Romford Nursing Care Centre

Romford Nursing Care Centre is a residential care home which was providing personal and nursing care to 47 people at the time of the inspection. Most people living at the service were older people, some of whom had dementia. The service can support up to 114 people in one adapted building over three floors. At the time of our inspection three of five units were in use, of these working units, two were nursing units.

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

Medicines were mostly managed in a safe way. We have made a recommendation to follow best practice so wording in some medicine protocols was clearer. People’s risks were assessed and monitored. Staffing levels had improved since our last inspection and the provider was actively engaging in recruitment. Recruitment processes were robust. There were systems in place to safeguard people from abuse. The service followed national guidance and infection prevention and control. Lessons were learned when things went wrong as there were processes in place to learn from incidents which had occurred.

Staff had received training and supervision to support them in their roles. People were supported with nutrition and hydration to ensure balanced diets. The provider had adapted the building to ensure it met people’s needs. People’s needs were assessed before the commencement of care so the provider was assured they could meet those needs. Staff communicated with other agencies to ensure people received good care. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People and relatives were involved in completing care plans.

People and relatives thought staff were caring. People were supported to express their views. People’s privacy and dignity were respected, and their independence promoted.

The provider responded to people’s complaints appropriately. People’s communication needs were met. People were supported to undertake suitable activities they could enjoy. People’s care was planned to meet their needs. The service sought to record people’s end of life wishes.

Staff understood their roles and the registered manager fulfilled regulatory requirements. There were quality assurance systems in place which supported the provider to improve the care and support people received. People, relatives and staff thought highly of the management. The registered manager understood duty of candour and acted appropriately where required. The service worked with other agencies to the benefit of people using the service. People, relatives and staff were able to engage with the provider and be involved with decisions that affected the outcomes of the service.

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 27 September 2019) and there were multiple breaches of regulation. The provider was issued warning notices for regulation 12, Safe care and treatment and also for regulation 17, Good governance.

Further breaches of regulation were found in relation to regulation 18, Staffing and regulation 14, Nutrition and hydration at a targeted inspection in 2020. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

Romford Care Home is a residential care home providing personal and nursing care to 41 people at the time of the inspection. Most people living at the service were older people some of whom had dementia. The service can support up to 114 people in one adapted building over two floors. At the time of our inspection three units were in use, two of which were nursing units.

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

We received information raising concerns about staffing and how people using the service were not being kept safe. At the inspection, people and staff had mixed views on staffing, evidence initially provided by the service indicated at times units were not adequately staffed to ensure people's needs were met, but the provider later told us of they had a flexed approach to staffing where by staff would work across different units to make up shortfalls.

There were robust recruitment processes in place. Incidents and accidents were recorded appropriately, and the service sought to minimise risk to people where possible. Infection control procedures had been enhanced due to the risk of Covid 19 and we observed the service was clean. Personal protective equipment [PPE] was readily available. However, not all staff wore PPE correctly, we fed this back to the registered manager, told us staff were continuously reminded about PPE and how to wear it correctly, and told us they would continue to address this following our inspection.

People had mixed views about the quality and choice of food. The registered manager told us they would take steps to address people’s concerns. People told us they had enough to drink. People’s nutrition and hydration was recorded appropriately, and staff followed care plans and health professional’s advice.

People told us activities were limited, they felt in part due to the recent departure of a wellbeing and activities coordinator. The registered manager told us care staff would cover these duties in the short term but that the provider was seeking to hire a wellbeing and activities coordinator. We have made a recommendation about activities. People had mixed views on whether their care was person centred. Care plans recorded people’s needs and preferences and were reviewed regularly.

Quality assurances processes at the service monitored the safety and wellbeing of people at the service. These processes were completed regularly and when actions were identified to improve elements of care, these were followed up on. However, these processes did not identify people’s concerns around staffing nor the shortfalls with staffing we identified.

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

Rating at last inspection

The last rating for this service was requires improvement (published 27 September 2019) and there were multiple breaches of regulation. The provider was issued warning notices for regulation 12, safe care and treatment and also for Regulation 17, Good governance. The provider completed an action plan after the last inspection to show what they would do and by when to improve.

Why we inspected

We undertook this targeted inspection to follow up on specific concerns we had about staffing, people’s welfare and how the service monitored, recorded and reported incidents and accidents. The overall rating for the service has not changed following this targeted inspection and remains Requires Improvement.

CQC have introduced targeted inspections to follow up on a Warning Notice or other 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 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.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Romford Care 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 a continued breach in relation to staffing numbers at this inspection. We have also identified a breach with regards to meet people’s nutrition and hydration needs. Please see the action we have told the provider to take at the end of this report.

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.

Romford Nursing Care Centre is a residential care home providing personal and nursing care to 64 people aged 65 and over at the time of the inspection. The service can accommodate 114 people across five separate units, each of which has separate adapted facilities. Three of the units specialises in providing nursing care to people living with dementia

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

People and their relatives were not always positive about the service. They commented on the many leadership changes and culture at the service, low staff morale and staffing levels. One relative told us, “The place needs straightening out.” When asked about the culture of the service one staff member said, “The carers here are good, the team are good but management needs to stand up.”

The service did not have effective systems in place to monitor or improve the quality and safety of the service provided. Medicines were not managed safely as people did not receive medicines as prescribed. Risk assessments did not always reflect all possible risks to people using the service to ensure they were safe. Accident and incident reports were not always completed in full to ensure the service can learn from lessons and minimise risk of reoccurrence. Staff supervisions were ineffective and infrequent and staff did not always feel supported. The service had not acted on a previous recommendation about end of life training.

People and their relatives had mixed views about safety and staffing levels at the service, however, the provider had a system in place for staff allocation. We have made a recommendation about involving people and staff in decisions about staffing levels.

Processes were in place to prevent and control the risk of infection. We have made a recommendation about kitchen monitoring processes as we found an oversight in food use by dates.

Staff knew about safeguarding and whistle blowing. Safe recruitment practices were followed to ensure staff were suitable to support people safely.

Assessments of needs were not always robust when people joined the service. The service did not always work together with other agencies in a timely manner to ensure people using the service were in the best of health. We have made a recommendation about working with other agencies.

Staff received training to carry out their roles. People were supported with maintaining nutrition and hydration. People’s dietary needs and preferences were detailed in their care plans. People’s rooms were personalised to reflect their choices.

People and their relatives had mixed views about staff with some telling us that the staff approach was less positive at times. They said this was linked to staffing continuity and use of agency staff rather than staff attitude.

People were included in decisions about their care. People told us staff promoted their dignity and privacy and encouraged their independence. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice.

The service did not always respond to complaints from people and their relatives in a timely manner. We have made a recommendation about the management of complaints.

Care plans were personalised and described each person’s needs, likes and dislikes and how to meet them. People did not always participate in regular activities. Information about the service was not provided in other accessible formats. We have made a recommendation about accessible information formats.

Relatives of people using the service told us they did not always feel involved in the service. Robust systems were not in place to gather feedback for continuous improvement due to management changes.

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

Rating at last inspection

At our last inspection on 7 August 2018, the service was rated Good (published 19 September 2018).

Why we inspected

The service had a local authority embargo in place since December 2018 restricting new admissions. The inspection was prompted in part due to concerns received about medicines management and administration, safeguarding referrals, care planning, record keeping and complaints about nutrition, hydration and supporting people with complex health needs. A decision was made for us to inspect and examine those risks.

We have found evidence that the provider needs to make improvements. Please see the safe, effective, caring, responsive 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. The provider has started to take action to mitigate the risks. The service was rated Good at the last inspection.

Enforcement

We have identified breaches in relation to staff support, medicines management and leadership of the service 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.

We brought forward our inspection to look into concerns we received in relation to the safety and the management of the home, including how the service operated at night times.

We carried out an unannounced inspection of the home on one night and on the two following days. We did not find evidence to substantiate the concerns we received and we have found the home remains ‘Good’.

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

Romford Care Centre accommodates up to 114 people across five units, each of which have separate adapted facilities. The units specialise in providing nursing and residential care to older people living with dementia. At the time of our inspection, 95 people were living in the home.

The home did not have a registered manager in post as the person who held this position, left their role a month before our inspection. 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 has since appointed a new manager who will register with the CQC.

Each unit in the home was managed by a registered nurse or a team leader, who were supported by a deputy manager and an operations manager. We met with both these managers during our inspection.

Risk to some people had been assessed and identified. However, we noted that risks to some people were not always identified in their risk assessments and there was a lack of overall consistency, to ensure all risks were being managed. We have made a recommendation for the provider to ensure risk assessments are clear and contain relevant and consistent information.

People were involved in the planning of their care and received care and support to ensure their individual needs were met. Care plans contained information on people’s backgrounds and preferences. However, we have made a recommendation for care plans to take a more person-centred approach towards people’s end of life care wishes and for staff to receive further training in this area.

The provider had safe recruitment procedures in place and carried out checks on new employees.

There were enough staff on duty to ensure people's needs were met. Staff rotas were not always completed to show that staff cover had been arranged when required.

The management team was committed to developing the service and this was done through quality assurance systems that were in place. Some further improvements were required to ensure people received a responsive service because some people and relatives did not always feel listened to.

Medicines were stored, managed and administered by staff who were trained. We saw that medicines on all units were managed and used safely.

Staff ensured people had access to appropriate healthcare when needed and their nutritional needs were met. People were provided with a choice of meals and were able to make specific requests.

Feedback was received from people and relatives in the form of questionnaires and surveys to help drive quality improvements.

Records of accidents and serious incidents showed that the provider learned from mistakes to prevent reoccurrence.

People and relatives were able to make complaints, which were investigated by the management team. Complaints were planned to be used to also learn lessons and make improvements in the service.

The premises were clean and regularly maintained. The environment was suitable for people who had specific needs such as dementia.

Infection control procedures were followed by staff to ensure the home remained safe and clean.

Staff knew how to keep people safe and protect them from abuse. They were able to describe the actions they would take if they had any concerns about people’s safety. The provider also had a whistleblowing policy, which staff were aware of and they knew how to report concerns both internally and to external organisations.

Staff were supported with regular training, meetings and supervision. Staff performance was reviewed on a yearly basis and they were encouraged to develop their skills.

The provider had systems in place to support people who lacked capacity to make decisions for themselves. Staff had received training on the Mental Capacity Act 2005. They were knowledgeable of the processes involved in assessing people’s capacity.

Staff were aware of people’s preferences, likes and dislikes. They also had an awareness of equality and diversity and challenged any discrimination they encountered.

People were encouraged to participate in activities and remain as independent as possible. Their choices were respected.

Staff were able to communicate with people in order to understand their needs.

Staff felt supported by the management team, who reminded staff of their responsibilities and requirements when providing care.

Romford Care Centre is a large, purpose-built care home providing accommodation, personal care and nursing care for up to 114 people. At the time of our inspection there were 62 older people, many of whom have dementia, using the service. Each person who lives at Romford Care Centre has their own room with ensuite bathroom, and the service premises are suitable for people with mobility needs. The service is divided into five units, however only three were in use at the time of our visit due to the number of people living in the service.

Following the resignation of the last manager, the service did not have a registered manager in place. However, the provider had employed an acting manager who was running the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We found that Romford Care Centre had a team of new managers who were willing to listen to people, people's relatives and staff to make improvements to the service. People, their relatives and staff spoke positively about the management of the service and told us the acting manager was approachable. They told us they were happy with the service and they knew how to make a complaint if they had a concern with it.

People’s care and health plans were detailed, person centred and described the individual care, treatment and support people needed and preferred. People or their representatives were involved in the review of care plans and risk assessments and it was evident that care was delivered in line with the principles of the Mental Capacity Act 2005 (MCA).

We found that new staff were appropriately checked to ensure they were suitable to work with people. People told us and records and observation showed that there were enough staff at the service who were kind, caring and friendly with people and relatives. We noted staff ensured people's privacy and treated them with respect and dignity when delivering care. Staff were trained and supported and these gave them opportunity to develop skills and experience necessary to support people. However, we recommended that the provider ensures that all staff have regular formal supervision, annual appraisal, training including attending refresher courses in MCA.

Medicines were stored and administered safely and there was evidence that people had access to healthcare professionals. People's dietary needs were met through proper monitoring and provision of meals that reflected their preferences.

The premises were clean, bright and spacious with appropriate facilities and equipment available for people's use.

The inspection was unannounced and was carried out by three inspectors.

Romford Care Centre is a nursing home registered to provide accommodation and support with personal care and nursing for 114 adults. At the time of our visit there were 67 people using the service in three units.

The home did not have a registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service and shares the legal responsibility for meeting the requirements of the law with the provider. At the time of the inspection the service was managed by an interim manager, who has since resigned and replaced by a temporary acting manager.

During the inspection we spoke with seven people 12 visitors and 10 staff members. We reviewed 11 people's care files and the home's various records including health and safety records, complaints procedures, staff rota and the menus. We observed people in communal areas and bedrooms. Visitors told us staff were attentive to people's needs.

However, we found that people who used the service were at risk because risk assessments about a prolonged use of wheelchairs were not completed and agreed; people with wound management plans were not turned as stated in their care plans; some people did not receive care and support they needed with changing clothes and shaving. We found a number of staff had recently left the organisation and the staffing level was not sufficient and people were at risk of not having their needs met. The provider told and showed us they had completed and reviewed dependency level assessment for each person. We saw the completed dependency assessment forms but people we spoke with told us there were not enough staff at the service.

The Care Quality Commission monitors the operation of the Deprivation of Liberty Safeguards (DoLS), which applies to care homes. We found that the provider had made 11 DoLS applications and was in the process of completing the forms for the rest of people to apply to the local authority.

Most parts of the home was clean and tidy on the day of our visit. However, there were some parts where we noted malodour.

The five questions we ask about services and what we found

We always ask the following five questions of services.

The service was not safe. There were not enough qualified and experienced staff to meet people's needs.

Is the service effective?

The service worked well with health and social care providers. People and their representatives were involved in their care plans and staff received supervision from the new interim manager. People were satisfied with the choice of meals provided.

Is the service caring?

The service was not caring. Visitors told us people's clothes were not changed regularly and some people were not shaved. people's privacy and dignity was not always respected. Care plans were not being followed to reposition people with wound management plans.

Visitors were not happy about management, which they described as intimidating. The last registered manager was de-registered on 6th May and the service had been managed by acting managers who had not been registered. An interim manager, who had been employed by the provider, has resigned after this inspection was carried out. We have sent a letter to the provider asking them what action they would take to address the lack of a registered manager.

Is the service responsive?

The service was not responsive. Care plans were reviewed and updated. Information about the processes of complaints procedures was available; but some people told us the provider had not responded to their complaints.

Is the service well-led?

The service was not well-led. There was no registered manager and people told us the management was "intimidating".

Comments from the relatives of people using the service included, "We have been coming here for about 5 years. We've had loads of different managers. We ask them, "are you going to stay?" but they always leave" and "Staff are very considerate. The biggest problem is the lack of them." Another relative said, "They have started to have separate relatives' meetings on each floor. So you don't know what's going on now."

At the previous inspection we identified issues of concern about the delivery of care and treatment, and the documentation, for people with pressure sores. At this inspection we looked at the care plans for people with pressure sores and people at risk of developing pressure sores. We spoke with people and their relatives as well as staff, and looked at the policies for preventing and managing pressure damage. The relative of a person on a nursing unit told us, "[My relative] is safe. They (nursing staff) will do dressings in front of us and we have been told we can look at the dressings anytime." At this inspection we found that improvements had been achieved in regard to managing and preventing pressure sores, although the frequency for carrying out clinical assessments for nutritional status and susceptibility to developing pressure sores was not consistently correct.

Relatives told us they felt that staff worked very hard and there were not enough staff. We found that one unit did not have enough staff and this meant staff did not get their morning break. The rotas we looked at showed that there were customarily sufficient staff rostered on each shift, and we saw staff spending time with people and supporting them in an unhurried manner.

The relatives we spoke with told us they felt worried about the frequent change of manager at the service. There were many expressions of disappointment that the most recent manager was no longer at the home, as relatives felt improvements were being made and the service had entered a more stable period. Relatives told us there had been a lack of information about the change of manager and they generally did not feel that their views were being sought and utilised.

During this inspection we found that care plans and risk assessments were in place which set out how to meet people's individual needs. Since our last inspection of this service we noted that continued improvements had been made. This included care plans in hard copy and skin integrity care plans for those people at risk of developing pressure ulcers. However, we still found that care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

We found one instance where despite wound management plans and risk assessments being in place the wound management plan had gaps on it indicating that wound dressings had not been changed as regularly as had been assessed. For another person, readmitted to the home with pressure ulcers, staff had not brought this to the attention of the district nurse and appropriate care had not been given. As a result of this omission dressings had remained unchanged for an extended period leading to a significant deterioration in the pressure ulcer wounds. This showed that adequate steps had not been taken to meet people's health care needs.

People we spoke with gave mostly positive feedback about their experience of the service. Most people told us that staff were able to meet their needs. One person said "I'm happy, I'm okay here, I'm treated well, they look after me." A relative said 'I'm happy with things, my (relative) has settled in well, staff are caring.' All the staff and most relatives we spoke with were content with the levels of staffing at the home and how this impacted on people's care. One relative was concerned that during busy times staff sometimes seemed 'rushed off their feet.'

During this inspection we found that for some people care plans and risk assessments were in place which set out how to meet people's individual needs. However, this was not always the case. We found instances where skin integrity risk management plans and turning charts were not in place in relation to people assessed as at very high risk of developing pressure ulcers. Also, other instances where despite wound management plans and risk assessments being in place they had not been followed appropriately by care staff. For instance, we found one person assessed at at 'very high risk' of developing a pressure ulcer on the 3 December 2013. However, there was no plan in place for the management of this risk. For another person, assessed as at 'very high risk' of developing pressure ulcers on the 5 January 2014, senior staff confirmed there was no turning chart or skin integrity risk management plan in place to minimise known risks. This showed that adequate steps had not been taken to meet people's health care needs.

People we spoke with gave differing feedback about their experience of the service. Some people told us that staff were able to meet their needs. One person said "I'm happy, I'm okay, they treat me well." A relative said 'the carers are good, they are regular now.' However, some staff and relatives we spoke with had concerns about the levels of staffing at the home and the impact this sometimes had on people's care. A relative said 'I came in at 12.30pm yesterday, the curtains in mum's room were closed, the bell was on the floor and she wanted to go to the toilet.'

Since our last inspection of this service we noted that a number of improvements had been made. This included care plans in hard copy, the appointment of a new manager, deputy manager and clinical lead and the amalgamation of two nursing units to provide improved care and resilience. However, we still found that care and treatment was not always planned and delivered in a way that was intended to ensure people's safety and welfare.

During this inspection we found that for some people care plans and risk assessments were in place which set out how to meet people's individual needs. However, this was not always the case. We found instances where care plans were not in place in relation to wound management and the treatment of pressure ulcers and some cases where despite plans and risk assessments being in place they had not been followed appropriately by care staff. We found other cases where risk assessments had not been updated.

People we spoke with gave mixed feedback about their experience of the service. Some people told us that staff were able to meet their needs. One person said "I'm OK, I've no complaints, the staff are good." A relative said 'I can't praise the care staff enough.' However, we found that most staff and relatives we spoke with had concerns about the levels of staffing at the home and the negative impact this sometimes had on people's care. Despite some improvements we still found that there were not enough members of staff to keep people safe and meet their health and welfare needs.

Risk assessments and care plans were in place which set out how to meet people's individual needs. However, we found that medical advice had not been sought for a person on a higher dependency unit and that not all care plans had been signed by people or their relatives.

We found that people were cared for in a clean environment and that adequate systems were in place to assess and monitor the quality of service provision.

However, we found that there were not enough members of staff to keep people safe and meet their health and welfare needs.