Heathfield House Nursing Home

At our last inspection in June 2017 we found people did not always receive their medicine as prescribed. Records relating the administration of medicines were not always accurate and some records relating to measures to reduce identified risks were not accurate or up to date. Risk management plans were not always in place. At this inspection we found significant improvements had been made.

Risk assessments were carried out and promoted positive risk taking, which enabled people to live their lives as they chose. People received their medicines safely. Records relating to risks and medicines were accurate and up to date.

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.

People were safe. There were sufficient staff to meet people's needs and staff had time to spend with people. People’s nutritional needs were met and staff supported people to maintain a healthy diet. Where people had specific dietary needs, these were met.

The service provided support in a caring way. Staff supported people with kindness and compassion and went the extra mile to provide support at a personal level. Staff knew people well, respected them as individuals and treated them with dignity whilst emotional support. People and their relatives, were fully involved in decisions about their care needs and the support they required to meet those individual needs.

There was a positive culture at the service that valued people, relatives and staff and promoted a caring ethos that put people at the forefront of everything they did.

People continued to receive effective care from staff who had the skills and knowledge to support them and meet their needs. People were supported to have choice and control of their lives and staff supported them in the least restrictive way possible; the procedures in the service supported this practice. People were supported to access health professionals when needed and staff worked closely with people's GPs to ensure their health and well-being was monitored.

People had access to information about their care and staff supported people in their preferred method of communication.

The service continued to be responsive to people's needs and ensured people were supported in a personalised way. People's changing needs were responded to promptly. People had access to a variety of activities that met their individual needs.

The registered manager monitored the quality of the service and looked for continuous improvement. There was a clear vision to deliver high-quality care and support and promote a positive culture that was person-centred, open, inclusive and empowering which achieved good outcomes for people.

Heathfield House is a care home in Bletchington near Oxford that is registered to provide nursing care to older people, many of whom have dementia.

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.

People did not always receive their medicine as prescribed. Records relating the administration of medicines were not always accurate.

Records were not always accurate. Some records relating to measures to reduce identified risks were not accurate or up to date.

Risks to people’s health and safety were identified. However, risk management plans were not always in place. One person was at risk of falls but had no risk management plan to manage the risk. We raised these concerns with the registered manager who took immediate action to address our concerns.

The registered manager monitored the quality of the service to look for continuous improvement. However, systems were not always effective. Audits had failed to identify our concerns relating to risk management plans being followed.

We were greeted warmly by staff at the service. The atmosphere was open and friendly.

People told us they were safe. Staff understood their responsibilities in relation to safeguarding. Staff had received regular training to make sure they stayed up to date with recognising and reporting safety concerns. The service had systems in place to notify the appropriate authorities where concerns were identified.

Staff understood the Mental Capacity Act (MCA) and applied its principles in their work. The MCA protects the rights of people who may not be able to make particular decisions themselves. The registered manager was knowledgeable about the MCA and how to ensure the rights of people who lacked capacity were protected, this included people who were deprived of their liberty.

People were supported by staff that were extremely knowledgeable about people’s needs and provided support with compassion and kindness. People received high quality care that was personalised and met their needs.

There were sufficient staff to meet people’s needs. Staff responded promptly where people required assistance. The service had robust recruitment procedures and conducted background checks to ensure staff were suitable for their role.

The service responded to people’s changing needs. People and their families were involved in their care and how their care progressed and developed.

Staff spoke extremely positively about the support they received from the registered manager. Staff supervisions and meetings were scheduled as were annual appraisals. Staff told us the registered manager was very approachable and supportive and that there was a very good level of communication and trust within the service.

The service sought people's views and opinions. Relatives told us they were confident they would be listened to and action would be taken if they raised a concern.

People had sufficient to eat and drink. Where people needed support this was provided discreetly and compassionately.

This inspection was carried out by an inspector and a pharmacist inspector. We looked at the management of medicines. During this visit we found that actions had been taken and we saw significant improvements. However further improvements are needed to ensure people are fully protected against the risks associated with medicines.

When we inspected medicines in May 2014, the impact on people was judged as moderate. At this inspection we have judged the impact to people to be reduced to a minor impact. We have told the provider to take action and we will follow this up with another inspection.

We considered our inspection findings to answer questions we always ask;

Is the service safe?

Is the service effective?

Is the service caring?

Is the service responsive?

Is the service well-led?

This is a summary of what we found;

Is the service Safe?

We found that the service was not always safe. Medicines were not always handled appropriately. We noted that two people had medicines prescribed to them which were not documented on their medication administration records. We also noticed that medicines were not always safety administered. We checked the current medicine administration records (MAR) charts for six people. For four people we found that the records of medicines received into the home and the number of doses signed for on the medicine administration record (MAR) chart did not match. This meant the service did not have appropriate systems in place for the safe administration of medicines. We looked at medicine audits for April and May 2014. We noted that the audit had systems in place to identify concerns in medicine stocks and records; however the audits did not identify these concerns.

Is the service effective?

We found the service was effective. People were supported in promoting their independence and community involvement. We observed that where possible people were encouraged to do things for themselves. Care staff told us how they promoted peoples independence. One care worker told us, 'it's important we do not forget that although people here can be highly dependent it's important we encourage any areas of independence, no matter how small it may seem, it's still important'.

Is the service caring?

The service was caring. People we spoke with felt their care needs were understood. One person told us, 'I have no complaints; they know what I need and do it very well'. Another person told us, 'I would rather be in my own home, but they [staff] make things very comfortable'. We saw that there was a wide range of activities for people to do. We saw that these activities were designed to offer individualised and meaningful stimulation. We observed a number of caring and positive interactions through our SOFI observation that clearly had a positive impact on people's mood.

Is the service Responsive?

We found the service was responsive. Support plans gave care staff clear guidance on how to meet people's needs and how to identify changing needs so the appropriate action could be taken. We saw through daily notes that this guidance was being followed.

Is the service well led?

We found the service was well led. People we spoke with felt the culture in the home had improved. One person told us, 'it can be challenging, but it's very open and that's good'. Another person told us, 'communication is good, we know what's happening and that helps us do our job better'. The provider had an effective system to regularly assess and monitor the quality of service that people received. We also found that People who use the service, their representatives and staff were asked for their views about their care and treatment and they were acted on. People we spoke with felt able to raise concerns and told us that the management were approachable available when needed.

The service had clear evidence of how the views of people, their representatives, staff and external stakeholders had been sought. We saw that meetings were conducted for people and their relatives. We also noted that people were provided information through a newsletter.

The service had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service, and visitors. The service kept a record of all incidents and accidents. We saw that each incident had a clear record of actions taken to ensure each person's health and wellbeing was maintained. We noted that the regional manager conducted an audit of all incidents and accidents.

The provider had systems in place to ensure people's records were maintained appropriately. New paperwork had been implemented, which included a new dependency assessment (a tool used by the service to identify people's needs). The regional manager told us that people's care files were being rewritten..

We looked at six people's care records and saw that they were appropriately maintained. For example, all six people's care records had been reviewed and five had been rewritten by nurses since our last inspection in December 2013.

The consent of people and their relatives were sought and documented. The regional manager showed us that as each care file was updated, people and their families were asked to look at the care plan and sign if they agreed with it. Five of the six files we looked at contained this document, and all five stated that the person or their relatives agreed to the plan of care.

People told us that they were treated with dignity and respect. However, our observations showed that people were not always treated with dignity and respect.

We found that peoples' care needs were being met, and that people were happy with how their care needs were met. We spoke with six people and five people's relatives and everyone was complimentary of the service they or their relatives received.

Appropriate arrangements were not in place for the secure storage of medicines and people were not completely safe because a fire exit in the building was blocked by moving and handling equipment.

Staff received appropriate training to meet the needs of people living at the home. Staff however were not always appropriately supervised and did not always receive appraisals.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

People's personal records were not always accurate or up to date. Care files we looked at did not provide an accurate reflection of people's current care needs.

We found improvements in the care and welfare of people who used the service. Action had been taken to improve the way people's hydration and nutrition needs were managed. For example, drinks and snacks were available and we saw people taking them when they wanted. People who used the service could choose alternatives to the daily menu. One of the people we spoke with said 'The food is alright. I tell them what I want to have'.

We found improvement in cleanliness and hygiene. The home was very clean and there were no bad odours. Food storage areas were free from debris and fresh goods were stored appropriately.

We saw improvements in recruitment processes. Staff files showed appropriate pre-employment checks had been carried out and records of interviews were kept.

There was evidence of improvement in the monitoring of the quality of service people received. A resident and relative group had been started, as a way of gaining feedback. A range of quality control audits had been put in place.

The quality of records, including medical records showed improvement. Care plans had been divided into easy to follow sections so staff could more easily find the information they needed.

We carried out this inspection in response to concerns received. The most serious concern raised was about dehydration. Due to this fact and the failings we identified in November 2012, we focused on people's food and fluid intake, weight monitoring and the prevention and management of pressure sores.

During this inspection we found that the provider was failing to protect people from the risks associated with dehydration, malnutrition and pressure sores. We told the management about our concerns on the day of our inspection.

We have shared our concerns with the local safeguarding authority.

We were not able to speak to any people who used the service. However, we did speak to four relatives who reported positive comments to us about the care their loved ones were receiving.