Inspection Report onMeddyg Care Nursing Home (Porthmadog)

GARTH ROADPORTHMADOG

LL49 9BN

Mae’r adroddiad hwn hefyd ar gael yn Gymraeg

This report is also available in Welsh

Date Inspection Completed 04/07/2019

Welsh Government © Crown copyright 2019.You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk You must reproduce our material accurately and not use it in a misleading context.

Description of the serviceMeddyg Care Home is situated in an elevated position with good views of Porthmadog Coband the mountains beyond. Meddyg Care Securities Ltd is registered with Care Inspectorate Wales (CIW) to provide personal care for up to 44 people, fifty years of age and above. The registered provider has appointed Kevin Edwards as the Responsible Individual (RI). There is a manager in post who is not registered with Social Care Wales (SCW).

Summary of our findings

1. Overall assessment

People living in the care home benefit from positive relationships with staff. Information within care plans does not support staff to provide appropriate, person centred care. People are therefore not always receiving the care and support they require, which may put them at significant risk of harm. People do not always have access to healthcare professionals and evidence suggests professional guidelines are not always followed to prevent further deterioration in people’s health and well-being.

People have opportunities to take part in activities. Improvements are required to the quality of care and support in the home to reduce the current risk to people in terms of their health, welfare and wellbeing. Improvements have been made to the environment. There is a lack of robust systems in place to monitor, review and improve the service and therefore we found significant, systemic failings in terms of the supervision of leadership and management of the home. Staff training and the accurate recording of what training staff has attended needs improvement. Staff receive regular supervision.

2. ImprovementsThis is the first inspection of this service since it was approved under The Regulation and Inspection of Social Care (Wales) Act 2016.

3. Requirements and recommendations

Section five of this report sets our recommendations to improve the service and the areas where the care home is not currently meeting legal requirements. These include the following:

Quality Assurance: The general oversight of the home was not in accordance with regulatory requirements;

medication management and administration; care documentation; management of risks to people’s safety; referrals to healthcare professionals; care and support; staffing levels; The home is not always conducted in a manner which always respects the dignity of

people using the service.

The recommendations include the following:

Communication between staff; notifications to CIW; the manager to register with SCW; the registered person must ensure documents are available at all times for the

purpose of the inspection; Staff training.

1. Well-being

People have some control over their day-to-day lives. We found that people were able to have control over some day to day decisions, such as, what time they got up and went to bed and what meals they wanted. People were able to personalise their bedrooms to ensure they reflected their personal interests and preferences. We observed that people were treated kindly by staff and people told us that they had built up good relationships with staff. There was some documentation used to gather people’s preferences when they moved to the home. We found no evidence that people, or their representative, were involved in the ongoing review and amendment of their personal plans to ensure they remained at the centre of their care. There are now opportunities for people, both formally and informally, to express their views and opinions on the future running of the service. There was limited documentation available to accurately outline what support and opportunities are available to people at the service. People are encouraged to make some verbal choices as part of their day to day lives; however, improvements are required to ensure people remain at the centre of their care and are able to have their voice heard.

People’s physical, mental and emotional wellbeing is at risk. We observed during the inspection that people had regular opportunities to participate in meaningful activities. We found some people’s preferences in terms of activities were documented in their personal plans, we found this information was not always up to date and accurate, or being used by staff when delivering care and support. Relatives were able to visit the home whenever they chose, to maintain personal relationships. We observed visitors receiving a warm, friendly welcome from staff. We found, from reviewing personal plans of care, that people were not receiving the right care and support to avoid unnecessary deterioration in their health, welfare and wellbeing, putting them at significant risk of harm and neglect. People cannot be confident they will receive a service which protects them from harm and ensures they are receiving the right care and support to achieve the best possible outcomes for them.

People are not always protected from harm and abuse. There were insufficient systems and processes in place to monitor, review and improve the service. We found that people were not always referred to other healthcare professionals when required, and when they were, the prescribed recommendations were not accurately followed. We found people were not always receiving care and support in line with their needs. Communication systems in place required improvement to ensure staff were aware of people’s up to date and current, individual needs. We found that robust systems are not in place to ensure people are supported by a sufficient number of suitably trained, qualified, skilled and supported staff in line with the home’s statement of purpose. We found that improvements had been made to the environment and the home was able to evidence all equipment was being maintained in line with current guidelines minimise risk to people. The training matrix was not up to date or accurate and did not evidence what training staff had received including safeguarding training. People do not benefit from receiving a service where the systems and processes protect them, and keep them safe from neglect and abuse. They are therefore being put at significant risk of harm.

2. Care and Support

People are not always supported in a dignified and respectful manner. We observed many interactions throughout the inspection which were all respectful, and warm in manner. People we spoke with confirmed they felt they were treated with dignity and that staff were kind. We also noted people interacted with humour, and people and care staff joined in laughter together. The people we spoke with told us how they enjoyed that. One resident told us ‘I feel lucky to live here’. However, we saw a bath/shower rota displayed in the nurse’s office detailing weekly baths/showers for people; no record was made of consultation with people regarding their choices and preferences and no reflection of these choices were documented in people’s personal plans. The manager explained she knew of one person who preferred a bath and had not had one for a while. We saw one person had a policy displayed on their bedroom door giving advice on how to care for someone with Methicillin-resistant Staphylococcus Aureus (MRSA). The care staff thought the person was no longer MRSA positive the nurse also thought this was the case but would check. This does not protect people’s privacy and dignity. People can feel assured they have meaningful interactions with staff who have a positive and caring attitude towards them.

Systems are not sufficiently robust to ensure safe handling of medicines. Medication is not always administered in a timely manner and significant improvements are required. We examined peoples’ medication administration records (MARs) and controlled drug records. Systems were in place to audit the accuracy of medication administration; however these had not been completed by the clinical lead nurse for some time. We found the medication room was disorganised and in an unhygienic state; the floor was sticky and the bin required emptying. We noted the temperature of the room where medication was being stored was not always being recorded. We also noted there were occasions when prescribed creams were not always being applied as prescribed. We saw hand transcribed entries made on the MAR charts had not been counter-signed by two members of staff to ensure these entries are accurate. During the review of medication systems, we undertook a stock check and found an excess amount of some medications. We discussed some of our concerns with the responsible individual and the manager who both provided assurance that action would be taken to improve concerns identified. We informed the RI that our concerns around the overall lack of management of medication had been referred to the community Pharmacist. We saw on both days that the nurse and care practitioner (CP) started their medication round at 8am and did not finish until after 11.15am. Further details can be found in the attached notice. Although we identified some positive practice such as photographs on MAR records, the overall evidence suggests there was a significant lack of management oversight in this area to ensure medication practices in place were safeguarding people from harm and in line with good practice guidelines. Significant improvements are required in the overall management of peoples’ medication.

The accuracy of personal plan documentation was inconsistent. We reviewed four people’s personal care plan documentation outlining how their care is to be provided, and found significant differences in terms of both the accuracy and quality. We found personal care plan documentation for one person accurately reflected their needs, and was updated and reviewed in a meaningful way. For example, we found for one person, their personal plan had been reviewed and updated following incidents occurring at the service and reflected their current needs, and the care and support they were receiving from staff. Other personal care plan documentation had not been updated when a person’s needs had changed. We

found that the personal care plans did not always contain the necessary advice and guidance for staff as to how they should assist people and they were not updated when peoples’ needs changed. Some care plans were missing and some were difficult to locate. We found personal plan audits had not been carried out for some time. We discussed the inconsistencies found with the responsible individual and manager who advised that they had arranged for a nurse manager and nurse from a sister home to assist in the updating care records. He also advised that the home was currently receiving support from the Practice Development Nurse (PDN). Further details can be found in the attached notice. People cannot be confident their personal plans accurately outline how their care and support needs will be met.

People are not being provided with the quality of care and support they require. We reviewed people’s personal plan documentation and found that the service was not proactive in identifying and mitigating risks for people, and was not referring people on for specialist advice where required. For example, we found the service had documented, numerous times, a deterioration in a person’s physical condition and had not acted on this until five weeks later. We found that when people had been assessed by external healthcare professionals, their prescribed recommendations were not always followed due to poor communication between nurses. We saw that people who were at risk of losing weight and were under the dietician had not been consistently weighed. We could not evidence that people’s monthly weights had been audited. We saw that one person, who was at high risk of falling, had sustained eight accidents whilst trying to mobilise. Their falls risk assessment and personal plan had not been updated or evaluated after each fall. We have issued a non-compliance notice in relation to referrals to healthcare professionals and standards of care and support. People are not supported to maintain their ongoing health, welfare and well-being which is resulting in avoidable deterioration in their health and wellbeing.

People are happy because they can do things that matter to them. Photos on display within communal areas showed people taking part in various activities, individually and within groups, and on trips within the local community. The manager told us singers regularly came to provide entertainment. Other arranged activities included board games, pet therapy, a recent Spanish themed day, pamper day, people recently enjoyed a craft workshop in which local children attended, and visit from a local library. We saw an outside entertainer was visiting on the day of the inspection and people appeared to be really enjoying the music. People were chatting together in a small group; others were reading daily newspapers and watching television. People told us they liked the staff who supported them and they were happy with the support they received.

3. Environment

People are cared for in accommodation that is as described in the home’s Statement of Purpose. People have access to a large conservatory, which is currently being used as a lounge and is well used by the people who live in the home. We viewed most bedrooms, and saw that they were of a sufficient size for people and included an en-suite toilet and basin. Bedrooms were personalised, as the individual wished, and the manager told us rooms were quite often re-decorated before a new resident came in, giving them a choice in colour schemes where possible. The home’s location is within easy driving distance of many community facilities. The home was clean and tidy and free from odours. The home had recently employed three new domestic staff and the domestic hours had increased. Plans were underway to provide an uplifting environment for people living in the home. We saw a small lounge area being redecorated and new furniture and curtains had been purchased, there were plans to install a fireplace in the newly refurbished lounge to make it more homely. The outside of the building was being painted and a refurbishment of a bathroom was underway. The second floor corridor had been re decorated. The new manager spoke in depth about plans to improve the environment and they discussed a proposal they had submitted to the RI. These included updating the external courtyard and updating the corridors to provide a stimulating area with points of interest and developing the dining area to create a positive a dining experience for the residents.

Arrangements are in place to continually assess the safety of the environment and to protect people from harm. We saw continuous environmental health and safety checks were in place to ensure facilities within the building were safe. Records we saw evidenced fire safety checks were routinely conducted and a fire risk assessment was in place. Personal emergency evacuation plans, which recorded the support people required to leave the building in the event of an emergency, were available. The kitchen had received the highest possible score of five (very good) following a foods standard agency inspection. Records we saw, evidenced water temperatures were checked and recorded before the showers were used, to check the water was at a safe temperature before use. We saw heavy furniture, such as wardrobes were secured to the wall, in order to reduce the risk of people pulling them upon themselves. Hoists had been serviced annually to ensure they were operating safely. Risks to people’s health and safety are identified and managed within the environment.

4. Leadership and Management

The arrangements in place to ensure effective oversight of all parts of the service are not sufficiently robust. We found the processes in place to monitor, review and improve the quality of the service were not adequate and were not being completed which had led to several failings in the service. The newly appointed manager told us the responsible individual (RI) visited the home on a regular basis. The RI was present during the first day of our inspection and acknowledged improvements were required to ensure arrangements were in place for the effective oversight of the service. The responsible individual was able to demonstrate plans that they, and the new manager, had put in place to improve the quality of the service prior to the inspection and they had identified failings in the clinical areas. The Practice Development Nurse was supporting the home and was working against a Corrective Action Plan (CAP) recently issued by the commissioners. The manager said they had developed their own action plan on the issues they had identified since being in post. Although the clinical lead nurse had introduced several audit systems, such as care plans, weights, falls and medication audit, we found that they had not been completed. There was also no evidence that the responsible individual had oversight of the auditing processes. We found the responsible individual regularly visits the service and is recording these visits; however, there is no evidence they are monitoring the performance of the service in relation to the aims of the service, and to inform the quality of care review. We also found CIW had not been notified of any Deprivation of Liberty Safeguards (DoLS) applications nor a recent incident involving a staff member’s conduct. We were informed by the RI and manager that the clinical nurse was asked to submit DoLS notifications at the beginning of June and this had not been acted upon. Since the inspection CIW have received fourteen DoLS notifications. Further details can be found in the attached notice. We found the quality of the care given needs to be audited and addressed, to ensure people living in the home receive appropriate, timely care.

During the inspection, we found there were insufficient staff to meet the individual needs of people in a timely manner and we found this was having a negative impact on the well-being of some people. Four people told us via the returned questionnaires, that staff were always rushed and too busy at times to help them get up in mornings, and felt that staffing levels were worse on the weekends. People told us they were reluctant to ask for assistance because they knew staff were busy. Returned questionnaires stated that “Staffing levels are very poor”, “There is not enough staff or management on weekends”, “No one to help if something goes wrong on weekends”. The newly appointed manager had recently completed a dependency tool, which identified that care staff levels were appropriate for level of care required within the service at that time. The home was trying to address this and was actively advertising for nursing and care staff. Two new care staff were undergoing their induction at the time of inspection and an interview for a qualified nurse was scheduled for the near future. However, at the time of the inspection, staff rotas showed the home fell below the ratios number on several occasions. Further details can be found in the attached notice. In light of our findings during the inspection, we conclude that despite the enthusiasm and willingness of staff, people cannot be confident their needs will be appropriately and safely met and nursing levels should be reconsidered.

People living in the home benefit from a service which follows a timely recruitment process. We viewed a selection of staff files. We saw application forms had been completed and

contained references, details of staff members’ educational and work experiences and their qualifications. Records indicated staff members had obtained or were working towards care qualifications at level two or above. We also saw Disclosure Barring Service (DBS) records had been completed and were up to date. Staff files contained a recent photograph of the staff member. The manager showed us a new interview template that they had developed and this would be used for all new potential staff. People benefit from a service where staff members are securely vetted.

Staff undertake some training to help build their knowledge and support them to carry out their role. We viewed staff training matrix which did not accurately reflect the training staff had recently undertaken or were currently completing, so it was difficult ascertain what training had actually been provided. We were told by the manager this was due to restrictions on an electronic system not allowing the user to input staff training information when staff had commenced their training. This was currently being looked at by the provider’s newly appointed training facilitator who stated that it would take much time to update the system and input the changes. The training facilitator confirmed they were new to the role and would be delivering Control of Substances Hazardous to Health (COSHH) training and Health, and Safety training. The manager confirmed nearly all staff had completed mandatory training such as manual handling, fire training, first aid and food hygiene. The manager further informed us training was being arranged in relation to them accessing specialist-training opportunities to further enhance their skills and knowledge base such as dementia care. Staff were in the process of accessing and attending other organised training through the practice development nurse (PDN) from the Local Health Board. Examination of induction records showed that care staff were receiving an induction, but this should be developed further to cover all elements of the Social Care Wales Induction Framework. Staff feel supported in their role. However, action is required to ensure people benefit from a staff team who have received relevant training to meet people’s needs and to ensure all training is evidenced in the training records.

The statement of purpose requires improvement. We reviewed the homes statement of purpose (SOP) and felt it was not a true reflection of the service available to people at Meddyg Care Home, and it did not provide people with an accurate insight into the service they can expect to receive, we have reflected on this throughout the report. The homes SOP states, “We have a registered nurse on duty throughout a 24-hour period and are responsible for the day-to-day management of the clinical care for our residents”. The evidence at inspection contradicted the SOP as follows -we asked the newly appointed manager at the beginning of the inspection if they were registered with Social Care Wales (SCW), they felt she did not have to, as they were not the manager. They were under the impression that their role was assisting the RI who they were told was also the manager of the service. They was unaware that they had been put forward to CIW as the manager. We were told by a qualified nurse during the inspection that they required training in some areas of clinical care such as diabetes, catheter care and that they were not confident in tissue viability care. We also found the home does not provide a person centred personal plan. People did not have access to accurate, accessible information about the service to ensure they are supported to have a thorough understanding of what they can expect from the service at Meddyg Care and whether it will meet their individual needs

Staff told us they do not always feel supported by management or their colleagues. Staff we spoke with told us they did not always work as a good team. Staff told us they do receive supervisions but could not be specific about how often they received them. We reviewed

the staff supervision matrix and found a majority of staff were up to date and were due their supervision in the next month or so. The manager had implemented a new coaching and support template. This would replace the old supervision forms and give a greater emphasis on staff development, reflection and personal development. Staff stated that there was lack of communication from the management and they generally went with the flow. Returned questionnaires from staff stated that “No support from the manager” and “Feel undervalued”, “Never feel I have enough support to do my job properly”. Another person reported they felt “Valued and supported”. We requested minutes from the last staff meetings. The new manager had held two staff meetings since starting in post in May 2019. The manager updated staff regarding the recent changes in the home, which consisted of staff training, importance of documentation, staffing levels, matters brought to the mangers attention related to “a physically challenging dementia patient”. A conversation took place around dementia care and staff were concerned that some people were keeping others awake at night and some were upset by noise and activity. The manager asked if they had received training in dementia care and they staff said they had some awareness but nothing to help them deal with such situations. The manager gave advice in how to diffuse a situation or support a potentially challenging situation. Staff have an opportunity to attend staff meetings and contribute their ideas to the running, and development of the service but some staff do not always feel valued.

5. Improvements required and recommended following this inspection

5.1 Areas of non compliance from previous inspections

None. This is the first inspection of this service since it was approved under The Regulation and Inspection of Social Care (Wales) Act 2016.

5.2 Recommendations for improvement

Communication between staff requires improvement. The responsible individual and newly appointed manager need to familiarise

themselves with what is reportable to CIW under Regulation 60. This is because CIW had not received any Depravation of Liberty Safeguard notifications nor a recent incident involving a staff member.

The manager has not yet registered with Social Care Wales. The service’s Statement of Purpose should be reflective of the actual services

provided in the home. The registered persons should ensure people and their relatives receive written information about the home to help them make an informed decision about whether the home can meet their needs.

6. How we undertook this inspection

This was a full inspection undertaken as part of our inspection programme. This inspection was carried out under the new regulations – Regulation and Inspection of Social Care (Wales) Act 2016. The unannounced inspection took place on the following dates: 3 July 2019 between the hours of 09:00 am and 17:30 pm and 4 July 2019 between the hours of 07:30 am and 12:15 pm.

The following methods were used: We considered the information held by us about the service, including the last

inspection report and notifiable events received since the last inspection. Discussions with four residents and three relatives. Discussions with the responsible individual and manager. We toured the home, observed staff and resident interaction and considered the

internal and external environment. Discussions with seven members of staff. Examination of four resident personal plans and associated monitoring charts. Examination of three staff personnel files and staff training statistics. Consideration of the home’s statement of purpose. Consideration of staff supervision records. Consideration of staff induction. We viewed a sample of the staff rotas over a four-week period. We viewed a sample of the home’s weekly food menus. Consideration of incident and accident records. Consideration of the home’s internal auditing reports. Consideration of the health and safety records, including fire safety. Consideration of the last responsible individual visit report. Consideration of team meeting minutes. Consideration of the home’s policies and procedures. Consideration of resident/relative meeting minutes. We carried out general observations of dining room experience and activity

engagement. We used the Short Observational Framework for Inspection (SOFI 2) tool during

dining experiences. The SOFI2 tool enables inspectors to observe and record care to help us to understand the experiences of people who are receiving a care service.

Further information about what we do can be found on our website: www.careinspectorate.wales

About the service

Type of care provided Care Home Service

Service Provider Meddyg Care Securities Ltd

Manager There is manager who is not registered with Social Care Wales

Registered maximum number of places

44

Date of previous Care Inspectorate Wales inspection

This is the first inspection of this service since it was approved under The Regulation and Inspection of Social Care (Wales) Act 2016.

Dates of this Inspection visit(s) 03/07/2019

Operating Language of the service Both

Does this service provide the Welsh Language active offer?

The service is working towards the Welsh language active offer. We recommend that the service provider consider Welsh Government’s ‘More Than Just Words follow on strategic guidance for Welsh language in social care’.

Additional Information:

Date Published – Wednesday, 11 September 2019

Care Inspectorate Wales Regulation and Inspection of Social Care (Wales) Act 2016

Non Compliance Notice Care Home Service

This notice sets out where your service is not compliant with the regulations. You, as the registered person, are required to take action to ensure compliance is achieved in the

timescales specified.

The issuing of this notice is a serious matter. Failure to achieve compliance will result in Care Inspectorate Wales taking action in line with its enforcement policy.

Further advice and information is available on CSSIW’s website www.careinspectorate.wales

Meddyg Care Nursing Home (Porthmadog)

BRYN MEDDYG CARE NURSING HOMEGARTH ROAD

PORTHMADOGLL49 9BN

Date Published – Wednesday, 11 September 2019

Welsh Government © Crown copyright 2019. You may use and re-use the information featured in this publication (not including logos) free of charge in any format or medium, under the terms of the Open Government License. You can view the Open Government License, on the National Archives website or you can write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: psi@nationalarchives.gsi.gov.uk You must reproduce our material accurately and not use it in a misleading context.

Care and Support Our Ref: NONCO-00007983-RQKW

Non-compliance identified at this inspection

Timescale for completion 22/08/19

Description of non-compliance/Action to be taken Regulation number

The service provider is not compliant with ‘The Regulated Services (Service Providers and Responsible Individuals (Wales) Regulations 2017’ 58. This is because the service provider has failed to ensure there are safe systems for medicines management.

58(1)

Evidence

The evidence:

We completed a full medication audit during the inspection with the clinical lead nurse and found the following:

• No medication audits could be produced by the clinical lead nurse or the registered person on the day of inspection to evidence continued oversight or monitoring of medication administration and management The clinical lead nurse confirmed medication audits are not conducted in the service and that they should be done every month. They were not carried out due to the lack of time she had and attending to other clinical duties and being the only nurse on duty. She explained she was allocated three supernumerary days per week to conduct such audits but was unable to as she often assisted the other nurse on duty with clinical commitments.

• Opening and expiry dates were not recorded on prescribed creams.• We saw there was generally an over stock of Movicol laxatives for people which had not

been administered from the previous two months. We saw six boxes in total for one person. We looked at the MAR charts and found the prescription was scheduled to be administered and the nurses had signed to say it had been administered for the people it was prescribed for. The overstocking could not be explained unless the medication was not administered by the nurses as per the prescription.

• We saw several hand written Medical Administration Records, (MAR), charts had not been signed by two nurses where it is required for them to do so.

• We saw the clinic room was cluttered and untidy.• Clinic room temperatures were not always carried out daily - several gaps seen for May

and June.• Medicine fridge temperatures were not always carried out daily. There were several

gaps seen for May and June. The medication fridge was not lockable as recommended by the Royal Pharmaceutical Society.

• Allergies were not recorded on two people’s charts.• We saw o/s (out of stock) was written for one person’s medication on the 3/7/19, the

2/7/19 was blank and on the 1/7/19 it had been signed to say it had been administered. We

asked the clinical lead nurse why this medication was out of stock. She said she had just noticed it and would look into it. We looked at the MAR charts for June and saw this medication was not recorded. The May MAR chart showed the GP had stopped this medication. It was unknown if this medication had actually been administered on 1/7/19, but this demonstrates a lack of oversight of people’s changing prescriptions and failure to update medication records.

• We saw the controlled drugs checks were not being carried out despite there being a note on CD cupboard door for nurses to check every week. We saw blank pages in the controlled drug book. The clinical lead nurse did not know why the nurses failed to check the controlled drugs on weekly basis. This also demonstrates a lack of management oversight.

• We saw the two medication waste bins were full and overflowing. There was medication in a cardboard box on the floor. The clinical lead nurse said the bins had not been collected. The manager explained shortly after she started her new position in May 2019 she had arranged for the medication waste bins to be collected and replacements were left. This is evidence of significant overstocking or medications not been given.

• We saw one person had been given an incorrect dose of Oramorph. The prescription stated give 1.25mls or 2.5mls 30 minutes before dressing changes. We found on1/7/19 a nurse had administered 1.5mls at 2350hrs before a dressing change. This had no effect as the nurse had documented the person was in pain. At 0330hrs a second dose of Oramorph was given. However, only 1ml was administered which was under the prescribed dose. This dose was not adequate to manage the person pain during the dressing change as they had documented that some relief had been given at this time.

• We saw the medication fridge was overflowing with excess medications. There was no room to store any further medication safely. We saw seven boxes of Nova Rapid (5 x pens in each box) for one person. Six boxes for another resident. We saw excess stock of eye drops and other medications. We asked the clinical lead nurse why there was so much excess stock being kept in the fridge as it was unsafe and wasted valuable financial resources on the health service. She said she did not know, and said she keeps putting the excess stock in the medication waste bin and the cardboard box ready for disposal but someone keeps putting them back in the fridge.

• We saw several boxes of Warfarin in a cardboard box on the floor amongst a surplus stock of other medications ready to be disposed of.

• We saw there was an excess stock of prescribed creams for people. We saw five tubs of Cetraban for one person, four tubs of Zerobase for another and seven tubs of Cetraban for another person. We saw that staff had documented to say it had been applied.

• We saw a cupboard which stored individual baskets, they had people’s room numbers on them. The clinical lead nurse explained the new monthly medications for the individual are placed in the basket and then the night nurse should then place the new month’s meds in the pods in the trolley when the new cycle is due. We saw that this did not happen. The new monthly medication was still in the individual baskets in the cupboard and there was a significant amount of new stock and old medication mixed up in the medication pods in the drug trolley.

• We saw several handwritten MAR charts. We asked the clinical lead nurse why the charts were not printed. She explained the charts do not always come with the monthly medications hence the hand written charts. She said this is because the pharmacist delivery is late and they do not always have enough time to print off the MAR charts. We could not see that the nurses had requested printed copies of the missing MAR Charts. We discussed this with the manager who explained this happens because the medication order goes in late from the home. We were told by the manager that a meeting had been arranged with the pharmacist to discuss the current issues regarding medication management.

• We saw some printed MAR charts did not show the key codes which explained why the medication was not administered and some MAR charts were mis-printed making it difficult to follow what medication is prescribed.

• We observed the medication round over two days. We saw the medication round started straight after handover at 8am and carried on until after 11.15am. A care practitioner administers medication on one floor and nurse on another. We were concerned about the time taken to administer medications at the prescribed time and discussed this with the clinical lead nurse. We were told it was like this on every shift as the nurse will answer phone, speak to Dr, attend any clinical duties such as dressings and attend all other queries. We specifically enquired how antibiotics and Parkinson medications were administered on time. She asked how does one nurse administer Parkinson’s medications to three people at the same time it is not possible. This was discussed with RI and the manager who said they were receiving support from the Practice Development Nurse from the health board (PDN) and this matter would looked at.

• Due to level of concerns found by the inspector during the medication audit, a referral was made to BCU Community Pharmacist during the inspection on the 3rd July 2019. The concerns were also fed back to the responsible individual and manager. The RI gave assurances that all the concerns identified would be addressed quickly and had requested a qualified nurse from a sister home to come to Meddyg on Friday 5/7/19 to address these issues.

Inappropriate staff practices and the absence of an auditing system means medication administration practices are not safe, robust or in line with current medication management and administration requirements. The impact for people using the service is that people’s health and well-being is at significant risk of harm because neither the registered persons nor staff are learning from known errors to inform future practice. This leaves medication management at the service open to confusion and abuse.

Care and Support Our Ref: NONCO-00008098-JDTD

Non-compliance identified at this inspection

Timescale for completion 22/08/19

Description of non-compliance/Action to be taken Regulation number

The service provider is not compliant with ‘The Regulated Services (Service Providers and Responsible Individuals (Wales) Regulations 2017’ 15 (1), (2) and (7). This is because the service provider has failed to prepare an accurate personal plan for all individuals as to how their needs are to be met. Personal plans and associated documents are not always available, reflective of people’s needs and risks, and they contain conflicting information.

15(1)

Evidence

The evidence:• We saw person ‘A’ had bilateral leg ulcers since admission to the home and the staff

nurses in home were attending to the dressings. We saw a care plan had been implemented. We found the information contained in the plan to be very basic and did not provide information how to manage the wound, how often to dress the ulcers or what dressings to use. The care plan referred the nurses to a wound dressing schedule which was said to be on the white board in nurse clinic room. We checked the white board in the clinic room and it was blank. The nurse on duty was asked how did she know what dressings to use and the overall management of the ulcer. She replied “I just follow what everyone else does, I think it might be daily but I’m not sure”.

• We looked at person ‘A’s wound file and found that the wound management documentation was placed in the file. However, it had not been completed. We saw that the nurses had been documenting when the dressings had been changed and no further information was seen in the care documents.

• We saw that person ‘A’ had become unwell on 1/7/19 and was seen by their GP and a course of antibiotics was prescribed. During the day their health deteriorated and they were admitted to hospital. Person ‘A’ was discharged from hospital on the 2/7/19 with a diagnosed urine infection. We sat in a morning handover and the night nurse told the day nurse person ‘A’ was on antibiotics for a leg infection. This contradicts what the diagnosis from the hospital which stated urine infection.

• We discussed persons ‘A’s care with a member of staff who stated ‘A’s health had deteriorated in the last three weeks and we thought ‘A’ was septic last week, not eating or drinking-‘A’s off their food.

• We saw person ‘A’ had a history of re-occurring urinary infections. There was no care plan in place to instruct staff what the signs and symptoms were or actions to take to help prevent possible future infections.

• Person ‘A’s communication care plan stated there were no known problems with their hearing. This contradicts a BCU recent assessment which stated “Has difficulties in

expressing them self and comprehend. Hard of hearing”. This care plan document was last reviewed on 19/5/19 and no changes were recorded to reflect the information from the health board assessment.

• We could not see there was pain assessment tool being used or that there was a pain management care plan in place for person ‘A’.

• We case tracked person ‘B’s care notes and found ‘B’ had a history of a deep vein thrombosis (DVT), pulmonary congestion and had a diagnosis of diverticulitis. There was no care plan in place to instruct staff what the signs and symptoms were.

• We saw person ‘B’s communication care plan gave very little information and did not state person ‘B’ was blind in one eye. It was generic and pre populated electronically by the computerised care system.

• Person ‘C’ had a diagnosis of dementia and had been recently admitted to the home. ‘C’ had a numerous medical conditions relating to their back. We were unable to locate person ‘C’s care documentation and risk assessments on the electronic care system and requested the assistance form the manager and senior carer. They were unable to locate the care documents either. The clinical lead nurse found a couple of pre-generated care plans which were generic and did not give any information.

• We saw person ‘C’ had a history of anxiety and depression. There was no care plan in place to inform staff in home to manage person ‘C’s anxiety, what the triggers were and how to manage this.

• Person ‘C’ communication care plan was generic and did not give information regarding the bi-lateral cataracts and how this this impacted on their mobility and general well-being.

• It was unclear what diet type person ‘C’ was on and what their likes and dislikes were as there no information recorded in their care plan.

• We saw person ‘D’ had a diagnosis of dementia and lacked mental capacity. We saw a behaviour care plan was in place for ‘D’ and it stated ‘D’ can be aggressive- verbally and physically during washing and dressing. The instructions to staff given were “Explain in a calm voice that this is not acceptable behaviour inside the home. Remove scissors, knifes that may harm ‘D’. The advice documented in the persons care plan was not appropriate or a recognised method for managing a person with a challenging behaviour and it is advised that the responsible individual seek specialist advice in this area.

The impact on people using the service is they may not receive appropriate care and support from staff to meet their assessed needs effectively, if personal plans are not accurate, up to date or reviewed. A lack of detailed risk assessments does not ensure people are safe from unnecessary harm.

Care and Support Our Ref: NONCO-00008099-VWTK

Non-compliance identified at this inspection

Timescale for completion 22/08/19

Description of non-compliance/Action to be taken Regulation number

The service provider is not compliant with ‘The Regulated Services (Service Providers and Responsible Individuals (Wales) Regulations 2017’ 21 (1). This is because the service provider has failed to ensure that care and support is provided in a way that protects, promotes and maintains the safety and wellbeing of individuals.

21(1)

Evidence

The evidence:

• We saw nurses had documented several times in the dressing record charts that from the 21/5/19 person ‘A’ was in pain and they reported there was green streaked discharge from the leg ulcer. We could not see that the nurses had requested the advice from the GP or Tissue Viability Nurse. Person ‘A’ was seen by their GP on 18/6/19 and antibiotics were prescribed for an infected leg ulcer and pain relief was prescribed. There had been a delay of 4 weeks where person ‘A’ had been receiving inadequate pain relief during dressing changes and a delay in seeking medical advice.

• We saw person ‘A’ had been given an incorrect dose of Oramorph. We found on1/7/19 a nurse had administered 1.5mls at 2350hrs, and then 1ml was again administered at 0330hrs. The prescription stated give 1.25mls or 2.5mls 30 minutes before dressing changes. We looked this person’s care notes for the time stated and found the nurse had documented this person was actually in pain when they changed the dressing. The manager was aware of this incident and had escalated her concern via a Datix. A Datix is a database for reporting significant events used by health services. She was also enquiring why the night nurse was changing a dressing in middle of the night.

• We saw a note documented in the nurses communication book on 29/6/19 stating “Person ‘A’s- dressings last renewed on 27/6/19- legs are soaking wet, pool of water under chair, dressing stuck to legs painful to remove”. The failure in renewing dressings in a timely manner had led to unnecessary discomfort for person ‘A’.

• We saw person ‘A’s weight had not been carried out on a monthly basis as instructed in their care plan. We saw this person had lost a total of 5kg from August 2018 to April 2019. We could not see that any weights had been carried out since April 2019. We were told by the clinical lead nurse the “June weights are lost, the paper is missing”. We could not see person ‘A’ had been referred to a dietician for advice or that a fortified diet had been offered.

• We looked at person ‘B’s diet and fluids care plan. The care plan stated - refer to likes and dislikes when providing menu choices, no other information was recorded. Weigh every month and record. May require minimal assistance x 1 staff. We saw person ‘B’ had lost 10kg from December 2018 to April 2019. We could not see that weights had been carried

out in February, March or May 2019.The last recorded weight was documented in April 2019. The clinical lead nurse said all residents weight for June were lost. We saw the person’s care plan was last reviewed in March 2019 and the evaluation stated “weight stable”. Person ‘B’ was referred to dietician in May 2019 and staff were advised the Dietician could not visit until the end of June and staff should offer person ‘B’ a fortified diet. We saw no evidence that a fortified diet has been offered to person ‘B’ and we were unable to assess if the weight loss had continued due to lack of documentary evidence.

• We were told by the clinical lead nurse that she needed to take blood and obtain a wound swab from person ‘B’ as they had been confused and had blisters. These instructions were reported to her in handover that morning. She stated she did not know who had requested them as there was nothing documented anywhere. She expressed concerns that person ‘B’ was asked to stay in their room as a precaution until a diagnosis was made. The clinical lead nurse phoned the GP surgery for clarification and there was no information logged on their system. It later transpired after much conversation and hours of the clinical nurse’s time that the nurse on shift from the previous day had requested a GP visit for ‘B’ and was seen by advanced nurse practitioner (ANP). The ANP had requested blood tests and a wound swab the previous day but the nurse on duty had failed to document what actions were required in the person’s GP notes but had documented the instructions from the ANP in the person’s daily records. The clinical lead nurse stated that the information should have been recorded in the GP notes where it would have been easier and quicker to access without going through all the records. On our return visit the following day we found the blood tests and wound swabs still had not been done. The nurse on duty was not qualified to take bloods so had to ask the GP surgery to send a practice nurse. The surgery was unable to do this until the following day. It is concerning that there was very poor communication between the nurses regarding a basic nursing task which had led to a delay in diagnostic tests and causing person ‘B’ to be possibly isolated in their room for longer than necessary which could impact on their mental well-being.

• We could not see that a pain assessment tool was used on person ‘C’ or that there was a care plan in place regarding the pain management for diagnosed medical conditions relating to their back problems and a hiatus hernia.

• We saw person ‘C’ was at a high risk of falling and had diagnosis of Parkinson’s. We could not see that there was a falls risk assessment. The falls care plan was generic and did give any information for staff. There was no care plan for management of their Parkinson’s disease.

• We looked at the care file for person ‘D’ who had a history of falling. We saw staff had recorded in their behaviour care plan that ‘D’ may occasionally sit on the floor. Staff to check frequently- approx. 10-15mins. We found staff had documented, between 5/6/19 to 3/7/19, ‘D’ was found on the floor nine times. Staff had assumed ‘D’ had put them self on the floor and had not checked for injuries. One resident alerted staff about one of the falls. We found no evidence to demonstrate that staff had taken any action to establish the reasons for the falls, or to support ‘D’ whilst moving around the home or to prevent falls occurring.

• We could not see in any documents that staff had been monitoring ‘D’ every 10-15 minutes to ensure their safety.

• We saw there was a completed falls risk assessment in place. However, this was not updated after each fall.

• On the 4th July the manager told us that a care staff member had informed the clinical lead nurse on the morning of 3rd July that resident ‘X’ was feeling unwell and they thought ‘X’ might have a urine infection, they asked if the clinical lead nurse could check ‘X’’s urine. The manager said the clinical lead nurse had not seen the resident nor had she obtained a urine sample. This was not carried until the afternoon on the 4th July when the manager had

intervened and asked another nurse on duty to obtain a urine sample.

The impact for some people is that their physical, emotional and mental well-being had significantly deteriorated due to the poor care and support they have received whilst living at the home. Some of this deterioration could have been avoided as some people were not receiving care and support in line with their current needs.

Leadership and Management Our Ref: NONCO-00008100-FKSM

Non-compliance identified at this inspection

Timescale for completion 22/08/19

Description of non-compliance/Action to be taken Regulation number

The service provider is not compliant with ‘The Regulated services (Service Providers and Responsible Individuals (Wales) Regulations 2017’ 66. This is because the responsible individual has failed to supervise the management of the service.

Evidence

This is because:

- The responsible individual had not ensured proper oversight of the management, quality, safety and effectiveness of the service in relation to tissue viability, falls, medication management and staffing levels. The home does not always operate in accordance with its statement of purpose:

- We found significant issues with the management of medication at the service. Medication audits had not been carried out. Failure to manage people's medication effectively and accurately puts people’s health and safety at risk because of potential medication errors.

- We found care plans were not being properly overseen and updated, some care plans were missing and did not provide sufficient detail to ensure people were supported with all their care needs.

- We requested that the responsible individual forward a copy of his last visit to the service. We received the document four days after the inspection on 8th July 2018. We noted that some information in the report had been discussed with the manager and responsible individual during the inspection on the 3rd July 2019 and they had not identified the issues themselves at the time of the inspection. We are not confident the report was completed prior to the inspection.

- We found that the staff training matrix was not up to date and did not give a true reflection of what staff had actually attended. This made it difficult evidence actually what training had been given to staff and what training was due.

- We found that the service did not have robust systems in place to oversee and monitor the health needs of people nor robust arrangements for seeking timely intervention from other health care specialists. In addition, there was a failing in the oversight of these systems by the management, consequently the required referrals were not made and some care interventions were not carried out.

- The service is in escalating concerns with the local authority and both the local authority and local health board are currently not placing people to live in the home. Due to the significant concerns found during this inspection on the 3rd and 4th July which relate to the standards of care provided at the care home, issues identified during the inspection have been shared with the Safeguarding team and BCU nurse reviewers.

The impact on people using the service is people will not benefit from effective continuity of care, therefore people are at risk.

Leadership and Management Our Ref: NONCO-00008101-GNVW

Non-compliance identified at this inspection

Timescale for completion 22/08/19

Description of non-compliance/Action to be taken Regulation number

The service provider is not compliant with ‘The Regulated Services (Service Providers and Responsible Individuals (Wales) Regulations 2017’ 34 (1), (2), (3) and (4). This is because the service provider has failed to ensure people are supported by appropriate numbers of staff who have the knowledge, competence, skills and qualifications to provide the levels of care and support required to achieve their personal outcomes.

34(1)

Evidence

The evidence includes:

• The home provides personal and general nursing care for up to 44 people. The home currently accommodates 37 people of whom, 23 people have complex nursing needs, and there were 15 residents in receipt of personal care at the time of the inspection.

• The home does not have a full complement of nursing staff permanently employed. The home had three permanent nurses working in the home at the time of this inspection and within this number it included the clinical lead nurse. Two other nurses were on long term leave which left the three permanent nurses to cover day and night shifts. These nursing shifts had been replaced with bank and agency staff. We were told the clinical lead nurse had handed in her notice but no leaving date had been given. The RI told us the clinical lead nurse works three supernumerary days per week and one day undertaking clinical care. This allocated time was used to provide an oversight of clinical duties such as auditing of medication, falls, and care documentation. We saw staff rotas from 17/6/19 to the 30/6/19 confirmed this. However, we found no evidence of auditing of any clinical areas as described throughout this report. The clinical lead nurse explained that she did not have time to complete such tasks as she was always busy helping the nurse on duty with the clinical care because there was not enough nurses on duty to attend to all tasks.

• We have requested on several occasions that the responsible individual provides evidence of the clinical oversight of the home and that a general nurse, or a nurse who is experienced in general nursing, is on duty 24 hours a day. To date CIW have not received this information despite several requests.

• The numbers of nurses on duty does not allow for the oversight and supervision of care delivery leading to people being placed at risk as evidenced by the incidents identified in this notice.

• People who spoke to us during the inspection and provided information in returned questionnaires, expressed concerns that there is only one nurse on duty from 8.00am until 8.00pm Monday to Sunday. The nurse was supported on a daily basis by a care practitioner

to assist with the administration of medication to residents.• During SOFI observations we noted that the staff seemed disorganised, staff were

rushing about, and they didn’t seem to have time to sit and talk with people.• We made several requests to the responsible individual and manager for staff rotas from

17th June to 22nd July we only received the rotas from 17th June to 30th June. We saw there was a shortage of care staff on most days from the 17th to 23rd June. On some days the care staff numbers went down to 4 care staff in the morning and four in the afternoon. One another day only five care staff worked from 8am to 8pm. The care staff numbers should have been eight care staff from 8am to 8pm. Three people we spoke with, including a visitor, were concerned about the low staffing levels and informed us that the care giving is often rushed. In returned questionnaires received, three staff commented that the home was often short staffed especially on the weekends. People also told us that, although the staff were very kind and caring in their attitudes, they were always very busy and tired.

• We could see from one person’s care records that they had suffered nine unwitnessed falls, which indicates that people are not supported sufficiently with their mobility needs or adequately supervised given that the majority of the falls were not seen by staff. Instructions in this person’s care notes stated they required 10—15minutues observations to ensure their safety. We saw this was not carried out.

• We saw on both days, the 8am medication round continued until after 11.30am and next medication started soon after lunch. The afternoon medication then started at 2pm. This did not match with the required duration periods between doses as stated in the prescription.

• At the time of the inspection, a nurse explained that they had recently qualified as a Mental Health nurse (RMN) and had not long started in the home, she had been requesting training in some specific clinical areas but was unable to attend due to other commitments. She stated that she felt out of her depth in some clinical areas and copied what others nurses had been doing such as dressing changes. She said, that as she was the only nurse on duty during the day, she did know who to go to for any clinical advice as the new manager was not a qualified nurse.

• The Clinical Lead nurse told us she had three supernumerary shifts per week and worked one day providing clinical care as the only nurse on duty. She told us she had been unable carry out her clinical duties such as auditing, staff supervision and other commitments as she was busy working on the floor and helping the nurses on her supernumerary days

• In general, the dependency level within the home at the time of the inspection visit was high with the majority of people requiring two care staff to attend to their needs. The manager had used a dependency tool to ascertain the number of care staff required and to ensure staff are allocated accordingly. It identified that eight care staff were needed from 8am to 8pm. We saw, on several days, staffing levels fell below this number.

The responsible individual is not ensuring there are systems and processes in place to ensure there are adequate numbers of staff who are sufficiently trained, competent and skilled to undertake their role; and who receive ongoing training and development. The lack of oversight in terms of staffing, to ensure people’s immediate and longstanding needs are met, is putting people’s health, welfare, wellbeing and dignity at significant risk.