This inspection took place over two days on 09 May and 14 May 2018. The first day was unannounced, which meant the service did not know in advance we were coming. The second day was by arrangement.Norlands Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. The Care Quality Commission (CQC) regulates both the premises and the care provided, and both were looked at during this inspection. Norlands Nursing Home is registered with CQC to accommodate a maximum of 21 older people, including those living with dementia. At the time of this inspection the home was full.
At this inspection we found two breaches of regulations concerning safe care and treatment and good governance. We have also made three recommendations relating to the mental capacity act, person-centred care, and equality, diversity and human rights. You can see what action we have asked the service to take at the back of the full report.
We looked at how medicines were managed and found a variety of issues. For example, on the front of each Medication Administration Record (MAR), there was no place to record if a person had any allergies. This placed people at an increased risk of receiving a medicine that they were allergic to. We also found arrangements for administering ‘as and when required’ medicines was ineffective and not response to people’s needs.
We looked at how the service assessed and mitigated risks. We found that not all people who used the service had individual risk assessments completed and that where a risk assessment had been completed, information was recorded in a variety of different places. For example, some risks were noted and addressed in care plans under the heading of ‘safety’ however these were not easily identifiable or clearly presented, others on a separate risk assessment page.
We looked at the use of thickeners in people’s drinks and how special diets were managed for those deemed a high risk of choking. We found the information recorded in people’s care plans was contradictory and did not reflect the most recent swallowing assessment completed by a Speech and Language Therapist (SaLT). As a result of this, we asked the service to complete an immediate review of each person deemed to be at risk of choking. We also raised safeguarding alerts with the local authority.
Norlands Nursing Home benefited from a low staff turnover and all members of staff were on permanent contracts. The service did not use an external staffing agency and short falls in shifts were covered by existing permanent staff. Recruitment procedures remained safe and effective.
Care staff understood how to help people make choices on a day to day basis and how to support them in making decisions. However, information recorded in care plans relating to the mental capacity was not decision specific and we found a blanket approach had been taken in respect of recording if a person was deemed to lack capacity.
We asked the registered provider to provide us with overarching records relating to the management of Deprivation of Liberty Safeguards (DOLS) made to the local authority and found these were not sufficiently robust to ensure oversight was maintained. For example, there was no DOLS matrix or tracker in place that would help the service to record key dates relating to the DOLS process.
People received care and support from staff who knew them well and who had the skills and training to meet their needs. Staff told us they continued to receive lots of opportunities for training and professional development.
We observed the mealtime experience and saw that people benefited from freshly prepared, home cooked food and were offered choice from a varied menu. At breakfast people could choose from a cooked option, cereal, toast or fresh fruit. At lunch time people were offered a choice of two options for both the main and desert. At tea time a selection of sandwiches was provided with a further desert option.
The daily menu was displayed on a white board in the dining room but no pictorial menus were made available This type of menu can help people who are living with dementia to communicate their personal preferences at mealtimes.
Norlands Nursing Home benefited from attractive landscaped gardens and an outside space that was accessible for wheelchair users and people with limited mobility. Weather permitting, visiting relatives were encouraged and supported to spend time with their loved ones outside in the fresh air.
Throughout our inspection we observed lots of instances of warm and caring interactions between staff and people living at the home. Without exception, people described the home as a very caring place to live.
People living at Norlands Nursing Home were diverse and multi-cultural. Through talking to staff, we were satisfied the ethos and culture at the home was non-discriminatory and the rights of people from certain groups would be respected.
Everyone was allocated a keyworker and their role was to get to know the person particularly well and to ensure their day-to-day needs were met.Throughout our inspection, it was clear that staff at Norlands Nursing Home knew people well and their basic care needs were being met.
However, care and support planning documentation was not reflective of this.
Documentation for recording day to day care and support was disorganised and spread across multiple systems. The majority of care files contained historical information that was not always reflective of a person's needs and this made eliciting the current picture difficult. We also found care and support records to be task and nursing orientated and did not take sufficient account of people's likes, dislikes, personal preferences and who was important to them.
People living at Norlands Nursing Home could choose to participate in a range of traditional activities. For example, sing-a-longs with a visiting entertainer, board games, dominos and bingo sessions. People were also supported to access the local community through visits to the local shops, cafes and the market.
In reviewing arrangements for good governance, we looked at systems for audit, quality assurance and questioning of practice and found records to be disorganised and not sufficiently detailed enough to provide assurance that oversight was being maintained. In particular, we found no regular overarching analysis was completed in order to identify trends or contributory factors.
We spoke at length with the registered manager to ascertain their understanding of the legal responsibilities associated with being a registered manager. In particular, the fundamental standards of quality of safety. Through these discussions, and from the evidence gathered during the inspection, it was apparent the registered manager had not kept pace with changes to legislation and they were not in a position to fulfil the role of registered manager effectively.