LondonandManchesterHealthcare(Darnton)Ltd ... · 1 Darnton House Nursing Home Inspection report 12/02/2016. upto32peoplewhoaremedicallyfitandtransitioning backintothecommunityforcareandsupportasneeded

Ratings

Overall rating for this service Inadequate –––

Is the service safe? Inadequate –––

Is the service effective? Inadequate –––

Is the service caring? Inadequate –––

Is the service responsive? Inadequate –––

Is the service well-led? Inadequate –––

Overall summary

This inspection was carried out over two days on the 16and 17 November 2015. Our visit on 16 November 2015was unannaounced.

This was the service’s first inspection following registeringwith the Care Quality Commission (CQC) in March 2015.

Darnton House Nursing Home provides accommodationfor up to 96 adults who require nursing care. It is aprivately owned service. The service is located in its owngrounds close to a local hospital.

The ground floor accommodates 32 people who are livingwith dementia. The 1st Floor accommodates 32 peoplewith physical care needs. The top floor accommodates

London and Manchester Healthcare (Darnton) Ltd

DarntDarntonon HouseHouse NurNursingsingHomeHomeInspection report

Darnton RoadAshton-Under-LyneOL6 6RL

Tel: 0161 342 1300Website:

Date of inspection visit: 16 and 17 November 2015Date of publication: 12/02/2016

1 Darnton House Nursing Home Inspection report 12/02/2016

up to 32 people who are medically fit and transitioningback into the community for care and support as needed.This is a joint project between the service and TamesideHospital Foundation Trust.

At the time of our inspection, 18 people lived in theservice and a further 18 were living there temporarilybefore moving back into the community.

Prior to the inspection the Care Quality Commission (CQC) received a number of serious concerns relating tomedicines management, appropriate care and support ofservice users and staff suitability.

We found a number of breaches of the Health and SocialCare Act 2008 (Regulated Activities) Regulations 2014. Wefound breaches of Regulations 9, 11, 12, 13, 14, 15, 16, 17and 18 of the Health and Social Care Act 2008 (RegulatedActivities) Regulations 2014.

There was no registered manager of the home at the timeof our inspection. A registered manager is a person whohas registered with the Care Quality Commission tomanage the service. Like registered providers, they are‘registered persons’. Registered persons have legalresponsibility for meeting the requirements in the Healthand Social Care Act 2008 and associated Regulations

about how the service is run.

The service was not well led. The provider did not haveeffective systems in place to identify the risks to people’shealth, welfare and safety and failed to provideappropriate care to maintain their safety.

People who lived in the service did not consistentlyreceive their medicines in a safe manner that met theirindividual needs. Arrangements to ensure that peoplereceived the correct medicines were not in place. Thestorage, administration and timing of medicines wereunsafe and did not meet individual needs. We saw thatthere were not clear instructions available for staff to givemedicines. Where instructions were available, these hadnot been correctly followed. This placed people at risk ofharm.

The service was not consistently respecting and involvingpeople who use services in the care, they received. Forexample, the care plans reviewed during the inspectiondid not involve the person or their relative when theywere written and the person’s views, choices andpersonal preferences were not reflected.

People had no input into the planning of menus oractivities which meant that people’s preferences, choicesand personal opinions had not be sought or consideredas part their right to participate in making decisionsabout their daily lifestyles and freedom of choice.

The service was not meeting its obligation under theMental Capacity Act (2005) for people who may lackcapacity to make decisions. For example, people’s mentalcapacity was not assessed and decisions were made thatdid not support people’s rights. Such decisions thatpeople may find difficult to make for themselves could besmall decisions – such as what clothes to wear – or majordecisions as where to live. In some cases, people can lackcapacity to consent to particular treatment or care that isrecognised by others as being in their best interests, orwhich will protect them from harm. The Mental CapacityAct (2005) has been introduced as extra safeguards, inlaw, to protect people’s rights and make sure that thecare or treatment they receive is in their best interests.

The Care Quality Commission (CQC) monitors theoperation of the Deprivation of Liberty Safeguards (DoLS)which applies to care homes. We found that whererequired, not all the necessary DoLS applications hadbeen made. The manager was unable to determine whatapplications had been made or if they had beenprogressed. The deprivation of liberty safeguards providelegal protection for those vulnerable people who are, ormay become, deprived of their liberty whilst living in acare home. Lack of appropriate DoLS applications andauthorisations being made could mean that restrictionshad been placed on a person’s liberty that are not in theirown best interests to protect them from harm.

We saw that people’s health care needs were notaccurately assessed and that risks such as poor nutritionwere not always recognised. People’s care was notplanned or delivered consistently. In some cases, this putpeople at risk and meant they were not having theirindividual care needs met.

Records regarding care delivery were not checked toensure accuracy or that they were up to date leavingpeople at risk of not having their current individual needsmonitored or met.

The provider’s staff recruitment practices were not inkeeping with their own policy. We saw that staff had notall received appropriate checks before they started

Summary of findings


working in the service. References were not validated tomake sure they were genuine before staff started workingin the service. Lack of appropriate and safepre-employment checks being conducted beforesomeone started working in the service placed bothpeople using the service and other staff at risk ofunsuitable people being employed.

We saw that the management of nutrition was notsufficient to make sure that people’s nutritional needswere identified in a timely manner and that they wereprovided with diets that met their needs.

The reporting and addressing of safeguarding incidentswas not sufficient for the service to be aware of whatconcerns were in place nor, what action they needed totake. Safeguarding concerns were not recognised oraddressed.

The environment was well decorated and furnished to ahigh standard, however it had not been adapted to meet

people’s needs and in some instances was not suitablefor the people living there. For example, decoration inparts of the home was not appropriate for people livingwith dementia and lighting in certain parts of the homewas poor, especially for people with restricted sight.

Feedback from people living in the service and theirfamilies was complimentary regarding staff and the carethat they received.

The overall rating for this service was ‘Inadequate’ andthe service is therefore in 'Special Measures'.

The service will be kept under review and, if we have nottaken immediate action to propose to cancel theprovider’s registration of the service, will be inspectedagain within six months. The expectation is that providersfound to have been providing inadequate care shouldhave made significant improvements within thistimeframe.

Summary of findings


The five questions we ask about services and what we found

We always ask the following five questions of services.

Is the service safe?The service was not safe.

People who used the service were being put at risk because medication was not given safely.

The service did not have sufficient arrangements in place to recognise risks to people’s healthand welfare. There was insufficient arrangements to deal with risks and to make sure that theservice took appropriate action to reduce any risks.

Staff were not always appropriately checked for their suitability before they started working inthe service.

Inadequate –––

Is the service effective?The service was not effective.

We found that care plans did not accurately reflect people’s individual health and social careneeds. As a result, people did not always receive care that met their personal needs.

Staff did not have up-to-date training and ongoing planned supervision.

People who had fluctuating capacity and were less able to make a decision did not havearrangements in place to maintain their rights.


Is the service caring?The service was not always caring.

We found that staff’s approach to people did not always take their individual needs intoaccount.

Although we saw some positive interaction between people and staff we found people’schoice and autonomy was not consistently promoted.

There was an institutional approach to care that did not take into account peoples diverseneeds or encourage them to be as independent as possible.

People who lived in the service thought staff were kind and caring.


Is the service responsive?The service was not responsive.

We saw that care records did not always reflect up-to-date information for staff to be able tomeet people’s needs. Information about people’s preferences, choices and risks to their carewere not recorded. As a result, some of the people had not received care that met theirindividual needs.

The service did not manage complaints that had been raised.

There were not enough meaningful activities for people to participate in as groups to meettheir social needs; so some people living at the home told us they felt that there was little todo.


Summary of findings


Is the service well-led?The service is not well led.

No registered manager was in post at the time of inspection.

People were put at risk because systems for monitoring quality were not effective.

The culture of the service was not centered on the person but was more around the tasks thatthe staff had to achieve each day. This approach did not support people’s individual needs.


Summary of findings


Background to this inspectionWe carried out this inspection under Section 60 of theHealth and Social Care Act 2008 as part of our regulatoryfunctions. This inspection was planned to check whetherthe provider is meeting the legal requirements andregulations associated with the Health and Social Care Act2008, to look at the overall quality of the service, and toprovide a rating for the service under the Care Act 2014.

This inspection took place on 16 and 17 November 2015and was unannounced. The inspection team consisted offour adult social care inspectors on the 16 November 2015and two adult social care inspectors on 17 November 2015.During the inspection, we spoke with nine people living atthe service, five relatives, ten staff, the manager and two ofthe Company’s Directors. We also spoke with five externalprofessionals, including doctors, before, during and afterthe inspection. The views of all the people we consultedwith are reflected in this report.

On this occasion we did not ask the provider to complete aprovider information return (PIR) before our visit. A PIR is adocument that asks the provider to give us some keyinformation about the service, what the service does welland any improvements they are planning to make. Prior to

our inspection we looked at all the data and informationwe held about this service and noted that a number ofconcerns had been highlighted. We had also receivedconcerning information from the Local AuthorityCommissioners and Clinical Commissioning Group thatalso used the services of this particular provider.

We used the Short Observational Framework for Inspection(SOFI). SOFI is a way of observing care to help usunderstand the experience of people who could not talkwith us. We observed care and support in communal areasand looked at the kitchen, laundry and the majority of thebedrooms. We reviewed a range of records about people’scare and how the home was managed. We looked at someaspects of care for thirteen people in total this includedlooking at care records, risk assessments, food and fluidrecords, turn charts, daily records, professional visitsrecords, diary records, menus, medication administrationrecords and care plans.

We looked at a variety of staff records including training,induction and supervision for all staff and recruitmentrecords for ten staff employed at the home. We looked atother records including quality assurance audits that wereavailable at the inspection.

DarntDarntonon HouseHouse NurNursingsingHomeHomeDetailed findings


Our findingsPeople we spoke with informed us that they were happyliving or staying in the service; comments included “it’s abeautiful place”, “I am very comfortable the staff are reallykind and helpful” and “Yes, I feel safe, I think they arealways trying to make sure I’m looked after properly. So far,it has been a pleasure to stay here.”

Relatives told us, “I can’t fault anything I’m very happy[name of person] is staying here”. Those relatives we spokewith told us they thought that staff did care for theirrelative.

Prior to our inspection, we received concerns related tounsafe care. These included information from relatives,Local Authority Safeguarding Team, Health serviceprovision and from anonymous concerns raised by staff.The information we received covered a variety of concernsincluding not managing wounds, incorrect medicines,where people living with dementia had behaviour that maychallenge, this was not managed well and poor medicinesmanagement.

At the inspection we were given a file that the managerinformed us contained all the safeguarding notificationsrecords, that they were aware of, that had been made tothe Care Quality Commission (CQC). We saw that there wasno records of the service’s own investigations or lessonslearnt in relation to safeguarding alerts. We spoke with themanager and the provider. They were unable to state howmany safeguarding alerts had been received in total nordemonstrate that the concerns they had received wereaddressed appropriately in order to make sure peopleliving in the service were protected from a recurrence of theconcerns. A copy of the local authority’s inter agencysafeguarding guidelines (April 2015) was displayed on eachfloor of the home to which staff had access.

Discussions with staff told us that they were aware of howto inform the manager of safeguarding issues but not allhad received up-to-date safeguarding training. The actionsthat the staff told us they would take if an alert was raisedwith them were inconsistent and, in at least two cases,would have interfered with any full investigation. Thetraining record provided by the manager indicated that 31staff had completed safeguarding vulnerable adultstraining.

Our inspection identified four further safeguardingconcerns that the service had failed to recognise or action.These included medicines not being given, not recognisingrisks related to falls and unexplained bruising. Werequested that the service made safeguarding referrals forthe four people. Following our inspection, we receivedconfirmation that the appropriate referrals for safeguardinginvestigations had been undertaken.

None of the safeguardings had been subject to the service’sown investigation once external parties had completedtheirs.

In discussion with the staff and on reviewing trainingrecords, staff were unclear on what a whistleblowingcomplaint was and the complaints policy did not referencewhistleblowing complaints made by staff or how theywould be dealt with.

Overall, there have been a significant number of concernsraised regarding care in the service that have been upheldas neglect. As a result, stakeholders had made a decisionnot to admit people into the service until the quality of theservice had improved.

This was a breach of Regulation 13 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the service did not have aneffective system in place that recognised potentialabuse or took appropriate action taken whenconcerns were identified.

There were no infection control arrangements available inthe service and the infection control codes needed in orderto monitor infection control correctly were not beingfollowed.

Furniture was of a good quality, but the appropriateness ofthe layout of the building, ifs fixtures and fittings and thepotential risks they presented to people had not beenrecognised. There were a number of sculptures and tableswith sharp corners throughout the building. Riskassessments as to the suitability of the furniture had notbeen undertaken.

We looked at how the service managed medications andfound that people were not getting their medications, asthey should in a safe way.

Is the service safe?



We saw from the records that five people had not receivedtheir medicines for two or more days. There was noexplanation available as to why the people had notreceived their medicines in accordance with theprescription.

Where medicines were given, these were not always givenaccurately, as an example, we saw that one personreceived antibiotic therapy that commenced with 200mlsand the person was given 140 mls. Staff then recorded thecourse as completed. The person should have in factreceived the entire 200mls before this was stopped.

We saw that medicines were not given at the correct times,as an example, medicines to be given before food andmedicines to be with food were given at the same time. Onall occasions, these medicines were given with food.

We saw that nursing staff were signing for items such asfood thickener, supplementary drinks and creams that theydid not administer, but was given by care staff. Additionallywe observed unsafe practice from nursing staff includingsigning for medicines before they were given.

The service operated two different medicationadministration processes. The first two floors operated acommunity care based system and the top floor a hospital-based system. There were policies and procedures in placefor the two lower floors and none available for the top floor.The policies and procedures for the first two floors did notfollow the guidance in place from NICE (National Institutefor Clinical Excellence). Staff on the top floor reported thatthey had not received training in the medicationadministration process and that they were unfamiliar withhow this worked. The service did not have anyarrangements in place to make sure that it’s staff gavemedicines correctly on the top floor. We were informed thatthe pharmacy team from the adjacent hospital checkeddaily that medicines were given correctly. We looked atthese records and found no evidence that medicines werechecked as given correctly by the staff. We saw concernswith medicines such as unclear records for discontinuedmedicines that had not been recognised by the pharmacyteam assisting with medicines. We discussed this matterwith the provider and a representative of the hospital. Wewere assured by both that this would be addressed.

We looked at how the service managed externalpreparations such as creams. There were no recordsavailable in the service that fully described the use of

creams. One record on the top floor included referencessuch as ‘apply to feet’. It was not specific about the area ofthe feet, how thickly or thinly the cream was to be applied.As such, instructions as to the appropriate use of the creamwere either not available or incomplete. Additionally, therewere no arrangements in place in the service to monitorthat creams had been correctly applied. We saw in someareas of the service creams were left unsecured in people’sbedrooms and were not kept safely.

We looked at how medicines that were “prescribed asneeded” (PRN) or of a variable dose were managed. Suchprescribed PRN medication could be paracetamol,prescribed to be given only when needed. There waslimited information available in the service for people whohad medication prescribed “as needed” (PRN). We saw thatnot all medicines ‘as needed’ or of a variable dose hadinstructions available to staff as to how, when or in whatcircumstances they were to be given. As such, staff did nothave access to the instructions they required to make surethey gave PRN or variable dose medication safely .

Handwritten instructions on medication records for peoplenew into the service were not checked as accurate orsigned. The service did not check on admission if themedicines supplied were current medicines, as theservice’s policy did not instruct them to do so.

We were informed by the provider, manager and staff thatcompetency assessments for staff to determine if theycould give out medicines safely were not in place. As such,the service could not be assured that staff had the skillsand competency to give out medicines safely.

On the top floor, we were told that there were noarrangements available for people to self-medicate,despite the fact that many were returning to their ownhomes or into the community. We saw one person stayingon the top floor was trying to use an empty inhaler and wasbreathless. This person did require the opportunity toself-medicate but as there were no arrangements in placeto assist people to manage any of their medicines thisperson was placed at risk. We also saw that this person didnot have direct access to the call bell system to requestassistance with their medication which placed them furtherat risk.

On the other two floors, we found one person wasmanaging their own medicines however; the arrangementsin place were not safe. There were no checks that the




person was taking their medicines correctly, noarrangements to review their ability and no arrangementsto ensure that their medicines were stored correctly. It isalways good practice in promoting independence forpeople that they manage as many of their own medicinesas possible however, this must be undertaken safely.

A review of care records showed that the service did notalways have nutritional risk assessments that monitoredindividual weight loss or gain. Where they were in place,they were not kept up to date. We did see that there hadbeen improvements in making appropriate referrals tonutritionalists. However, where the risk assessmentdescribed a certain level of action, such as, ‘weigh weekly’this was not carried out. When potential weight loss wasidentified limited action was recorded as being taken.

We looked at accident records and noted that one personfell out of bed despite bedrails being on the bed and riskassessed as appropriate. No investigation had beenundertaken to determine what the cause of the fall was orwhat actions needed to be taken to reduce the risk. As aresult, the risk continued and the fall risk assessment andcare records were not updated. A further person fell onseven different occasions over a two months period andthe risk assessment had not been updated and no actionsrecorded as to what the service had done to reduce therisks. Following our inspection, both matters were referredto social services for review as potential investigation underthe local authority’s safeguarding protocols.

Risk assessments for the development of pressure ulcerswere undertaken but not reflected in care records. Whenwounds were identified, the treatments in place to preventfurther risks were not clear. The monitoring of positionalchanges to assist in preventing further pressure ulcers werenot always in place. A recent investigation had up held thatthe service had failed to protect a service user from theprevention of pressure ulcers. There were inconsistent careplans in place to reduce the risks of further damage orpromote healing. Some of these contained instructionsthat were not followed, whilst others did not refer towounds or pressure ulcers even when dressings for woundswere in place.

We asked for, but were not shown a fire risk assessment.One had been completed prior to the opening of theservice but had not been updated. Following ourinspection, we received a copy of the updated fire risk

assessment undertaken on the day after our inspection.Lack of an up-to-date fire risk assessment being carried outand available placed people using the service, staff andvisitors at risk.

People’s records showed that moving and handling riskassessments were not updated and did not contain clearinformation that would inform staff how to appropriatelymove and handle people safely. Lack of appropriate andup-to-date moving and handling risk assessments being inplace and available placed both people using the serviceand staff at risk.

Where risks to people were identified these were notreflected in the care records. As an example, two peoplewere detailed by the manager and staff as requiring inputfor behavioural needs. Some people using the service mayhave behaviour that can be challenging or, at times, placeother service users and staff at risk. Neither person had riskassessments in place to manage the risk to themselves andothers, neither had care plans in place to assist staff toreduce and manage any potential risks. This meant thatpeople living in the service and staff were placed at risk ofpotential harm.

This was a breach of Regulation 12 of the Health,Social Care Act 2008 (Regulated Activities)Regulations 2014 as the provider was failing to ensurethat care, and treatment was provided in a safe way.

We reviewed the records regarding staff recruitment andspoke to staff about their recruitment. We saw that not allstaff were checked prior to their employment as suitable towork in the service. Additionally, not all staff files had arecord of their initial interview and a copy of theirapplication available. This meant that evidence was notavailable to demonstrate that a fair and robust recruitmentprocess had been adopted and used for the recruitment ofstaff.

Two references were not consistently available and thesewere not checked as valid references. The service’s ownpolicy stated that two references are needed; one of whichmust be from the person’s last employer. In at least twofiles we saw that no references from the previous employerwere available. The service had not met it’s own policy andprocedure in making sure staff were safely recruited.

Where staff did have gaps in their working history, thesewere not consistently explored in order to protect peopleliving in the home.




We saw that legally required checks on potentialemployee’s backgrounds had been carried out. Thesebackground checks were carried out by the Disclosure andBarring Service (DBS). These checks help the serviceprovider to make an informed decision about the person’ssuitability to work with vulnerable people. However, wenoted that the organisations own policy on recruitmentsuggested that newly employed staff could start workbefore a full DBS check had been completed and returnedas satisfactory. Such action could place people using theservice and others at risk of unsuitable people beingemployed to work in the service.

The service had a recruitment scoring system that is usedto make sure that staff are recruited fairly andappropriately, however, none of the scores had beencompleted. We saw that these were not used at all forhigher-level recruitment; interview notes were written onthe reverse of other documentation and did not containscoring. The provider stated that these were her notes andshe accepted it was possibly not the best method to ensurethat the most appropriate and skilled staff were recruited.

This was a breach of Regulation 19 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider was not following itsown arrangements to recruit staff safely.

We looked at how many skilled staff were employed in theservice to meet people’s needs. People who lived in theservice told us that there were, “lots” of staff available.Relatives stated that there were always many members ofstaff around. Comments regarding the staffing levels andavailability were positive and people were complementaryas to the kindness and attendance of staff.

We spoke to the manager who informed us that at the timeof our inspection, as the service was new, there was nomeans to determine the number of staff available based onpeople’s assessed needs. The manager also explained thatat present staffing levels were sufficient on a day-to-daybasis. Staff spoken with also confirmed that, in general,they thought that there was sufficient staff available tomeet the needs of people living in the service. They didhowever, express concerns as to poor recruitment ofnursing staff. This meant that the majority of nursing staffavailable were not employed by the service but workedthrough an agency . As such, agency staff were not alwaysfamiliar with the service or the people who lived there. Themanager did explain that they do endeavour to use thesame agency staff in order that they can be familiar withthe service and people living in the service.




Our findingsPeople we spoke with told us that they enjoyed the foodthat was available to them. Relatives told us that theythought there was plenty to eat and that drinks wereavailable.

We looked at how the service supported people to eat anddrink and the arrangements in place to meet people’snutritional needs.

We observed people during the lunchtime period over twodays and saw that support to eat meals was appropriate.Meal times were relaxed and unhurried. All of themealtimes were well organised with people beingsupported to eat appropriately. Staff reported that kitchenstaff assisted them to give out meals in order that theyremained hot. However we did see one example were staffdid not appropriately support a person to have a drink. Weobserved one person to be given a drink whilst the memberof staff stood over them.

Kitchen staff we spoke with explained that all the mealswere prepacked off site. The staff explained that, as aresult, they were unable to fortify food appropriately forpeople losing weight. This limited the kitchens staff’s abilityto provide appropriate diets, and meet peoples needs.

The kitchen staff were able to provide meals that were of athickened consistency for people with swallowingdifficulties, but were unaware of what consistency theywere thickened to or what consistency individual peopleneeded their food thickened to. We observed staff usingthickener in people’s drinks. When we asked whatconsistency the drinks should be we received a variety ofdifferent answers. There was information available in theservice that described the consistency needed but staffwere not following this information. There was nomonitoring arrangements within the service that made surestaff recorded the usage of the thickener at all or that it wasused correctly. This placed people at risk of not receivingtheir food and drink in a safe manner.

Menus had been set by the company that provided thepre-packed food. There was no information available in theservice to highlight what special diets the food was suitablefor and as a result, this information could not be passed onto people living in the service. Additionally, the menus didnot highlight if the food was nutritionally of value. As themeals were individually pre-packed there was no evidence

to demonstrate that people could have larger portions ifthey wanted. This meant that some people may not bereceiving the right level of nutrition they require or couldstill be hungry following their meal.

Records showed that at least five people were onsupplementary drinks. All had fortified diet instructionsfrom nutritionals that were not followed. Although staffwere recording the food offered, they did not always recordthe amount of food the individual person had eaten. Wespoke with nursing staff who did not check the food recordsshowing what was eaten by people in order to monitortheir nutritional intake. The supplementary drinks were notalways recorded on diet or on medication records. As aresult, the service was unaware if people were getting theirsupplementary drinks or not.

Prior to the inspection there were concerns raisedregarding people losing weight. At the time of ourinspection a dietetic assistant visiting the service gavepositive feedback about the response the dieticians hadreceived from Darnton House. We were told by the dieticianthat the staff were responsive to suggestions and wouldfollow up on ideas and instruction.

We saw in the records that where weights of individualswere to be monitored, this was not always done.Assessments to determine the risk of poor nutrition werenot correctly calculated to show the relevant risk or whataction needed to be taken. Care staff we spoke with told usthey did not read care records and therefore, were notalways aware of who was at risk of poor nutritional intake.

One person was listed on an information board as adiabetic who needed insulin. In their care records, it statedthey did not need insulin. We spoke with the staff aboutthis discrepancy and they explained that the person’sneeds varied. There was no information at all within thecare records that would support staff to make sure thatthey suitably assisted the person with the management oftheir diabetes or that the person received a suitablediabetic diet.

Soft diets were available however; the menu choices didnot offer someone on a soft diet two choices and as a resultthe staff made those decisions.

This was a breach of Regulation 14 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not ensure thatpeople’s individual nutritional needs were met.

Is the service effective?



We looked at how staff were inducted to the service. Theinduction was a large list of items, mainly to do withorientation to the service and detailed that this was allcompleted in a single day. In all cases, it was signed by theperson undertaking the induction and the person beinginducted. However, there was no explanation available asto how such a list of items could be covered thoroughly inone day and at a level that would have introduced staffappropriately to the needs of people living in the serviceand how to manage those appropriately. Additionally, theinduction was general and did not take into account thedifferent practices amongst the three floors of the serviceor the differing needs of the people living in the service.Overall, the induction would have orientated the staff tothe building and practices but would have been unable togive staff the specific understanding they would need intheir job role to meet people’s individual needs in the oneday allotted timescale.

There was no evidence of nursing qualifications on nursingstaff files. All nurses are required to register with theNursing and Midwifery Council (NMC) on commencementof their nursing training. At registration, they receive aunique number known as PIN. A PIN is renewed each yearand show that a person is on the register and has paid thefees for the year; they are not evidence of whatqualifications the nurse holds. We saw that PIN numbershad been checked initially but there was no system in placeto check that these were renewed each year. There werelimited training certificates for the majority of staff. Theseveral files we looked at did not contain any evidence ofany training.

We looked at how the service managed the training andcompetency of staff. Staff who gave out medicines had notall received training and their competency assessed. Wesaw one competency assessment for one person, but thisdid not show any observations of the persons practice, orconfirm their knowledge. There had been four staff, up tothe date of the inspection suspended for not giving outmedicines safely.

A review of staff training showed that this was out of date ornot in place. This was particularly noticeable with regardsto the mental capacity act and safeguarding training. Wesaw examples throughout the inspection where staffdemonstrated a lack of understanding of safeguarding andsupporting people with fluctuating mental capacity.

Despite a request, we were unable to locate a training planthat made sure staff were up-to-date with training andwhat training the service considers was essential for therole staff were to undertake.

There was was a supervision policy. However, the majorityo staff had not received any formal supervision since theycommenced employment. Staff told us that they had nothad the opportunity to discuss their views of the servicewith the previous manager, current manager or provider.

This was a breach of Regulation 18 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014. The provider did not have sufficientarrangements in place to ensure that that staff weresuitably qualified, competent and skilled in order tomeet the needs of people living in the service.

Observations during the inspection showed that, whilststaff talked to people in a caring manner anddemonstrated a caring attitude, they were not all able tocommunicate effectively with people who requiredadditional communication input, such as people withdementia care needs. This meant that some people livingwith dementia could become isolated through lack ofinteraction and communication with staff and others.

The Mental Capacity Act 2005 (MCA) provides a legalframework for making particular decisions on behalf ofpeople who may lack the mental capacity to do so forthemselves. The Act requires that, as far as possible, peoplemake their own decisions and are helped to do so whenneeded. When they lack mental capacity to take particulardecisions, any made on their behalf must be in their bestinterests and as least restrictive as possible.

People who lack capacity can only be deprived of theirliberty in order to receive care and treatment when this is intheir best interests and legally authorised under the MCA.The authorisation procedures for this in care homes andhospitals are called the Deprivation of Liberty Safeguards(DoLS).

We checked whether the service was working within theprinciples of the MCA and whether any conditions onauthorisations to deprive a person of their liberty werebeing met.

Mental capacity assessments to determine if somebodyhad fluctuating capacity, and to determine the best timeand way to support them, were not in place. Information




about people’s mental capacity and how to support themto make decisions or give consent was not included inpeople’s care records. The home provided support topeople living with dementia. There was a lack ofappropriate arrangements for supporting people withfluctuating capacity as the service did not havearrangements in place to make sure that people living withdementia had their mental capacity needs met.

We discussed with staff their understanding of how tosupport people who lacked capacity and theirunderstanding of the law to support this, such as, theMental Capacity Act 2005 and its associated codes ofpractice (MCA). Staff members’ understanding wasinconsistent with some staff being able to explain clearlyhow to support people, whilst others demonstrated alimited understanding, particularly in relation to peopleliving with dementia.

We spoke with staff and the manager about who had alasting power of attorney. A lasting power of attorney is alegal arrangement that supports the relatives of people tomake decisions on their behalf. The lasting power ofattorney information and the decisions allowed were notreflected in people’s care records. There were no recordsavailable for this and there was no ability within the serviceto identify if a lasting powers of attorney were in place orwhat legal authorisation a relative may have to act onbehalf of their relative.

We saw on the top floor that Do Not Attempt Resuscitation(DNAR) arrangements in place were not made available tostaff. DNAR from the hospital were in place but these werenot transferable and as such any arrangements that hadbeen in place in the hospital were no longer relevant asthey had not been updated or reviewed as relevant. Wewere unable to find any records of a best interest meetingand capacity assessment prior to the development of DNARby the service. As such, this significant decision had beenmade without making sure that a person’s rights weremaintained.

One person was receiving medicines that are known ascovert. This means the person was not aware that theywere taking them. The service had received an email from adoctor given permission to do this. However, there were norecords that the person did not have capacity, whether abest interest meeting had been held or clear care planningas to what actions staff needed to take prior to giving themedicines. Additionally, there was no information that

where tablets were to be crushed, that this was appropriateto do or what medicines were essential. The policy formedicines available on two floors of the service did detailthe necessary arrangements for covert medicines, but alack of understanding on behalf of the staff regarding theMCA meant that staff were not following the policy.

This was a breach of Regulation 11 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not have suitablearrangements in place for obtaining, and acting inaccordance with, the consent of people who lived inthe home.

We checked whether the service was working within theprinciples of the MCA and whether any conditions onauthorisations to deprive a person of their liberty werebeing met.

The records within the service and discussions with themanager and the provider showed that they were unable toidentify what DoLS authorisations had been applied for,where the authorisations were up to, if the order had beengranted, and if so, for what timescale. As such, the servicewas unlawfully depriving people of their liberty and wasunable to make sure that any authorisations in place werecorrectly monitored. We observed, as an example, that oneperson was supervised constantly by staff due to concernsregarding their ability to manage their behaviour. Therewas no DoLS authorisation in place to restrict the person’sliberty and the service was unable to determine if one hadbeen applied for or granted. As result, the person’s rightshad not been recognised and the potential abuse of thoserights had not been acted on.

This was a breach of Regulation 13 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not ensure thatpeople’s rights were maintained.

We looked at how the service had been adapted to meetthe variety of needs of people living in the service. Theservice is a new service and was built for the purpose ofaccommodating people requiring health and social caresupport. All areas are well decorated and to a highstandard. This presented as an environment that isspacious and modern.

On the days of our inspection we found that the communalareas in some cases may not be suitable for some people




with poor or limited eyesight. This was because all themain corridors had very low lighting. Each floor has a roomthat is designated as the cinema room with a large screentelevision. There were other lounge areas within the servicewhere televisions were available. We saw that these cinemarooms were dark as the lighting was subdued. We sawpeople sitting in both these areas for long periods of time.

The ground floor is designated as used by people withdementia care needs. We saw that this floor did notsupport people with dementia care needs to be asindependent as possible. Each of the doors were all brownand there was no signage that would assist people withdementia or other communication and visual needs tomove around the service independently. Attempts hadbeen made to use “memory boxes” this included photos ina box next to bedroom doors. However, due to the lowlighting, we found these difficult to see and in some casesdid not use imagery that the person would be ablerecognise as relevant to them.

The top floor of the service had a keycode to the door forboth exit and entry. However part of the admittance criteria

for this floor is that people must have capacity. There wasno arrangements in place to give people access to the codeto allow them to come and go freely. This meant people’sliberty was being deprived.

Bedrooms all had the ability to lock independently and akey given to people living in the home who requestedthem. We discussed this with staff, people living in theservice and other stakeholders from the hospital. Therehad not been any arrangements put into place to allowpeople to have their own key to their bedrooms. We saw allbedroom doors for people living in the service wereunlocked regardless of whether the person was spendingthe day elsewhere in the service.

There was an outdoor space available however; thiscontained a large plastic cow that could blow around thegarden on a windy day. The garden area was not adaptedfor the differing needs of people living in the service. Thismeant that people using the service could have their rightto freedom to access the outdoor space restricted.




Our findingsFeedback from people about the attitude and nature ofstaff was positive. Some people spoke positively about thecare provided by staff. Comments included, “flawless”, “Sokind and caring, I wish [name of person] could stay here allthe time. It’s lovely.”

We saw information on advocacy services was notdisplayed. The only information we saw on display was anotice to visitors that meals were for people living in theservice. None of the people we spoke with were aware ofwhat advocacy services were available. As some peoplelacked capacity and there were no clear arrangements inplace to show who could legally act on their behalf. Thearrangements for advocacy were not able to meet people’sindividual needs.

We used the Short Observational Framework for Inspection(SOFI) on the first day of the inspection over lunchtime.SOFI is a way of observing care to help us understand theexperience of people who could not talk with us. We didsee however that some staffs communication methodswith people living with dementia or sensory impairmentdid not meet their needs.

One person who was deaf and not wearing hearing aids,was repeatedly asked the same question by a staffmember. It had to be highlighted to this staff member bythe inspectors, that the person required communicationaids. One person who had been assessed as needingglasses was not wearing their glasses. Another person waswearing glasses that were dirty and had been broken, theywere taped at arms and they did not fit properly. A furtherperson had records stating that they needed glasses to seebut were not wearing their glasses. We spoke to staffregarding the support to people with sensory impairment,but they were not aware of what aids people needed.

We saw no evidence that people were able to participate inactivities during our inspection visit. Three people wespoke with told us there was very little to occupy them andthey had very little to do during the day. People using theservice lacked opportunities to participate in activities thatwould encourage their independence and reduce thepossibility of social isolation. Care plans did not identifyactivities that people may have been involved with whenliving at home or activities that people may have aninterest in participating in whilst living in Darnton House.

There was no information within the service, that was in aformat suitable for people living with dementia regardingchoices, as observed over meal times. No information inthe service that was available in different formats such aslarge print to meet individual needs.

This was a breach of Regulation 9 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not ensure thatcare and support was provided in a way that wasdesigned to meet people’s preferences.

On the Transitional Care Unit (TCU) we saw thatconfidential records were left on view in people’s bedroomsas medical staff had wished to review these and did notwant to not disturb nursing staff in their duties. The recordshad been removed from a locked space thereforebreaching people’s confidentiality.

We looked at arrangements in place for supporting peopleat the end of life. We saw that the needs of people receivingend of life care were not recorded and kept under review. Insome examples, there was no care plan in place for theperson’s end of life needs and wishes, or arrangements toensure that the person’s preferences were kept underreview and acted on.

Although the service did undertake end of life care., recordsshowed that most of the staff had not received training inthis area. Staff we spoke with were confident that theycould support an individual appropriately with any carethey needed at the end of their life. We reviewed recordsavailable within the service and this showed that there wasno discussion with people around their wishes at the endof their lives or what advanced decisions they would like tomake.

We looked at how the service supported the dignity ofpeople living in the service. All the people we spoke withhad appropriate clothing on and looked well presented.Observations showed us that people were addressedappropriately and treated with dignity. We saw and heardstaff and people using the service enjoying chatting andlaughing about different things. This indicated that peopleusing the service felt comfortable with the staff on duty.

Care, when delivered, was undertaken behind closed doorsin order to preserve people’s dignity and staff knocked ondoors before entering.

Is the service caring?



Our findingsPeople living in the home told us that they had limited orno input into deciding on the activities or meals available.One person told us, “Nobody has ever asked me what timeI would like to go to bed or when I would like my meals.However, if I don’t want to eat at a certain time they willkeep it for me to have later.” People spoken with reportedthat their visitors were welcomed into the service. On erelative told us that they always felt welcomed and wereoffered a cup of tea and a meal if they visited duringmealtimes.

The menu available in the home did show a choice of food.The manager and kitchen staff confirmed that as yetpeople had not been asked about what they would like tosee on the menu. Kitchen staff told us that meal times, andwhen lighter meals were to be given, were changed withoutconsultation with the people living in the service.

There was no information available regarding activities andno activities were observed during the two days of ourinspection. Feedback from people confirmed that therewas not enough for them to do and we observed there waslimited stimulation for people.

We spoke with people living in the home about how thehome supported their cultural needs. Care records vieweddid not highlight people’s religion or if they required anysupport to have their cultural needs met. We spoke topeople about their preferences to have their personal careneeds met by staff of the same sex. None of the people wespoke with could recall being asked what their preferenceswere.

There were two types of records in use across the home;records on the first two floors were complex and large andcontained information that quickly went out of date and insome cases, had not been updated correctly. The recordson the top floor gave very limited information and did notinform staff how to support people. None of the carerecords and assessments we viewed had been undertakenwith the involvement of the person or their representative.None were signed by the person or their representatives.Staff confirmed that although they did involve people inthe assessment process they did not get them to check theinformation once completed and confirm its accuracy.

We did see a history of a person that included familyphotographs and stories about the person. However, this

had been undertaken by the Speech and Language Team(SALT) and was not part of the service’s own systems. Thecare records we viewed prepared by the service containedminimal information about who the person was, what theirpreferences were, their cultural needs or how they wishedto live their lives. The records and plans centred on thepersons physical needs but little or no information wasincluded on their social needs. We saw that there was verylittle or no information available in people care recordsthat would assist staff to help people make choices. Weasked for information that showed us how people whowere less able to vocalise a choice, such as food oractivities, were supported to take into account theirpersonal preferences. The manager and staff told us thatno information was available. Staff told us that they oftenmade choices for people living in the service. We did seethat one person preferred a no meat diet and this wassupplied to them.

We looked at how the service responded to people’s healthcare needs and made sure that they received care that mettheir needs. We reviewed six care plans in total. None ofwhich were person centred, with the same generic plansavailable for different people such as how to support ahygiene need. Care plans were “task and medicalcondition” orientated and not person orientated. People’sindividual needs were not recorded in plans, for exampleone person had behavioural concerns and these were notrecorded in their care plan. There was no informationavailable to staff that told them how to respond when thisperson became upset or distressed.

Nursing staff on the top floor informed us that they hadbeen directed to make sure that they gave medicines outbetween 8 am and 10 am regardless of the individualroutine of the individual.

We spoke with health care professionals who visited theservice. They told us that they thought staff did their bestbut needed further development to respond to people’sindividual needs.

This was a breach of Regulation 9 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not have suitablearrangements in place to make sure that peoplereceived care and treatment that met their needs,reflected their preferences and was appropriate.

Is the service responsive?



The complaints policy and the means to raise concerns wasnot on open display in the service. We were informed that itwas in the information given to people when they wereadmitted to the service. We checked peoples bedroomsand spoke to people living in the service, but we wereunable to locate the information.

The manager provided a copy of the service’s complaintspolicy. The policy did not allow a complaint to pass directlyto the provider and it also implied that complaints can bemade directly to the Care Quality Commission (CQC) andsocial services directly for investigation. The policy did notmake any provision for people, their relatives or staff toraise concerns anonymously should this be appropriate.

At this inspection, we asked to see how complaints werebeing progressed and what any investigations hadrevealed. There were no investigation records available andthe registered manager explained that they unaware ofhow many complaints they had received. They initially toldus that there was one complaint and produced a record

that did not show a full investigation or response to thecomplainant. On reviewing records and after discussionswith staff, there were a number of complaints that hadbeen made. We were eventually provided with threedifferent figures as to how many complaints had beenmade. The service was unable to make sure that they wereaware of what complaints had been made and to addressboth the satisfaction of the complainant and to make surethat lessons were learnt.

Prior to the inspection, the CQC had been approached byfamily members and whistleblowers raising concerns thathad not been addressed or actioned by the service.

This was a breach of Regulation 16 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not have aneffective system to ensure that they recognised,investigated and responded to complaints in a timelymanner.

Is the service responsive?



Our findingsThe culture of the service was not based on the needs ofthe people who lived in the home but was task orientated.This could be seen by the routines in place in the servicethat were not flexible to meet people’s needs, the lack ofchoices available to people, care that did not meetpeople’s needs and care that was not appropriatelyplanned.

A manager was in place on the date of the inspection butthey were not registered with the Care Quality Commission.A registered manager is a person who has registered withthe Care Quality Commission to manage the service. Likeregistered providers, they are ‘registered persons’.Registered persons have legal responsibility for meetingthe requirements in the Health and Social Care Act 2008and associated Regulations about how the service is run.

The provider did not have a formal system to assess andmonitor the quality of care provided to people or tomanage risks of unsafe or inappropriate treatment. Therewas some evidence of recent quality monitoring ofmedication and an audit had been completed by theservice. This audit had identified some of the gaps inpractice identified at this inspection, however, this had notbeen shared with the staff to improve their practice or anaction plan in place to bring about improvements.

We found that the service was not aware of how manyincidents of suspected abuse were being investigated, howmany complaints they had received or how mayapplications for Deprivation of Liberty Safeguards (DoLS)had been authorised. The systems in place were notsufficient to ensure the delivery of high quality care. Duringthe inspection we identified failings in a number of areas;these included medication, meeting people’s choices,stimulating activities for people who lived in the service,recognising risk, care and welfare, dealing with complaints,identifying and managing safeguarding and staff training.

A care plan audit had been undertaken; however, carerecords did not record people’s needs and plans of how tomeet those needs accurately. Staff said they did not readcare records and records did not reflect needs. We foundseveral instances of care not meeting people’s needs.These issues could have been identified through a formalsystem to assess and monitor the quality of care if one had

been in place. At the inspection, we identified four peoplewhose care needs had not been fully met and requiredinvestigation as part of a potential neglect concern. Theservices systems had failed to recognise concerns or actionthem appropriately.

Where issues or improvements had been identified, we sawappropriate action had not always been taken to addressthem. For example, unexplained bruising on a person hadnot been investigated and complaints had not beenaddressed.

Policies and procedures were not all specific to the service.Policies were inconsistent with different practices inoperation within the service, such as different processes onthe top floor for medicines as examples without policies inplace for these practices. Several of the policies we viewedwere out of date, having been purchased from a privatecompany in advance of the service opening. These policieswere without consistency for subject, content, review andimplementation. The policies in place did not reflect thepractice in the service and as such, did not guide staff tomake sure they had a consistent approach in their job role.

Risks to people’s health, safety and welfare were notappropriately reported, managed and analysed. Forexample, we found accidents or injuries that were recordedin people’s care records and accident records. These hadnot been analysed or actions taken to determine the causeand prevent them from reoccurring. We saw that peoplescare records such as diets, medications, behavioural needswere not reviewed and changes to care highlighted in orderto improve people’s care experiences.

People who lived in the home and the staff had not had theopportunity to give their views and opinions of the careprovided or any input for improvement.

We asked to see a copy of the audits that the providerundertook in the service. We were informed by the providerthat they did not undertake audits, however, they hadrecognised the need to do so and had plans in place toaddress this in the future.

This was a breach of Regulation 17 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not have suitablearrangements to assess and improve the quality of theservice provided.

Is the service well-led?



The table below shows where legal requirements were not being met and we have asked the provider to send us a reportthat says what action they are going to take. We did not take formal enforcement action at this stage. We will check thatthis action is taken by the provider.

Regulated activityAccommodation for persons who require nursing orpersonal care

Treatment of disease, disorder or injury

Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment

The service did not have an effective system in placethat recognised potential abuse or took appropriateaction taken when concerns were identified.

Regulation 13 (1) (2) & (3).



Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

The provider was failing to ensure that service usersreceived care, and treatment that was provided in asafe way.

Regulation 12 (1) (2) (a) & (b).



Regulation 19 HSCA (RA) Regulations 2014 Fit and properpersons employed

The provider was not following its own arrangementsto recruit staff safely.

Regulation 19 (2) & (3) (a).



Regulation 14 HSCA (RA) Regulations 2014 Meetingnutritional and hydration needs

Regulation

Regulation

Regulation

Regulation

This section is primarily information for the provider

Action we have told the provider to take


The provider did not ensure that people’s individualnutritional needs were met.

Regulation 14 (4) (a).



Regulation 18 HSCA (RA) Regulations 2014 Staffing

The provider did not have sufficient arrangements inplace to ensure that that staff were suitably qualified,competent and skilled in order to meet the needs ofpeople living in the service.

Regulation 18 (1) (2) (a).



Regulation 11 HSCA (RA) Regulations 2014 Need forconsent

The provider did not have suitable arrangements inplace for obtaining, and acting in accordance with,the consent of people who lived in the home.

Regulation 11 (1)



Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment

This was a breach of Regulation 13 of the Health andSocial Care Act 2008 (Regulated Activities)Regulations 2014 as the provider did not ensure thatpeople’s rights were maintained.

Regulation 13 (1) (5)

Regulation

Regulation

Regulation






Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

The provider did not ensure that care and supportwas provided in a way that was designed to meetpeople’s preferences.

Regulation 9 (1) (c)



Regulation 9 HSCA (RA) Regulations 2014 Person-centredcare

The provider did not have suitable arrangements inplace to make sure that people received care andtreatment that met their needs, reflected theirpreferences and was appropriate.

Regulation 9 (1) (a) (b) (c)



Regulation 16 HSCA (RA) Regulations 2014 Receiving andacting on complaints

The provider did not have an effective system toensure that they recognised, investigated andresponded to complaints in a timely manner.

Regulation 16 (1) (2)



Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation

Regulation

Regulation

Regulation




The provider did not have suitable arrangements toassess and improve the quality of the serviceprovided.

Regulation 17 (1) (2) (a)




Documents

LondonandManchesterHealthcare(Darnton)Ltd ... · 1 Darnton House Nursing Home Inspection report 12/02/2016. upto32peoplewhoaremedicallyfitandtransitioning backintothecommunityforcareandsupportasneeded