessed or were met.

There was no evidence to confirm that people and/or their relatives were involved in planning and reviewing their care. Care plans did not always provide detailed information about people’s care needs or have social histories that staff could access. Staff and management acknowledged that care plans did not always contain updated information about people or that they were reviewed regularly. Care staff told us that they relied on handover meetings to share information about people’s care and support needs. However, handover sheets did not provide detailed information about people and staff commented that this would be of concern for new or agency staff who did not know people well.

Systems had not been established to identify areas of improvement. Some audits that were in place were not effective, for example, in relation to care plans or with hospital admissions. Care records were not always stored securely so that confidential information about people was not protected.

Signage or contrasting colours had not been utilised effectively within the environment to enable people to navigate around the home.

Some positive caring relationships had been developed between people and staff. People had mixed views about the staff who cared for them. Relatives spoke positively about the caring nature of staff. As much as they were able, people were encouraged and given choices in relation to day-to-day decisions with their care. Apart from one incident we observed, staff treated people with dignity and respect.

Health and safety audits were completed as needed and checks made on the safety of equipment, electrical installations and gas safety. People felt safe living at the home. Staff had been trained to recognise the signs of potential abuse and knew what action to take. Safe recruitment practices were in place. Aside from the issues above, medicines were managed safely.

Staff we spoke with understood the requirements of the MCA, although not all staff had completed this training. Staff completed training in a range of areas including safeguarding, moving and handling, basic life support, dementia awareness and health and safety. New staff followed the Care Certificate, a nationally recognised qualification. Staff meetings took place from time to time and records confirmed this. There were mixed views about the meals on offer. We observed that people did not always receive the support they needed from staff in order to eat their meals. Special diets were catered for. People received support from a range of healthcare professionals and services.

Staff had a good understanding of person-centred care. A range of activities was organised for people at the home and an activities co-ordinator helped to arrange and deliver these. Complaints were managed in line with the provider’s policy. People and their relatives knew who to talk with if they had any concerns or wished to make a complaint.

Accidents and incidents were reported and monitored to identify any patterns or trends. People and their relatives were asked for their views about the service and actions taken where needed. Staff we spoke with felt supported by the management and leadership of the home. Some people and their relatives did not feel the home was well led.

Following the inspection, an operations manager sent us information on the actions that would be taken to address the issues and concerns we found at inspection.

You can see what action we have asked the provider to take at the end of the full version of this report.