This unannounced inspection took place on 20 August 2018. At the last inspection carried out on 25 and 26 May 2017, we found that there were areas which required improvement. At this inspection, we found that the service had deteriorated and there were more areas which required improvement. We found five breaches of regulations relating to keeping people safe, staffing, person-centred care, mental capacity and governance.

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

Dussindale Park accommodates 58 people in one adapted building across two floors. There were 43 people living in the home when we inspected, many of whom were living with complex health conditions.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager was not available at the time of our inspection, and we were supported to carry out the inspection by other members of staff, such as administration, quality assurance staff, nurses, and the deputy manager.

Risks to people were not always properly assessed and mitigated. There was not always accurate guidance for staff on how to mitigate risks to people associated with their mobility, choking and associated long-term health conditions. People did not always receive medicines as they had been prescribed, and there were gaps in recording around people’s topical medicines such as skin creams.

There were not always enough staff deployed throughout the home to ensure that people received support in a timely manner.

People who lived with variable mental capacity did not always have their capacity assessed in line with specific decisions about their care. Records did not support that decisions were always made by staff in people’s best interests, or that they were only deprived of their liberty in the least restrictive way available. Staff had not always sough consent from people about their care.

Care plans were not always completed, and there were inaccuracies and inconsistencies. People did not always receive individualised care according to their diagnosed health conditions, needs and preferences. There were not always activities or occupation on offer to people based on their interests, life histories or hobbies.

Accurate, contemporaneous records of people’s care were not always kept. The quality assurance systems in place had not always identified areas for improvement.

Staff received training relevant to their role, however they did not receive training in the complex health conditions which people they cared for lived with. Nursing staff had their competencies checked regularly.

Staff were kind to people but at times rushed to deliver care. Family members were consulted about some areas of their relative’s care, but there were no records around people themselves being involved in their care.

There were recruitment checks carried out to ensure that staff were suitable to work with people living in the home. Staff had knowledge of safeguarding and reporting concerns.

There was a choice of meals available and people received enough to eat and drink. The cook had good knowledge of how to prepare specialist meals for people.

Staff supported people to access healthcare professionals and appointments.

There was a complaints procedure available and we saw any concerns were investigated and resolved. The home had also received many compliments.

There was good team work in place and staff worked well together. They felt supported by their ma

Dussindale Park is registered to provide nursing and residential care for up to 58 people. At the time of the inspection 46 people were living at the home. The home supports older people with a range of nursing and physical needs. Some people at the home were living with dementia. The accommodation is comprised over two floors and was built in the 1990’s.

There was a registered manager in place. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have a legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. For the purposes of this report the registered manager will be referred to as the manager. There was also a deputy manager who was also a registered nurse.

There was a new manager in place from when the home was last inspected. Whilst we recognised that the new manager had identified and taken action regarding several areas and made improvements. We also found other areas which required improvements to be made.

People’s call bells and alarms in their rooms were not always working. The provider and manager were aware of this, but there were no plans in place to address this issue to ensure people’s call bells and alarms worked. There were other systems to check people’s safety when they were in their rooms. However, the call bells and alarms were not being checked regularly enough, considering they were faulty.

There had been some medication errors but the quality assurance system had not identified all of them. There were quality monitoring systems in place, but these did not identify the issues which we found during our inspection.

We made a recommendation about the service improving the systems and audits they use to monitor the quality of the service.

People had thorough risk assessments relating to their health and physical needs. There were also regular reviews taking place of people’s needs and what action was needed when a person’s health needs changed. The nursing staff monitored people’s health needs closely if they were very unwell. Referrals to the GP and specialist health teams were taking place when required in a timely way.

Records gave guidance to staff about how to manage people’s needs and what actions were needed to keep people safe. However, people’s diabetic care plans were not effective, but we were told these were being reviewed and it was confirmed that this process had started.

The manager responded effectively to some accidents and incidents. However, they and the provider had not taken appropriate action regarding the faulty call bells system at the home.

The manager and staff knew how to protect people from potential harm and abuse. There were systems for staff to report their concerns to the manager. The manager knew of external agencies they must report such concerns to. Staff knowledge about these agencies was variable, but the manager said they would address this issue.

People benefited from being supported by staff who were safely recruited. There was consistently enough staff to safely meet people’s care and nursing needs, at the time of this inspection.

Care staff and the nursing staff felt their induction to their job prepared them for their work. The Care staff and the nursing staff also received regular training. The competency of the nursing staff was monitored and assessed. Additional training relevant to the care staff role was not taking place. However, we were told of plans to address this issue.

The Care Quality Commission (CQC) is required to monitor the Mental Capacity Act (MCA) 2005 Deprivation of Liberty Safeguards (DoLS) and reports on what we find. The service was working within the principles of the MCA. Staff had a good understanding about the need to seek consent from the people they were supporting.

People told us

Dussindale Park is a registered care home and provides accommodation and care, including nursing care, for up to 58 people for short or long term care. At the time of our inspection there were 41 people living at the home. The care home is located in a residential suburb of the city of Norwich.

A registered manager was not in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. A registered manager was not in post and action was taken to try and fill this vacancy.

At our unannounced inspection on 17July 2014, a breach of a legal requirement was found. After the inspection, the provider wrote to us to say what they would do to meet the legal requirement in relation to respecting people’s choice about when they wanted to get up. During this inspection of 06 May 2015 we found that the provider had followed their plan which they had told us would be completed by 30 September 2014 and the legal requirement had been met.

People were safe living at the home and staff were knowledgeable about reporting any abuse. People were looked after by enough staff to support them with their individual needs. Pre-employment checks were completed on staff before they were judged to be suitable to look after people at the home. People were satisfied with how they were supported to take their medicines and medicines were safely managed.

People were supported to eat and drink sufficient amounts of food and drink. They were also supported to access a range of health care services and their individual health needs were met.

People’s rights in making decisions and suggestions in relation to their support and care were valued and acted on.

People were supported by staff who were trained and supported to do their job, which they enjoyed.

The CQC monitors the operation of the Mental Capacity Act 2005 (MCA 2005) and the Deprivation of Liberty Safeguards (DoLS) which applies to care services. DoLS applications had been made to the appropriate authorities to ensure that people’s rights were protected.

People were treated by kind, respectful and attentive staff. They and their relatives were informally involved in the review of people’s individual care plans.

Support and care was provided based on people’s individual needs and they were supported to maintain contact with their relatives and the local community. People were invited to take part in a range of hobbies and interests. There was a process so that people’s concerns and complaints were listened to and these were acted upon.

The acting manager was supported by a regional director and a quality assurance manager. Staff enjoyed their work and were supported and managed to look after people in a caring and safe way. People and their relatives were able to make suggestions and actions were taken as a result. Quality monitoring procedures were in place and action had been taken where improvements were identified.

An adult social care inspector carried out this inspection. During this inspection we spoke with the regional director, quality assurance manager, five staff members, three people who lived in Dussindale Park and relatives of another five people. We reviewed four people's care records and various service related information.

We reviewed the evidence we had obtained during our inspection and used this to answer five key questions we always ask: Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led?

This is a summary of our findings. If you would like to see the evidence supporting this summary please read the full report.

Is the service safe?

People or their relatives told us they or their family members felt safe living at Dussindale Park and would speak with a staff member if they were concerned about anything. The service had guidance for staff in protecting people from abuse and we found that staff members had received adequate training in this area.

Risk assessments for people's care needs were completed and provided appropriate actions for the identified risk to be reduced.

The provider was aware of recent guidance in relation to the Deprivation of Liberty Safeguards. Area managers had met and decided what changes needed to be implemented pending the organisation receiving definitive legal advice. It had been decided to take a cautious approach and submit applications in respect of a significant proportion of the people living at Dussindale Park who were thought most likely to meet the new criteria for applications.

Is the service effective?

People had individual care plans which set out their care needs. People and/or their relatives had been involved in the assessment of their health and care needs.

People’s nutrition and hydration needs were well supported. People received sufficient fluids to ensure they were hydrated. We saw assessments of people’s dietary needs and where special diets were advised, these were provided and adhered to.

Is the service caring?

The service had made improvements to activities' provision and had encouraged more people to participate socially within the home. Where people had tended to stay in their rooms for meals previously, this was not always the case in recent months.

People or their relatives were generally happy with the care they or their family member received. However, prior to this inspection we had received information of concern that people were not always washed and dressed before lunchtime. We were able to substantiate this during our inspection. This meant that people's dignity was not always ensured.

Is the service responsive?

We saw from responses to a survey that the service co-operated and worked well with other health care professionals to ensure people’s needs were met. For example, we noted that the service followed up requests to pharmacists for progress on filling people’s prescriptions.

We noted that people's individual physical and mental support, care and treatment needs were assessed and planned for.

Is the service well-led?

In this report the name of a registered manager appears who was not in post and not

managing the regulated activities at this location at the time of our inspection. Their name appears because the de-registration process had not been completed at the time of this inspection.

The registered manager had left the service the week prior to our inspection. The regional director and quality assurance manager were at the home on the day of our inspection. They told us that recruitment was underway to the manager’s role. In the meantime they were providing additional support.

The provider had robust systems in place to assess and monitor the quality of the service they provided for people. People’s views were obtained on a regular basis and systems were in place to monitor the service provided. Where suggestions and improvements had been made, action was taken to implement changes where possible.

We inspected this service with our pharmacist inspector to assess compliance with Outcome 9 (Medicines Management) following our previous inspection in August 2013 when we found shortfalls in the way medicines were managed at the service.

During this inspection we found appropriate arrangements for the recording, handling, storage and safe administration of medicines. We noted improvements had been made to the way medicines were administered to people and our checks found that overall medicines were given to people correctly. There were improvements to information about people’s medicines.

We inspected this service with our pharmacist inspector to assess compliance with Outcome 9 Medicines Management following our previous inspection on 31 May 2013 when we found shortfalls in the way medicines were managed at the service.

During this inspection we found there were appropriate arrangements for the storage of medicines. We noted there were some improvements to information about people’s medicines but further improvements were still needed. There were clear systems in place for recording medicines. However, we again noted some discrepancies where we were unable to account for medicines we looked at. Therefore we could still not be assured people received their medicines as scheduled and intended by prescribers. The service has started but not completed a programme of assessing staff competence in relation to safe medicine management.

On the day of our inspection 44 people were using the service. We spoke with four of them and with nine family members and friends. We spoke with the provider’s senior quality manager, the area quality manager and four members of staff.

We saw care plans that were up to date, based on assessments of need and reviewed at least every month. This showed that the provider reduced the risk of inappropriate care by assessing the needs of people who used the service. The home was clean and spacious. People were able to decorate their rooms with personal mementos. One family member described the staff as “fantastic” and said, “I trust the nurses totally.”

We found evidence that the provider carried out weekly audits of medication management, that medicines were stored safely and that staff authorised to handle medicines had received appropriate training. However, we were not assured that people were protected from the risks of inappropriate medication management.

The home was staffed by skilled, qualified staff who could meet people’s needs. However, staff did not always meet these needs in a timely manner. One person told us that staff were “too busy.” The provider had already identified this issue and was actively recruiting new staff.

The provider had systems in place to effectively monitor the quality of service provision through processes such as regular audits. They kept records in accessible, secure storage and ensured that they were disposed of securely.

The purpose of this inspection, carried out on 5 March 2013 was to follow up on a previous area of non-compliance.

On 10 December 2012 we visited Dussindale Park and found that the kitchen was not kept in a clean and hygienic way.

This was brought to the attention of the provider and we were provided with an action plan which demonstrated they would be taking action to address the issues highlighted.

During this inspection we found that improvement has been made.

During our inspection at Dussindale Park we spoke with three people using the service. They told us that they liked living at the home and that staff helped them with what they needed. One person commented, “They come when I call for them” and another person said, “I have found that the staff are very helpful, I have been clear about my aims [to achieve independent living] and have been determined to meet them”.

We spoke with another person and asked them how they felt staff met their needs. They told us that their needs were met but was very “erratic” with staff often having to leave them.

We also spent time observing the care and support provided to people during lunch time and found that staff did not a provide a good level of care and support. This meant that people’s dignity was not respected.

We did not speak to people about the service during our visit on 03 November 2011.

The purpose of this inspection, carried out 12 December 2012, was to ensure that the necessary improvements had been made following concerns identified by us in July 2012.

We found improvement had been made to the level of care and support people received during meal times. We observed lunch time and found that people were now cared for in a way which promoted their dignity.

We also found improvements had been made to the completion of mental capacity assessments. Staff spoken with now had a better understanding of their duties and ensuring decisions made in the best interests of a person were clearly documented.

During this inspection we also responded to whistle blowing concerns made about the level of support provided to people during the night and the hygiene standards at the home.

We did not find poor levels of care being provided during the night however we did find that cleanliness standards in the home were not being maintained and have asked the provider to take action to ensure these standards are met.