Priory Gardens

We found the following examples of good practice.

The home was clean and well ventilated.

Cleaning schedules had been increased during the outbreak, to ensure high contact areas, such as door handles, light switches and appliances were regularly cleaned during the day.

Staff had received specific training in managing the risk of the COVID-19 pandemic and how to safely use and dispose of personal protective equipment (PPE).

The home was accessing the government testing scheme. Staff put systems in place to support and reassure people with the testing process.

Some people residing at Priory Garden are living with dementia and like to wander with purpose. The registered manager and staff managed this by providing supervision of these people when outside of their rooms and wiping down hand rails etc every time they were touched.

People were supported to keep in touch with family and friends through regular video calls.

Further information is in the detailed findings below.

Priory Gardens is a residential care home that was providing personal and nursing care to 42 people at the time of the inspection.

People’s experience of using this service:

People told us they felt safe and were happy living in Priory Gardens. Many told us of the improvements they had seen since the previous inspection. They felt staff were knowledgeable and confident in their role and were happy and friendly in their approach. Staff had received regular supervision and training and told us they felt valued. They worked well as a team.

People were safe as staff understood how to manage any risks to their wellbeing. Guidance was well documented to help staff to keep people safe, and staff adhered to the guidance in most instances. Recruitment checks were more robust and staff received an appropriate induction. There were enough staff to meet people’s needs, although people told us they sometimes had to wait for staff. We did see some periods of unattended communal areas as staff were always busy, although the general atmosphere was calm and organised.

Medicines were administered safely and the home was clean. The registered manager was pro-active in responding to incidents and accidents, and evidenced learning from such events where necessary.

The registered manager used evidenced based guidance to improve the service. They displayed sound understanding of best practice and used feedback from a variety of sources to continuously improve care. There had been fewer complaints and none about care provision which showed an improving service.

People were supported to eat and drink and visual options helped people to choose. Records for those people at risk of a poor diet were not sufficiently detailed. We recommend records where people were at nutritional risk needed to evidence what measures were in place to address these rather than generic statements. People accessed health and social care services as needed.

There had been significant improvement in obtaining people’s consent to care and treatment. Some records needed updating where people could not consent to their care and treatment. We recommend the capacity assessments are reviewed to ensure people with the relevant legal authority were involved in decisions. People’s privacy and dignity was respected.

There was a comprehensive activity programme for people to engage with in communal areas. We saw people involved and animated during various events.

Care documentation had been made more person-centred and reflective of people’s needs. It was regularly reviewed and audited to ensure it was still current.

The registered manager had worked hard, along with the staff team, to improve the experience of living at Priory Gardens. By using the tools for quality assurance they ensured each aspect was considered in depth regularly and any actions responded to quickly. There had been significant improvements in the culture at the home but more work was needed to ensure this became embedded.

This service has been in special measures. 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 this service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

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

Rating at last inspection:

Inadequate (Report published 15 August 2018)

Why we inspected:

This was a planned inspection based on the rating at the previous inspection. The service had previously been in breach of five regulations which resulted in three warning notices and two requirement notices. At this inspection we found improvements had been made.

Follow up:

The service will continue to be monitored in line with our inspection programme, and if information of concern is raised, this will be investigated.

Priory Gardens is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Priory Gardens accommodates 72 people in one adapted building divided into three units. One of the units, Grace, specialises in providing care to people living with dementia. Nightingale supports people with predominantly nursing needs and Symphony supports people requiring assistance with daily living. On the days of the inspection there were 46 people living in the home.

There was no registered manager in post at the time of the inspection. The home was being supported by a relief manager, an area director and an area quality director. 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.

People and relatives told us there were insufficient staff to provide safe and effective care. Many relatives advised us they came in to assist staff otherwise their relation would not be cared for properly. Staff were extremely busy, and became task-focused in their roles due to the continuous demands on their time. This was to the detriment of team work on occasion. Staffing rotas did not reflect the amount of staff needed in relation to people’s true dependency levels.

Risk management was not consistent and while some had been improved, the correlation between care plan guidance and risk management had not been identified.

Staff were confident in how to report any concerns. We found reporting of such incidents was mostly timely but evidence of lessons learned was limited, partly due to the new management team.

Medication management was not always safe as people had missed medication and records were sometimes incomplete.

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; the policies and systems in the service did not always support this practice. The provider had allowed legal safeguards to lapse with incomplete records of people’s mental capacity, and staff’s understanding of these safeguards was poor.

Although people had regular food and fluid, their experience was not in line with best practice in every instance and relatives were relied on to assist people.

Staff had received induction, supervision and training although we found some issues with recruitment records and records of agency staff. The manager relied on resources from the provider to keep abreast of current practice.

Most staff treated people with kindness and consideration on an individual basis. However, the pressures of too much to do showed on occasion when people’s needs were ignored as staff were dealing with others. Dignity and privacy was promoted in most instances and we saw some discreet interventions when people needed more personal care.

Care documentation, whilst still being amended, was not always consistent or accurate in the new records. There was a lack of cohesion in some records with staff not always being aware of what was contained in them. The delivery of care was task-driven rather than based on person-centred involvement.

Although activities were organised in some areas of the home, there was little evidence of personal interaction with people, especially those in their rooms. Complaints were acknowledge and responded to well under the current management structure.

The home had no registered manager and had had a number of different managers. Although they had all attempted to drive forward change, the lack of consistency and oversight meant people and staff had differing knowledge and understanding of who was in charge and what direction the home was going in. There was no shortage of commitment to transform the home but the differing personnel each had their own vision. The current management structure had not been in the home sufficiently long to ensure sustainability.

The governance framework was being used but further work needed doing to ensure all aspects of care delivery was assessed and evaluated, particularly considering people’s direct experiences.

The provider was offering guidance and support, and regular briefings to all managers, and was keen to establish consistency of management in the home to provide stability.

We found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, two of which were continuing from the previous inspection.

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

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.

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

Priory Gardens is a nursing home currently providing care for up to a maximum of 72 older people. The home has three separate units which provide care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 49

people were living at the home.

The service had a registered manager in place. 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.

People told us they felt safe and staff understood the potential signs of abuse and how to report any concerns.

Peoples moving and handling records were not robust and needed further work to ensure they addressed all aspects of peoples care and support including any equipment they used, for example to access the bath or specialist seating. Where people were at risk of falls, their care plans needed more information as to how the risk to their safety was being reduced.

People had a personal emergency evacuation plan (PEEP) in place and there was a system to ensure all staff received regular fire drills. External contractors were used to service and maintain equipment, and internal maintenance checks were made on the premises and equipment to ensure the home was safe.

Staff were recruited safely. Changes had been made since the last inspection to the staff numbers and skill mix. During our inspection we identified further concerns with the staffing levels but the registered provider assured us they were taking steps to address this.

Staff who had responsibility for the management of medicines received training and audits were regularly undertaken on peoples medicines to highlight any concerns at an early stage. We found issues identified at our previous inspection had been addressed but improvements were still needed to the management of people’s creams.

The home was generally clean but we identified some areas of uncleanliness which we informed the registered manager about. We also noted on the dementia unit staff were not adhering to good practice as hoist slings were not being used on an individual basis.

Relatives felt staff had the skills they needed to do their job. New staff completed an induction but this was not always completed in a timely manner. There was a programme in place to provide staff with training in a range of topics. However, we identified staffs knowledge of other methods which may be deployed to effectively support a person with behaviour which challenged others, was limited.

Staff understood people had different abilities in regard to making decisions about their daily lives. We saw evidence of mental capacity assessments in peoples care plans but we identified aspects of some peoples care where they were unable to consent yet there was no evidence of a capacity assessment or that best interest’s decisions had been made.

People received their meals in a timely manner. Although we identified one person who was not provided with adequate staff supervision to reduce the risk of choking while drinking. Staff recorded the food and fluid intake for some people and although we found the standard of recording had improved since our last inspection they were not yet consistently accurate.

Each of the units had communal lounge and dining areas and there was a kitchenette to enable staff to easily provide drinks and snacks for people. There was signage throughout the home to indicate shower and toilet facilities to enable people to find these rooms when they were required.

Everyone we spoke with told us the staff were caring. We observed staff interact with people in a kind way. Staff knew people’s needs but they told us they did not have time to read peoples care plans. We saw staff enabling people to make choices but we also saw where people were less able to communicate their preferences, staff did not consistently support them to make their own choices. People’s privacy and dignity was respected by staff but people were not able to lock their bedroom doors to prevent unauthorised access. We found peoples care records were stored confidentially.

People gave mixed feedback about the activities provided at the home. We saw little evidence of any activities on the dementia unit and people’s activity records did not evidence a comprehensive programme designed around individual’s needs.

Peoples long term care plans were person centred and provided information about the individuals support needs. However, they lacked adequate detail to ensure all aspects of their care and support were thoroughly recorded. There had been an improvement to the quality of recording regarding personal hygiene records and position change records. Although there was no evidence staff had changed the position of three people on six consecutive nights during 2017.

People told us they knew how to raise a complaint. We saw complaints were recorded on an online management system. Issues were investigated and responded to in writing, including, if needed, an apology.

Each of the relatives we spoke with told us the home was well led. The registered manager and the assistant operations director were professional, speaking openly about the progress made since the last inspection and where further attention was still needed.

Systems of governance were in place, regular audits of the service were taking place and issues identified were being acted upon. There were regular meetings with staff and people who used the service and we saw evidence that actions were taken to address issues.

Staff had recorded two incidents in a person’s daily notes which should have been reported to CQC, when the registered manager investigated them they said the records were inaccurate and therefore there was no requirement to submit a statutory notification regarding them. It is imperative staff understand the need to ensure accurate records are kept of all aspects of peoples care and support.

This service has been in Special Measures. 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 have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures. However, we identified continuing breaches in regulation 12 and 17 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 the report.

Priory Gardens is a nursing home currently providing care for up to a maximum of 72 older people. The home has three separate units which provide care and support for people with nursing and residential needs including people who are living with dementia. On the days of our inspection 51

people were living at the home.

The service has not had a registered manager in place since July 2015. 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.

Medicines were not managed safely. We found evidence one person had not received a prescribed medication on a number of occasions. A care plan recorded one person was allergic to a medicine but this information was not recorded on the medicine administration record. We could not evidence topical medicines were administered correctly. This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Personal emergency evacuation plans were not all fully completed. Information regarding the correct settings for individual pressure mattresses was not completed. The information in care plans and risk assessment regarding peoples moving and handlings needs was inconsistent and did not always reflect the practices we observed. Positioning records for people failed to evidence people received pressure area care appropriate to their need. We noted a person’s blood sugar had been recorded at 26mmol but was no evidence to suggest staff had rechecked this to see if they required medical attention. This was a breach of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People were bathed although not always to the frequency they preferred. People’s daily care record was task orientated and contained gaps regarding the care of people’s nails and teeth. Food and fluid records did not evidence people always received sufficient to eat and drink and snacks were not consistently recorded. This was a breach of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People who lived at the home and staff, told us there were not enough staff on duty. This concern had been raised in resident meetings but no action had been taken by the registered provider. People on the nursing and dementia unit did not receive their lunchtime meal in a timely manner. Staff received regular training but one to one supervision of staff was not completed on a regular basis. New staff had not received a thorough induction to their role. This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

People told us they felt safe and staff had completed training in safeguarding adults. Staff were aware of how to raise concerns about harm or abuse. Where people were deprived of their liberty, the home had requested appropriate authorisation from the local authority in order for this to be lawful and to ensure a person’s rights were protected. Mental capacity assessments were in place but lacked sufficient detail to ensure they met all the requirements of the Mental Capacity Act 2005.

A programme of refurbishment had been completed at the home. This had enabled people in the dementia and residential unit to access the garden.

Staff were caring. Interaction between staff and people who lived at the home was kind and professional. Staff enabled people to make choices about their day and took steps to maintain people’s privacy and dignity. There was programme of activities, entertainment and trips for people who lived at the home.

Care plans were individualised and not generic, although we could not consistently evidence people or their family’s involvement in the planning and review process.

There was a system in place to enable people to provide feedback or raise concerns about the service they received.

The management of the home had been inconsistent since the departure of the registered manager in July 2015. There was no recorded evidence of senior management oversight in April or June 2016. Audits were completed in the home but evidence of action taken to address issues was lacking. Staff meetings were irregular. Meetings with people who lived at the home took place on a regular basis although issues identified at these meetings did not appear to be addressed by the organisation. Although the registered provider’s governance system monitored the performance of the home it had failed to ensure people were satisfied with the service that the home was complaint withal relevant legislation. This is a breach of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

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

During this inspection we spoke with the registered manager, three relatives, six people who lived in the home and five staff.

We found improvements had been made to care records and people were receiving the care and support they needed from staff. People we spoke with who lived in the home told us they were satisfied with the care they received. Comments included:-

'I'm well looked after here'

'I get the help I need'

'Staff are lovely, I've no concerns'

We found improvements had been made in the management of medicines. People were receiving their medicines as prescribed and records were maintained. The home was in the process of moving to a new medication system and staff were receiving training on the day we visited.

We found more staff had been recruited and staffing levels had consolidated. A new management team was recruited following the last inspection and staff were now allocated to specific units which provided people with better continuity of care.

We found the home was clean and comfortable. We saw that staff treated people with respect, offered them choices and maintained their privacy and dignity. One person said, 'Staff are lovely and treat me with respect'.

We found people were generally well cared for but found shortfalls in the care documentation which we considered could impact on the care people received.

We identified concerns with some of the medication systems and practices in place, which meant some people had not received their prescribed medication.

We found there were not always enough staff to meet people's needs due to the dependency levels and layout of the building. We found staff had access to ongoing training and development and there were supervision and appraisal systems in place. There were systems in place to monitor the quality of service people received.

The manager was not available when we visited but we spoke with her the following day and she provided information for us on our request.

We found that there had been some difficulties with appropriate staffing levels but this had now improved.

The incidents reported to us had been investigated by the manager and appropriate steps had been taken to remedy them.