This unannounced inspection was carried out on the 17 March 2015 with a further announced visit on the 16 April 2015.
Westwood Lodge Care Home is a purpose built home with three units, which provides nursing and personal care for up to 76 people. It is situated in a residential area of Wigan and is about five minutes drive from Wigan town centre. All rooms are for one person and they all have a toilet and a hand wash basin. The home is situated in its own grounds and has gardens with car parking spaces at the front of the home.
There was a registered manager in place at the time of our inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service and has the legal responsibility for meeting the requirements of the law; as does the provider.
At the last inspection carried out in September 2014, we identified concerns in relation to staffing levels and the management of medication. As part of this visit, we checked to see what improvements had been made by the home to address these concerns.
During this inspection, we found five breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponded to new regulations under 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.
During our last inspection in September 2014, we judged the provider to be in breach of Regulation 13 Health & Social Care Act 2008 (Regulated Activities) Regulations 2010, because the provider did not have appropriate arrangements in place to manage the administration of medicines. We found that people were still not protected against the risks associated with the unsafe use and management of medicines.
We found the home had processes in place for all aspects of medicine handling, however we found some staff were not consistently following procedures.
We saw evidence that medicines which needed to be taken before food being given after breakfast and lunch time meals. Failure to administer medication as directed could affect how the medicine worked or cause unwanted side effects.
From looking at records, we found that two people had run out of their medicines. We found the procedures for reordering medicines had not been followed. We also found that on one unit, staff were failing to store insulin pens that were currently being used at the correct room temperature.
Nurses told us that they felt the medicines round was difficult particularly in the morning when there were often various other disruptions. The use of 'do not disturb' tabards had not made any difference and that they did not have time to spend with people that required support with their medicines. We were also told that nurses felt unable to plan the medicines around people’s needs due to the volume and other tasks that were required.
We found the registered person had not protected people against the risk of associated with proper and safe management of medicines. This was in breach of regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.
During our inspection, we spoke with one person who was living in the nursing unit known as ‘The House,’ who was suffering with a contagious infection. The care plan for this person clearly stated that ‘barrier nursing of the patient’ should be put in place. However, we could see no visible evidence that this was the case.
We were also unable to see any hand sterilising gel or guidance advising other people or visitors that ‘barrier nursing’ was in place and the actions that they were required to take in order to reduce the risk of cross infection.
We found the registered person had not protected people against the risk associated with spread of health care associated infections. This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.
When speaking with relatives and people who used the service we were consistently told that there was a problem of understaffing throughout the home. We noted that a student on work experience had been left alone with between nine and eleven people during this period. Our observations indicated the student was being used by staff as a ‘minder’ for people in the lounge which was unsafe practice.
Both nurses and care staff told us they believed there were insufficient numbers of staff on duty. Care staff felt that the care staffing levels were very poor and felt that management planned staffing on the numbers of people who used the service as opposed to individual dependency needs.
At 10.25am a person who used the service asked to go to the toilet just as two care staff were transferring another person who wanted to use the bathroom. The student who was present in the room spoke to the person and said that as soon as the care staff had finished they would attend to their needs.
At 10.40am the two members of staff returned to the lounge. However we found the person had to tolerate the indignity of wetting themselves as there were no qualified staff to support them using the toilet when they required it. One member of staff told us; “We usually have two carers on each corridor which is not enough. People have to wait to be toileted, turned or sat up in bed, it’s not good enough.”
In relation to providing planned care, we looked at the Service Communication Book for week commencing 09 March 2015, which showed that seven people who were living in nursing unit located in The House, did not have an assisted bath/shower that week. We spoke with staff about this concern. Staff told us this was not due to the person’s preference, but due to the lack of time available to them. They found it frustrating that they were not able to meet the hygiene needs of these people.
We found staffing arrangements did not protect people from the risks associated with inappropriate or unsafe care, because care was not delivered in such a way to meet people’s individual needs. This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, person-centred care.
Westwood Lodge provided care for people coming to the end of their lives due to deteriorating palliative illnesses. The home was part of the National Gold Standards Framework for end of life (EoL) care, which enabled people to have a comfortable, dignified and pain free death.
We could not find any evidence that confirmed training or a competency measurement framework around safely caring for a person who was attached to a syringe driver during EoL care. We spoke to management team and nurses about end of life care and were unable to obtain assurances that safe and consistent syringe driver care was being delivered by the service. We found the service could not provide us with a policy or procedure that would support staff to deliver a safe and consistent level of care. When we spoke to staff we received conflicting responses about EoL care.
Both management and staff confirmed individual nurse competencies around managing EoL care was not measured by the service.
We found the registered person had not protected people against the risk of associated with the safe delivery of EoL care, . This was in breach of regulation 23 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, safe care and treatment.
The service undertook a range of audits of the service to ensure different aspects of the service were meeting the required standards. However, as a result of the concerns we identified around medication, infection control, meeting people’s individual needs and EoL care, it was apparent the service was not effectively assessing and monitoring the quality of service provision.
We found the registered person did not effectively monitor the quality of service provision. This was in breach of regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which corresponds to regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, good governance.
We found the home had suitable safeguarding procedures in place, which were designed to protect vulnerable people from abuse and the risk of abuse. We reviewed a sample of recruitment records, which demonstrated that staff had been safely and effectively recruited.
We looked at the training staff received to ensure they were fully supported and qualified to undertake their roles. On the whole, staff told us they felt fully supported in their roles and were valued by management. One registered nurse told us; “I feel we get plenty of support and training. I do feel valued. The management are like friends to us so we can speak easily about any concerns we have.” We looked at training records to confirm what training staff had received. This included; National Vocational Qualifications (NVQ), manual handling, health and safety, infection control and safeguarding adults.
We spoke to a senior visiting health care professional from the local hospital, who spoke very favourably of the services provided by the home. They told us the model of care at the home had been excellent and they were very pleased with the services they received. They had a large team that visited the home to support patients and they had never received negative feed-back about the service.
We saw there were procedures in place to guide staff on when a Deprivation of Liberty Safeguards (DoLS) application should be made. We spoke to the registered manager, who was able to demonstrate that the service had submitted a number of applications in line with guidance from the local authority. We spoke with staff to ascertain their understanding of the Mental Capacity Act (2005) and DoLS. We found that they all demonstrated an underpinning knowledge regarding this legislation.
We found the home did not have signage features that would help to orientate people living with varying degrees of dementia. We have made a recommendation about environments used by people with dementia.
We observed staff offering a choice of hot and cold drinks to people and asking them whether they wanted to wear an apron to protect their clothing. We saw that a three week menu was displayed on the dining room wall though it did not represent what was being served on the day of our inspection.
On the whole, people who used the service told us that staff were kind and considerate. One person who used the service said “The staff will do anything for you, but there’s not enough of them.” Another person who used the service said “Bless them, nothing is too much trouble for them.” A visiting relative of a person coming to the end of their life said “We have never had any concerns regarding the care. The staff are great and also update you on any changes.”
We looked at one care plan which documented that one person who used the service had five Grade 4 pressure sores on various areas of their body. The documentation advised that these were present on the transfer of the person from another care provider. We found that these were safely documented within the care plan and suitable wound management plans for each area had been completed.
We were told by the registered manager that the service employed an activities coordinator who was currently on leave. On the day of our inspection we saw limited physical and mental stimulation for people who used the service.
We looked at minutes from family and residents meetings that had taken place. People had also completed a customer satisfaction survey in 2014. The result of which had been analysed by the provider and included areas such as overall satisfaction with service and likelihood to recommend.
Staff told us they believed there was an open and transparent culture within the home and would have no hesitation in approaching managers about any concerns. However, some staff stated that while the managers were very approachable, they were not proactive in dealing with issues or personal problems.
We looked at minutes from staff meetings. These included external professionals meetings, nurses and housekeeping. We found minutes to be detailed and included topics such as medication, internal audits and handovers.
We found the provider had been accredited with a Gold Award for Investors in People recognition.