Archived: Willow Grange Care Limited

People living at Willow Grange (formerly known as Coombe Hill and Blenheim Lodge Nursing home) receive accommodation and personal care as a 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.

The care home can accommodate up to 44 people living across three floors in one adapted building. Most people living in the home were older people living with dementia and/or who had nursing needs. The service also specialises in supporting people with mental ill health problems, learning disabilities or autistic spectrum disorders, acquired brain injuries or sensory loss. At the time of our inspection 37 people resided at Willow Grange.

The service continues to have the same registered manager who has been in post since 2016. A registered manager is a person who has registered with the CQC. Registered managers like registered providers 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, which we carried out in April 2017, we rated the service ‘Requires Improvement’ overall and for the three key questions, ‘Is the service effective, caring and well-led?’ This was because we found staff did not always given sufficient opportunities by their managers to reflect on their working practices and develop their knowledge and skills, some staff did not always respect people’s privacy and governance systems were not always effective.

At this comprehensive inspection, we found the provider had taken appropriate steps to address the issues we identified at their last inspection. This included ensuring care staff were now suitably trained and supported, staff always respected people’s privacy and more effective management oversight and scrutiny arrangements were established to help monitor the quality and safety of the service people received. This included the appointment of new clinical nurse lead and an independent care consultant and the introduction of a new electronic care planning system.

However, we also identified a number of new issues at this inspection where the provider still needed to take further action to improve and meet the essential standards and regulations. The service has therefore been rated ‘Requires Improvement’ overall for the third consecutive time and for all five key questions.

This was because we found some staff did not always ensure people were treated with kindness and respect. Although we saw most staff interacted with people in a kind and compassionate manner, we observed several instances of poor practice including one incident when a member of staff used inappropriate language and gestures to ‘encourage’ an individual to eat their lunch and other staff not engaging well with the people they were assisting to have their lunch.

Furthermore, people did not always receive care and support which met their individual needs and reflected their preferences. Half the relatives we spoke with expressed being concerned that staff did not always follow their family members wishes or guidance in their care plan. Examples given included several incidents of people’s family members being left in bed too long or being assisted to go to bed too early by staff contrary to guidance in their care plan about their preferred daily routines.

These shortfalls represent two breaches of the HSCA (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

The home was adequately staffed on both days of our inspection. However, it was evident from most of the comments we received from people living in the home, their relatives and staff we spoke with that they felt there were sometimes issues with the way staff were deployed in the care home. We discussed this issue with the registered manager at the time of our inspection who told us they had recently reviewed current staffing levels and were in the process of recruiting new staff to increase the number of staff that were on duty at night. Progress made by the provider to achieve this stated aim will be assessed at their next inspection.

In addition, although care staff were suitably trained to effectively carry out their roles and responsibilities; we found not all nursing staff had completed the specialist training they needed to effectively meet peoples more complex health care needs and use specialist medical equipment safely. We discussed this issue with the registered manager who showed us a time specific action plan they had developed to ensure all nursing staff completed up to date training in the safe use of syringe drivers, Percutaneous Endoscopic Gastrostomy (PEG) feeding tubes, catheters and pressure sore care within the next three months.

People also did not always have sufficient opportunities to participate in meaningful activities that reflected their social interests. We recommended the provider seek advice and guidance from a reputable source, about developing a programme of social activities that met the needs and social interests of people living with dementia.

Finally, although we found the provider had made some progress to improve their governance systems, further improvements were still required because of the number of new issues described above that we identified during this inspection.

These negative comments notwithstanding, we found the provider continued to have robust procedures in place to safeguard people from harm and abuse. Staff were familiar with how to recognise and report abuse and neglect. Appropriate recruitment checks took place before staff were permitted to commence working at the home. The environment was kept hygienically clean and safe. People received their medicines as prescribed.

People were supported to eat and drink enough to meet their dietary needs and preferences. Managers were aware of their duties under the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff sought people's consent before providing any care and support and followed legal requirements when people did not have the capacity to do so. They also received the support they needed to stay healthy and to access health care services.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. When people were nearing the end of their life, they received compassionate and supportive care.

People had new electronic personalised care plan, which set out how their care and support needs should be met by staff. The provider had suitable arrangements in place to appropriately deal with people’s concerns and complaints.

We carried out a focussed inspection in April 2016 to check the provider’s progress in meeting legal requirements. We found the provider had taken action to meet legal requirements, although we did not change their overall rating because we wanted to ensure the improvements made were well established and could be sustained over a longer period of time.

The service now had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

Coombe Hill and Blenheim Lodge Nursing Home provides nursing and personal care for up to 44 people. The service specialises in supporting older people living with dementia and younger adults with acquired brain injuries, mental ill health or learning disabilities. At the time of our inspection there were 37 people using the service.

At this comprehensive inspection we found the provider had maintained improvements in the way they reviewed care plans, mitigated risks, recorded complaints and reported safeguarding incidents to the relevant agencies.

Although there were systems in place to support, supervise and appraise staff’s working practices, we found these were not always followed. This meant some staff might not have the right knowledge, skills and support they needed to effectively meet people’s needs, wishes and choices.

We also found that although the provider had governance systems in place these had not always been operated effective. This was because they had failed to identify a number of issues we had found during our inspection in relation to staff not always respecting people’s privacy and staff not always being suitably trained and supported.

These failings represent two breaches of the Health and Social Care (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

At this inspection we found the provider did not ensure staff treated people with respect and dignity at all times. Although people told us they were happy living at the home and we observed most of the interaction between staff and people using the service were characterised by dignity and compassion, we found some staff did not always respect people’s privacy by making sure they knocked on people’s bedroom doors to ask the persons permission to enter.

The breaches described above notwithstanding, most people told us they were happy living at Coombe Hill and Blenheim Lodge Nursing Home. We saw staff looked after people in a way which was kind and caring. Staff had built caring and friendly relationships with people. Our discussions with people using the service and their relatives supported this.

There continued to be robust procedures in place to safeguard people from harm and abuse. Staff were familiar with how to recognise and report abuse. The provider assessed and managed risks to people’s safety in a way that considered their individual needs. Recruitment procedures were designed to prevent people from being cared for by unsuitable staff. There were enough staff to keep people safe. The premises and equipment were safe for people to use because staff routinely carried out health and safety checks. Medicines were managed safely and people received them as prescribed.

Staff were in the process of completing their required training, which continued to improve since our last inspection. This ensured they had the right competencies to perform their roles effectively. People were supported to eat and drink sufficient amounts of nutritious food that met their dietary needs. They also received the support they needed to stay healthy and to access healthcare services.

People received personalised support that was responsive to their individual needs. Each person had a personalised care plan, which set out how their care and support needs should be met by staff. This meant people were supported by staff who knew them well and understood their needs, preferences and interests. Opportunities for people to participate in meaningful social activities that reflected their social interests had improved since our last inspection.

The service had an open and transparent culture. People felt comfortable raising any issues they might have about the home with staff. The service had arrangements in place to deal with people’s concerns and complaints appropriately. The provider also routinely gathered feedback from people living in the home, their relatives and staff.

The provider wrote to us in December 2015 to say what they would do to meet their legal requirements in relation to all six breaches of the regulations we described above. We undertook this unannounced focused inspection on 13 April 2016 to check the provider had implemented their action plan and was now meeting legal requirements.

This report only covers our findings in relation to this topic. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for ‘Coombe Hill and Blenheim Lodge Nursing Home’ on our website at www.cqc.org.uk’

Coombe Hill and Blenheim Lodge is a residential service that can provide nursing and personal care for up to 44 younger and older people. The home is divided into two separate units. The unit known as Coombe Hill comprises the ground and first floors and specialises in supporting older people living with dementia. The unit known as Blenheim Lodge is situated on the lower ground floor and caters for both younger and older adults with physical disabilities. At the time of our inspection 40 people lived at the home, 24 of whom were living with dementia.

The service is required to have a registered manager. The home has not had a registered manager in post since March 2015, although a temporary acting manager has been in day-to-day charge of Coombe Hill and Blenheim Lodge for the last 12 months. In March 2016 a new permanent manager was appointed. They have applied to the Care Quality Commission (CQC) to become the registered manager. A registered manager is a person who has registered with the (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

During our focused inspection, we found that the provider had followed their action plan, which they said would be fully implemented by the end of January 2016. We saw legal requirements had been met.

Where people had been identified as a being at risk of malnutrition or choking staff monitored their food and fluid intake and ensured they received the right levels of food and drink to stay nourished and well. People’s care plans and risk assessments were continually reviewed and updated accordingly by staff.

Staff received all the training and support they required from their managers to perform their duties and to meet the needs of the people they cared for. This included supporting people with complex health needs, moving and handling, managing challenging behaviour, basic life support, and understanding the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS).

Records in relation to complaints made about the service and the provider’s response to them were appropriately maintained by staff and regularly monitored by managers.

The managers also liaised with the local authority and the CQC as and when appropriate if they had concerns regarding safeguarding procedures or people’s safety. Furthermore, the provider now operated effective governance systems to routinely assess and monitor the quality and safety of the service received by people who lived at the home. Regular audits were carried out and, for areas where issues were identified, appropriate and timely action was taken to ensure people’s welfare and safety.

Following that inspection we asked the provider to take action to achieve compliance with the appropriate regulation. The provider sent us an action plan on 30 July 2014 setting out the steps they had taken to do this. During this visit we checked these actions had been completed.

This visit was carried out by a single inspector who helped answer one of our five questions: Is the service effective?

Below is a summary of what we found. The summary is based on our observations during the inspection, from looking at records and from speaking with the home's manager. In this report the name of a registered manager appears who was not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our records and an application had not yet been received to remove them. If you want to see the evidence supporting our summary please read the full report.

Is the service effective?

We found at this visit the provider had made improvements that were needed. Care and support had been planned and delivered in a way which ensured people's safety and welfare. We saw appropriate action had been taken to reduce risks to people's health, safety and welfare, where these had been identified. This included clearer instructions and guidance for staff and the purchase of new equipment to adequately support people.

People's care records had been reviewed and updated and now contained more detailed information about people's specific needs and wishes so that staff had information they needed to provide the appropriate care and support.

We found records monitoring people's food and fluid were in place which gave staff better information about whether people were eating and drinking sufficient amounts to stay healthy and well. There were also records in place to monitor and review people's outputs to ensure there were no underlying issues or concerns about an individual's health.

We saw changes were made to the way people were served their meals so that people received their food in a timely manner and that there were sufficient numbers of staff available to support them to eat and drink, where this was needed.

Below is a summary of what we found. If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents. This reduced the risks to people and helped the service to continually improve. There were no Deprivation of Liberty Safeguards in place for any people using the service at the time of the inspection. Staff had a good understanding of the mental capacity act and deprivation of liberty safeguards, and there were policies in place regarding these topics. Staff also had a good understanding of safeguarding and how to respond to signs of abuse. This meant that there were mechanisms in place to safeguard people from the risks of abuse and to protect their rights.

The service was clean and hygienic. Equipment was well maintained and serviced regularly but not all risk assessments were carried out in relation to the safety of the premises. We found that people were getting adequate nutrition and hydration.

Is the service effective?

People’s health and care needs were assessed, and information in care plans and risk assessments was regularly reviewed. However, when risks to people’s health and welfare were identified, action was not always taken to mitigate the risks. We also found that action was not always taken to support people with specialist communication needs. Also, guidance in care plans to avoid pressure sores was not always followed, and so staff were not consistently meeting people’s needs.

Is the service caring?

People using the service made positive comments about the staff, as did family members we spoke with. People using the service told us they liked living here. People also liked the food. We saw staff expressing warmth through smiles and reassuring touches, and by speaking to people in a kind manner.

Is the service responsive?

The service responded appropriately to allegations of misconduct by staff, as well as to safeguarding allegations, informing the local authority. The manager responded well to suggestions and comments made by people who use the service, their representatives and staff.

Is the service well-led?

In this report the name of a registered manager appears who was not managing the regulatory activities at this location at the time of the inspection. Their name appears because they were still a registered manager on our register at the time.

Staff felt well supported by management and received training to support them in their role. The manager monitored and assessed quality and safety within the home, in various ways, and held meetings to seek the views of people using the service, staff and family members and friends. This meant that they could come to an informed view about the care and treatment provided to people.

Appropriate agencies, such as health services and social services were involved in the care planning process and regular reviews of care were seen to have taken place. We saw that people were able to approach staff in an informal manner and that visitors were welcomed in the home. Visits by other professionals, for example health service or social services also took place.

We saw that meals were provided in spacious dining areas, assisted by staff, and those people who wished to have meals in their rooms were able to do so. We observed drinks being given regularly throughout the day.

Staff we spoke with were able to give a clear description of what was meant by terms such as "safeguarding" and "abuse" and confirmed that they had received training in this subject. Staff records confirmed this.