Archived: Preston Private

Preston Private is a nursing home providing personal and nursing care to 58 people aged 65 and over at the time of the inspection. The service can support up to 109 people across four units. One of the units specialises in providing care to people living with dementia.

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

People and their relatives told us they felt safe living at the home. However, our observations in two parts of the home showed people could not be assured of their safety because there were times when there were not adequate numbers of staff to supervise them safely. The system for deploying staff did not robustly consider people’s presenting risks and needs. There had been an increase in unwitnessed falls resulting in fractures. Risks to were assessed and in some cases, actions had been taken to reduce the risk however, this was not always consistent.

Staff were recruited safely. Medicines were managed and administered safely. Infection prevention protocols were in place and we were assured by measures in place including measures to reduce the risks associated with COVID-19. Safeguarding procedures were in place to protect people from the risk of abuse, and to educate staff on how to recognise and respond to concerns.

We found on this inspection some inconsistencies in applying audits and quality monitoring tools, such as those that determined staffing levels and those that acted on staff feedback. The provider’s systems and processes for ensuring the deployment of adequate numbers of staff were not robust to effectively monitor, respond to people’s needs and reduce known risks. We received mixed feedback from staff regarding management support and the impact of staffing levels in the home. Staff told us,“People are having to wait longer for help and for their medicines some nights, we have shared this with management we are told there is enough staff.”

The registered manager used a variety of methods to assess and monitor the quality of the service. They worked in partnership with a variety of agencies to ensure people's health and social needs were met.

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 good (published 18 December 2019)

Why we inspected

The inspection was prompted in part due to concerns received about people experiencing falls and sustaining serious injuries and staffing levels in the home. A decision was made for us to inspect and examine those risks.

We undertook a focused inspection to review the key questions of safe and well-led only. 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.

We have found evidence that the provider needs to make improvements. Please see the safe sections of this full report. 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 Preston Private Nursing Home on our website at www.cqc.org.uk

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.

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 register providers to account where it is necessary for us to do so.

We have identified breaches in relation to keeping people safe from risks and deploying suitably qualified staff at this inspection.

Follow up

We will request an action plan from the registered provider to understand what they will do to improve the standards of quality and safety. We will work alongside the registered 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.

Preston Private Nursing Home is a nursing home registered to provide accommodation and personal care for 101 people with either nursing or residential care needs. Care is provided between four units. These includes people living with dementia, people requiring residential and two units for people requiring general nursing care. At the time of the inspection, 90 people lived at the home.

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

People who lived at the home received good care and told us they felt safe. Staff knew how to identify signs and symptoms of abuse and who to report concerns. Risks had been identified and plans were in place to reduce harm. We made a recommendation about updating risks management plans promptly. Accidents and incidents had been reported and medical attention sought where required. We found some shortfalls to medicines administration practices. These had no significant impact and the manager acted promptly to rectify this. We made a recommendation about this. People were protected through robust recruitment procedures and told us there were enough staff to response to their needs. People lived in a clean environment and were protected from the risk of infections.

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 were asked to consent to care. Staff had received training and were knowledgeable about the principles of the Mental Capacity Act 2005. People were supported by staff who were trained and had the skills to provide effective care. Staff felt very supported by the manager and management team. People’s nutritional and oral hygiene needs were assessed and met. Staff worked with community health professionals to ensure people received effective care.

People told us staff treated them with dignity and were respectful. Our observations supported these views. We saw lots of positive interactions between people and staff, no one was rushed, and activities were person-centred. Staff had awareness of people’s diversity needs and respected them.

Care plans contained personalised information on people’s health and communication needs plus their likes and dislikes. However, improvements were required to ensure all care plans provided to staff were up to date and reviews completed to show changes to people’s needs. We have made a recommendation about this. People were provided with activities of their choice and supported to keep active in the community. People were able to make complaints concerning their care. People were supported to share their end of life wishes and care preferences.

The service was well-led. People, their relatives and staff spoke positively about the management team. There was a positive culture throughout the home which focused on providing care that was individualised and promoted independence. Staff and management had worked hard to improve the quality of care and people's experiences.

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 (published 27 November 2018) and there were a breach of regulation in relation to care records. 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 the regulation.

Why we inspected

This was a planned inspection based on the previous rating.

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.

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 of safe and well-led to at least good. At this inspection although we found that the provider had made improvements and completed those actions and recommendations we found a new breach of Regulation 17 good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This was because records we viewed on the dementia care unit (Fernyhalgh) were not always current, accurate, properly analysed and reviewed.

Preston Private is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

Accommodation is provided on the ground floor level and the building is set in its own grounds with parking and an easily accessible, private and secure garden with seating areas. Accommodation and nursing care is provided for up to 106 people. On the day of the inspection there were 92 people accommodated across four units. Fernyhalgh dementia care unit, Durton residential care unit, and two nursing units Longsands and Ladywell.

There was a registered manager 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.

We saw significant improvements had been made to the overall management of risks in the service since the last inspection and that the registered provider had acted on recommendations that we made on a number of areas.

People received their medications as they had been prescribed. Appropriate arrangements were in place in relation to the storage, care planning and records for the administration of medicines. However, we have made a recommendation about reviewing the time taken to dispense medications in the morning on the nursing units. Ensuring there is a consistency across all the units for the written protocols used for ‘as and when required’ (PRN) medication and the implementation of a pain assessment tool for people who have communication difficulties.

There were sufficient numbers of suitable staff to meet people’s needs. However, we noted that the use of agency staff used for night time cover in comparison to day time was much higher. The registeredprovider was actively recruiting for staff and we saw how this was an ongoing process. We also noted at times during the inspection that the deployment of staff on the dementia unit left the communal areas unsupervised for short periods of times.

Staff employed had received sufficient training to safely support and care for people and the provider had a training delivery plan in place which covered refresher training in a variety of topics. However, we noted that the agency staff used in the home were not all trained in the same subject areas. The registered manager took action during the inspection and consulted with the supplier of the agency staff to address this.

Staff were also supported through regular staff meetings, supervision and appraisals.

We saw that the service worked with a variety of external agencies and health professionals to provide appropriate care and support to meet people’s physical and emotional health needs.

Where safeguarding concerns or incidents had occurred, these had been reported by the registered manager to the appropriate authorities. We could see records of the actions that had been taken by the home to protect people and the identified lessons that had been learned.

People’s rights were protected. The registered manager was knowledgeable about their responsibilities under the Mental Capacity Act 2005. People were only deprived of their liberty if this had been authorised by the appropriate body or where applications had been made to do so.

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.

People living in the home were supported to access activities that were made available to them and pass times of their choice.

Auditing and quality monitoring systems were in place that allowed the service to demonstrate effectively the safety and quality of the home.

We observed people's dignity and privacy were actively promoted by the staff supporting them.

Further information is in the detailed findings below.

We found that improvements had been made at this inspection and many of the actions from the previous two inspections had now been completed. However, we did still have concerns in some areas. At this inspection we found one breach to Regulation 12 of the Health and Social Care Act (Regulated Activities) Regulations 2014. This was predominantly around concerns we had at the previous inspection and included; a lack of action to risk assessments, including updating assessments at the point of change and ensuring action identified to reduce risks was implemented and carried out. We also identified a number of actions had begun but were not embedded or needed some further thought to ensure they were practical. This included the consistency of the Personal Emergency Evacuation Plans (PEEPs) and the completed plan for evacuation. We noted work had been done to develop the PEEPs and they were generally person centred, however the overall plan for evacuation was not achievable due to the size of the home. We also had on-going concerns around the electrical installations in the home and had not seen a satisfactory certificate for the last two inspections. We have insisted this work is completed as a matter of urgency and the certificate forwarded to us as soon as it becomes available.

We have also made 12 recommendations. Recommendations are made when a regulation has not breached but are used to encourage improvement. We have made recommendations about staffing and training, dementia care and consent and the availability and use of information. We have also made recommendations about the completion and use of records and their audit and the availability of clinical waste depositories.

The home is a large service which can support up to 105 People. The home has two nursing units, ‘Longsands’ and ‘Ladywell’ a residential unit named ‘Durton’ and a specific unit to support people living with dementia named ‘Fernyhalgh’. At the time of the inspection there were 101 people living in the home.

The main body of the home has not changed in its layout or decoration since the last inspection. The main entrance leads into a small reception area and administration office. From this area you walk onto a wide corridor at a ‘T’ junction. One way leads down to Fernyhalgh, which is the separate unit supporting people living with dementia and the residential unit and the other way leads to the two nursing units, Ladywell and Longsands. Durton and Longsands have an interlinking corridor at the back of the building thus creating one circuit of the home. A number of smaller corridors interlink units. It is very easy to get lost in the home and whilst each unit has a different coloured hand rail this does not help identify where you are or how to get to where you want to be. At the previous inspection we identified this as a concern and asked the home to review this. We were told people had been asked if they liked the decoration of the home and had responded “Yes.” There was not any detail available of who was asked, how many people were asked and how they were asked. As a consequence no changes had been made. We discussed this with the current manager and quality manager and it was agreed this review would be completed again, with the premise that the review was to ascertain if people found it easy to navigate the building and what improvements could be made.

There is a large laundry in the basement area of the home. All other facilities are on the ground floor including a large catering kitchen and lounge and dining areas for each of the units

Since the last inspection there have been a number of managers in the home. The home is required to have a Registered Manager. A Registered Manager is a person who is 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 previous Registered Manager had left shortly after the previous inspection. No one had registered since. At this inspection we were told the previous Registered Manager was returning to the home the week after the inspection and would re-register with the Care Quality Commission.

Since the last inspection in February 2016, the home had made significant investment into the home and the staff who work there. We found the atmosphere in the home had changed and staff and people living in the home told us they were much happier. It was clear there had been financial investment in meeting the requirements of some of the regulations including, investment into the environment in the dementia unit, Fernyhalgh. We found this unit was much calmer and staff were more confident in meeting people’s needs.

As a consequence of the investment, people in the home felt more in control of their lives and felt involved in decisions about their care. People all told us the staff treated them with dignity and respect. This was evident in the observations we made and conversations staff and people in the home engaged in. People were well presented and looked forward to the planned activities available in the home. The addition of a home minibus had been well received around the home and people were looking forward to trips out in the coming summer months.

Staff had engaged in a comprehensive training programme and nurses had the opportunity to keep their skills up to date and to learn new ones. Staff felt supported by each other and the management of the home and their professional roles had seen an obvious investment. This of course had an impact on how they undertook their role and each staff member we spoke with told us in varying degrees how much they enjoyed working at Preston Private.

People we spoke with complimented the choice and quality of the food and felt they dietary requirements and needs were met. Information was available to the people in the home via the notice boards and the regular resident and relative meetings. Information from these meetings was shared with everyone in the home.

The home had significantly improved since the last inspection and with the further work planned on improvements to the service we envisage seeing care provision and the environment continue to improve.

You can see what action we told the provider to take at the back of the full version of the report.

The service is a large building that can support up to 105 people. Support at the home is split into three categories. There is one unit specifically supporting people living with dementia. One unit supporting people with residential care needs and two units supporting people with nursing needs. At the time of the inspection there were 92 people living in the home.

The home has a number of corridors. The main entrance leads into a small reception area and administration office. From this area you walk onto a wide corridor at a ‘T’ junction. One way leads down to the dementia unit which is a stand-alone unit and the residential unit. The other leads to the two nursing units. The residential unit and one of the nursing units also join at the other end of the building. A number of smaller corridors interlink units. It is very easy to get lost in the home and whilst each has a different colour hand rail this does not help identify where you are or how to get to where you want to be.

There is a large laundry in the basement area of the home. All other facilities are on the ground floor including a large catering kitchen and lounge and dining areas for each of the units.

The home has a registered manager who has been in post for 15 months. 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.

At the last inspection in July 2015 four breaches of the regulations were found in the areas of; person centred care, good governance, meeting nutritional needs and the environment. The CQC was provided with an action plan stating the areas identified in breach would be addressed by April 2016. We inspected the provider before this date as we had received information of concern by way of complaints and whistle blowers. We did look at the action undertaken so far by the provider to address the concerns but are unable to take any further action until after the deadline has been passed.

At this inspection we found the home were in breach of nine of the regulations. Two of which had been identified previously and a further seven found at this inspection.

We found whilst the staff in post were motivated and committed to delivering a quality service in all but one of the units this was not borne out due to a lack of suitably qualified and experienced staff. People living in the home and their family members told us there was not enough staff and we saw on each day of the inspection circumstances where more staff was required. This included over 20 people still in their bedrooms undressed at 11am. We spoke with a number of these people and some were ok with this situation and others were not. We asked four people if this was usual and were told yes.

People were not routinely asked for their consent before support was given and it was not always given in a timely way when it was requested. We saw people calling out for help when no staff were available. One person told us they were asking for help for up to twenty minutes and eventually the cleaner came in to see what they needed. We saw people were not always treated respectfully and their dignity was not upheld. This included people being fed food when they had said they didn’t like it and doors not being closed without being entered when people were being supported with their personal care.

We saw people were often sitting in chairs that were tipped back restricting them from getting up. We were aware of safeguarding concerns which identified staff were unaware of the legalities around restrictive practice. We looked in the files of people being supported in this way and did not see any effective assessments to support this type of intervention.

Risk assessments had been completed to ensure people living in the home and staff were safe but these were not always followed. Where professional checks had identified concerns these had not routinely been followed up and not all records showed equipment was safely tested to ensure it was in working order.

The building and environment were difficult to navigate and the provider had not taken the required action to ensure it was suitable for the people living in it. The purpose of actions taken thus far to support people living with dementia had not been suitably understood to ensure they were fit for purpose. For example a pictorial menu board had been purchased with pictures of plates of food decorating the border. For this to be effective the board should only contain pictures of the meals on the menu as the others simply added as a distraction away from the purpose of simplifying the menu.

The provider had a comprehensive complaints procedure but not every complaint received at the home was managed in line with the procedure. The home had three recorded complaints in the last 12 months but the CQC were aware of five complaints received in the five months preceding the inspection. Two of which the provider was aware of without being previously informed by the CQC.

Audits had been completed monthly and a system was in place to monitor service provision. However we found the audits did not always identify the issues external professional audits identified. This included fire doors that were not up to standard and medication administration procedures that required further thought.

We found that where the provider assessed people’s needs they developed care plans to meet those needs. However when we spoke with people it was clear that some specific needs had not been assessed. Reviews of people’s needs were completed monthly or when people’s needs changed. We saw changes at point of review were incorporated into plans of care and people’s needs were mostly met. Some people or their relatives we spoke with told us they were involved with developing their care plans and staff we spoke with knew people living in the home well.

The food at the home was varied and a menu had been developed in consultation with people in the home. The chef was aware of people’s dietary needs and changed people’s diets to better support them when they were losing weight.

People’s medicines were managed well with staff were following the home’s procedures. We saw medicines were administered safely and people in the home received their medicines as prescribed.

Activity coordinators were in post at the home and we saw a number of activities taking place with the people in the home over the course of the inspection.

You can see what action we told the provider to take at the back of the full version of the report.

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people using the service, the staff supporting them and from looking at records. The inspection team consisted of three inspectors, a specialist advisor and an expert by experience. This is a person who has personal experience of using or caring for someone who uses this type of care service.

Is the service safe?

People we spoke with told us they felt safe living at Preston Private. Staff spoken with had an understanding of the procedures in place to safeguard vulnerable people from abuse and had received training on this subject. This meant staff knew how to recognise and respond if they witnessed or suspected abusive practice.

We found the location to be meeting the requirements of the Deprivation of Liberty Safeguards. Policies and procedures were in place and training had been provided to guide staff in relation to the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. However we found assessments of people's capacity to support best interest decisions and their advanced wishes was not always in line with best practice.

Staffing levels were continually assessed and monitored to ensure there was sufficient staff available to meet the needs of people who lived at the home. However from our observations and from what people told us during the inspection visit, there was not enough staff to meet the needs of people who lived at the home.

Is the service effective?

People were encouraged and supported to express their views about how they wanted their support delivered. This started before the person moved into Preston Private. The staff team worked with the person to plan, communicate and develop relationships so that everything about them, their needs and desires were understood.

People discussed their healthcare needs as part of the care planning process and we noted there was guidance for staff on how best to meet people's health needs. However we did not find this in all cases. This meant staff were not always aware of people's medical conditions and may not know to respond if there were any signs of deterioration in the person's physical or mental health.

Staff had the training and support to meet the individual and diverse needs of the people they supported.

Is the service caring?

We found staff to be caring and compassionate to people who lived at the home treating them with respect. People confirmed to us that staff were caring and told us they were happy with the care and support provided.

Care records we looked at showed people's needs were assessed. We saw evidence that people's needs were assessed before they started to use the service. This ensured staff had the required skills and training to meet people's needs. Assessments included aspects of the person's health, personal and social care needs.

During the morning we observed at times there was limited staff interaction with people who lived at the home. However in the afternoon we saw an activities co-ordinator actively engaging people in a programme of activities. There was also a 1940's singing group entertaining people on one of the units. We saw people responded positively to this. There was a notice board with information of forth coming events and activities planned.

Is the service responsive?

We observed staff being responsive and attentive to people who required support. This confirmed people who required care and support were being treated with respect and dignity.

People's needs were assessed prior to their admission to the home. Records showed people and their family members had been involved in making decisions about what was important to them. Each person had a key worker who liaised closely with them and their family members. People's care needs were kept under review and staff responded quickly when people's needs changed.

The management and staff at the home worked well with other agencies and services to make sure people received care in a consistent way. This demonstrated the service had an open and co-ordinated approach in ensuring people received the support they needed.

Is the service well-led?

The provider had policies and procedures in place to monitor the quality of the service. These included seeking the views of the people they supported by way of surveys, care reviews and regular monitoring. We saw copies of surveys completed by the people being supported. This meant that people who lived at the home and their family members had the opportunity to give their views about how the service was run.

Records reviewed showed that the service had a range of quality assurance systems in place, to help determine the quality of the service offered. During our inspection there were a number of concerns we had in respect of capacity assessments, record keeping and staffing levels. Through the quality systems, the registered manager had identified a number of the concerns and had actions in place to address them.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care.

People also told us they could choose what and when they did things in the home. People told us they decided how they wanted to be supported with their care and this included the gender of their carer. We saw that there were no rules imposed on people.

People had their needs assessed and we saw that they were asked about their care and support and agreed to it. People told us they were treated with dignity, kindness and respect.

People's care and support plans detailed their care needs and these were kept under review. We found family members were happy with the care of their relations

People told us that they were consulted about the quality of the service they received and if they had concerns or complaints about their care they knew who to talk to.

People told us what it was like to live at this home and described how they were treated by staff and their involvement in making choices about their care.

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experiences of people.

On the day of our visit we saw that a church service and group activities had been arranged and people were encouraged and supported to participate.

People had their needs assessed and we saw that they were asked about their care and support and agreed to it. People told us they were treated with kindness and respect. People had care and support plans detailed their care needs. These were kept under review. People also told us they could choose the gender of their carer and staff respected this. The provider had policies and procedures in place to ensure people's dignity was respected but we observed people were not always treated as such.

We found family members were happy with the care of their relations

There were no rules imposed on people. Staff were trained to protect people and people said they were safe. They told us if they had concerns or complaints about their care but would speak with the manager or the staff if they needed to.