Bluewater Care Home

Bluewater Nursing Home is a residential care home providing personal care to 15 people aged 65 and over at the time of the inspection. Some people were living with dementia. The service can support up to 60 people. Although it is called Bluewater Nursing Home, the home does not provide nursing care.

The home is based over four floors accessed by an interconnecting passenger lift. The ground floor provides communal areas for people and the first, second and third floors provide bedrooms, communal bathrooms and a small communal area. Only the lower two floors were in use at the time of the inspection.

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

The provider continued to fail to ensure risks to people’s health, safety and wellbeing were assessed and managed, which put people at increased risk of avoidable harm. Care provided was not always safe, in line with national guidance and risks were not always managed in the least restrictive way. There had been improvements in the management of health and safety, fire safety and other environmental risks identified at the last inspection.

There was evidence the provider had continued not to consistently and appropriately report and investigate incidents. The safeguarding authority had not always been informed of relevant incidents. There were not always enough suitably skilled and competent staff deployed to meet people’s needs and manage risks to people’s safety.

There had been some improvements in medicines management, however some issues remained. Staff had received a range of training. The provider was not able to demonstrate staff had been trained in specialist administration of one person’s medicine which was to be given in the event of them choking.

The home was visibly clean. There were appropriate arrangements for visitors. The environment was spacious, we identified a need for further signs, in line with dementia friendly guidance, to support people to know where the toilets were.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People’s capacity to consent to decisions about their care was not always assessed, and it was not clear they had been provided with enough information to make an informed choice.

There had been improvements in managing people’s nutrition and hydration needs. One person had gained weight, which was positive for them. Another person was being supported to lose weight, which was their goal. People were usually offered enough to drink but were not always given choices about what they wanted to drink.

Some people told us there was not enough to do, we observed some people were isolated and anxious and did not have enough occupation or emotional support. There were a range of activities available, however these were not always tailored to meet people’s individual needs.

Although more audits had been completed, these were not sufficiently robust to assess and improve the quality and safety of the service. There were a number of continued breaches of regulations. Although some actions had been completed to address issues identified at the last inspection, not all issues identified had been addressed and people were still not receiving safe care. The required actions had also not been incorporated into a service improvement plan. New issues were identified at this inspection, demonstrating the provider was not pro-actively assessing their compliance with the regulations and working to improve in these areas.

Although the provider regularly engaged with other healthcare professionals, we were not assured their advice was consistently followed or clearly written into care plans. The local authority told us the provider had failed to attend large scale safeguarding enquiry meetings to review incidents which had taken place within the home, and had failed to provide an improvement plan when this was requested.

The provider was found to be defensive and not receptive to CQC ‘s feedback

Relatives gave mixed feedback, they felt they could raise concerns with the provider and these were usually resolved. One relative described the home as “OK, not the best”, another said the staff “looked after [their relative] well”. Other feedback included that “the environment is very unique” and “overall, I am happy with the care and support”.

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 inadequate (published 1 February 2022) and there were breaches of regulation. At this inspection we found the provider continued to be in breach of regulations.

This service has been in special measures since 19 May 2021.

Why we inspected

We carried out an unannounced inspection of this service between 25 March and 15 April 2021 and identified breaches of legal requirements. We undertook a follow-up, focussed inspection from 4 to 16 November 2021 to review if actions had been completed and if the breaches were met. We identified continued breaches of regulations in relation to consent; safe care and treatment; nutrition and hydration; good governance and fit and proper persons employed.

We carried out this inspection to follow up on these breaches of regulation and to understand if these were now met.

Enforcement and Recommendations

One breach has been resolved on this inspection, however we identified two new breaches of regulation and four ongoing breaches of regulation. We have identified breaches in relation to person-centred care, consent, safe care and treatment, good governance, staffing and fit and proper persons employed at this inspection.

Following this inspection we cancelled the provider's registration.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions of their registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Bluewater Nursing Home is a residential care home providing personal care to 16 people aged 65 and over at the time of the inspection. Some people were living with dementia. The service can support up to 60 people. Although it is called 'nursing home', it does not provide nursing care.

The home is based on four floors with an interconnecting passenger lift. The ground floor provides communal areas for people and the first, second and third floors provide bedrooms, communal bathrooms and a small communal area. Only the lower two floors were in use at the time of the inspection.

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

The provider did not ensure that risks to people’s health, safety and wellbeing were assessed and managed, which put people at increased risk of avoidable harm. Decisions made to manage people’s risks were not consistently clear or in line with national guidance, were not always safe and were not always the least restrictive. Medicines were not always well managed or stored in line with requirements. People’s medicines care plans did not have clear information for ‘as needed’ medicines.

Recruitment processes were not robust and did not always ensure staff were suitable to work with people who use care services. There were enough staff to deployed to keep people safe. Staff were busy throughout the inspection, moving from task to task. Although staff had an understanding of safeguarding and knew how to report concerns, we were alerted to bruising to one person which had not been properly reported to the local authority. Improvements had been made in reporting incidents, however incidents related to behaviours which may challenge staff were not consistently reported and reviewed for learning and improving care.

The provider had made improvements to infection prevention and control in the home, which was visibly clean and staff were wearing appropriate personal protective equipment (PPE).

People were not supported to have maximum choice and control of their lives and we were not assured staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People’s capacity to consent or to make decisions was not always properly assessed. It was not clear the provider had followed the principles of the Mental Capacity Act 2005 and that decisions made in people’s best interest appropriately considered the pros, cons and alternatives related to the decision, or were the least restrictive.

We could not be assured that people were always offered or received enough to drink. People’s risks related to malnutrition had been assessed, however care plans were not always clear where nutrition was a priority over other risks related to eating and drinking.

Improvements had been made in staff completing training and understanding of topics relevant to their role, such as mental capacity, risk and safeguarding. We raised some concerns over the number of courses staff had completed in one day, which we highlighted to the manager.

The provider had not taken a systematic and proactive approach to identifying and addressing quality and safety issues. On inspection we identified risks to the health, safety and wellbeing of people which had not been identified by the provider, despite checks, reviews and audits which should have identified them, or which had been signed off as completed in an action plan.

Staff and relatives fed back that there had been some improvements since the last inspection. Staff felt that some staff, who were not providing good quality care, had left. Staff fed back positively about the new manager.

Some improvements had been made in response to previous inspections and in response to external audits of the home. These included improvements in staff approach to people, in the cleanliness of the building, the introduction of resident and relatives’ meetings and the introduction of champion roles for staff. Relatives mostly fed back positively about the staff in the home, with some relatives naming specific staff to praise their patience and kindness.

For more details, please see the full report which is on the Care Quality Commission (CQC) website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was inadequate (19 May 2021).

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 some improvements had been made and some breaches of regulations had been resolved, however in other areas improvements had not been sufficient and the provider was still in breach of five regulations.

This service has been in special measures since 19 May 2021.

Why we inspected

We carried out an unannounced inspection of this service on 25 March – 15 April 2021 and identified breaches of legal requirements related to respect and dignity; consent; safe care and treatment; nutrition and hydration; good governance; fit and proper persons employed and duty of candour. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the key questions safe, effective and well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service remained inadequate. This is based on the findings at this inspection.

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 COVID-19 and other infection outbreaks effectively.

You can read the report from our last inspection, by selecting the ‘all reports’ link for Bluewater Nursing Home on our website at www.cqc.org.uk.

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

We have identified continued breaches in relation to consent; safe care and treatment; nutrition and hydration; good governance and fit and proper persons employed at this inspection.

Following this inspection, we cancelled the provider's registration.

Follow up

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

Special Measures

The overall rating for this service is ‘Inadequate’ and the service remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe, and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Bluewater Care Home is a residential care home providing personal care to 15 people aged 65 and over at the time of the inspection. Some people were living with dementia. The service can support up to 60 people.

The home is based over 4 floors accessed by an interconnecting passenger lift. The ground floor provides communal areas for people and the first, second and third floors provide bedrooms, communal bathrooms and a small communal area. Only the lower 2 floors were in use at the time of the inspection.

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

People continued to be at increased risk of harm as their risks were not consistently, robustly assessed and managed. Records showed care plans were not consistently followed related to managing people’s safety, and this had not been appropriately acted upon by the provider. Incidents were not always reported or appropriately reflected in people’s risk assessments or care plans, with identified actions of how risks would be managed or reduced in future.

Guidance and information from professionals was not always clearly captured in people’s care plans. Where advice from professionals was unclear or conflicted, this was not escalated to ensure people’s care was delivered safely.

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. Assessments of people’s mental capacity were not consistently in place, or did not follow the code of practice to ensure people were able to make or participate in decisions about their care as much as possible.

Staff did not have appropriate pre-employment checks in place in line with requirements. This put people at risk of receiving care from staff who were not suitable to work with them.

There was no clear and credible plan in place at the time of the inspection to ensure past issues had been resolved and similar issues were prevented. Records were not consistently completed, or were not up to date, or contained inaccurate information. There was an improvement plan in place, however this reflected regular tasks which were required, not issues which needed to be addressed. After the inspection the registered manager sent a draft improvement plan which identified improvement actions needing completion, but this was not yet embedded.

The registered manager had failed to notify CQC of relevant incidents in line with regulations, and the current CQC rating of the service was not displayed on the provider’s website.

There had been some improvements in medicines management, however some recording issues remained, including in monitoring people to ensure they received their medicines appropriately.

Staffing deployment had improved on our inspection site visit, and staff were more mindful of ensuring people in communal areas were not left unattended where they needed support should they wish to move. Some issues with staff training had been resolved, however we remained concerned about staff knowledge of modified food textures.

The home was visibly clean, and staff were wearing appropriate personal protective equipment (PPE). People were supported to have visitors to the home in line with current guidelines.

There was an improved culture amongst the staff team, and the registered manager and head of care were open and receptive to feedback. They took some immediate actions in response to issues we identified and showed they were open to making improvements.

Staff, people and relatives fed back positively about the staff and management team.

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 inadequate (published 15 October 2022) and there were breaches of regulation. At this inspection we found the provider continued to be in breach of regulations.

This service has been in special measures since 19 May 2021.

Why we inspected

We carried out an unannounced inspection of this service between 25 March and 15 April 2021 and identified breaches of legal requirements. We undertook follow-up, focused inspections on 4 to 16 November 2021 and 7 June to 5 July 2022 to review if actions had been completed and if the breaches were met. On the last inspection we identified new or continued breaches of regulations in relation person-centred care, consent, safe care and treatment, good governance, staffing and fit and proper persons employed.

We carried out this inspection to follow up on these breaches of regulation and to understand if these were now met.

Enforcement and Recommendations

We found 2 breaches had been resolved on this inspection, however we identified 2 new breaches of regulation and 4 ongoing breaches of regulation. At this inspection we identified breaches in relation to consent, safe care and treatment, good governance, display of ratings, notifications to CQC and fit and proper persons employed.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The service was previously rated inadequate and was placed in special measures. Though the overall rating had improved to requires improvement, there is still a rating of inadequate for one key question and remains in special measures. We will take action in line with our enforcement procedures. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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

We carried out this inspection to look at specific risks we had been told were a concern. This included risks associated with choking, risks associated with safety equipment and risks associated with a lack of personal care. We found ongoing concerns about the risks associated with choking for one person. Although, we did note that some action had been taken to address wider concerns about the risks of choking for other people following our last inspection. We found ongoing risks associated with the use of safety equipment, which included a failure of staff to follow care plans.

Other risks were identified at the time of this inspection, including risks of scalding from a freshly boiled kettle being left unattended, fire extinguishers not being secured, and the sluice room door being left open on a number of occasions. Items within the sluice room were known to be a risk to one person if they were to consume them, which was a known risk. We were also concerned that one person was being cared for in bed, but it was not evident that a multidisciplinary assessment had taken place to confirm this was appropriate for this person.

We found concerns relating to people’s hygiene needs not being met as some people had unclear fingernails.

We asked the provider and manager what action they had taken to address our concerns and they told us of some action taken, which would reduce any immediate risk to people. However, our findings at this inspection demonstrated an ongoing concern about the culture and oversight in the service. Based on our feedback as well as previous inspection findings, we would have expected the provider to have implemented a clear systematic approach to addressing the culture in the service. Furthermore, we would expect checks on staff actions and competence, which would aim to ensure that people were not placed at risk. The provider and manager did not advise us of this as part of their response to our request. Due to finding ongoing concerns of a similar nature, we were not assured the registered person had taken the required action. We asked the provider to send us assurances and are considering our regulatory response.

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 inadequate (published 19 May 2021).

Why we inspected

The inspection was prompted due to serious concerns we had received about the safety of people living in the home. This included risks associated with choking, the use of safety equipment and a lack of personal care. We undertook this targeted inspection to inspect and examine those risks. The overall rating for the service has not changed following this targeted inspection and remains inadequate and in special measures.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We have found evidence that the provider needs to make improvements and there is an ongoing breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Please see the Safe section of this report.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bluewater Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified an ongoing breach in relation to safe care and treatment at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

At the time of this inspection the service was receiving input and support from a number of health and social care professionals to keep people safe. We will continue to liaise with the provider and all relevant agencies already involved in supporting the service. This will inform our ongoing monitoring of the service until we return to visit. If we receive any concerning information we may inspect sooner.

Bluewater Nursing Home is a residential care home providing personal care to 22 people aged 65 and over at the time of the inspection. Some people were living with dementia. The service can support up to 60 people. Although it is called a 'nursing home', it does not provide nursing care. The home is based on four floors with an interconnecting passenger lift. The ground floor provides communal areas for people and the first, second and third floor provide bedrooms, communal bathrooms and a small communal area. Only the ground and first floors were in use at the time of the inspection.

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

This inspection was undertaken because since our inspection in March and April 2021 we had received numerous concerns from a variety of sources. These concerns related to the management of risk and the management of medicines for people.

At this inspection whilst people did not tell us they felt unsafe, we found ongoing concerns regarding the management of choking risk, skin integrity, falls, behaviours and constipation. Staff lacked an understanding of the needs of people and we were not assured people received the support they required to keep them safe at all times. We found ongoing concerns regarding the management of medicines and people were not receiving their medicines in line with their prescriptions.

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 inadequate (published 19 May 2021).

Why we inspected

The inspection was prompted due to concerns received about the safe care and treatment for people and the management of medicines. We undertook this targeted inspection to inspect and examine those risks. The overall rating for the service has not changed following this targeted inspection and remains inadequate and in special measures.

CQC have introduced targeted inspections to follow up on Warning Notices or to check specific concerns. They do not look at an entire key question, only the part of the key question we are specifically concerned about. Targeted inspections do not change the rating from the previous inspection. This is because they do not assess all areas of a key question.

We have found evidence that the provider needs to make improvements and there is an ongoing breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Please see the Safe section of this report.

We asked the manager to take immediate action to address our concerns about the management of choking risks and medicines. The manager told us what action they would be taking, and we sent us some evidence of this. We also referred these concerns to the local authority responsible for safeguarding people.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bluewater Nursing Home on our website at www.cqc.org.uk.

Enforcement

We have identified an ongoing breach in relation to safe care and treatment and medicines management at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

At the time of this inspection the service was receiving input and support from a number of health and social care professionals to make improvements needed as a result of our previous inspection and safeguarding enquiries. We will continue to liaise with the provider and all relevant agencies already involved in supporting the service. This will inform our ongoing monitoring of the service until we return to visit. If we receive any concerning information we may inspect sooner.

Bluewater Nursing Home is a residential care home providing personal care to 27 people aged 65 and over at the time of the inspection. Some people were living with dementia. The service can support up to 60 people. Although it is called a 'nursing home', it does not provide nursing care.

The home is based on four floors with an interconnecting passenger lift. The ground floor provides communal areas for people and the first, second and third floor provide bedrooms, communal bathrooms and a small communal area. Only the lower two floors were in use at the time of the inspection.

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

People did not receive a service that ensured they were safe and received the care they required.

The recruitment of staff did not always ensure people were protected against the risks of unsuitable staff. The registered person was unable to demonstrate safe recruitment processes were followed and that appropriate pre employment checks had been completed for all staff before they were allowed to work with people. People who were able to tell us said staff were available when they needed them however, on occasions we observed staff were not always present to be able to provide prompt support to people. We have made a recommendation about this.

Appropriate policies were in place regarding safeguarding and staff had access to training however, they were not always able to describe safeguarding and explain how they could report concerns externally. We have made a recommendation about this. Whilst training was available to staff, due to the concerns we found at this inspection we were not assured the registered person had ensured staff were competent to perform their role.

Staff were not always aware of the risks associated with people’s needs. People's care plans and risk assessments did not always contain the information needed to guide staff how to meet their needs and keep them safe. Where risks were known, people did not receive the care and support they required to reduce these risks. Examples of this included records which documented people did not receive the correct food types to manage risks of choking and people were not supported to change position and reduce the risks of developing pressure sores. Where people were at risk of falls, equipment specified in the care plans was not used and when people fell, the appropriate checks did not take place following these falls.

The management of medicines was not safe. The amount of stock of medicines in the service did not match the records, meaning we were not confident people received their medicines as they were prescribed. Where people were prescribed creams to help maintain good skin integrity, these were not always applied. Information to guide staff about the use of ‘as required’ medicines was not available to guide staff appropriately. The management of infection, prevention and control was not always effective and did not keep people safe. However, the provider took and number of actions throughout our inspection to address the infection control concerns. People’s nutrition and hydration needs were not always met, and staff did not escalate concerns about people’s health needs promptly. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests.

Staff in leadership roles did not always promote the delivery of high quality person centred care or act in an open and transparent way. Governance processes were ineffective. When things went wrong in the service, we were not assured these were incidents were analysed effectively, and lessons were learned and applied to reduce the risks to people and ensure their safety. The provider has demonstrated a consistent failure to make and sustain improvements. They have demonstrated a consistent failure to meet the requirements of the regulations.

Feedback from people, relatives and staff was mostly positive about the management of the service. Although we observed some negative interactions, we did on occasions observe some interactions by staff that were caring and kind. The environment had been adapted to provide several areas of interest which aimed to simulate ‘real life’ experiences for people.

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 requires improvement (published 2 March 2021) and there were multiple breaches of the regulations. 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 not been made, breaches of regulations remained, and the rating deteriorated.

Why we inspected

We received concerns in relation to the recognition of and timely escalation of health concerns to professionals; Appropriate nutrition and hydration; Recruitment of staff; Infection control; Injuries sustained by people; Personal care.

As a result, we undertook a focused inspection to review the key questions of Safe, Effective 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.

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 COVID-19 and other infection outbreaks effectively.

The overall rating for the service has changed from requires improvement to inadequate. This is based on the findings at this inspection.

We have found evidence the provider needs to make improvement. Please see the Safe, Effective and Well led sections of this full report.

You can see what action we have asked the provider to take at the end of this full report.

Enforcement

We have identified breaches in relation to the safe care and treatment for people, management of medicines, consent, recruitment, and governance at this inspection.

Please see the action we have told the provider to take at the end of this report.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

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

Special Measures:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures.’ This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it. And it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Bluewater Nursing Home is a residential care home providing personal care to 29 people aged 65 and over at the time of the inspection, an additional person was in hospital. Some people were living with dementia. The service can support up to 60 people. Although it is called a 'nursing home', it does not provide nursing care.

The home is based on three floors with an interconnecting passenger lift, although only the lower two floors were in use at the time of the inspection. The home is in the heart of Portsmouth, on a main street with lots of local shops.

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

Medicines management was not always carried out safely, improvement was required with medicines records.

Care plans and risk assessments did not always contain enough detail to inform staff about people’s needs and in some instances risk assessments were not in place where needed. There was a lack of guidance to staff in relation to nutrition and hydration. People receiving care were at increased risk of choking.

People were not always supported to have maximum choice and control of their lives and staff did not always support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

It is a requirement of registration that all significant events are reported to CQC. CQC was not always notified about significant events that occurred at Bluewater Nursing Home.

Quality assurance systems had not always been effective in identifying the concerns we found at this inspection and bringing about improvement.

Infection control practices were not always carried out safely. A child visiting the service was not social distancing and did not wear a mask. We have made a recommendation about this.

Safe recruitment practices were not always followed. We made a recommendation about this.

Staff were positive about the management of the service and told us the registered manager was very supportive and approachable.

Staff told us they were supported by regular training and supervision. People were supported to access other healthcare services in a timely way. Many adaptations had been made to the home to meet the needs of the people living there.

The registered manager demonstrated a willingness to make improvements and during the inspection began reviewing their systems and processes to ensure the service consistently provided good, safe, quality care and support.

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 requires improvement (published 24 October 2018), there was one breach of regulations. The service remains rated requires improvement. This service has been rated requires improvement for the last three consecutive inspections.

The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection enough improvement had not been made and the provider was still in breach of regulations.

Why we inspected

The inspection was prompted in part due to concerns received about staffing, nutrition and hydration and non-notification to CQC of incidents. A decision was made for us to inspect and examine those risks. We also undertook this focused inspection to check the provider had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Safe, Effective and Well-led Key Questions which contain those requirements and concerns which had been raised.

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.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has remained requires improvement. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Bluewater nursing Home on our website at www.cqc.org.uk.

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

We have identified breaches in relation to safe management of medicines, safe management of food and nutrition, consent, good governance and failure to notify, at this inspection.

Follow up

We identified four breaches of regulation and because this is the third consecutive time the service has been rated as requires improvement we will request a clear action plan from the provider to understand what they will do to improve the standards of quality and safety. We will also meet with the provider following receipt of this plan. We will work alongside the 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.

Bluewater Nursing Home is a residential care home providing personal care to 24 people aged 65 and over at the time of the inspection. Some people were living with dementia. The service can support up to 60 people. Although it is called a ‘nursing home’, it does not provide nursing care.

The home is based on three floors with an interconnecting passenger lift, although only the lower two floors were in use at the time of the inspection. The home is in the heart of Portsmouth, close to local amenities.

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

People and their relatives were positive about all aspects of the service and the care provided.

However, we found a new medicines system needed further time to embed, to ensure accurate records of medicine administration were maintained.

Risks were usually managed safely. However, the system to ensure pressure-relieving mattresses remained at the right setting was not always effective and risks relating to the management of a person's diabetes were not fully recorded.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. However, records of mental capacity assessments were not always robust.

Quality assurance systems were in place, but had not always been effective.

Infection control risks were managed appropriately.

Safe recruitment procedures were followed and there were enough staff to meet people’s needs.

People were treated in a kind, caring and compassionate way by staff who were competent and understood their needs.

People were supported to express their views and be involved in decisions about their care and the running of the service.

Staff were clear about their safeguarding responsibilities and knew how to recognise and report potential abuse.

Staff carried out their roles and responsibilities effectively. They had a good understanding of managing risks.

People’s nutritional needs were met, and they were supported to access health and social care professionals if needed.

People's care and support needs were met in a personalised way.

Adaptations had been made to the home to meet the needs of people living there and imaginative use had been made of the communal areas.

People were supported to access a range of activities, including trips to the local community.

People’s end of life wishes were explored and recorded in their care plans.

People knew how to raise concerns and there was an accessible complaints policy in place.

People and their relatives had confidence in the management and said they would recommend the home.

Managers worked in an open and transparent way and understood their regulatory responsibilities.

Positive links had been developed with community groups that benefited people.

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 requires improvement (report published in February 2019) and there were two breaches of regulation. Following the inspection, we imposed conditions on the provider's registration, including sending the results of monthly audits to CQC, together with any resulting action. All imposed conditions were fully met. At this inspection we found some improvement had been made, but the provider was still in breach of Regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

We have identified a breach of regulation in relation to governance. Please see the action we have told the provider to take at the end of this report.

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.

Bluewater Nursing Home is a ‘care home’ and is registered to accommodate up to 60 people. People in care homes receive accommodation and personal care as single package under one contractual agreement. The CQC regulates both the premises and the care provided, and both were looked at during this inspection. This home provides a service to older people some living with dementia or mental health needs.

The home had a registered manager. 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. A second general manager had also been appointed who was in the process of registering with the CQC to become a joint registered manager.

We last inspected the service in October and December 2017 and rated it ‘inadequate’ overall. We identified five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection, we found improvements had been made; however, there was a need for further improvements and the opportunity for the changes to become embedded into practice and sustained to ensure people received the care and support they required in a safe and effective way. Improvements had been made in respect of breaches of regulations 12 and 18; however, these regulations remain in breach and further improvements were required to achieve compliance. Not all risks for people were being managed safely and in a consistent manner. There were not always enough suitably qualified and competent staff deployed to meet people's needs. In respect of the other previous breaches of regulation 9 and 11 sufficient action has been taken to become complaint although there remains room for further improvement such as the development of more specific end of life care plans and ensuring legislation designed to protect people's rights was followed consistently.

Medicines were managed safely; systems were in place to ensure people received medicines as prescribed and that medicines were stored safely.

There were systems in place to protect people by the prevention and control of infection although staff were not following these in respect of one area of the home.

Staff protected people's privacy although people were not always treated with dignity or respect when they had to wait for care to be provided which caused them anxiety and distress. We observed positive interactions between people and staff throughout the inspection.

Appropriate recruitment procedures were in place and staff felt supported in their role by managers.

People felt safe. Staff knew how to identify, prevent and report abuse.

Staff had completed a programme of training.

People's nutrition and hydration needs were met. When people needed support to eat, this was provided done a dignified way.

Adaptations had been made to the home to make it supportive of the people who lived there.

People were supported to access healthcare services when needed. Staff made information available to other healthcare providers to help ensure continuity of care. Each person had a care plan that was centred on their needs and reviewed regularly.

People's needs were met in a personalised way. People were supported at the end of their lives to have a comfortable, dignified and pain-free death.

People had access to a range of activities including access to the community. They knew how to make a complaint and a complaints procedure was in place.

Managers were visible and approachable. Staff were organised and felt engaged in the way the service was run. They demonstrated a commitment to the values of putting people first.

Visitors were welcomed and the registered manager notified CQC of all significant events.

We identified three breaches of Regulations of the Health and Social Care Act 2008 (Regulated Activities). We are currently considering our regulatory response.

Bluewater Nursing Home provides accommodation and personal care for up to 60 people, the service does not provide nursing care. There were 19 people living at the home when we visited. The service also provided some day care and on the second day of the inspection two people were receiving a day care service. The service was operating at approximately one third occupancy during the inspection. People were all accommodated on the first floor of the home. All areas of the home were accessible via a passenger lift and there were communal areas on the ground floor. There was an accessible outdoor courtyard garden.

Bluewater Nursing Home 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. We found the home to be clean and tidy throughout the inspection.

The home had a registered manager. 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.

Since 2015 all comprehensive inspections of the service have resulted in Inadequate or Requires Improvement ratings.

The last comprehensive inspection of this service was in October 2016 when the service was rated Requires Improvement; we found three regulatory breaches. In July 2017 we undertook a focused inspection to check on these breaches and found sufficient improvements had been made

At this comprehensive inspection we found five breaches of regulations. This was within six months of the focused inspection in July 2017; this demonstrated that the provider of this service was unable to sustain improvement in the long term. There were systemic failings identified during this inspection which had already been identified at the last three comprehensive inspections of the service. All three regulatory breaches from the last comprehensive inspection in October 2016 were repeated. Failures to provide safe and care and treatment, person centred care, good governance and failing to act in accordance with the Mental Capacity Act 2005 were common themes.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.

Quality and safety monitoring systems were ineffective in identifying and directing the service to act upon and mitigate risks to people who used the service and ensure the quality of service provision.

Care plans were not consistently person centred and lacked detailed guidance for staff to ensure people received care in a safe way. Risk assessments that related to peoples health and safety did not ensure that all risks were effectively assessed. Action had not always been taken to reduce identified risks to ensure the safety of people. This exposed people to a risk of neglect and unsafe or inappropriate care or treatment.

Records relating to the management of the service had not been effectively reviewed and assessed; we found errors, omissions and discrepancies that had not been identified by the registered manager’s quality assurance systems.

The administration, safe management and security of medicines was not in line with best practice. Medicine administration records did not confirm that people had received all medicines as prescribed. There was a lack of guidance for staff to support people with medicines and PRN (as required) medicines were not effectively recorded or monitored for effectiveness. .

Records of the assessment of people’s ability to make some informed decisions had been undertaken. However records did not show that the principles of the Mental Capacity Act 2005 were being applied in respect of best interest decisions to provide care or use restrictive practices. Staff we spoke with had a variable understanding of the Mental Capacity Act 2005.

Staff received training; however records were unclear as to what training each staff member had received. Staff had not received regular and meaningful supervision. The provider had not ensured that staff performance and progress was monitored effectively and that staff had an opportunity to voice their individual views.

People we were able to speak with said they felt safe. Staff said they knew how to prevent and report abuse. We were concerned however that staff practice which amounted to omissions of care had not been considered as neglect by them or the registered manager.

Staffing was not planned effectively. There were not enough staff to meet more than people’s basic personal care needs; staff were task orientated and did not spend one to one time with people.

Peoples' wellbeing was not promoted due to a lack of person centred activities. We observed and people told us that activities were limited and did not take place as per the advertised schedule of activities.

We received some positive feedback about the care staff and their approach with people using the service; however we observed occasions when people's dignity had been compromised.

Staff said they worked well together and that this created a relaxed and happy atmosphere that was reflected in people's care. Our observations however did not always find this to be the case particularly when people’s needs were ignored by staff.

People and some external health professionals we spoke with were positive about the service people received and people’s visitors were welcomed. However not all external stakeholders we spoke with felt that the provider engaged with them positively.

People had access to healthcare services. People were positive about meals and they were supported to eat and drink when required. However records used to monitor peoples' fluid intake were not always completed with the correct intake; this had not been identified by reviews of records. This exposed people to the risk of dehydration.

There was a complaints policy in place. People and relatives knew how to raise concerns; however there was no process to record informal complaints.

People were encouraged to maintain relationships that were important to them. Bluewater Nursing Home was animal friendly and people were able to bring their pets with them when they moved in.

Appropriate recruitment procedures were in place and pre-employment checks were completed before staff started working with people.

Plans were in place to deal with foreseeable emergencies such as fire risk; staff we spoke with said they had had received training to manage such situations safely.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We are currently considering our regulatory response.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures

The home provides accommodation for up to 60 older people with personal care needs. There were 15 people living at the home when we visited. All areas of the home were accessible via a lift and there were communal rooms and areas on the ground floor and adjacent to people’s bedrooms. There was accessible outdoor space from the ground floor. All bedrooms were for used for single occupancy and had en-suite facilities.

The home did not have a registered manager. 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 manager had submitted an application to the commission to become the home’s registered manager.

The provider had taken appropriate action to address the concerns identified at previous inspections. People’s legal rights were protected and the provider’s systems to support this were in accordance with the Mental Capacity Act 2005. People received care that was personalised to meet their individual needs. Care plans and individual risk assessments were comprehensive and reviewed regularly to help ensure they reflected people's needs. These and other records related to the care people had received were well maintained and up to date.

Services that are in special measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements had been made, and it is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of special measures.

Although the service was no longer in special measures, there remained continuing breaches of three of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see the action we told the provider to take at the end of the full version of this report. We also made a recommendation about risk assessments.

Bluewater Nursing Home is registered to provide accommodation, personal care and nursing care for up to 60 older people. There were 16 people resident at the home with another person who used the home as a day care service. One of the 16 people was in hospital at the time of our inspection. None of the people resident at the time of our inspection was receiving nursing care from the provider. This meant the home was less than one third occupied, and our observations of and judgements on systems and processes reflect that level of occupation.

The home provided accommodation on four floors. Two floors were not in use at the time of our inspection. The ground floor comprised shared areas including the dining room, lounge, cinema, conservatory with indoor herb garden, hair dressing salon and sensory room. The first floor contained the occupied rooms and a small shared area. The rooms were large, with en suite bathroom facilities and double glazed windows. There was an internal courtyard garden with an aquarium and aviary, which could be moved inside for people who were not able to go outside. The provider had made installations to provide interest for people on all four floors of the home.

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. The registered manager had been in post since April 2016, and had completed the registration process with us on 4 October 2016. Prior to this manager’s appointment there had been no registered manager at the service since November 2014.

Where risks to people’s safety and welfare were identified and assessed, appropriate actions were carried forward into people’s care plans, but we found examples of risks that had not been identified, documented and assessed. However the provider had put suitable arrangements in place to protect people from the risks of avoidable harm and abuse. Staffing levels were sufficient to support the number of people using the service safely. The provider had recruitment processes designed to make sure they only employed workers who were suitable to work in a care setting. There were now arrangements in place to store medicines safely and securely, and to administer them safely and in accordance with people’s preferences.

Staff did not always comply with the principles of the Mental Capacity Act 2005 where people lacked capacity, but there was good awareness of the need to obtain consent for people who did not lack capacity. Where people were at risk of being deprived of their liberty, appropriate authorisations were in place. Staff had received appropriate training and supervision to maintain and develop their skills and knowledge to support people according to their needs. People were supported to eat and drink enough to maintain their health and welfare. People were supported to access healthcare services, such as GPs and specialist nurses.

Care workers had developed caring relationships with people they supported. People were encouraged to take part in decisions about their care and support and their views were listened to. Staff respected people’s privacy and dignity.

For most people, care and support were now based on assessments and plans which took into account people’s abilities, needs and preferences. However we found one person’s assessments and care plans were not followed and did not take into account all relevant factors. People were able to take part in leisure activities which reflected their interests. People were kept aware of the provider’s complaints procedure, and complaints were managed in a professional manner.

The home had a warm, welcoming atmosphere. The provider had put new systems in place to manage the service and to monitor and assess the quality of service provided. However the systems had not identified that some people’s records were inaccurate or out of date.

After this comprehensive inspection three warning notices were served on the registered provider on 23 December 2015 requiring them to be compliant with the Regulations by 23 January 2016. The service was placed into special measures. The registered provider sent us an action plan in December 2015 and an operational improvement plan in January 2016 to tell us the actions they would take to be compliant with the Regulations.

On the 6, 7 and 14 April 2016 we carried out an unannounced comprehensive inspection of the service to check they had met the legal requirements. We found the registered provider had failed to meet the required legal requirements in relation to standards of care and welfare for people who use the service. This inspection found that there was not enough improvement to take the provider out of special measures. CQC is now considering the appropriate regulatory response to resolve the problems we found.

Bluewater Nursing Home is registered to provide accommodation and nursing care for up to 60 older people. The home is a large, converted property and accommodation is arranged over four floors, the ground floor offering dining, recreational and reception facilities, with the additional three floors of accommodation which also contained some smaller recreational areas. Two lifts are in place to assist people to move between the four floors. Most rooms are for single occupancy and have en-suite facilities. There were 20 people living over the first and second floor of the home at the time of our inspection. At the time of our inspection nursing care was not being provided.

A registered manager had not been appointed for the service since November 2014. 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 provider had employed a number of managers since November 2014 however these had not become registered with the Commission before employment with the provider ceased.

Whilst people felt safe at the home and relatives had no concerns about the safety of people, risk assessments had not always been completed to ensure people received safe and effective care in the home. A new electronic system for recording plans of care and the risks associated with this had been implemented in the home and required further embedding in the service. People’s preferences and needs were not always included in these records.

Staff at the home had not been guided by the principles of the Mental Capacity Act 2005 (MCA) when working with people who lacked the capacity to make decisions. The CQC monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Three people who lived at the home were subject to a DoLS. Whilst all appropriate actions had been taken to support these people, staff lacked knowledge and understanding of the MCA and DoLS.

People were not always protected by staff that had a good understanding of the risk of abuse against vulnerable people. Whilst staff felt confident to report any concerns they may have through the appropriate channels, they had not received appropriate training in this area. The provider had not identified areas of concern in relation to the safeguarding of people which required further action.

There were not sufficient staff available to meet the needs of people. The provider did not have robust recruitment processes in place to ensure people were cared for by staff who had the right skills to meet their needs.

People had access to health and social care professionals as they were required, though staff were not always vigilant in following up appointments.

Whilst people found staff to be caring and supportive we observed some staff act in a way which was not caring and did not respect the dignity of people. Staff knew people at the home well.

There was a lack of stimulation in the home to encourage people to participate in activities, although there were extensive facilities available in the home for people to use. People were not encouraged to use these facilities independently.

People were provided with opportunities to express their views on the service through meetings and in discussion with the provider and nominated individual for the service.

There was no system of quality assurance by which the provider could monitor the safety and welfare of people in the service. The provider and nominated individual did not have a good understanding of the requirements of the Regulations and their responsibility with this. There was a lack of sustained leadership in the home.

Staff who worked and people who lived at the home felt able to express any concerns they may have and have these responded to promptly.

The provider had failed to adequately display the ratings for this service on their website in line with requirements.

We found multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.You can see what action we told the provider to take at the back of the full version of this report.