We carried out this unannounced comprehensive inspection on 01 and 02 October 2018. Freshfields Nursing Home provides care for people who may require nursing care and for people who are living with dementia. The service provides care and accommodation for up to 38 people. On the day of the inspection 32 people lived in the home.
There was a manager in place, who was registered with the Care Quality Commission. 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 was due to retire at the end of 2018, therefore the provider had been pro-active and already employed a new manager, who had been working alongside the current registered manager for the past four months, to help ensure a smooth transition. The new manager would be applying to be registered with the Commission shortly.
At our last inspection in October 2017 the overall rating for the service was Requires Improvement because the recruitment of staff was not always carried out safely, and records relating to people’s medicines were not always accurate. In addition, people’s records did not clearly detail how their human rights were being protected in line with the Mental Capacity Act (2005); and the providers systems, to monitor the quality of care people received were not robust, in identifying when improvements were needed. Whist some improvements had been made, we found additional areas requiring action. Therefore, the rating of Requires Improvement remained.
People were not always protected from risks associated with their care. People had risk assessments in place to help guide staff to deliver safe care in line with people’s individual needs. However, people’s risks assessments, relating to their nutrition were not always accurate to help ensure people received safe support. We asked the registered manager to take immediate action to ensure one person received the correct meals, that records were updated to ensure their accuracy and staff knowledge and awareness improved.
People were not always supported by suitable numbers of staff who knew how to meet their needs safely and effectively. The registered manager told us, that whilst they had good numbers of nursing staff, they had experienced a difficult time, with large numbers of care staff recently leaving. They explained, recruitment was ongoing and that three new members of staff had recently been appointed.
People’s medicines were not always managed safety. People’s medicine administration records (MARs) were completed, but not always accurate. People received topical medicines (creams, pastes or lotions). However, these were not always dated upon opening, which meant staff could have applied topical medicines, which were out of date. There was no system in place to help determine if people needed their pain relief and/or whether it was successfully working; this is good practice especially with people living with dementia and/or who find communication difficult.
Overall, people were protected from abuse. However, whilst staff received safeguarding training and had access to safeguarding polices, some staff were not fully aware of the local authorities’ involvement in the investigation of allegations of abuse. The registered manager told us they would speak to staff to refresh their knowledge.
Overall, people were kept safe from environmental risks. All equipment was serviced in line with manufactures guidelines, the fire system was checked on a weekly basis and underwent an annual review to ensure its continued safety. However, on both days of our inspection we found two doors propped open, because batteries in fire release door guards were not working. We also found a large number of wheelchairs, and three carpet cleaners stored in a designated fire escape. The assessment of these risks, had not been included within the providers fire risk assessment. Therefore, the provider told us immediate action would be taken.
People had care plans in place to help provide guidance and direction to staff about how they wanted to receive their care and support. However, staff told us they did not always have time to read them, and told us they just got to know people by watching a listening to see how other staff supported them.
People’s care plans were handwritten therefore consideration had not been given to whether they were in a suitable format for people and/or their loved ones to be able to understand. People’s communication needs were documented in their care plans, staff told us how they adapted their own communication styles to help people to understand them.
People’s continence needs were managed. People were reminded to go to the toilet discreetly and supported when required. Staff, however told us, that when there are staffing shortages, some people are not supported when they should be, resulting in them being uncomfortable or incontinent.
Despite positive feedback from relatives, people’s social needs were variably met, and people living with dementia did not always receive the time and support they needed from staff, to help positively distract or engage them.
Staff told us, they found it difficult to promote people’s independence because they did not always have time and/or the resources to be able to. Staff explained how they felt people’s care was task ordinated, rather than being person-centred and tailored to people’s individual social and emotional needs.
Overall, people’s privacy and dignity was promoted by staff, most staff knocked on people’s bedroom doors before entering, and when risk assessed, people could have their own lock and/or key. One person was wearing excessively large and loose trousers, which fell down whilst they were walking. This resulted in them exposing their incontinence pad and pants. Whilst, a member of staff at the time, pulled them back up, the situation wasn’t resolved.
People’s care plans now included a section regarding their mental capacity and how they should be suitably supported. Staff had undertaken training in the Mental Capacity Act (2005). However, despite staff receiving training, staff’s knowledge was limited about the deprivation of livery safeguard applications (DoLS). Staff were unaware of who had DoLS applications in place, and what this meant for people. This meant people’s human rights may not be suitably protected.
Overall, people received care and support from staff who had undertaken training, the provider had deemed to be mandatory. However, despite staff receiving training it was not always put into practice. For example, staff undertook privacy and dignity training, however we found improvements were required in this area.
People were supported to eat and drink, and offered drinks by staff at certain times of the day. However, records about people’s consumption, were not always detailed and/or accurate.
The dining experience did not fully support and enable people, living with dementia. The principles of good dementia care were not followed, for example people were all verbally asked what they wanted for lunch and not shown. People and their relatives told us they liked the food and the options which were available.
The registered manager and provider told us they had already recognised that action was needed to improve the dining experience for people. The provider had already sourced a new training course called dignity and dinning, and would be asking staff to attend.
People living with dementia, were not always fully supported by the decoration of the service. Areas of the home, such as people’s bedrooms, toilets and bathrooms were not always labelled with pictorial images to help ordinate people.
The registered manager had a variety of quality audits which formed the basis of the providers ‘global audit’. Audits were completed on a monthly and quarterly basis by the registered manager, and designated staff. However, despite these being in place, they had failed to identify the areas found to require improvement as part of this inspection.
Most staff told us they liked working at the service, but at times, felt that there was a poor culture which resulted in staffing indifferences, and task ordinated care provision
People were seen to comfortably approach and speak freely to staff, and families told us they felt their loved ones were “Safe”. Since our last inspection, the provider had installed closed circuit television (CCTV) in communal areas, to help ensure peoples ongoing safety.
People, at our last inspection in October 2017, were not protected by the provider’s own recruitment procedures, but at this inspection we found action had been taken to ensure people were fully protected. The provider had also introduced a new monitoring and checking system of recruitment procedures.
People were supported safely when mobilising, and wheelchairs were used appropriately with footplates. People’s accidents were reviewed, and themes and trends analysed so action could be taken to help minimise reoccurrences.
People lived in a service whereby the provider learnt when things had gone wrong and used the learning to help improve the service.
People were protected by infection control processes to help reduce the unnecessary spread of infection. Staff received infection control training and wore the required personal protective equipment (PPE), such as gloves and aprons, when assisting people with personal care.
People were supported with dignity, at the end of their life. Staff had received palliative care training. People had care plans in place to help staff know what their end of life wishes were. Pain management and end of life medicines were discussed with external pr