Solent Grange Nursing Home CQC Report

Ratings

Overall rating for this service Inadequate Is the service safe? Inadequate Is the service effective? Inadequate Is the service caring? Requires Improvement Is the service responsive? Inadequate Is the service well-led? Inadequate

Overall summaryThis inspection took place on 17 and 18 March 2015 andwas unannounced. The service provides accommodationfor up to 76 people who have nursing and/or dementiacare needs. There were 39 people living at the servicewhen we visited. The service is split into three areas.Sunflower and Daffodil units provided a mix of nursingand dementia care; Bluebell unit providesaccommodation and care for people living withdementia. People lived in each of the units and were ableto move freely between them, but spent most of theirtime in their own areas. Staff were allocated to, andgenerally worked on a specific unit.

The service did not have a registered manager in place.However, the current manager had applied to becomeregistered with CQC. A registered manager is a personwho has registered with the Care Quality Commission tomanage the service. Like registered providers, they areregistered persons. Registered persons have legalresponsibility for meeting the requirements in the Healthand Social Care Act 2008 and associated regulationsabout how the service is run. The lack of a registeredmanager has been shown to have a detrimental impacton people using the service.

London Residential Healthcare LimitedSolentSolent GrGrangangee NurNursingsing HomeHomeInspection reportStaplers RoadWoottonIsle of WightPO33 4RWTel: 01983 882382Website: www.lrh-homes.com

Date of inspection visit: 17 and 18 March 2015Date of publication: 26/06/2015

1 Solent Grange Nursing Home Inspection report 26/06/2015

At the last inspection on 9 and 13 October 2014, weidentified breaches of Regulations 9, 10, 11, 12, 13, 14, 17,18, 20, 21 and 22 of the Health and Social Care Act 2008(Regulated Activities) Regulations 2010. We tookenforcement action to prevent the provider fromadmitting new people to the service until 26 April 2015.The provider sent us an action plan on 23 February 2015stating they were now meeting the requirements of theregulations.At this inspection we found monitoring systems were notalways effective in identifying areas for improvement andaudits of care plans had not been started. As a result,peoples safety was compromised.Incidents that caused harm to people were not alwaysreported to the manager and were not investigatedappropriately. Dangerous substances were found in anarea accessible to people. Procedures were alsoinadequate to ensure the security of the building.Emergency procedures were inadequate to ensurepeoples safety. The risks of people choking were notmanaged safely and, if people choked or aspirated onfluids, emergency equipment was not immediatelyavailable. The fire evacuation register was not up to date.People were not occupying the rooms specified, whichcould compromise their safety if they had to beevacuated in an emergency.Bruising or other injuries had occurred which had notbeen reported to the local safeguarding team. There wasinadequate evidence that all of these had beeninvestigated appropriately within the home to preventfuture incidents. People did not always receive the healthand personal care they required and had developedavoidable skin damage. Action was not always takenwhen routine observations indicated a need to seekmedical advice and the providers policies for monitoringpeople who had suffered head injuries were not alwaysfollowed.Care plans were not always representative of peoplescurrent needs and although some contained a lot ofindividual detail others did not have all necessaryinformation or had conflicting information. Where careplans had been reviewed, this did not necessarily meanthe information in them had been updated.There were appropriate arrangements in place for thesafe handling, storage and disposal of medicines and

most people received their medicines as prescribed.Records for the administration of topical creams andointments were not always completed and did not alwayscontain information about where they should be applied.Pain assessments and as and when necessary (prn) careplans did not contain sufficient detail for people whowere unable to state they were in pain.Staff did not always follow legislation designed to protectpeoples rights. Although staff showed someunderstanding of the legislation and people were askedfor their consent before care or treatment was given, carerecords demonstrated that staff did not understand howto make decisions on behalf of people who lackedcapacity.We found the provider had made improvements to staffrecruitment procedures, training, staff support and toinfection control procedures.People were encouraged to eat well and were positiveabout the meals provided but they did not always receivethe support or supervision they needed to ensure theirsafety when eating.People were cared for with kindness and compassion andcould make choices about how and where they spenttheir time. When staff provided support for people tomove from one position or location to another, theyexplained what they were going to do and checkedpeople were ready to move. Peoples preferences, likesand dislikes were recorded and known to staff. Supportwas provided in accordance with peoples wishes.Staffing levels, including those of the nursing staff, weredetermined using a formal staffing tool however therewere not always enough staff on duty. Staff recruitmentprocedures were safe and ensured staff were suitable fortheir role. Staff received training and were supported bysenior staff.Appropriate arrangements had been put in place tomanage infection control risks and staff demonstrated agood understanding of infection control procedures.Although information about the complaints procedurewas not available to all visitors, people and visitors wereable to make a complaint. These were investigated andwhere necessary action taken to prevent recurrence ofthe issue.

Summary of findings


People and relatives were able to express their viewsthrough meetings with senior managers and theproviders representative, and surveys of people and theirrelatives. A range of group and individual activities wereprovided.

We found a number of breaches of the Health and SocialCare Act 2008 (Regulated Activities) Regulations 2010.This corresponds to breaches of the health and SocialCare Act 2008 (Regulated Activities) Regulations 2014. Youcan see what action we have taken at the back of the fullversion of the report.

Summary of findings


The five questions we ask about services and what we foundWe always ask the following five questions of services.Is the service safe?The service was not safe.Procedures had not ensured that all risks, such as the risk of choking, weremanaged effectively. Emergency medical equipment was not immediatelyavailable and emergency information was out of date.Incidents of unexplained bruising, skin injuries and falls had not always beenreported to the manager and investigated, meaning action was not taken toprevent further incidents.Medicines were stored securely and most were administered safely and asprescribed. However, topical creams were not applied as directed and therewas inadequate guidance for staff to determine when as required medicinesmay be required.There were not always enough skilled and experienced staff to meet peoplesneeds. The recruitment process was safe and ensured staff were suitable fortheir role.People were protected against the risk and spread of infection.

Inadequate

Is the service effective?The service was not effectiveLegislation designed to protect peoples rights was not correctly applied wherepeople lacked the capacity to make decisions themselves. The Deprivation ofLiberties Safeguards (DoLS) had been applied for however, despite training,staff were not aware of people who had had restrictions placed on their libertyto keep them safe.People did not always receive the correct healthcare and health monitoringthey required. Action was not always taken to monitor peoples conditionswhen observations indicated a new health need.People were offered a choice of nutritious meals and most receivedappropriate support to eat and drink.Staff were suitably trained and received appropriate support from themanager.

Inadequate

Is the service caring?The service was not always caring.Care practises did not always ensure peoples dignity. Peoples privacy wasusually protected and confidential information was kept securely.People were cared for with kindness and treated with consideration.

Requires Improvement

Summary of findings


People were supported to express their views and actively involved in makingdecisions about their care, treatment and support. Peoples preferences, likesand dislikes were recorded and known to staff.

Is the service responsive?The service was not responsive.Care plans had not always been updated following changes in the personsneeds and therefore did not always reflect peoples current health andpersonal care needs.People did not always receive the correct healthcare and health monitoringthey required. Action was not always taken following falls or when routineobservations had indicated a concern. People had developed skin damagewhich may have been avoidable.People and visitors were able to make complaints. These wereinvestigated and, where necessary, action taken to prevent recurrence of theIssue.People and relatives were able to express their views through meetings withsenior managers and the providers representative, and surveys of people andtheir relatives. A range of group and individual activities was provided.

Inadequate

Is the service well-led?The service was not well led.The monitoring systems were not always effective. Concerns we had identifiedin our previous inspection report, in relation to the safety and effectiveness ofthe service had not been addressed.Incidents that caused harm to people were not always reported to themanager or investigated appropriately. Dangerous substances were found inareas accessible to people. Procedures to ensure the security of the buildingwere not adequate.People, relatives and staff praised the manager and said the home was runwell. Feedback from people and staff was sought and the information used toimprove the home.

Inadequate

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 17 and 18 March 2015 andwas unannounced. The inspection team consisted of threeadult social care inspectors and a specialist advisor in thecare of older people.Before the inspection we reviewed information we heldabout the service including previous inspection reports and

notifications. A notification is information about importantevents which the service is required to send us by law. Wealso gathered information from Isle of Wight Council AdultCommissioning Unit.We spoke with five people using the service and 8 familymembers. We also spoke with the providers OperationsSupport Manager, the manager, the deputy manager, threenurses, 10 care staff, two activity coordinators, twohousekeeping staff and the cook. We looked at care plansand associated records for 16 people, staff duty records,three recruitment files, records of complaints, accidentsand incidents, policies and procedures and qualityassurance records. We observed care and support beingdelivered in communal areas. We used the ShortObservational Framework for Inspection (SOFI). SOFI is away of observing care to help us understand the experienceof people who could not talk with us.

SolentSolent GrGrangangee NurNursingsing HomeHomeDetailed findings


Our findingsAt our last inspection on 9 and 13 October 2014, we foundthe service was in breach of regulations. The provider didnot notify the safeguarding authority of incidents ofunexplained bruising. Risks of people falling or choking ontheir food were not managed safely, nor wereenvironmental risks. There was not always enough staff.Pre-employment checks and processes were not robust.The obtaining, administering and recording of medicineswere not always safe. Guidance on the prevention andcontrol of infections was not followed and the risks of crossinfection were not managed effectively. We tookenforcement action to prevent the provider from admittingnew people to the service until 26 April 2015. The providersent us an action plan on 23 February 2015 stating theywere meeting the requirements of the regulations.At this inspection, we found the provider had madeimprovements. However, peoples safety was stillcompromised in several areas.Where people had been assessed by specialists as being atrisk of choking on their food or drinks, they did not alwaysreceive the care and support they required. The specialistadvice for one person stated use a teaspoon do not use astraw or spouted beaker. We saw care staff giving theperson a drink from a plastic beaker with a spout. Theperson was not sitting upright and started to cough as soonas sips were taken. The care staff told us everyone doesthis, none of us knew (that they should not use the spoutedbeaker). For another person we saw the specialist advicewas not followed and they were coughing in response toattempts to eat. Three people had been assessed byspecialists as being at risk of choking on their food ordrinks and needed full support from staff to prevent this.However, we saw these people eating independently intheir bedrooms without support or supervision. Peoplewere at risk of choking and were not receiving the care theyrequired to minimise this risk.If people choked or aspirated on fluids, emergencyequipment was not immediately available. In one bedroomcontaining emergency suction equipment there were nosuction tubes present. These are essential to enableemergency suction to occur. We asked nursing staff wherethe tubes were. It took fifteen minutes before these couldbe located. In an emergency this would have been toolong.

The risks of people falling were not managed effectively.Records showed some people had had repeated falls. Riskassessments and care plans had been reviewedand people had been referred to falls clinics. However,additional measures had not always been followed toprevent further falls. One person had had several falls in theweek preceding our inspection. Their care plan specifiedthe need for protective mats to be in place next to theirbed, in case they fell out of bed, and for an alarm mat to bein place to alert staff if the person moved about. We sawthey were asleep on their bed without this equipment inplace. Their care plan stated staff need to supervise meand ensure I am safe. We saw the person moving aboutunsupervised and records of a recent fall recorded thatstaff found the person on the floor.The above issues are a breach of Regulation 9 of the Healthand Social Care Act 2008 (Regulated Activities) Regulations2010. This corresponds to Regulation 12 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.We identified instances when bruising or other injuries hadoccurred which had not been fully investigated or actiontaken to reduce the risk of future injuries. One personsuffered three injuries within 48 hours. The person was notmobile and the cause of the injury had not beeninvestigated. Care records detailed unexplained bruising onanother person, again there had been no investigation todetermine the cause of the injuries. The failure to takeaction when people had unexplained injuries meantpeople remained at risk of further injury.The above issues are a breach of Regulation 11 of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2010. This corresponds to Regulation 13 of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014.Personal evacuation plans were not all accurate in respectof the support individual people would need if they had tobe evacuated. The fire evacuation register was not up todate as four people were not occupying the roomsspecified, which could compromise their safety if they hadto be evacuated in an emergency. Emergency informationheld at the front entrance was also not up to date andlisted people who were no longer living at the home. Thiswould mean emergency services would be looking forpeople who were not present or in the rooms specified.

Is the service safe?

Inadequate


The above issues are a breach of Regulation 9 of the Healthand Social Care Act 2008 (Regulated Activities) Regulations2010. This corresponds to Regulation 17 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.Medicines were not always managed correctly. TheMedication Administration Records (MAR) charts showedthat one medicine prescribed to several people, whichshould be given half an hour before food, was often givenwith or after food, so may not have been effective. Recordsfor the administration of topical creams and ointmentswere not always completed and did not always containinformation about where they should be applied. Arecognised pain assessment tool was used for some peoplesome of the time. Pain assessments and as and whennecessary (prn) protocols did not contain sufficient detailto inform staff where people would be unable to state thatthey were in pain. One stated staff should observe fornon-verbal communication such as facial expression butdid not say what the facial expressions were or what theymay mean. People therefore could have been in painwithout staff being aware, and may not have received thecomfort and pain relief required.The above issues are a breach of Regulation 13 of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2010. This corresponds to Regulation 12 of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014.People and relatives told us staff usually respondedpromptly. However, one relative said that at lunch timethey could do with more staff as it seems to get busy then.If someone needs the toilet, or food in a room, then foodcan get cold. On one unit staff seemed to have little time tospend with individuals and as a consequence theinteractions tended to be task orientated and eventfocused. This meant, at times, the staff had to hurry fromone person to the next and back again. Staff said to peopleIll be back in a minute but it was several minutes beforethey were able to return. One staff member said to be

honest with you, we are short of staff, which meanssometimes we have to rush and none of the staff here wantto do that. Other staff expressed similar views. Staff told usif staff reported sick at short notice this could not always becovered. This situation occurred on the first day of ourinspection in one unit. This meant that some people didnot receive their morning personal care until almost lunchtime and staff did not have time to provide activities ormental stimulation. Staffing levels, including that of thenursing staff, were determined using a formal staffing toolby the manager who stated the home had adequatenumbers of staff employed although on occasions theymay have been short of staff.Records showed the process used to recruit staff was safeand helped to ensure staff were suitable for their role.Interviews included relevant questions to assess theapplicants knowledge and attitudes. Relevant checks werecompleted to make sure staff were of good character withthe relevant skills and experience needed to supportpeople appropriately. Staff confirmed this process wasfollowed before they started working at the home.Appropriate arrangements had been put in place tomanage infection control risks. The providers policy wasappropriate and up to date. It was supported by infectioncontrol risk assessments and cleaning schedules whichdetailed how each area of the home should be cleaned.Check sheets confirmed all cleaning had been completedas planned. An annual statement of infection control hadbeen completed, together with a recent audit whichshowed procedures were working effectively.Staff demonstrated a good understanding of infectioncontrol procedures. All had received training in infectioncontrol and had ready access to personal protectiveequipment (PPE), such as disposable gloves and aprons.They used this when appropriate and followed bestpractice guidance when handling soiled linen. Clinicalwaste was stored safely and disposed of by an approvedcontractor.

Is the service safe?

Inadequate


Our findingsAt our last inspection on 9 and 13 October 2014, we foundthe service was in breach of regulations. Mental capacityassessments were not completed and decisions made onbehalf of people were not made in accordance withlegislation. Care staff did not have an understanding ofDeprivation of Liberty Safeguards and did not know whichpeople they applied to. People were not supported to eatand drink enough and action was not always taken whenpeople lost weight. Staff had not completed all essentialtraining and there was no system in place to help identifytheir development needs. We took enforcement action toprevent the provider from admitting new people to theservice until 26 April 2015. The provider sent us an actionplan on 23 February 2015 stating they were meeting therequirements of the regulations.At this inspection we found peoples nutritional needs werebeing met and staff had received all necessary training.However, staff were not following the principles of theMental Capacity Act, 2005 (MCA).The MCA provides the legal framework to assess peoplescapacity to make certain decisions, at a certain time. Whenpeople are assessed as not having the capacity to make adecision, a best interest decision should be made involvingpeople who know the person well and other professionals,where relevant.Care records demonstrated that staff did not understandhow to make decisions on behalf of people who lackedcapacity, such as those living with advanced dementia. Therelatives of five people had signed their consent for theperson to receive the care and treatment that staff hadplanned. However, the relatives did not have the legal rightto make such decisions. For five other people, staff hadmade best interest decisions for people without having firstassessed the persons mental capacity. One of these peoplewas being given medicines hidden in their food withouttheir knowledge. Peoples rights, therefore, may have beencompromised.The Deprivation of Liberty Safeguards (DoLS) protect therights of people using services by ensuring if there are anyrestrictions to their freedom and liberty, these have beenauthorised by the local authority as being required toprotect the person from harm. No one was subject to aDoLS however these had been applied for in respect of

three people and were waiting assessment. One staffmember said they thought everyone was on a DoLS, its adementia floor. People were at risk of not having their legalrights upheld as staff were unaware of if and whorestrictions could legally be applied to.People received healthcare from the trained nurses. Thisincluded wound dressings, blood sugar monitoring andinsulin injections. However, records did not always showthat action had been taken when routine observationsidentified a concern. One person, who had a history ofstroke, had a recorded monthly blood pressure readingwhich was significantly higher than previous recordings.Another persons care plan stated that blood pressureshould be checked before and after administration of amedicine which could significantly affect blood pressure.This had not occurred and no action had been taken todiscuss this with the GP. This placed the person at risk offurther health problems. In other situations, where peoplehad seen specialists, such as speech and languagetherapists, records showed guidance was not alwaysfollowed. One persons care plan stated they should havehand splints for a medical condition. These were not beingused and there was no indication why they were not beingused or what action was being taken to ensure the personshands were being protected from further deformity. Thismeant people may not have their medical needs met.Staff monitored the food and fluid intakes of people at riskof malnutrition or dehydration. However, there were notarget fluid intakes for individual people recorded on careplans or fluid charts. This meant staff may not have knownhow much individual people should have to drink. Dailyintake was not always totalled up, meaning staff may nothave recognised when people were having insufficientfluids. Guidance for staff within care plans was vaguestating, for example, give fortified drinks and pureed diet.The above issues are a breach of Regulation 9 of the Healthand Social Care Act 2008 (Regulated Activities) Regulations2010. This corresponds to Regulation 9 of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2014.People praised the quality of the food, which they said hadimproved. One person said, The food is better and looksbetter. Another person told us, The food is good and you

Is the service effective?

Inadequate


always get a choice. People were offered varied andnutritious meals including a choice of fresh food and drink.Kitchen staff were aware of people who needed their mealsprepared in a certain way or fortified.People were encouraged to eat well and staff. When peopledid not eat their meals, staff tempted them withalternatives, such as sandwiches or fresh fruit and gavepeople time to eat at their own pace. The manager hadrecently started monitoring peoples meal timeexperiences. They had identified how this could beenhanced and had made changes, including ensuringmore staff were available to support people.A programme of induction training was completed by allnew staff. In addition, new staff shadowed experienced

staff by working alongside them until they were confidentin their role. Training records showed staff had completedall essential training required by the provider. Staff trainingwas provided in a variety of formats, including face to faceand by viewing DVDs. The DVDs included a knowledgecheck at the end of the training which checked staff hadgained the necessary knowledge. New staff were positiveabout their induction and other staff said ongoing andrefresher training had been of value.Staff received appropriate support through the use ofone-to-one sessions of supervision and appraisals. Theseprovided opportunities for them to discuss theirperformance, development and training needs.

Is the service effective?

Inadequate


Our findingsAt our last inspection on 9 and 13 October 2014, we foundthe service was in breach of regulations. Staff did notalways treat people with dignity and respect. People werenot always involved in planning their care. We tookenforcement action to prevent the provider from admittingnew people to the service until 26 April 2015. The providersent us an action plan on 23 February 2015 stating theywere meeting the requirements of the regulations.At this inspection, we observed several occasions whenstaff shouted to each other down corridors. This was to dowith their work programmes such as have you done(persons name) yet and did (persons name) eat much.This was in an area open to visitors and others accessinganother service run from the same building and meantpeoples dignity and confidentiality was compromised.One persons dignity was not protected when they werebrought into a lounge wearing clothing which did notconceal the leg drainage bag from their urinary catheter. Onother occasions we saw a portable dignity screen was usedwhen people were transferred by a hoist betweenwheelchairs and lounge chairs. This ensured their dignitywould be maintained if, for example, their clothing becamedislodged in the process. Peoples privacy was protected bystaff knocking on peoples doors before entering andensuring doors were closed when they delivered personalcare. Confidential information, such as care plans werekept securely and only accessed by staff entitled to view it.We found people were cared for with kindness andcompassion and could make choices about how and wherethey spent their time. One person told us Things areimproved. They treat me better now, on the whole.Another person described staff as marvellous. A familymember of a person said, Ive never seen [the person] sohappy. Staff are very kind and caring. Comments made inresponse to a recent survey conducted by the providerwere positive and showed staff were caring. One said: Thestaff are always cheerful and nothing is too much trouble.Great care is taken when seeing to residents who areunable to see to themselves.When staff provided support for people to move from oneposition or location to another, they explained what theywere going to do and checked people were ready to move.

Where people were not able to respond verbally toquestions, staff observed their reactions to assess whetherthe person understood and was ready to receive thesupport offered. For example, one person was gentlywoken and invited to visit the hairdresser. They were tiredand showed no interest in moving, so staff left them tosleep. Later, when the person was more alert, staff againoffered them opportunity to go to the hairdresser. A familymember said of the staff, They always take time to ensure[the person] makes choices by constantly talking to[them].Comments in care plans showed people and relatives wereinvolved in planning the care people would receive andthat family members were kept up to date with anychanges in their relatives needs. Two people in the BluebellUnit, who were living with dementia, had no one close tothem to speak on their behalf. Lay advocates had not beenappointed to support them, although the manager told usthey were planning to arrange this.Peoples preferences, likes and dislikes were recorded andknown to staff. Records showed support was provided inaccordance with peoples wishes. People chose when toget up and go to bed and records confirmed their wisheswere respected. One person said, I chose to have a lie intoday, so did. We found people (or their families whereappropriate) had been involved in decisions relating to endof life care and resuscitation. We heard people being askedfor their consent before care or treatment was given.Staff communicated effectively with the people they weresupporting and treated people with warmth and interest.They knew the people they were caring for well and wereable to deliver care in the way the person preferred. Forexample, when a GP had prescribed tablets for a person,staff requested the prescription was changed to a liquidform of the medicine, which the person preferred. Weobserved positive interactions between staff and people.For example, when a staff member helped one person puttheir socks on and gave another person a cup of tea, theyspent time chatting and engaging with them. When peoplebecame upset or anxious, staff offered comfort and supportby speaking kindly and using touch appropriately. In one ofthe lounges we heard staff asking people where theywanted to sit, whether they wanted the radio on and gavethem a choice of drinks. A member of staff told us, Welaugh and joke and it makes for a happy atmosphere.

Is the service caring?

Requires Improvement


Our findingsAt our last inspection on 9 and 13 October 2014, we foundthe service was in breach of regulations. There was a lack ofactivity provision, care plans did not contain enoughinformation or were not up to date and neurologicalobservations were not always conducted when peoplesustained head injuries. The provider did not always takeaccount of complaints to make improvements to theservice. Records did not show people had received the carethey needed. We took enforcement action to prevent theprovider from admitting new people to the service until 26April 2015. The provider sent us an action plan on 23February 2015 stating they were meeting the requirementsof the regulations.At this inspection we found more activities were provided,care plans had been developed, record keeping hadimproved and complaints were used effectively. However,care plans were not always reviewed in line with theproviders procedures and did not always reflect peoplescurrent needs.People were not always adequately monitored in situationswhere their health may change such as following a fall. Fullneurological observations were not conducted when twopeople had a fall and suffered a head injury. This meantpotentially serious injuries may not have been identifiedand prompt action taken to prevent further complications.Records of skin care and skin damage did not show peoplereceived all necessary care. We found a person haddeveloped two open red areas. Records of repositioningand care showed that in the preceding two days there hadbeen several periods of up to 14 hours, when repositioningwas not shown to have occurred. Records showed anon-prescribed topical cream had been applied which wasnot suitable for the persons skin condition and may havecontributed to the deterioration of the persons skin. Thepersons care plan identified they were at risk of pressureinjuries and should receive care every three to four hourswhich records showed had not occurred. Records viewedshowed two other people had developed avoidablemoisture lesions, which are caused by extended contactwith urine or faeces, and skin pressure injuries.Care plans had not been updated to reflect the changes inpeoples skin condition. For a person who sustained aninjury there was no information detailing wound care

required or how staff should provide care when moving theperson or providing personal care. The records of anotherperson stated that they had sustained a skin abrasionunder their left elbow. A wound care plan wassubsequently found however, there was no information orinvestigation as to how the injury had occurred. Care plansdid not always reflect the care people were receiving. Onepersons care plan stated they should have a plate guardand food cut up. We saw that a plate guard was notprovided during any of their meals during the inspection.Staff were therefore not following the guidance in the careplan.Staff did not always have correct information aboutpeoples current care and support needs. Some care planscontained inadequate or conflicting information. Forexample, records of peoples weights in their care plans didnot agree with records in the weight recording book. Therewere also inconsistencies with how often some peopleshould be weighed and between information in care plansand the way people were cared for. Information about onepersons ability to communicate was contradictory withinformation in their daily records which showed they wereable to make communicate their wishes.Care plans were not always reviewed as directed by theproviders procedures. Where care plans had been reviewedthis did not necessarily mean the information in them hadbeen updated. We discussed our findings with the managerwho agreed Care plans were not reflective of needs buthad been reviewed and not updated. This placed peopleat risk of not having their needs met in a responsive andconsistent manner.People who displayed behaviours that challenged were notalways supported appropriately. The care plans for twopeople did not provide clear guidance to staff about thesupport needed. One stated the person should besupported to accept appropriate techniques, but didntsay what these were. Similarly, the records of incidentswhere this person had displayed such behaviour were notcomprehensive. They did not always identify what triggeredthe behaviour, how long the behaviour lasted or whatinterventions were used. Similar concerns were found inanother care plan which contained no information for staffas to how they should support a person with a particularbehaviour. Consequently, this person may not have

Is the service responsive?

Inadequate


received consistent, responsive support. The managershowed us a comprehensive new tool they were planningto introduce to monitor peoples behaviours and pain moreeffectively.Staff told us they used a recognised scale to assess andmonitor the pain levels of people who could not verbalisetheir pain. However, although staff were clear about thesigns and behaviours people displayed when they neededpain relief, these were not always recorded. We saw noevidence of a recognised assessment tool being usedconsistently, which meant people may not have receivedappropriate pain relief when needed.This was a breach of Regulation 9 of the Health and SocialCare Act 2008 (Regulated Activities) Regulations 2010. Thiscorresponds to Regulation 9 of the Health and Social CareAct 2008 (Regulated Activities) Regulations 2014.People were satisfied with the quality of care and told ustheir needs were met. One person said, I get all the help Ineed and get baths every week. One staff member saidWe have a handover which is really helpful and tells uswhat we need to know but to be honest with you we donthave time to look at the care plans.Activities were provided by three activity coordinators. Inaddition, staff were encouraged to spend time with peopleon a one to one basis. Records showed staff did thisregularly and talked about topics of interest to eachperson. These included reminiscing about their lives,looking at photographs or listening to music. One personenjoyed watching a particular type of film and these hadbeen provided for them. A bird feeder had been set upoutside the room of a person who enjoyed wildlife, so they

could watch the birds. We observed people taking part incraft activities and a visiting singer provided live musicwhich people enjoyed. People and their families wereaware of a fete which was due to take place shortly afterour inspection and they had been involved in planning it.For example, one person showed us paintings they wereplanning to display at it.The service had a complaints policy and a system to recordand investigate complaints. This was provided to peoplewhen they moved to the home. The procedures were notdisplayed anywhere in the home, although people told usthey knew how to make a complaint. We viewed the mostrecent complaints and saw they had been dealt withpromptly and in accordance with the providers policy.Following a complaint relating to missing property, themanager described the extensive actions they had taken tofind the item and the changes they were making to ensurea similar incident did not occur again.The provider conducted regular surveys of people and theirrelatives. We viewed the latest survey and saw mostcomments were positive. The manager had responded toany negative comments by contacting respondents directlyand addressing their concerns effectively. Residentsmeetings were held monthly and were used to updatepeople on changes to the home and to seek their views.These had resulted in changes to the laundry and theintroduction of new activities. A senior representative of theprovider had also visited to run a meet the MD meeting.Although this had not been well attended it had givenpeople and staff an opportunity to provide feedback to theprovider at a senior level.

Is the service responsive?

Inadequate


Our findingsAt our last inspection on 9 and 13 October 2014, we foundthe service was in breach of regulations. Action had notbeen taken to address previous failings, the system used tomonitor the quality of care provided was not effective,audits were not robust, lessons were not learned fromprevious incidents and there was a lack in the continuity ofmanagement. We took enforcement action to prevent theprovider from admitting new people to the service until 26April 2015. The provider sent us an action plan on 23February 2015 stating they were meeting the requirementsof the regulations.At this inspection we found the monitoring systems werenot always effective and concerns we had identified in ourprevious inspection report, in relation to the safety andeffectiveness of the service, had not been addressed.Consequently, people continued to be at risk of choking ontheir food, action not being taken due to unexplainedinjuries and skin damage and having their rightscompromised.Quality assurance systems were not always effective inensuring the service met all necessary standards. Careplans were reviewed by senior staff but were not audited bymanagement. As a result, gaps and contradictions withinthem had not been identified. The registered managershowed us a tool they were intending to introduce toconduct these audits after our inspection. Two medicinesaudits had been completed; one by the externalpharmacist and one by staff. The audit by staff hadidentified and addressed some concerns, although neitherhad picked up that a medicine was not being given at thecorrect time or that topical creams were not managedsafely. The head of housekeeping conducted audits of theenvironment and infection control. However, these had notidentified that dangerous substances had been left in anarea accessible to people or that records of cleaning for thejuice machines were not up to date.Incidents that caused harm to people were not alwaysreported to the manager and were not investigatedappropriately. Staff did not always follow guidance toensure safe care. Five of the care records we looked at indepth demonstrated that people were not always providedwith safe care. This should have been identified duringaudits. Dangerous substances including concentratedweed killer and slug pellets were found in the garden where

people could have been walking unsupervised. Nail varnishremover was found in an unlocked drawer in an areaaccessible to people living with dementia. Procedures toensure the security of the building were not adequate.Environmental audits had not identified these items andensured they were stored correctly. A garden gate was leftopen by contractors meaning people could have left thegarden and had access to nearby roads.There was a process in place for recording accidents andincidents. These included falls and incidents of urinaryinfections. However, the manager had been unaware ofsome instances of unexplained injuries. This meant theyhad not been investigated in line with the providersprocedures.This is a breach of Regulation 10 of the Health and SocialCare Act 2008 (Regulated Activities) Regulations 2010. Thiscorresponds to Regulation 17 of the Health and Social CareAct 2008 (Regulated Activities) Regulations 2014.People and their relatives praised the management of theservice. One relative told us Theres a good manager incharge now. Another said, [The manager] is always aboutand she has a no-nonsense approach. This was confirmedby responses to a survey conducted recently by theprovider. Comments included: Care and environment ismuch improved; Weve noticed a huge improvement overthe last few weeks; and The home and care is improvinggreatly.There were appropriate management arrangements inplace. Although the service had not had a registeredmanager for five months, the current manager, who hadbeen in post since the previous registered manager left,was going through the process of registering with CQC.Support for the manager was provided by an OperationsSupport Manager, who visited several times each week, anda new deputy manager. Daily meetings were held with theheads of all departments, in addition to shift briefingswhich all staff attended.Regular staff meetings were also held and minutes showedthese had been used to reinforce the values and vision ofthe service. Staff spoke highly of the management, receivedappropriate support and felt valued. One staff member saidof the management, Theyre making real progress withimproving things. Another told us, Things have reallysmartened up and are better now. A third staff member

Is the service well-led?

Inadequate


said, The manager always asks how we are, she caresabout us. Another commented things are betterorganised and you feel appreciated, but you know who is incharge.There was a whistle blowing policy in place and staff wereencouraged to raise concerns. Where the performance ofstaff was raised as a concern, action was taken in atransparent way in accordance with the providers policies

and recorded in staff records. During the inspection, wefound the management team was open to receiving ourfeedback about the service and showed a desire toimprove. The manager encouraged visitors and familymembers to provide feedback. They had a clear vision forthe service and an appropriate plan for achieving it. Staffunderstood this and shared the managements desire toprovide a high quality service.

Is the service well-led?

Inadequate


The table below shows where regulations were not being met and we have taken enforcement action.

Regulated activityAccommodation for persons who require nursing orpersonal careDiagnostic and screening proceduresTreatment of disease, disorder or injury

Regulation 9 HSCA 2008 (Regulated Activities) Regulations2010 Care and welfare of people who use servicesRegulation 9(1)(a)(b) Health and Social Care Act 2008(Regulated Activities) Regulations 2010 - Care andwelfare. This corresponds to Regulation 9(3) of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014 Person-centred care.

The registered person had not taken proper steps toensure service users were protected against the risks ofreceiving care and treatment that is inappropriate orunsafe by means of the planning and delivery of care tomeet service users individual needs.

The enforcement action we took:We have added a condition to the providers registration to prevent the service from admitting new service users.


Regulation 10 HSCA 2008 (Regulated Activities) Regulations2010 Assessing and monitoring the quality ofservice provisionRegulation 10(1), Health and Social Care Act 2008(Regulated Activities) Regulations 2010 Assessing andmonitoring the quality of service provision. Thiscorresponds to Regulation 17 of the Health and SocialCare Act 2008 (Regulated Activities) Regulations 2014Good governance.The registered person had not protected service users,and others, against the risks of inappropriate or unsafecare and treatment by means of the effective operationof systems designed to regularly asses and monitor thequality of services provided and identifying, assessingand monitoring risks relating to the health, welfare andsafety of service users and others.


Regulation

Regulation

This section is primarily information for the provider

Enforcement actions



Regulation 11 HSCA 2008 (Regulated Activities) Regulations2010 Safeguarding people who use services from abuseRegulation 11 Health and Social Care Act 2008(Regulated Activities) Regulations 2010 Safeguardingservice users from abuse. This corresponds to Regulation13 of the Health and Social Care Act 2008 (RegulatedActivities) Regulations 2014 Safeguarding service usersfrom abuse or improper treatment.

The registered person had not protected service usersagainst the risk of abuse or improper treatment.



Regulation 13 HSCA 2008 (Regulated Activities) Regulations2010 Management of medicinesRegulation 13 Health and Social Care Act 2008(Regulated Activities) Regulations 2010 Management ofmedicines. This corresponds to Regulation 12 of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014 Safe care and treatment.

The registered person had not protected service usersagainst the risks associated with the unsafe use andmanagement of medicines.



Regulation 18 HSCA 2008 (Regulated Activities) Regulations2010 Consent to care and treatment

Regulation

Regulation

Regulation


Enforcement actions


Regulation 18 Health and Social Care Act 2008(Regulated Activities) Regulations 2010 Consent to careand treatment. This corresponds to Regulation 11 of theHealth and Social Care Act 2008 (Regulated Activities)Regulations 2014 Need for consent.

The registered person had not made suitablearrangements for obtaining, and acting in accordancewith, the consent of service users in relation to the careand treatment provided.



Enforcement actions


Solent Grange Nursing HomeRatingsOverall rating for this serviceIs the service safe?Is the service effective?Is the service caring?Is the service responsive?Is the service well-led?

Overall summaryThe five questions we ask about services and what we foundIs the service safe?Is the service effective?Is the service caring?

Summary of findingsIs the service responsive?Is the service well-led?

Solent Grange Nursing HomeBackground to this inspectionOur findings

Is the service safe?Our findings

Is the service effective?Our findings

Is the service caring?Our findings

Is the service responsive?Our findings

Is the service well-led?Regulated activityRegulationThe enforcement action we took:

Regulated activityRegulationThe enforcement action we took:

Enforcement actionsRegulated activityRegulationThe enforcement action we took:



Documents

Solent Grange Nursing Home CQC Report