Nettleton Manor Nursing Home

We found the following examples of good practice.

The provider exceeded government guidance in requiring staff to conduct a lateral flow test at the start of every shift, to reduce the risk of COVID-19 entering the home.

The provider also exceeded government guidance in continuing to conduct temperature checks on all visitors to the home.

The provider had proactively sourced some care staff from overseas to help address the staffing challenges created by the COVID-19 pandemic and other pressures on the social care workforce.

Nettleton Manor is a residential care home providing personal and nursing care to 33 people at the time of the inspection. The service can support up to 43 people in one adapted and extended building over two floors.

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

The risks to people’s safety were assessed and measures were in place to mitigate these risks. Staff had received appropriate update training for their roles. Medicines were well managed and there was clear auditing processes in place to monitor the quality of the service.

Staff received training on infection prevention and control practices, their practice was monitored by senior staff and they followed national guidance in relation to wearing personal protective equipment during the Covid-19 outbreak.

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 20 November 2020). We found breaches of regulations and the provider was served with a Warning Notice. 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

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 coronavirus and other infection outbreaks effectively.

We undertook this targeted inspection to check whether the provider had met the breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated activities) Regulations 2014 and that the Warning Notice we previously served had been met. The overall rating for the service has not changed following this targeted inspection and remains Requires Improvement.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

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 coronavirus and other infection outbreaks effectively.

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.

Nettleton Manor Nursing Home is a residential care home providing personal and nursing care to 31 people and is registered to provide care for younger and older adults at the time of the inspection. The care home can accommodate 43 people in one adapted and extended building.

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

The risks to people’s care were not always assessed and measures in place to mitigate these risks. Staff did not always follow national guidance around donning and doffing personal protective equipment or undertake best practice to reduce the risk of infection to people living at the service. People’s medicines were not always managed safely and of the quality monitoring processes had not identified some of the concerns we found.

People were supported with adequate numbers of staff who had received training for their roles. Staff were recruited safely. There was an ongoing refurbishment of the service which had a positive impact on the environment. The service was clean and there were effective cleaning schedules in place being followed by the housekeeping staff.

The registered manager responded to and undertook learning from any safeguarding concerns raised to them.

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 Requires Improvement report published 21 November 2019 the provider was in breach of the regulations. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been sustained and the provider was still in breach of regulations. This service had been rated requires improvement for the last three consecutive inspections.

Why we inspected

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 coronavirus and other infection outbreaks effectively.

We undertook this focused inspection to follow up on concerns we had received and 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. The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

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 monitor the service to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified a continued breach in relation to Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014, good governance. There was also a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulation 2014, safe care and treatment.

We have taken enforcement action against the provider. Further information on the action we have taken is provided at the end of this report.

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.

The provider has taken positive steps to mitigate the risks to people’s safety when we highlighted concerns to them.

Nettleton Manor is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. It provides accommodation for older people including people living with dementia. The home can accommodate up to 43 people. At the time of our inspection there were 33 people living in the home.

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

There was a process in place to carry out quality checks. These were carried out on a regular basis however the provider had failed to act when issues had been identified.

Some areas in the home were not clean, and the environment was not consistently adapted to support people living with dementia. Staff understood how to prevent and manage infections.

There was enough staff to support people. Appropriate employment checks had been carried out to ensure staff were suitable to work with vulnerable people. Arrangements were in place to safeguard people against harm. People said they felt safe.

People enjoyed the meals and their dietary needs were catered for. This information was detailed in people’s care plans. Staff followed guidance provided to manage people's nutrition and pressure care. People were supported by staff who had received training to ensure their needs could be met. Staff received regular supervision to support their role.

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 good health care support from external professionals. When people were unwell, staff had raised the concern and acted with health professionals to address their health care needs. People had access to a range of activities and leisure pursuits.

We saw evidence of caring relationships between staff and people who lived at the home. Staff were aware of people's life history and preferences and used this information to develop relationships. People felt well cared for by staff. Care records were personalised and were regularly reviewed.

The provider had displayed the latest CQC rating at the home. When required notifications had been completed to inform us of events and incidents.

More information is in the detailed findings below.

Rating at last inspection

The last rating for this service was Requires improvement (published 10 July 2018) and there were two breaches 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 enough, improvement had not been sustained and the provider was still in breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

Why we inspected

This was a planned inspection based on the previous rating.

We have found evidence that the provider needs to make improvement. Please see the safe, effective, and well led sections of this full report.

Follow up

We will request an action plan for 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.

A registered manager was in post during the inspection. 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 of the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our previous inspection in May 2017, we rated the service as Requires Improvement as we found the principles of the Mental Capacity Act 2005 had not always been followed. Although people had not been deprived of their liberty unlawfully, the assessments undertaken around people’s mental capacity lacked sufficient detail to show correct processes had been followed during the assessments. At this visit we found the provider had made improvements in this area of care and the principles of the Mental Capacity Act had been followed. 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.

At this inspection we found evidence to show the provider was in breach of two regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Our overall rating for the service is Requires Improvement, this is the second consecutive time the service has been rated as Requires Improvement. You can see what action we told the provider to take at the back of the full version of the report.

People living at the service were protected from the risk of abuse as the provider had responded to and reported safeguarding concerns relating to the people in their care. Staff had a good knowledge of their responsibilities in relation to safeguarding and they had received recent training to support their knowledge base. The registered manager dealt with safeguarding issues openly, and worked with the local authority to deal with any safeguarding issues.

The risks to people were assessed and measures were in place to reduce these risks. However, on the day of our inspection we saw some staff lacked knowledge of particular risks to people’s safety and the measures meant to be in place to reduce the risks. This had resulted in an incident that impacted on one person’s safety. We did see evidence of staff knowledge of how to manage risks to other people who lived at the service.

People received their medicines from suitably trained staff and majority of medicines were managed safely. However, we found one person did not have their protocols in place to guide staff when they were prescribed ‘as required’ medicines. We also found some of the daily medicine checks, undertaken by staff, identified discrepancies that were not followed up, which meant errors may not be addressed.

While we saw the provider and registered manager had made some significant improvements to the environment to protect people from the risks of infection. People were not always protected from the risks of infection as some staff did not follow safe practices in preventing risks associated with cross infection.

Staffing levels met the needs of the people in the service and they were supported by staff who received an induction, were well trained and received regular assessments of their work. Staff used nationally recognised tools to assess the needs of people who lived at the service.

People lived in an environment which met their needs, and we saw there had been improvements to the environment since our last inspection. The provider had an on-going refurbishment plan in place to support this as there were aspects of the service still in need of refurbishment. People’s health and nutritional needs were well managed and staff acted on advice given to them by health professionals to manage people’s health and nutritional needs.

People at the service were not always treated with respect and dignity. They were not always supported in the way they wanted to be supported, and we saw some interactions with people that were not always respectful.

People received individualised care from staff; however, there were some aspects of care not clearly documented to give staff the knowledge they needed to provide people with the required care. Some records showing the daily care people were meant to receive were not kept up to date.

There was minimal information around people’s wishes in relation to their end of life care in their care plans. However, the registered manager told us this was because people did not always wish to discuss this aspect of care, but at the appropriate times the registered nurses spent time with people and their relatives to ensure their wishes were known.

People were not always supported to take part in social activities however the provider was working to improve this aspect of care.

People and relatives told us they knew who to discuss any complaints or concerns they had and we saw complaints and concerns had been dealt with in line with the provider’s complaints procedure.

The registered manager was a visible and approachable presence at the service. They undertook a range of quality monitoring processes and continued to work to improve the service for the people who lived at Nettleton Manor. People and staff felt they were listened to and the registered manager worked with people, relatives, staff and external professionals to provide an open and transparent service for the people who lived there.

At the time of the inspection the service did not have a registered manager working at the service. The previous registered manager had retired in October 2016 and the new manager had applied to the Care Quality Commission to become registered. Following our inspection their registration was approved. 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 who used the service were protected from the risk of abuse and staff had a good understanding of their roles and responsibilities if they suspected abuse was happening. The manager shared information with the local authority when needed.

The risks to people’s safety were assessed when they were admitted to the service and measures identified to reduce the risks. Staffing levels were sufficient to support people’s needs and people received care and support when required. Medicines were managed safely and people received their medicines as prescribed at the times they needed them.

People were encouraged to make independent decisions, however staff did not always follow the principles of the Mental Capacity Act (2005). Although people had not been deprived of their liberty unlawfully the assessments undertaken around people’s mental capacity lacked sufficient detail to show the correct processes had been followed during the assessments.

People were protected from the risks of inadequate nutrition. Specialist diets were provided if needed. Referrals were made to health care professionals when required.

People who used the service, or their representatives, were encouraged to contribute to the planning of their care. People were treated in a caring and respectful manner and staff delivered support in a relaxed and considerate manner.

People felt they could report any concerns to the management team and felt they would be taken seriously.

There were audits and analysis in place to monitor some aspects of the quality of the service. However there was a lack of robust audits around cleaning and this had an impact on the cleanliness of the service.

We looked at records.These included care records and information about how the service operated.

We also observed how people received their care in order to help us understand the needs of people who we were not able to speak directly with.

For example, we observed how staff used their training and experience to interact with, and support people with their care, meals and activity needs.

One person said, 'I have complete privacy when I need it.' Another person told us, 'They (staff) get me everything I want. When I ask for drinks or help at any time during the night and it's always given.'

We found the environment was maintained appropriately to support the safety of the people who lived there. A visiting relative told us, 'The home always seems clean and tidy.'

We also found the home owner and manager had monitored the service and gained views on the quality of services provided from people and their relatives.