About the service:

High Meadow Nursing Home is a ‘care home’ and was providing personal care, nursing care and accommodation to 24 people at the time of the inspection. Most of the people using the service were older people living with dementia. The service was set in a large detached house in a street with similar houses. The accommodation is split over three floors with access to all floors by lift or stairs.

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

People’s experience of using this service:

• There was not enough staff to support people’s needs. This had an impact on the quality of care that people received and there were times when people were left waiting for support. Staff were extremely busy and did not have time to stop and chat to people or take their full breaks.

• The environment that people lived in was not designed for people who lived with dementia, it was not well maintained and was not always safe.

• Risks to people from their health conditions were not always mitigated, nor were risks to people from equipment.

• Most of the staff had worked at the service for a long time and had the skills and experiences they needed to support people well. However, staff were not positive about the training they were offered, and it did not promote best practice. We made a recommendation about the training staff were offered.

• The support people received was not always personalised and people and their relatives were not always positive about the activities at the service.

• Staff worked to support people to maintain their dignity. However, the care people received was not always dignified due to the design of the service and the lack of staffing.

• The service was not well-led and this had an impact on the care that people received. People, relatives and staff were all positive about the registered manager. However, they were less positive about the provider. People’s relatives told us that they had raised concerns with the provider but that they had not felt listened to. When relatives had raised concerns about the maintenance it had not been recorded as a complaint and the complaints process was not always accessible.

• An audit undertaken by a consultant on behalf of the provider identified a number of the concerns we identified during this inspection. However, these had not been addressed.

• There was a nurse at the service at all times and people received their medicines on time and as prescribed.

• When people were unwell or needed support from a health and social care professional they received this.

• People were supported to eat and drink safely. Where people needed support to maintain their weight or eat a specialist diet this was in place.

• Staff understood that people had the right to make choices about their care. Where people were not able to make decisions, these were made in their best interests.

The service did not meet the standard of Good in any area and there were a number of breaches of the regulations.

Rating at last inspection:

At the previous inspection (published on 5 April 2018) the service was rated Requires Improvement.

Why we inspected:

This was a planned inspection based on the previous rating.

Enforcement:

You can see what action we told the provider to take at the back of the full version of the report. Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up:

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within six months to check for significant improvements.

The inspection took place on 16 and 17 November 2017 and was unannounced.

High Meadow Nursing Home is a care 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.

High Meadow Nursing Home is registered to provide accommodation and personal care for a maximum of 34 people. The home provides care to older people, people who are frail and some people living with dementia as well as a range of health and support needs such as diabetes, epilepsy and catheter care. At the time of our inspection there were 25 people living in the service. At the last inspection on 1 and 2 March 2017 we asked the provider to take action to make improvements. Six breaches of regulation were found and the service was rated as Inadequate in the key questions of safety and leadership. It was rated as Requires Improvement for the remaining key questions of effective, caring and responsive. This was because the provider had failed to ensure actions designed to minimise risk were always adequate in practice. These related to diabetes and pressure wound management and the risks of people being isolated and unable to use call bells to summon staff. Staff were sometimes neglectful of people’s need to use the toilet, asking them to wait for up to 30 minutes while other tasks were completed. There were not enough staff on duty to meet people’s needs, and staff training needed improvement in some areas. Dietician advice was not always followed to ensure people received adequate nutrition and staff were not aware of target fluid intake for individuals. Records about food and fluids were filled out in retrospect and were sometimes inaccurate. Staff were not consistently caring; some had become desensitised to people’s calls for assistance. There was not enough interaction or stimulation for people who stayed in bed every day. Quality assurance processes had not picked up and addressed these issues. Following the last inspection, the service was rated as Inadequate overall and placed into Special Measures. The provider sent us regular updates about improvements they were making.

When we completed our previous inspection March 2017 we also found concerns relating to people’s hopes and wishes for their end of life care. At this time, this topic area was included under the key question of Caring. We reviewed and refined our assessment framework and published the new assessment framework in October 2017. Under the new framework this topic area is included under the key question of Responsive. Therefore, for this inspection, we have inspected this key question and also the previous key question of Caring to make sure all areas are inspected to validate the ratings.

At this inspection significant improvements had been made and the legal requirements of the previous breaches had been met. However, we identified some areas where further improvements could be made, these related to a formal review and resolution of an adhoc way in which some nursing needs were covered, for staff to always ensure that call bells were within people’s reach, for choice to be offered and an understanding about how people preferred to receive their medication and an enhancement to the way in which the size of wounds were recorded. The registered manager met with people and carried out an in-depth assessment of their needs and wishes before they came to live in the service; to ensure these could be appropriately met. Potential risks to people’s health and welfare were assessed and there was detailed guidance for staff to follow to mitigate those risks; for example, in relation to diabetes, epilepsy, wound, pressure and catheter care.

People had been asked about their end of life wishes and these had been recorded to ensure people’s these were respected. Staff had received training appropriate to their role, including

This inspection took place on 1 and 2 March 2017 and was unannounced.

High Meadow is registered to provide nursing and personal care for up to 34 people .There were 28 people using the service during our inspection; who were living with a range of health and support needs. These included; diabetes, Parkinson’s, catheter care, dementia; and people who needed support to be mobile. Many people were nursed in bed.

High Meadow is a large detached premises situated on the edge of the city of Canterbury, Kent. The service had a very large communal lounge/dining room; with armchairs and a TV for people and a separate, quieter conservatory. Bedrooms are situated over three floors; with a passenger lift available.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. 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.

High Meadow was last inspected in January 2016. At that inspection it was found to require improvement. There were a number of breaches of Regulation and we issued requirement actions about these. The provider sent us an action plan showing that all of these areas had been improved. At this inspection however, we found that none of the Regulation breaches had been fully addressed. In addition, other issues had emerged, resulting in further breaches of Regulation.

Assessments had been made about individual risks to people but actions designed to minimise these were not always adequate in practice. This related to diabetes and pressure wound management and the risks of people being isolated and unable to use call bells to summon staff.

Staff were sometimes neglectful of people’s need to use the toilet, asking them to wait for up to 30 minutes while other tasks were completed. There were not enough staff on duty to meet people’s needs, and staff training could be improved in some areas.

Dietician advice was not always followed to ensure people received adequate nutrition and staff were not aware of target fluid intake for individuals. Records about food and fluids were filled out in retrospect and were sometimes found to be inaccurate.

Staff were not consistently caring and some had become desensitised to people’s calls for assistance. There were scant records about people’s hopes and wishes for the end of their life. There was not enough interaction or stimulation for people who stayed in bed every day.

Quality assurance processes had not picked up and addressed the issues we found during this inspection. Effective action had not been taken following our last inspection to make positive changes and provider oversight had been inadequate. A poor culture had developed in which staff had become desensitised to people’s needs.

Medicines were well-managed and safely administered by staff. The service was maintained to a good standard and all equipment was routinely safety checked.

People’s consent had been sought formally and verbally for day-to-day care tasks. Staff were knowledgeable about the Mental Capacity Act (MCA) 2005 and worked within its principles. The registered manager had made applications for deprivation of liberty safeguards (DoLS) and received authorisations for some of these.

Staff received regular supervision and appraisal. There was a robust recruitment system in operation and all necessary checks had been made prior to taking on new staff.

There was a system for recording all complaints and people and relatives knew how to raise concerns. Feedback was sought through a variety of sources.

The registered manager was respected by staff who described good teamwork.

We recommend that the provider obtains from a reputable source; information about first aid during and after seizures.

We recommend that the provider seeks professional advice about best practice guidelines for people’s ind

The inspection took place on 6 and 8 January 2016 and was unannounced. At the previous inspection on 17 May 2014, we found there were no breaches of legal requirements.

High Meadow Nursing Home provides accommodation with personal and nursing care for up to 34 older people, some of whom are living with dementia. There are 28 single rooms at the home and 27 people were living at the home at the time of inspection. The accommodation is over three floors and bedrooms can be accessed by a passenger lift. People share a communal lounge/dining room and a conservatory. There is an accessible and secure garden to the rear of home. This contained a summer house, which had been turned into a tea room for people to use in the warmer weather.

The service has a registered manager who was available and supported us during the inspection. A registered manager is a person who has registered with the Care Quality Commission (CQC) 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.

Medicines were stored safely and administered by qualified nurses. However, there was not always clear guidance in place for them to follow to ensure they gave people medicines prescribed to be given ‘as required’ appropriately and consistently.

Although people’s personal care needs were met, there were not sufficient numbers of staff available to interact with people so they received stimulation and emotional support. Information had been gained about people’s likes, preferences and past history. However, this information was not effectively used to plan and deliver an individual and group activities programme. An activities coordinator was available for six hours a day. Staff did not have time to sit and talk to people, but chatted to them about their interests and families when supporting them with their personal care. External entertainers visited and special occasions were celebrated such as people’s birthdays.

Quality assurance systems were in place, but where shortfalls had been identified the action taken to address them had not always been reviewed to ensure that it was effective.

Checks were carried out on all staff at the home, to ensure that they were fit and suitable for their role. Staffing levels ensured that people’s physical and personal care needs were met, but were insufficient to meet people’s social needs.

Assessments of risks to people’s safety and welfare had been carried out and action taken to minimise their occurrence, to help keep people safe. Health and safety checks were effective in ensuring that the environment was safe and that equipment was in good working order. Staff knew how to follow the home’s safeguarding policy in order to help people keep safe. Accidents and incidents were monitored.

People had their health care, nutritional and fluid needs assessed and monitored and professional advice was sought as appropriate. People were offered a choice at mealtimes, and where appropriate support was provided and people were not rushed.

New staff received an induction which included shadowing new staff. Staff were provided with training in the areas necessary for their role, and this was refreshed on a regular basis. All staff had received training in the Mental Capacity Act 2005 and staff understood the principles of the Act and how to apply them. CQC is required by law to monitor the operation of the Deprivation of Liberty Safeguards. DoLS applications had been made for people who lived in the home to ensure that people were not deprived of their liberty unnecessarily.

The environment had been adapted for people living with dementia and people had memory boxes with information and photographs that were important to them. However, these boxes were not accessed on a regular basis.

People’s care, treatment and suppor

Our inspection was carried out by one inspector on the day. We looked for information and evidence to answer our five questions:- Is the service caring? Is the service responsive? Is the service safe? Is the service effective? And is the service well led?

Below is the summary of what we found. The summary is based on our observations during the inspection, speaking to people using the service, their relatives, the staff supporting them and from records in place.

If you would like to see the evidence supporting our summary please read the full report.

Is the service safe?

We saw that people were treated with respect and dignity by all of the staff. People spoken with told us they felt safe. Staff were aware of the whistleblowing procedure. Policies were in place and had been signed as read by all of the staff. Systems were in place to follow up accidents, incidents and complaints, in order to see if any improvements could be made. We found evidence that all of these were followed up by the manager and action plans were put in place when required. Care plans included mental capacity assessments where they were needed. Some people had documents in place for Do Not Attempt Resuscitation (DNAR), and we saw that the person, or their family members had been appropriately consulted by the health professionals completing the forms. This showed that people's individual wishes were safeguarded.

We saw evidence that the home's equipment was well maintained and routinely serviced. The environment had been improved since our last visit and recently redecorated. The home was seen to be clean and tidy and well cared for. This showed that the provider ensured the people were safe from risks.

The manager ensured the staffing was sufficient and each shift had a good mix of experienced staff members to ensure that all the people living at the home were well cared for. The manager also ensured that staff were fully trained and proficient in their roles by the use of staff supervisions and direct observations. This ensured that all of the people's needs were being met at all times.

Is the service effective?

People's health needs were monitored routinely by trained nursing staff and professional support was requested as a matter of urgency when required. People were monitored monthly for their blood pressure and skin integrity to ensure their safety and well being. Amendments were made to care plans as changes were found. This showed that the service was effective at meeting the needs of the people living at the home. Part of the communal areas had been adapted to promote memory links for those with dementia. We found that this area was highly popular with people living at the home and family members that we talked with. Family members said that they felt welcome and were made to feel at home at each visit. People’s family and friends could visit them in their own rooms or in one of the communal rooms, according to the person’s own choice.

Is the service caring?

We observed that people living in the home were treated respectfully by the staff, and their privacy and dignity were maintained. A family member stated that their father was more than happy with the support they received and felt 'at home'. People's family members were invited to take part in care review meetings if this was applicable. We found that there was an open chain of communication between the management, the staff, and people living at the home, which promoted a relaxed atmosphere. We saw that people were very involved in the running of the home, and were able to take part in tasks, such as baking and gardening to enable them to keep as active as possible.

Is the service responsive?

The home employed an activities co-ordinator to enable people to be active on a daily basis in line with their personal preferences. Activities seen included gardening and baking. The people living at the home assisted in the newly opened sweet shop. The cook was actively involved with the people living at the home and talked with them regularly to ensure that changes to their likes and dislikes were acted upon quickly. The cook also acted quickly to provide menu changes to meal presentation when requested by the person or by health professionals.

Is the service well led?

The manager and two other staff members had been trained as 'dementia-champions'. This aided the home to be proficient in the care of people with dementia and to work proactively with them.

The home had systems in place to monitor the quality of the service provided and action plans were put in place to address any requirements. We found that any actions required were carried out quickly. The staff were very committed to the ethos of the home to provide best practice at all times. The introduction of the memory lane cafe and sweetshop had been welcomed by people living in the home. We saw that the manager was active in hands-on care on a daily basis and was in touch with the staff team. All of the staff that we spoke with said they were happy working in the home and felt supported. Relatives that we spoke with also stated their confidence in the manager and the staff team and said they particularly liked the recent improvements to the premises.

People we spoke with who used the service and their relatives were satisfied with the service they received. People felt the staff supported them and met their needs. One person who used the service told us, "I'm alright here the staff really look after me well."

People told us that staff treated them with dignity and respect; they said they felt listened to and were supported to remain as independent as possible. We saw staff speaking and responding to people in a gentle and respectful manner. We found records to show how people's health needs had been assessed before they came to live in the home. These included information from health and social care professionals to make sure the home could provide the care people needed.

Staff recruitment records showed that new staff had been thoroughly checked to make sure they were suitable to work with vulnerable people. Systems were in place to monitor the service that people received and suitability of the premises to ensure that the service was satisfactory and safe. People told us they did not have any complaints but would not hesitate to speak to the manger or staff if they had any concerns.

We made an unannounced visit to the service to check on a compliance action we made at our last inspection. This involved parts of the care that one person was receiving. We found that the compliance action had been met.

The person concerned had reduced comprehension and used a combination of sounds, gestures and body language to express themselves. They showed us that they were relaxed and comfortable with how staff were supporting them.

Other people who use services said or showed us that that they were satisfied with the health and personal care services they received. They considered staff to be kind and helpful and they felt safe. We saw that staff spoke to people with kindness and patience.

People were supported to keep in touch with carers (relatives) and a range of individual and group social activities were provided.

Patients said that staff treated them with respect and supported them to raise any concerns they had. They said that they received the health and personal care they needed and that they were comfortable in their home.

All of the five patients with whom we spoke gave us positive feedback about the service. One of them said, ‘This place is okay for me. I get on well enough with the staff and they help me with everything that I need. Some of the building is a bit basic but it’s the staff that make it homely’.

We also used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of patients who could not talk with us.

People who use services said that the staff treated them with respect, listened to them and supported them to raise any concerns they had. They said that they received the health and personal care they needed and that they were comfortable in their home. One person said, 'The staff are very good really and they're always willing to help and they're kind in their manner'. A carer (relative) said, 'We're very happy with the care provided in the home, the staff are kind and helpful'.