Archived: The Grove - Care Home with Nursing Physical Disabilities

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Prior to our most recent assessment key members of the management team had left the service including the registered manager, deputy manager, clinical lead and operational manager. This had resulted in interim management arrangements being put in place which were not effective because of the lack of knowledge of people using the service, systems and processes. Agency nurses we met and spoke to were unsure of peoples needs and one described the service as completely chaotic. Nurses were constantly asking our medicines inspector for advice. Staff worked in silos and nurses in particular did not have regular clinical support and reflective practice was not embedded. Although improvements were made these were not sustained and there was poor learning and oversight from incidents. Multiple breaches of regulation were identified for the third time which meant people had lived in an unsafe service for a number of years.

This service scored 29 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Care staff and nurses told us communication and support was poor and systems and processes were not firmly embedded. Nurses for example were not familiar with guidance relating to peoples care and care plans and risk assessments were not kept up to date. Nurses spoken with did not always have access to clinical support or information necessary to run the shift effectively. Staff told us they had a good rapport with relatives which was confirmed by relatives we spoke with but there was a lack of continuity ie no named nurse or key worker system to ensure communication and infromation sharing was seamless .

There was limited evidence of a shared direction and culture within the service. Constant changes within the management team and the employment of interim staff with no long-term commitment had a destabilising effect on the home and its longer-term vision. Agency nurses were not firmly embedded within the service although heavily relied on. We saw quality reviews from the provider and noted that during a recent quality assurance visit by the provider, they identified that their improvement plan did not incorporate actions identified by external reviews from the Care Quality Commission CQC and the local authority which could result in some actions not being addressed. Although improvements necessary were being identified it was not always clear who was actioning these. Supervision and training was largely up to date but direct observation of staff practice and supporting staff to be their best selves at work was poorly developed. Staff were self motivating and people received differential expereinces depending on which staff were on and their level of experience. Surveys had been completed to seek peoples feedback but we could not see clear actions stemming from these.

We had mixed feedback about leadership. Care staff and activity staff appeared more settled and clearer about their responsibilities and were supportive of each other. Activity staff prioritised peoples needs and worked well as a team. Nursing staff were clearly struggling due to the lack of support from a clinical lead or regular manager. The domestic and catering staff were working efficiently but were also struggling due to the lack of permanent staffing and trying to cover their roles effectively. The service was not inclusive and staff felt senior management had let them down. The knowledge, and experience Leonard Cheshire had as an organisation had not been fully utilized to ensure the right level of resources had been made available when the home started to experience difficulties. A lot of faith had been placed in managers to oversee and manage their services with limited evidence of oversight of their practices and oversight of risk.

Audits were being completed and only recently had actions from audits been carried across to the service improvement plan incorporating issues identified by both the local authority and CQC . Whilst it was agreed improvements were being made these were not being sustained due to the lack of continuity of management and skill levels of the staff. Reliance on agency nurses who changed frequently meant the day to day oversight and culture was poor . Actions identified were not disseminated effectively across shifts and it was not clear who was responsible for what. This resulted in unidentified risks and a lack of updating documents to ensure all staff had clear infromation.

Staff raised concerns with us that in the absence of constant, reliable management they did not always have anyone to refer to and were not always clear of process. This was particularly true with agency nurses who said the absence of management meant they had to make decisions without being able to check these out and in the absence of clinical support. Agency nurses stated this made them feel vulnerable. Care staff were working autonomously but there was limited oversight of their practices or clear leadership within the service. Family members felt management had been responsive but also families told us they often micromanaged their families members care because of the lack of systems such as running out of medication or poor auditing of epilepsy. In one instance the family had developed their own charts. People and their relatives had not had much communication from the senior management team or asked to share their thoughts and ideas as to how the service could be improved upon.

The service had undergone multiple changes of management, so we were not assured people received consistent care and support or that there were always sufficient numbers of staff deployed to meet peoples needs. The organisation had processes in place to engage and involve people, but we were not assured of the effectiveness of these. For example, there was no lead nurse or key worker for each person. There was a monthly review of peoples needs. Whilst these reviews were completed well actions from them were not clearly delegated to ensure they were followed through. Objectives set for people were not time limited and there was no clear evidence of how people were supported to achieve their goals. Feedback from people was incorporated in the monthly provider visits where people were spoken to as part of this audit and feedback forms were used but we were unable to see how people’s experiences were firmly embedded in the providers improvement plan.

A number of staff were spoken to as part of this inspection and although it was clear staff enjoyed working at the service staff expressed concerns about direct, communication and leadership. Nurses told us they worked without clinical support, care staff worked well as a team but teams within the service were not integrated with staff working in silos. Activity staff reported working well together and clearly enjoying their role. Staff received training and supervision, but it was not clear how staff development was promoted and how management ensured staff were supported and valued in the work place or were working to person centred value.

Processes were in place to recruit and support staff, but these processes had been undermined by constant changes in management and poor oversight leading to a poor culture in which staff practice was not effectively overseen or that learning and improvement could be firmly embedded.

Prior to our site visit a number of staff had left including the operational manager, registered manager and clinical lead. The work force was struggling without regular management on site who had a good understanding of staff and peoples needs. Whilst care staff felt competent in their own roles they expressed concern about management and oversight. Other staff were planning to leave, and some staff were on sick leave. Interim management arrangements had been made but these were not firmly embedded at the time of our visit. We had concerns about the deployment and competencies of staff particularly for the trained nurses who had no clinical support and were not familiar with the service. Agency nurses were unhappy with how the service was run and said they had no one to refer to and did not know how to escalate concerns.

Interim management arrangements were in place but not firmly embedded at the time of our visit. We had concerns about the deployment and competencies of staff particularly for the trained nurses who had no clinical support and were not familiar with the service. Management teams had failed to maintain proper oversight and governance and we had some immediate concerns during our inspection. Conditions imposed on the home’s registration were not being met. We had concerns about staff deployment, clinical oversight, medicines management. and incident management. Key documentation on site was out of day and, or misleading, including the clinical register, the medication records and the individual emergency fire evacuation plans. The continuity plan was not up to date, and we were not assured agency staff were familiar with its content as it was not on the agency induction checklist and there was not always a clinical lead or manager on site. Staff training, supervision and support was in place, but the training statistics ranged from 62 percent to 92 percent and staff were not regularly observed to ensure they were competent in their roles and could carry out all elements of their tasks. This was particularly true around medicines where not all agency staff were familiar with the Emar electronic systems. There was a lack of clear process and training around the administration of medicines and nurses were not adequately supported to understand the electronic medication systems in place. In addition people's medication records had not been updated to ensure each persons room number was correct as some people had recently changed bedrooms. This significantly increased the risk of people being administered the wrong medicines and not at the time required. Audits completed by the senior management team showed widespread actions including concerns about records, communication, cleanliness equipment and a lack of reporting up for all incidents.

People’s experiences were variable across different care settings, and we received comments from partner agencies about continuity of care and support across these setting including admissions to hospital which were not always managed seamlessly. People did not receive their medicines consistently which put them at increased risk of unsafe care, and we identified that at times medicines ran out and there was poor communication between the service, The GP and the supplying pharmacy which resulted in increased risk of people not receiving the care they required.

Feedback from nurses in particular was one of a fragmented service where there was no continuity of care and support for people and people being supported by nurses unfamiliar with their needs and processes within the home. This resulted in people experiencing delays in the support they needed. We also noted that missed appointments occurred due to poor communication and handover of information.

Family member expressed a wish for the service to remain open and stated staff kept them up to date with things they needed to know, and some felt like equal partners within the care provision. However, others spoke of systematic failures within the service. Health and social care provider raised concerns and frustrations about communication and consistency which made it difficult to understand and respond to changes in people’s health.

The provider had worked with other agencies including other regulators to improve the service and outcomes for people using the service. Improvement plans were in place and audits helped to identify progress towards the improvement plans. Whilst improvements were being made, they were not being sustained due to the staffing and particularly management turnover which resulted in poor outcomes for people using the service. There was a lack of accountability and duty of candour which would help to ensure processes and communication were strengthened through reflective learning and learning from incidents.

The provider had not brought about sustained improvements which improved people’s quality of life. Processes were in place to ensure the environment was maintained and there was an adequate workforce with the training and skills to deliver the care that was needed but without the necessary oversight service growth and creativity had not been possible and care was not innovative. The provider has been responsive to our concerns, however realistically have not been able to sustain or embed the improvements required.

Clear guidance had been drawn up to help staff understand the care required but we found generally guidance and records were not clearly up to date and nurses new to the service were not given the information they needed to provide safe, effective care.