About the service:

Greystones Nursing Home provides nursing or personal care for up to 31 people including people living with dementia or who have mental health needs. At the time of our inspection, there were 29 people living at the service.

People’s experience of using this service:

¿ We found four breaches of the regulations in relation to recruitment, premises, person-centred care and good governance. The provider was not always recruiting staff safely. The provider was not always ensuring premises was appropriately maintained. The provider did not always ensure people were offered enough social stimulation throughout the day. We also identified concerns relating to medicine competencies, staff supervisions and appraisals, premises not adapted to suit all residents’ needs, policy and procedures and the Accessible Information Standard. The provider’s quality assurance processes in place were not effective in identifying the issues found at this service. The management of the service failed in their oversight and monitoring of the quality of the service.

¿ People told us they felt safe.

¿ People were supported to take their medicines in a safe way and were safely managed.

¿ People enjoyed the meals and their dietary needs had been catered for.

¿ Records showed people had regular access to healthcare professionals to make sure their health care needs were met.

¿ People and relatives felt staff were kind and caring and treated them with dignity and respect when providing care.

¿ A complaints procedure was in place. People and relatives told us they would have no hesitation in raising concerns.

Rating at last inspection:

At the last inspection the service was rated ‘requires improvement’ with three out of the five key questions rated as ‘good’ (report published 5 April 2018). At this inspection the overall rating has remained ‘requires improvement’, although only one out of the five key questions remained rated as ’good’.

Why we inspected:

This was a planned inspection based on the rating at the last inspection. This inspection was part of our scheduled plan of visiting services to check the safety and quality of care people received.

Enforcement:

Please see the ‘action we have told the provider to take’ section towards the end of the report

Follow up:

We will continue to monitor the service to ensure that people received safe, high quality care.

Further inspections will be planned for future dates. We will follow up on the breaches of regulations we have made at our next inspection.

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

Our inspection of Greystones Nursing Home took place on 20 December 2017 and was unannounced.

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

Greystones Nursing Home provides nursing and personal care for up to 25 people, some of whom are living with dementia or have mental health needs. There were 22 people using the service when we inspected. Accommodation is provided in single and shared bedrooms over three floors. There is a passenger lift to the first floor and chair lift access to the second floor. There is a lounge, dining room and smoking room on the ground floor.

The home has a registered manager. 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.

Policies and procedures ensured people were protected from the risk of abuse and avoidable harm. Staff told us they had regular safeguarding training, and were confident they knew how to recognise and report potential abuse. Where concerns had been brought to the registered manager’s attention, they had worked in partnership with the relevant authorities to make sure issues were fully investigated and appropriate action taken to support people’s safety and protection.

Comprehensive risk assessments identified individual risks to people’s health and safety and there was information in each person’s care plan showing how they should be supported to manage these risks. Systems were in place to ensure people received their prescribed medicines safely.

There were enough staff on duty to meet people’s needs and staff had undertaken training relevant to their roles. Staff told us there were clear lines of communication and accountability within the home and they were kept informed of any changes in policies and procedures or anything that might affect people’s care and treatment.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and acting within the legal framework of the Mental Capacity Act 2005 (MCA).

People told us they enjoyed the food. We saw staff members were proactive in supporting people to maintain their fluid and food intake; especially people identified as being at risk of malnutrition. However, we found food charts had not been completed accurately to carry out recommendations of the Speech and Language Therapist (SALT). We have made a recommendation about food charts not accurately reflecting the risk of malnutrition.

We saw the complaints policy had been made available to everyone who used the service. The policy detailed the arrangements for raising complaints, responding to complaints and the expected timescales within which a response would be received.

The care plans in place were person centred and identified specific risks to people’s health and general well-being; such as falls, mobility, nutrition and skin integrity.

We saw arrangements were in place that ensured people's health needs were met. For example, people had access to the full range of NHS services. This included GPs, hospital consultants, community health nurses, opticians, chiropodists and dentists.

Relatives told us they were made welcome and encouraged to visit the home as often as they wished. They said the service was good at keeping them informed and involving them in decisions about their relative’s care.

There was a quality assurance monitoring system in place that was designed to continually monitor and identify shortfalls in service provision.

This inspection took place on 4 August 2016 and was unannounced.

At the last inspection on 26 January 2016 we rated the service as ‘Inadequate’ and in ‘Special Measures’. We identified ten regulatory breaches which related to safeguarding, staffing, recruitment, consent, dignity and respect, safe care and treatment including medicines, person-centred care, premises, complaints and good governance. We issued warning notices for the breaches of safeguarding, person centred care and safe care and treatment with a compliance date of 15 March 2016 and for the premises and good governance with a compliance date of 29 March 2016. We issued requirement notices for the other breaches. Following the inspection the provider sent us an action plan which showed how the breaches would be addressed. This inspection was to check improvements had been made and to review the ratings.

Greystones Nursing Home provides nursing and personal care for up to 25 people, some of who are living with dementia or have mental health needs. There were 22 people using the service when we inspected. Accommodation is provided in single and shared bedrooms over three floors. There is a passenger lift to the first floor and chair lift access to the second floor. There is a lounge, dining room and smoking room on the ground floor.

The home has a registered manager. 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.

Overall we found significant improvements had been made since our last inspection.

People told us they felt safe and we found there were enough staff on duty to meet people’s needs. Staffing levels were kept under review and adjusted according to people’s dependencies and needs.

Recruitment procedures had improved which helped ensure staff were suitable to work in the care service. However, records needed to reflect decision making where issues had been identified in criminal record checks. Staff received the training and support they required to carry out their roles and meet people’s needs.

Staff understood safeguarding procedures and how to report any concerns. Safeguarding incidents had been identified and referred to the local safeguarding team and notified to the Commission. Risks to people were assessed and managed to ensure people’s safety and well-being.

Medicines management systems had improved and were being monitored through regular audits. This helped to ensure people received their medicines when they needed them. Some issues around administration practices were identified, however, these related to one staff member and were being addressed by the registered manager.

Standards of cleanliness had improved and we found the home was well maintained. Some areas of the home had been refurbished and this was ongoing. Work had started on making the environment more dementia friendly with the use of signage and colours to help people living with dementia find their way around the home more easily.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and acting within the legal framework of the Mental Capacity Act (MCA).

People told us they enjoyed the food. We saw people were offered choices and given the support they required from staff. People's weights were monitored to ensure they received enough to eat and drink.

People and relatives praised the staff who they described as 'good’ and 'kind'. We saw staff treated people with respect and ensured their privacy and dignity was maintained.

Care records had improved and this process was ongoing to ensure all the care files were up-to-date and accurately reflected the care people needed.

People were provided with activities in-house and supported to go out in the co

This inspection took place on 26 January 2016 and was unannounced. At the last inspection on 20 June 2014 we found the service met the regulations.

Greystones Nursing Home provides nursing and personal care for up to 25 people, some of who are living with dementia or have mental health needs. Accommodation is provided in single and shared bedrooms over three floors. There is a passenger lift to the first floor and chair lift access to the second floor. There is a lounge, dining room and smoking room on the ground floor.

The home has a registered manager. 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.

People told us they felt safe and we saw staff were attentive and responsive to people’s needs. Staff lacked understanding of what constituted abuse and we found safeguarding incidents had not been referred to the local authority safeguarding team. We found this was a breach in regulation as safeguarding incidents were not always recognised or reported appropriately. Risks to people were not always well managed which meant people were at risk of harm. We found this was a breach of regulation as people were not receiving safe care and treatment.

Some aspects of medicine management showed good practice, however other areas were not meeting requirements such as the lack of protocols for ‘as required’ medicines and the systems for checking medicines people brought in with them from home when admitted for respite care. We found this was a breach in regulation as people’s medicines were not managed safely.

A refurbishment programme was underway and the lounge, dining room and reception areas had been redecorated, re-carpeted and refurnished. Some bedrooms had also been refurbished and the registered manager told us people had been involved in choosing the colour scheme. However, we found many areas of the home were not clean or well maintained. For example, windows which did not close fully causing a draught in some bedrooms and broken locks on doors. We found the lack of signage and adaptions in the environment meant people living with dementia were not supported in finding their way around the home. We found this was a breach in regulation as the premises were not clean or well maintained.

There was no tool used to calculate the staffing levels and no evidence to show that the layout of the building or people’s dependencies had been taken into consideration. We found staffing levels were at a minimum level and although the registered manager told us additional staff were brought in to provide one to one support to people this was not reflected on the duty rotas. At weekends there were no ancillary staff which meant cleaning and laundry tasks were completed by the care staff. We found this was a breach in regulation as there were not enough staff to meet people’s needs.

Staff recruitment processes were not robust as thorough checks had not been completed. We found this was a breach in regulation as staff’s suitability to work in the care service had not been assured..

The legal framework relating to the Mental Capacity Act 2015 (MCA) and Deprivation of Liberty Safeguards (DoLS) had been followed as some people had DoLS authorisations in place and applications had been made for others. However, we found a lack of understanding around the principles of this legislation as one person who was assessed as having capacity had restrictions in place with no evidence to show they had agreed to these decisions. We found this was a breach in regulation as people’s consent had not been determined.

Staff received the training and support they required to fulfil their roles. People had access to health care services. People enjoyed a range of activities

We considered all the evidence we had gathered under the outcomes we inspected.

We used the information to answer the 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 what we found. The summary describes what we observed, the records we looked at and what people using the service, their relatives and the staff told us.

Is the service safe-

Each person's care file had risk assessments which covered areas of potential risk such as pressure ulcers, falls and nutrition. When people were identified as being at risk, their plans showed the actions required to manage these risks.

We found appropriate arrangements were in place for obtaining medicines and discontinued medicines were disposed of appropriately and stored safely. This helped to prevent mishandling and misuse.

We saw the equipment used by people who used the service and operated by staff were maintained and serviced in line with the manufacturers' guidelines.

We spoke with six people who used the service and they told us they were pleased with the standard of care and facilities provided by the service. One person said “"I enjoy living at Greystones all my friends are here."

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The manager told us they were familiar with the requirements of the Mental Capacity Act 2005 (MCA) and was aware of the recent Supreme Court judgment on the Deprivation of Liberty Safeguards.

Effective -

People had an individual care plan which set out their care needs. We saw wherever possible people had been involved in the assessment of their health and care needs and had contributed to developing their care plan.

The home had a good working relationship with other health care professionals and followed their guidance and advice. The input of other health care professionals involved in people's care and treatment was clearly recorded in their care plan.

We saw all staff completed a comprehensive induction programme which took into account recognised standards within the care sector and was relevant to their workplace and their roles.

Caring –

People who used the service told us they were very happy with the care and facilities provided at Greystones. One person said, “All the staff do a good job and are always there for you if you need them.” Another person told us, “The staff understand that I have good and bad days and help me through the bad times.”

We found the staff we spoke with demonstrated a good knowledge of people’s needs and were able to explain how individuals preferred their care and support to be delivered. They felt confident the service provided to people who lived at the home was good and they encouraged them to remain as independence as possible within a risk management framework.

We found the atmosphere within the home was friendly and welcoming and we saw staff approached individual people in a way which showed they knew the person well and knew how best to assist them.

Responsive –

People’s needs were assessed and care and support was planned and delivered in line with their care plan. Care records contained good information about how care and support should be delivered

Wherever possible people who used the service and/ their relatives were involved in discussions about their care and the risk factors associated with this. Individual choices and decisions were documented in the care plans and reviewed on a regular basis.

People knew how to make a complaint if they were unhappy and were confident if they made a complaint it would be investigated thoroughly and action taken if appropriate. There was evidence that learning from incidents/investigations took place and appropriate changes were implemented.

Well led –

We saw there was a quality assurance monitoring system in place that was designed to continually monitor and identify shortfalls in the service and any non-compliance with the essential standards of quality and safety.

The staff we spoke with confirmed they were well supported by the manager and said they could contact them at any time if they had concerns. They also told us communication between management and staff was very good. This ensured the needs of people who used the service were met in line with their agreed support plan.

At the time of the inspection the manager had only been in post for approximately four months. However, we found they had already significantly improved the procedures in place relating to the management of people's money and financial affairs which made sure they were safeguarded from the possibility of financial abuse.

We also found systems had been put in place which ensured records and reports relating to the care and welfare of people who used the service and the management of the service provided accurate and up to date information and could be provided promptly on request.

People who used the service told us they enjoyed living at the home and were well supported by the manager and staff. One person said “The home is comfortable, the food is good and all the staff are friendly” and “I am happy living at Greystones, all the staff are friendly and approachable and will do anything they can to help and assist you.” Another person said they were "comfortable at the home" and "well looked after."

The support workers we spoke with told us there were now clear lines of communication and accountability within the home and they were supported by the manager to carry out their roles effectively through a planned programme of supervision, appraisals and training.

In this report the name of a registered manager appears who was not in post and not managing the regulatory activities at this location at the time of the inspection. There name appears because they were still registered with us as the registered manager for this service when we carried out this inspection.

The inspection was carried out to follow up compliance actions we made in September 2012. The compliance actions were because we had concerns that people who used the service were not being protected from abuse, in particular financial abuse and record keeping.

The inspection focused mainly on looking at the records relating to people's finances and found the policies and procedures in place still did not protect people from financial abuse. We therefore did not have the opportunity to talk at length with people who used the service.

We used a number of different methods to help us understand the experiences of people using the service. This was because some of the people using the service had complex needs which meant they were not able to tell us their experiences.

For example the atmosphere within the home was relaxed and friendly and people appeared well looked after. We saw that staff gave people time and engaged with them in a respectful, encouraging and patient way. Four people who we were able to speak with told us that there always appeared enough staff on duty and they never had to wait if they required assistance.

People using the services said that they were happy living at the home and that staff were friendly.

People who use the service told us that staff were generally good at explaining any changes to their care, treatment and support. They also told us that they were pleased with the standard of care and support provided and that staff were approachable and listened to what they had to say.