We submitted a factual accuracy response form to which you can see our comments and responses below
To whomever it may concern,
Please see the attached factual accuracy comments form.
Please be aware that the form was unable to be correctly formatted past a certain amount of pages but we have clearly marked the key questions in the titles of each section. The page numbers include all the pages of the report as evidence is taken from all areas but the actual statements used as evidence within the report are always clearly referenced throughout the response comments.
We would like to start our response by saying that Flixton Manor is a caring and trustworthy nursing home and we do our very best to ensure the residents within our nursing home are well cared for and looked after to the very best of our ability. We know that any service can always improve its standards and we look to do this in a common sense manner that will have an actual real and positive impact on the residents who live at our home.
We welcome feedback and constructive criticism and always action anything we feel would help our residents quickly and promptly. We try to promote an informal atmosphere where any resident staff or family member can raise their concerns easily and at any time and we encourage everyone to voice their opinions and seek out our support wherever they feel necessary.
We see our staff team as a close family and have a core group of staff that have been with our home between 10 and 20 years. Our common sense approach to care has always served us very well and our 30 years’ experience running a successful nursing home has taught us many lessons and ways to implement care in an efficient, reliable and robust manner. Over the years due to our caring staff, many of who are still with us today, we have received hundreds of glowing comments, letters of appreciation and kind and complementary words said about our nursing home.
This means the world to us and to this day, these comments continue to pour in which is the primary motivator for our nursing home and staff. Happy residents and family members are what running a nursing home is all about and seeing the positive difference that we can make to people’s lives is worth more than anything to all of us at Flixton Manor. It takes very special people to work in a nursing home and this is clearly a job motivated by the rewards we get out of helping others.
We were extremely disappointed with the outcomes identified within our recent inspection and whilst we welcome some areas of constructive criticism, we found a very large number of factual inaccuracies within the report that have forced us into this thorough and lengthy response to justly protect the good reputation that our home has built up over the last 30 years.
We hope that this response it taken seriously and dealt with fairly and thoroughly based on our evidence and observations.
Due to everything that we have pointed out as not relevant or factually incorrect within this report we see no reason for our nursing home to be placed under “special measures” and find the consistency, accuracy and evidence in this report to be flawed in virtually every area with regards to this outcome. In the 30 years that our nursing home has run we have never been placed under “special measures” and feel that the quality of our care is better now than it ever has been in the past. There is numerous statement’s from staff, residents, family members and outside professionals to support this within this inspection reports own findings and many of the findings contradict the outcomes suggested in the report especially when considered against the corrections in relevance and factual inaccuracies outlined in this response.
It is very sad and disappointing that this inspection and report was conducted in this way as Flixton Manor does not seek out adversarial relationships with any outside agency, professional or governing body and simply look to take on board helpful and intelligent criticism and improve the standards of care with in our home with the ultimate view of improving our residents’ quality of life.
We aim to have a constructive and co-operative relationship with the CQC as after all we are both seeking the same outcomes which is to provide the best quality care to the residents within our home. We do not find this report to be consistent with an organisation that is seeking these goals as under the section “Action we have told the provider to take”, there is not one single action listed but rather a list of “alleged” breaches in regulations with no advice or recommendations has to how to remedy these “alleged” breaches.
We do not find these to be the actions of a caring and helpful organisation looking to help improve the lives of vulnerable residents but an unsupportive and false statement that offers no constructive criticism. It is clear from this report that we find all alleged breaches apart from regulation 16 which has already been corrected, to be false and unsubstantiated. A report like this has real consequences to our good reputation and for the moral of our staff and unless this report is amended accordingly, we have been placed in a position where we have no alternative but to seek legal action against the CQC for publishing a factually inaccurate report that is not a genuine and fair reflection of the care in our nursing home. These false breaches in regulations are evidenced very clearly in the CQC’s own findings from the inspection and so create a conflicting, confusing and contradictory report that is inconsistent with itself and previous inspections carried out within our nursing home.
We hope that we can work together to correct and amend this report accordingly as we genuinely wish to have a good relationship with the CQC and welcome their inspections as constructive ways for us to improve our service.
—
Yours Sincerely
Rashad Al-Safar
Flixton Manor – Company Director
Direct +44 161 746 7175
Mobile +44 7772 480 414
Website www.flixtonmanor.com
Email rashad@flixtonmanor.com
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Company number: 7654283 (England & Wales)
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To whom ever it may concern,
We then received the following
Your account number: 1-303667371
Our reference: INS2-2445278139
| Rashad Al-Safar
Flixton Manor 2-8 Delamere Road Urmston Manchester Greater Manchester M41 5QL
|
5 October 2016
Care Quality Commission
Health and Social Care Act 2008
Factual accuracy check
Location name: Flixton Manor
Location ID: 1-303667371
Dear Mr Al-Safar
Comments on Draft Inspection Report (Factual Accuracy)
Following our recent inspection of Flixton Manor we have drafted the inspection report which is enclosed for your information.
If you have any comments about factual inaccuracies or the completeness of the evidence in the report, please send them to us by 19/10/2016. Any factual accuracy comments that are accepted may result in a change to one or more ratings. You should record your comments using the categories set out in the factual accuracy comments form provided. Please do not send in a pdf format.
If you do not have any comments to make and are happy for the report to be published, we would be grateful if you could please advise us of this prior to the deadline for comments. We can then publish the inspection report on our website.
We would prefer you to send this information to us by email, to this address: HSCA_Compliance@cqc.org.uk. If you are unable to do so, please send it by post to the address shown below.
Please include your account number (1-303667371) and our reference number (INS2-2445278139) in your letter or email as it may cause delay if you do not.
We will review your comments and amend the report if we consider it appropriate to do so. If we do not accept your comments we will explain why.
If we do not receive any comments from you by the date shown above, we will finalise the report and publish it on our website.
Ratings used in the Draft Inspection Report
Your draft inspection report has been produced using our new approach to regulating and inspecting adult social care services. For adult social care services, part of this approach is the publication of ratings for each service, at both key question and overall location levels. Ratings are awarded on a four-point scale; ‘Outstanding’, ‘Good’; ‘Requires Improvement’, or ‘Inadequate’.
Ratings are awarded by comparing the evidence we gather during inspections with the characteristics of ratings we have published in the provider handbooks and appendices. Ratings are awarded for each of the key questions inspected. We then use rules and principles to aggregate all five key question ratings into one overall rating for your location. For focused inspections, we will only award a new rating to the key question(s) inspected; for key questions not inspected, the previous ratings continue to apply.
Please note, where a focused inspection is carried out more than six months after the comprehensive inspection, the revised key question ratings will not usually lead to a change of the overall rating. This is because we will not be able to make judgements about all aspects of the service at a reasonably similar time, which we must be able to do to change an overall rating.
We will explain how and when you can request a review of your ratings in the letter we send with the final report. You can only request a review of your ratings if you think we have not followed our published process for awarding ratings.
The table below shows the ratings this location has been awarded for this inspection:
| Safe | Effective | Caring | Responsive | Well-led | |||||
| Key question
rating |
Requires Improvement | Requires Improvement | Requires Improvement | Inadequate | Inadequate | ||||
| Overall location
rating |
Inadequate | ||||||||
If you have any questions about this letter, you can contact our National Customer Service Centre using the details below:
Telephone: 03000 616161
Email: HSCA_Compliance@cqc.org.uk
Write to: ASC Inspections
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
Yours sincerely,
Michael Gorton
Inspector, Adult Social Care
Enclosed:
- Draft report
- Factual accuracy comment form
Factual Accuracy Comments Form
You are invited to provide comments on the accuracy of this report and the completeness of the evidence on which the ratings are based.
We will be able to respond to your comments more effectively if they are received on this form.
Please note this is your last opportunity to provide evidence that you consider should be taken into account in the report, or comment on the interpretation of evidence or the impact of evidence on the judgement. (This must be limited to evidence that was available at the time of inspection).
Challenging the evidence and ratings
Factual accuracy process (before report publication)
Ratings can be changed if the evidence on which they are based is wrong or incomplete. Most concerns about ratings errors should be dealt with through this factual accuracy process.
Rating review process (after report publication)
A rating review involves checking whether or not CQC followed its published methodology (the guidance in the provider handbook and appendices) in making judgements and awarding the rating(s). We will explain how and when you can request a review of your ratings in the letter we send with the final report. A rating review does not involve a reconsideration of the evidence and ratings awarded, unless we find the process has not been followed.
Complaints
Complaints about the conduct of the inspection should be directed to Complaints@cqc.org.uk. They will not be considered as part of the factual accuracy process or a rating review.
Warning Notices/Enforcement Action
Representations should be directed to HSCA_Representations@cqc.org.uk using the appropriate forms. They will not be considered as part of the factual accuracy process or a rating review.
Factual accuracy comments form
Please complete this form and return:
By email to: HSCA_Compliance@cqc.org.uk or
By post to: CQC ASC Inspections, Citygate, Gallowgate, Newcastle upon Tyne, NE1 4PA
| What does your challenge relate to? | Go direct to: |
| Typographical/numerical errors | Section A |
| Accuracy of the evidence in the report | Section B |
| Completeness of the evidence | Section C |
| Conduct of the inspection | Complaints via email to Complaints@cqc.org.uk |
| Representations against a Warning Notice | Representations via email to HSCA_Representations@cqc.org.uk |
| Account Number: | 1-303667371 |
| Our reference: | INS2-2445278139 |
| Location name: | Flixton Manor |
| Location address: | 2-8 Delamere Road, Urmston, Manchester, Greater Manchester, M41 5QL |
| Completed by (name(s)) | Rashad Al-Safar |
| Position(s) | Owner |
| Date | 18-10-2016 |
| Section A: Typographical / numerical errors in the draft report | ||||
| Page No | Key Question
e.g. Safe |
Please set out any typographical or numerical errors
e.g. Operations Director not Operations Manager If the same error occurs more than once, it is sufficient to identify the first occasion, adding “(throughout the report)”. |
CQC decision
✓or X |
CQC response
|
| Section B: Other challenges to the accuracy of the evidence in the draft report | ||||
| Page No | Key Question
e.g. Safe |
Please set out any other challenges to the accuracy of the evidence in the draft report (providing evidence demonstrating the inaccuracy) and describe any impact on the rating(s). Challenges to the interpretation of evidence/importance attributed to the evidence should be included here. Any evidence provided must relate to the position on the day of inspection. | CQC decision
✓or X |
CQC response
If you agree to make amendments you must confirm any impact on breaches or the rating. If you choose not to make any amendments you must provide a rationale. |
|
|
Is the service safe? | Is the service safe?
The inspector states The service was not always safe. We do not accept this as a factual accuracy and request this be removed due to the below points and as by the inspectors’ own findings that Everyone we spoke with said they felt safe living at Flixton Manor. They said the staff were kind and caring. Staff had received training in safeguarding adults and knew the correct action to take if they witnessed or suspected abuse. Staff were confident that the registered manager would act on any concerns raised.
A further statement was made stating
The recruitment process was not robust enough to ensure only suitable people were employed. Staffing levels meant the staff were task orientated and had little time to interact with people who used the service.
This comment about recruitment procedures not being robust enough to ensure that suitable people were employed would suggest that there is evidence that we have unsuitable staff working within the building who pose a “safety” risk to our residents or each other and yet no evidence has been found to show that any particular staff member is unsuitable or unfit to be employed. Flixton Manor has fantastic dedicated and caring staff members within our team, a fact that has been evidenced multiple times within the inspectors finding. A lack of full employment history or references is not evidence that a staff member poses a “safety” risk to a resident or another staff member.
All new staff are fully supervised at all times until made permanent and we feel that as a nursing home with 30 years’ experience, we have the ability to make our own judgements during this period about a person’s character and ability to work safely within our home.
There has been no evidence to suggest the contrary and no allegation of neglect or abuse against our home or our staff members has ever been substantiated. Further to this, opinions can differ greatly from employer to employer and we rely on our own common sense and judge of character more than any other attribute to employ suitable and “safe” people within the home. In some situations, people for whatever reason have gaps in their employment history and on many occasions employers are not willing to provide references. This does not mean they are of poor character and “unsafe” to work and we would find this kind of judgement to be discriminatory and unfair in allowing people the chance to show their abilities and make a positive contribution to our residents and society.
Flixton Manor values kind, caring people with a willingness to learn and improve more than a simple statement from a person we have no knowledge of. We are confident that we have a keen sense of judgement when it comes to recognising these qualities and this has always served us well in the many years running a well reputed and established nursing home.
References are always sought but not always received and in order to satisfy the inspectors points we will make extra efforts to gain a more detailed employment history and obtain 2 references in the future. However, we will not accept that our service is unsafe and stand by our staff members as caring hard working individuals who pose no safety risk to our residents or anyone else.
The inspection report states
Accommodation for persons who require nursing or personal care Treatment of disease, disorder or injury Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed.
We found the lack of references and full employment history to be a breach of Regulation 19 (2)
We quote regulation 19(2) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
19 Fit and proper persons employed (1) Persons employed for the purposes of carrying on a regulated activity must– (a) be of good character, (b) have the qualifications, competence, skills and experience which are necessary for the work to be performed by them, and (c) be able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the work for which they are employed. (2) Recruitment procedures must be established and operated effectively to ensure that persons employed meet the conditions in– (a) paragraph (1), or (b) in a case to which regulation 5 applies, paragraph (3) of that regulation
The above regulation does not state any requirement to obtain 2 references or obtain a full employment history and only states that people should be able to perform tasks that are intrinsic to the work for which they are employed, be of good character and have the qualifications, competence, skills and experience which are necessary for the work to be performed by them. Our recruitment procedures place staff on a fully supervised training and trial period before being offered employment, giving us time to assess the character of the prospective employee and so we clearly have sufficient recruitment procedures to meet this regulation. We therefore state that this finding has no relevance as to the breach of this particular regulation and we therefore request this be removed from the report.
With the exception of “dementia training” which we are now undertaking, all new staff members are fully supervised on a trial period before being made permanent and being offered the position within the home. During this period, we are able to provide training which includes manual handling, food hygiene, dols safeguarding, infection control, fire safety, safeguarding adults and are now adding dementia training to this list. The lack of dementia training whilst beneficial for residents does not have a direct relation to their safety and is not evidence that the service was not always safe.
As stated above Flixton Manor’s 30 years of experience in employing “proper persons” give us the ability to assess people of “good character” during this period and provide necessary training, support and supervision to ensure that new staff are qualified, competent and skilled for the work performed by them.
Unless specific evidence can be provided where a lack of this has caused an unsuitable person to be employed, then we cannot accept that breach of this regulation has occurred and find our recruitment procedures to be robust enough to ensure suitable persons are employed at Flixton Manor. We therefore request that this be removed from our inspection report and also see no evidence here to suggest that out service is “not safe”
As further evidence to support the service being “safe” we always obtain DRB checks are POVA checks for all staff before starting their trial period and this was again evidenced during the inspector’s findings. We would also add that the inspector has not observed or reported one single unsafe practice during the 2 days spent at the home
The comment relating to staffing levels will be addressed in a later area but we are puzzled as to how resident interaction and staff being task orientated equates to the service being unsafe. I refer again to the inspector’s own findings
“Everyone we spoke with said they felt safe living at Flixton Manor. One person said, “It’s alright here”. A relative told us, “I believe this is a very safe place. All the residents are checked every two hours; day and night” and another said, “I am delighted with the quality of care [name] receives here.”
We therefore request that the above statement regarding a robust process or staffing levels be removed accordingly as whether factually accurate or not, does not have a direct relation to the safety of the service but rather relates to the quality of time that our staff are able to spend with residents through interaction, conversation and activities. Being task orientated is common place within in a busy nursing home and a lack of interaction whether factually accurate or not is not evidence that the service is unsafe.
The inspector states
Risk assessments had been completed; however duplicate assessments with differing outcomes were seen.
This will be explained in more detail later but this is factually inaccurate as duplicate assessments were only held on the system due to a connection error saving the last assessment worked on in a few cases. The last dated assessment was the correct one for that particular assessment and was an accurate reflection of the risk identified using that particular assessment tool. Whilst improvements can be made within care sys to ensure that the old assessment is removed it most certainly did not pose any risk of safety to the residents all as our nurses are fully confident that the care plans were all completed accurately from the correct assessments and this is what is important for the correct identification of needs and appropriate care planning and action for each individual resident. No evidence has been found to indicate that an incorrect assessment has led to inappropriate and inaccurate care planning. As this is clearly not affecting the residents’ safety and no evidence has been presented to show how this clerical discrepancy caused harm to a resident or jeopardised their safety, we request that this be removed as a factual inaccuracy.
The inspector states
However, we saw the same risk had been assessed using different tools. For example, one person had three different assessments for the risk of developing pressure ulcers. One stated there was a low risk, one that there was a high risk and the third that there was a very high risk of developing pressure ulcers. This meant it was not possible to see what the actual risk to the person was.
The above statement is not clear as we know that certain risks are assessed using different tools and can produce different results based upon the area that is being assessed. For example, an incontinence assessment may provide a low risk outcome for a pressure sore but this assessment does not take into account other assessment criteria such as skin integrity, nutrition or waterlow assessments which may produce a high risk for this particular area. Whilst the risks identified through each particular assessment may differ due to the criteria, a nurse relies on “all” the assessments to reach a clinical judgement upon the overall risk that would be identified in the care need. The final risk identified in the actual care need is what is relied upon when delivering the care for the resident and we are confident in our nurses’ experience and clinical judgement to use “all” the assessment outcomes to make an educated decision on this. We therefore see no evidence to show that “the service was not always safe” as a result of this and request that this be removed from the report.
Furthermore, the inspector has not noted any of the dates within these particular assessments and therefore it cannot be concluded that it was not possible to see what the “actual risk” was, as these assessments could have been completed at different times where residents’ condition could have changed. It would therefore only be reasonable to look at the most recently dated assessment in order to attempt to identify the current risk.
We find the lack of detail in the information and evidence provided by the inspector, does not indicate that the “service was not safe” and would require a more thorough inspection of this area to be able to accurately make a judgement here. We would also expect that an inspection of nursing practices be carried out by a registered general nurse at the very minimum.
The report states
People received their medicines as prescribed. Guidelines were needed as to when ‘as required’ medicines needed to be administered.
It also states that
We did not see any guidelines for when any prescribed ‘as required’ medicines should be administered. Some people using the service were not able to verbally communicate if they needed an ‘as required’ medicine such as pain relief. Guidelines for nurses and care staff as to how people would communicate non-verbally their need for an ‘as required’ medication were required. The clinical lead nurse said that they and the nurse team knew people well and knew if an ‘as required’ medicine was needed.
This is factually inaccurate as “as required” medications are administered as per the nurse’s clinical judgement in which they are trained and experienced. Administration of an “as required” medication is given based on a wide variety of observations that only a clinical professional could assess. In situations where a resident is in need of these medications our nurse would look at many signs and symptoms that would not need to be verbally communicated on order to be seen and acted upon, and this is the role of an experienced registered nurse. Whilst care assistants may sometimes apply creams but no other PRN’s this would always be done under the instruction and supervision of a nurse who clearly has the training to identify these needs.
The inspector goes on to say
However new staff, nurses or agency nursing staff would not know. The registered manager told us they would add this to each person’s medicines file. We saw the care staff signed a separate sheet when they had applied any topical creams. One person had been prescribed creams to be applied four times a day. Staff had only been applying it twice a day. This meant the person had not received the prescribed creams as directed by their GP. The clinical lead nurse told me they would talk with the staff team and ensure the prescribing instructions were followed. This was the only cream we saw that was required to be applied four times a day. All other creams were applied as prescribed.
This is not factually accurate as the cream in question could be applied “up to 4 times a day” and as with any other PRN’s would be administered under the judgement of a trained and qualified nurse. It is factually inaccurate to say that it was required to be applied four times a day for the same reason as just stated. It is also factually inaccurate to state that staff would “not know” due to the robust handovers and handover sheets mentioned below.
He then goes on to say
As part of our inspection we looked at whether medicines were being administered, stored and disposed of safely. We saw an up to date medicines policy was in place. Training records showed, and we were told, that the nursing staff had received training in the administration of medicines. The clinical lead nurse told us they observed the nurses administrating medicines; (although this had not been recorded.) This meant the nurse staff were provided with the skills and knowledge to administer medicines safely.
This statement is contradictory to the statement that guidelines are required, as if the above statement is true then all nursing staff would know how to identify non-verbal signs and symptoms of people who required “as required” medications.
It must also be stated that a robust handover is given to all staff including agency staff before each shift and information like this would be passed over to them so that everyone including the registered general nurse would be informed as to who required PRN’s and what symptoms and particular signs to look out for. This has always worked very well within the home and the inspector has not produced any evidence of where this has failed and a residents’ “safety” has been compromised. Handover sheets are available in the clinic room for all staff on the shift including agency staff but we felt that conclusions were drawn by the inspector without asking questions or seeking further evidence as to how this information would be passed to other staff members starting their shift.
We request that this statement be removed as there is no evidence to suggest that the service is not “safe” with regards to the administration of “as required” medications.
The inspector also stated that
There were trip hazards due to the uneven floor on the first floor and rumpled carpets.
The inspectors’ findings state
We found the trip hazard of the uneven floor and the rumpled carpets to be a breach of Regulation 15(1) e of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
15(1) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 states
Premises and equipment 15.—(1) All premises and equipment used by the service provider must be— (a) clean, (b) secure, (c) suitable for the purpose for which they are being used, (d) properly used (e) properly maintained, and (f) appropriately located for the purpose for which they are being used.
We are unsure to which point is in breach here is as there was a hand written sign noting UNEVEN FLOOR, BE AWARE, BE SAFE in place at the time of the inspection. We must add that at the time of the inspection we did not have one single mobile resident within the building and therefore there was no resident who would have access to use this area unattended or without the aid of 2 care assistants or a wheel chair. The 2 residents that surround that area are both bed bound and immobile and all staff members are fully aware of this area. The floor has been like this for over 10 years since the extension was built and in that time we have never had one a regulation breach identified from any previous inspection or an accident resulting from the small ramp in this area. The fact that this has never been raised during any of previous inspections as a breach of The Health and Social Care Act begs the question as to why it has been identified as a breach now. Surely the fact that this only “requires improvement” would indicate that this is not a breach of the regulations as this would clearly be “inadequate” and we therefore find this to be an inconsistent and factually inaccurate statement.
There is no way to change the gradient that exists in that area but due to the inspectors concerns, we have already replaced any rumples in the carpet and have ordered 3 larger printed signs to be installed in this area to further improve the safety. We feel that this was not “unsafe” to begin with but know that things can always be improved and have therefore taken immediate action to remedy this. We do not feel this should be used as evidence to say that the service was not always safe and request that this be removed as a factual inaccuracy.
Finally, the inspector states
We have recommended best practice guidance is sought for formulating a written business continuity plan.
The inspector also states
We saw contact details were kept in the home’s office for utility companies in case of an emergency such as a gas or water leak. There were no formal plans in place to set out the action staff had to take in the event of an emergency or if the building, or part of it, needed to be evacuated for any period of time. We recommend the provider uses current best practice guidance to formulate a written business continuity plan for such eventualities.
He then states
People had a personal emergency evacuation plan (PEEP) in place. This gave details of the support a person would need in order to evacuate the building if they were in the communal lounge or in their bedroom.
This second statement contradicts the first statement as surely a PEEP is a formal plan that details the action that a staff member would need to carry out to support a person who needed evacuating from the building in an emergency. Also the fact that this is “recommendation” would go against the finding that this is a “requirement” and for this and the above reason we therefore find this to be a factually inaccurate statement and request that it be removed.
We would add that the director Dr Jan Al-Safar, his son Mr Rashad Al-Safar, the clinical lead nurse, Mr Fradreck Mukada and the home manager Miss Susan Porter’s contact details are always available in the office and we are all on call 24 hours a day to react, advise and deal with any emergency should this happen. On one occasion the owner Mr Rashad Al-Safar was called late Saturday night when the heating failed on one side of the building and the problem was solved within one hour during which all residents were immediately supplied with extra blankets. The management and the owners have their hearts invested within our home and will always do whatever is required to keep every single resident safe and protected.
Due to all of the above points we do not find the above statements to be “requirements” but rather recommendations of good practice and areas that may be improved upon. The areas that we agree could be improved upon are as follows and immediate action has already been taken to remedy these.
We would request that due to the above points and shortfalls constituting minor clerical errors or recommendations and due to the numerous comments from people and multiple evidenced areas identifies as safe that the statement be changed to “the service was safe” and the outcome be changed to “good”
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This is what we were told and found. The overall rating for the safe domain is dependent on the findings for all the Key Lines of Enquiry (KLOE’s) with in CQC’s methodology. I refer the provider to the provider guidance on the CQC website for more details.
As the report states there was a lack of references and full employment history. Having gaps in employment history does not mean people are not suitable. However employers should explore and record the reasons for the gaps in employment. The homes policy states that references will be gained. The registered manager told us this would be 2 references. The home failed to follow it’s own policy. Good practice is for employers to obtain 2 references, including from the most recent employer. This did not happen. This indicates the system for recruiting staff was not robust and there is a risk that unsuitable staff could be employed due to the lack of a robust system of recruitment.
Following recruitment the period of probation is then used to make judgements about staff suitability to work in the home.
The report is factually accurate and therefore does not need to be changed.
The regulation states providers must have regard to the following guidance: 19 (1) (a) When assessing whether an applicant is of good character, providers must have robust procedures and make every effort to gather all information to confirm that the person is of good character. 19 (2) Providers must have effective recruitment and selection procedures that comply with the requirements of this regulation and ensure they make appropriate checks for both employees and directors. The evidence as described in the report means that the provider did not meet this regulation.
This is within the KLOE’s for the safe domain and has followed our methodology. The number of staff on duty meant they were focused on tasks and did not have the time to interact with people.
The report is factually accurate and therefore does not need to be changed.
I viewed seven people’s care records. Duplicate records, as explained in the report, relates to the same risk being assessed using different tools and each resulting in a different level of risk being identified. For example Person GG had three assessments for pressure sores, each of these conflicted as they had a different outcome (Pressure Ulcer risk assessment – low risk, Braden risk assessment – high risk and Waterlow assessment – very high risk). The statement highlighted is factually accurate, you state that they were on the system as we saw them.
For example Person GG had three assessments for pressure sores, each of these conflicted as they had a different outcome (Pressure Ulcer risk assessment – low risk, Braden risk assessment – high risk and Waterlow assessment – very high risk). All these risk assessments are designed to assess a person’s risk of developing pressure area sores.
The report is factually accurate and therefore does not need to be changed.
Dates were noted. For example IL assessments completed 10/2/15, ME completed between 6 and 11/5/16.
The evidence is robust in what was detailed on the Care Sys and the difficulty in establishing what the actual assessment was for an individual. An inspection of the quality of risk assessments does not need to be undertaken by a nurse.
The report is factually correct as there were no ‘as required’ guidelines. Good practice guidelines state that ‘as required’ guidelines should be in place to inform staff of how people will communicate they need an ‘as required’ medicine is required. This is especially important in a service where people cannot communicate verbally and staff need to be able to observe other forms of communication such as body language. This is even more relevant when agency or new staff are on duty.
BV MAR chart states Diprobase 4 times per day, E45 4 times per day when required. Cream chart states Diprobase 4 times per day alternating with E45 4 times per day. Chart signed twice per day by staff to state cream applied.
See comments above ref ‘as required’ medicines. Nurse were trained in the safe administering of medicines and the MAR charts were correctly completed.
We observed a morning handover. An update on people’s health and well-being is given to all staff. However detailed information about how people would communicate if they required an ‘as required’ medicine during the shift is not discussed. I refer the provider to current best practice guidelines for ‘as required’ medicines and to the CQC provider guidance on the Key Lines of Enquiry for each domain.
Flixton Manor is a nursing home for elderly people. As such at any time there will be people living at the home with different levels of need and mobility. Therefore the people living in the rooms next to the uneven floor may currently be nursed in bed; however the next occupants of the rooms may be ambulant and would then be at risk of falls due to the steep slope in the floor. There is also an ongoing risk for staff and visitors. The risk has been recognised by the provider in the fact that a warning notice has been placed on the wall by the slope, however further action has not been taken to mitigate the risk.
I refer the provider to the CQC providers guidance. Breaches of regulations can occur with a consequent rating of requires improvement in the relevant domain.
It is noted that you have removed the rumples in the carpet.
A Personal Emergency Evacuation Plan is a plan for how people would physically get out of the building if required. A business continuity plan is an overall plan stating how the business would continue in the event of an emergency and the actions required by staff and managers, for example if after people had to evacuate the building and they could not return to it, what arrangements have been made for emergency alternative accommodation should this be required?
We recommend that the provider uses the current best practice guidance to write a formal business continuity plan. I refer the provider to CQC’s provider guidance with reference to recommendations being made and domains being rated as requires improvement.
It is noted that you have contacted Care Sys to look at the assessment system. However we saw the unfinished assessments all had different sections completed, therefore all needed to be looked at to see all the information required.
Thank you for your comprehensive response.
See comments above. Please also refer to the CQC provider guidance about meeting the regulations and the Key Lines of Enquiry used in inspections. Following a review of your comments here we have responded to each of your points individually. This report remains factually accurate and our judgement is reflected in the outcome of this domain. |
| Is the service effective? |
Is the service effective?
The inspector states
The service was not always effective.
We accept that the service may not always be fully effective but also believe that no establishment can “always” be fully effective and would question anyone who says that it is. If an establishment is “always” fully effective in every single area, then there can be no room for improvement and we do not believe that any service is perfect and that all services must constantly strive to improve and grow in a productive way with a view to strengthening the outcomes for its customers. This is exactly what we are always looking to do. We feel that some of the inspectors’ points in this area do offer constructive criticism and we embrace these points and are keen to use this feedback to improve our service. We find this question to be extremely subjective and, with no direct outcomes stated as to how this is assessed or judged, find any statement regarding this to be factually inaccurate and questionable.
The inspector states
Staff received on-going mandatory training. New staff had not received training in a timely manner to equip them to undertake their role. Staff did not receive training in dementia care. Regular staff supervisions were not completed.
We also agree with the points on training for dementia care: we agree that we are not currently “experts” in this area and we see definite room for becoming more skilled with some of our residents who suffer from dementia. Even though we always look to offer reassurance where we see it is needed and assist in calming a possibly agitated resident, courses have now been booked for all our staff with regards to dementia training and we look forward to improving in this area.
We do not agree with the statement that regular staff supervisions are not completed as whilst “formal” staff supervisions are not regularly completed, our open, supportive and friendly management style promotes staff communication with the management team at all times. Supervisions are completed very regularly and any issues or areas for improvement and support are always openly discussed with the management whenever the staff feel they need. The management also identify areas for improvement with staff on an informal basis very regularly and we feel that this relaxed and friendly style promotes a motivational atmosphere within the home, praising staff for the good work they do and encouraging and supporting them when improvement may be required. In the past we have found that formal supervisions have yielded little constructive gains for staff or the management, simply because all points for discussion have already been discussed and actioned as a matter of course on a daily or weekly basis.
However, we are happy to try this procedure once again to see if gains and benefits can be achieved from this, and so have immediately implemented “formal” supervisions again. We will review this practice again after 12 months years to see if we find it beneficial for the management, staff and, most of all, our residents.
Evidence that we perform informal supervision was found by the inspector at many points referenced in the below comments and findings:
People we spoke with said the staff had the skills to meet their needs. One person said, “I think the staff are well trained and professional in the way they meet my needs.” A relative told us, “They (the staff) know how to support [Name] really well.”
All staff we spoke with said they felt well supported and were able to speak to the senior carers, nurse on duty or registered manager if they needed to.
The inspector stated:
There were not enough available facilities for the number of people living at the home and the decoration of the home was not ‘dementia friendly’.
We take on board the point about facilities with regards to “We found the lack of bathing facilities and the environment not helping to promote the well-being of people living with dementia” and at the time of the inspection had already purchased tiles for a new bathing facility within the home. However, the inspector states
On our tour of the building we noted there was only one shower room available for people to use. The shower room in the basement was not used and the bathroom on the first floor was old and again not used. We saw there were en-suite toilets in the newer bedrooms. However, these were not accessible for people who needed to use a hoist and needed staff to support them with their mobility. This included the majority of people living at Flixton Manor. The registered manager told us these facilities were therefore not used. This meant everyone was using the shared accessible toilets and the one shower room available. People were not able to have a bath. This meant there was a queue to use the toilet at times. People told us they had one shower a week. Staff said they offered people additional showers when they could. However, one person said they would like more showers but hadn’t asked as they thought they would not be able to because the staff did not have time. The registered manager told us they were planning to upgrade the first floor bathroom.
Due to the immobile condition of currently “all” our residents, we have found the on-suite facilities to be totally inadequate for our residents and in hindsight, would never of have had them installed. We therefore installed a luxury shower that would be extremely accessible for immobile residents and provided soft mood lighting and a spa like finish. Many residents and visiting professionals have commented on how nice this room us but this was not mentioned by the inspector.
We feel that this large accessible shower room is much more beneficial to staff and type of nursing residents that occupy our home. Flixton Manor cannot provide daily showers due to the time that this would take for 37 residents and we do not claim to be a facility that can accommodate this. Our pricing reflects this and residents and families are aware of this when choosing our home. We do however provide daily bed baths to ensure that residents are clean and fresh before beginning the day.
As a business we cater to a certain type of resident and the fact that we remain mostly full would indicate that there is a definite need for our type of service within the marketplace. People have a “choice” where they wish to be accommodated and if our facilities were not acceptable, we would not have any residents “choosing” our home. We have found that many people value the caring and dedicated staff that look after them within the home over a luxury private bathroom within their room. Of course, if people do prefer a home that has large private bathrooms they are more than welcome to “choose” a home that does but it should not be held against us that our home does not provide these specific services.
We completely disagree that the lack of facilities leaves people waiting to use the toilet and when fully staffed as we were on the second day of the inspection, residents would only have to wait a short while before being taken to the toilet. In our 30 years’ experience in caring for nursing residents we know that there will always be a short wait at toileting times and unless Trafford funding (which had not increased in over 5 years) was to dramatically increase allowing us to employ many more staff members, there would be no way of ensuring that people were toileted instantly upon request. Again, people who view the home always question these types of things like anyone would when “choosing” a care home. We have had no complaints regarding the waiting times for toileting and residents and family members whilst fully aware of the level of our services, choose or choose to have their loved ones stay at Flixton Manor.
We have however, installed a high tech self-cleaning toilet in our luxury toileting room which was not mentioned or commented on during the inspection. The toilet has been a fantastic success eliminating any abrasive cleaning after toileting and making the toileting experience much more pleasant and calm for both residents and staff. We believe we have gone well beyond what other homes are providing in regards to this and this has been commented on numerous times by visitors and family members. We would say that this kind of forward thinking makes our service very “effective”, especially when compared to the price people pay to stay at Flixton Manor. Considering that people are aware of the level of care we provide before choosing our nursing home, surely the cost to the resident versus value should be taken into account when judging how “effective” a nursing home is? We are always looking to increase the value to our residents when funds allow and the new bathing facility we are planning to install will have soothing music, soft lighting and excellent accessible facilities to aid in this. We plan to give residents full and regular pampering sessions.
The inspectors’ findings state:
Flixton Manor supports people who are living with dementia. However, the décor of the home was not ‘dementia friendly.’ Doors were not painted in a colour to clearly differentiate them from the surrounding walls. People did not have pictures or memory items on their bedroom doors so they could identify their own room. Signage was not available to assist people to know where they were in the home.
Flixton Manor does look to support people living with dementia and at the same time also aim for the home to be attractive to other residents without dementia. The décor within the home was chosen after a consultation with many residents and family members and was based on a local golf club which had a familiar feel for many residents and yet did not aim to be too old fashioned.
However, we take on board some of the inspector’s points and whilst we do not feel that the doors are difficult to differentiate from the walls (being clearly dark brown and the walls being cream), we do feel that the home could be improved by more clearly identifiable pictures around the home to help aid in the recognition of certain areas. However, again, people “choose” our home before admission and have a full chance to see our décor before coming in. If the décor in our home was disliked by our residents and family members, then it is highly unlikely that we would remain close to “full” the majority of the time. The CQC promotes people having a “choice” in the care that they are provided and people are most certainly “choosing” to stay at Flixton Manor.
The inspector states:
Systems were in place to assess people’s capacity to consent to their care and treatment.
We are somewhat confused at this point as it has been placed under the “requires improvements” section of the report yet highlights no shortfalls.
The inspector states:
People received the support they needed to help ensure their health and nutritional needs were met.
Again we are also confused by this statement being placed in the “requires improvements” section as no improvement has been outlined as a requirement. If positive comments are to be placed in this section, then we would ask that all the positive points the report makes are placed here too as this would be a much fairer reflection of the home than simply putting only areas for improvement. This is another area where we feel the report is inconsistent.
We have welcomed the constructive criticism that has been raised here and are looking to action the following points:
We are happy to accept this outcome as being “requires improvement” and look forward to learning and improving our service for our residents and family members.
Is the service caring?
The inspector stated
The service was not always caring.
We disagree with this comment for the reasons below.
The inspector states:
There was little or no interaction between staff and people being supported.
On the day of the inspection 3 out of the 5 care assistants were agency staff. as a result of unforeseen staff sickness and absence. Whilst this is not ideal, we had already made significant efforts to employ many of our own full time permanent staff and this can be evidenced by the multitude of job applications that we had received. We had chosen 6 suitable candidates and had offered them positions.
Unfortunately, due to the untimely manner in which DBS checks are currently processed, many of these staff were simply not prepared to wait the 2 months that it takes to receive the DBS checks. We find this bureaucratic incompetence to be a major hindrance for us in recruiting new staff as people simply cannot wait that long to start a new job.
We feel this is really tying our hands and negatively affecting the quality care we can provide to our residents as there is simply no substitute for permanent, kind and caring staff who are a part of our team and who grow together with our organisation. It is particularly frustrating that many of the candidates we select would make excellent additions to our care team but they become disillusioned with the unnecessary wait to start their anticipated employment.
We feel massively unsupported by the government with regards to this and it begs the question of how effective these DBS checks are if it stops residents from receiving care from a consistent and reliable team. We are now making formal complaints regarding this to see if anything can be done. We were fully aware of the staffing situation at the time of the inspection and it is very hard to rely on true caring agency staff when trying to create a caring atmosphere around the home. However, the subjective question of whether our service was effective as a whole was clearly evidenced by the many positive comments that were made by residents and family members in the inspectors’ findings and as a care service, their opinions are more important to us than anyone else, as they are the ones who use and benefit from our service.
At the time of the inspection we had plans to employ extra staff and planned to have someone rotate on shifts to be in charge of activities for the residents. Unfortunately, staff recruitment issues as mentioned above have delayed this but we are getting closer to achieving this goal. We now have a dedicated activities’ coordinator again and have recently employed a number of new staff members.
The inspector has mentioned many positive comments to support the fact that we are a caring home such as follows:
Everyone we spoke with said the staff were kind and caring. One person said, “I think this is a very friendly place in terms of the staff and residents.” A relative commented, “There is a nice rapport between the staff and residents; there is a relaxed atmosphere.” Another said, “They (the staff) are very thoughtful and caring.”
The home is registered with the Six Steps end of life programme. This is a recognised system for supporting people at the end of their lives. We saw people or their relatives were involved in discussions about the care people wanted at the end of their lives and their wishes after their deaths.
We also saw some staff serve people’s lunches in the small lounge area without speaking to them. We noted other staff interacted more with people when providing support. Staff completed the required tasks in a caring and gentle manner.
This last comment serves to support our point as we believe the staff who interacted more with the residents would have been our permanent staff although there is no way to confirm this. It is clearly very difficult to expect the same caring nature from the agency staff who we have not chosen to employ, over our own staff who we have selected because of their kind and caring nature.
We feel that these factors were not taken into account by the inspector and a very harsh view was placed on us in a very challenging and difficult circumstance. However, we still believe that everyone’s essential needs were fulfilled which surely shows us to be a caring home. The very term and definition of caring is subjective and we would suggest that the statement “we were not always caring” is factual inaccurate as there are many ways to show care than simply talking to a resident.
The inspector states:
People’s wishes for their care at the end of their lives were sought. Staff were trained in providing sensitive end of life care.
People and relatives said the staff were kind and caring.
We are again confused as to the placement of these comments as they again fall under the “requires improvement” section of the report. This statement contradicts the inspector’s finding that the “service was not always caring” and actually shows clear and strong evidence that “the service was caring”. We require an explanation be provided to justify these points being placed there, as if positive and negative points are to be placed in this section then we would require all the positive points to be listed here (of which there are clearly many). The final point made should surely hold a lot of weight as the clients and their families are the most important judges of our care, especially during a short but difficult staffing period where we still maintained adequate agency cover at short notice to combat this challenge.
We would request that due to the above points that the comment be changed to “the service was caring” and the outcome be changed to “good” as we know that we are a caring home and virtually every comment evidenced by the inspector from people around the home confirmed this.
Is the service responsive?
The service was not responsive.
We find this statement to be factually inaccurate for the below reasons.
Multiple assessments were seen. Not all were fully completed and some were duplicated.
This point was previously mentioned and we will now elaborate on this response here. The inspector states that multiple assessments were seen which is very true as we have around 18 assessments that are usually very relevant and helpful tools in identifying and judging peoples care needs and risks. The point that the inspector makes about them not being fully completed and duplicated is incorrect for the following reasons
On reviewing our assessments, we have found that all of our residents had around 18 assessments within the initial stages of their care planning. In one instance there were 23 but this was due to the fact that we had system problems on that day and incomplete assessments were automatically saved in the middle of the process of completing one. The nurse then tried to continue through but the system “internet” kept going down during this particular assessment. Due to the robust nature of the system, it does not allow us to easily delete these unfinished assessments.
Our clinical lead nurse and other nurses involved were fully aware of the final and correct assessment that was completed in order to arrive at that particular risk or need. Once the correct need was identified then a correct and accurate care plan was created which was specific to that residents’ requirements. We do not accept that this has made our service “non-responsive” and do not believe that the inspector had taken the time or asked enough appropriate questions in order to fully understand what we know to be a minor clerical error.
We find no evidence of how this would lead to a non-responsive service and therefore find this statement regarding “not fully completed” and “not accurate” to be factually inaccurate. All assessments were fully completed in a way that was fully understood by our nurses and therefore their ability to make an accurate clinical judgement regarding the residents specific care needs was “responsive”.
We can clearly show how the needs in the care plans were arrived at and are fully confident that the care plans are person-centred and accurately focussed on each individual’s specific requirements. The actual care plans used to administer care were and are accurate, and no evidence has been provided to show otherwise. We therefore do not accept that this has any bearing on the “responsiveness” of the service and believe that the inspector has not provided any evidence as to how this clerical and system error has made our service “not responsive”.
The inspector states:
We reviewed seven care plans. The care plans were written and stored on a computer system called Care Sys. We found that people had multiple assessments for different areas of their care. We also saw the same assessment had been duplicated, in one case six times; each duplicate assessment had a different section of the assessment completed. Therefore, to see the entire assessment you had to look at six different files.
As stated above this is minor clerical error due a system (internet) issue on one residents main care sys assessment. It has no material bearing on the individual clients’ welfare or care. The relevant point with regards to the “effectiveness” of the service is whether the assessment was understood by our nurses and accurate care needs were created, which they were and no evidence has been produced to suggest that they were not. This therefore again, does not qualify as evidence to show that our service was “ineffective”.
The inspector states:
As noted previously, where there were duplicate assessments the outcomes were conflicting. One person had 23 assessments saved in their care file. Six were duplicates of the same assessment and other assessments covered the same areas; for example, pressure ulcers, a separate assessment for continence when this was also included in another, larger, assessment.
As stated previously there are usually 18 relevant assessments that we use to aid us in identifying care needs and they are exactly that, “aids”. We disagree that the outcomes are conflicting for the following reasons. Each assessment tool can cover different areas and produce different scores by the very nature that they are a “different” way of assessing care than in other tools and assessments. It is what nurses “do” and how they interpret these scores that creates the care needs that our whole care team act upon. Care sys provides many tools to help identify the needs of care and the scores they create are by no means an exact science due to the complex and highly variable factors that can make up a person’s condition within that particular assessment. All of the assessments are guides to assist a nurse in using their experience and trained clinical judgement and ultimately, a nurse will take a view to the respective resident’s needs based on that training and experience with the aid of these tools.
The fact that Flixton Manor uses a range of different tools and assessments to aid in our care planning is a positive thing and the fact that care sys provides this large range of assessments and tools, goes above and beyond what other care homes are doing. We feel the inspector did not fully take the time to understand this process and has made comments that whilst being somewhat accurate, fail to understand how this is a benefit to competent and qualified nurses. Rather than providing conflicting outcomes, they provide a broad range of tools and outcomes that assist nurses in using their clinical judgement.
The inspector states:
Not all assessments had been fully completed; for example, a mini mental state examination (MMSE) tool was used to assess people’s cognitive abilities. For two people only one question of the assessment had been completed. For three people the same comment had been made about the support they required for making decisions and with their memory. This meant the assessment information was not easily accessible and was in some cases contradictory. The assessments were not completed in a person centred way, with the same comments seen in different people’s assessments.
Again, the inspector has not taken the time to understand the specific tool he is commenting on and has not asked any questions or sought out the support of the qualified nurse in understanding this tool.
The MMSE tool is used to assess peoples’ cognitive abilities by using a tick box method. If the resident is able to respond and answer the question in the tool, then the box is ticked. If they are unable to respond, then the box is left unticked. For many residents none of the boxes are ticked and for some of them some of the boxes are ticked and this is how the tool works. The inspector has understood this as indicating that the unticked boxes mean that the questions were not asked which is clearly incorrect.
With regards to the same comment being made regarding three of the residents, these comments are entirely accurate and person-centred as – being a nursing home which specialises in “nursing” care – we have many residents whose outcomes and needs are the same in specific areas.
This in no way means that things are duplicated or not person-centred as it is simple common sense that many residents would require very similar or the same actions to be taken in certain individual areas for certain individual residents. “the same” comments seen in different people’s assessments is not evidence that these comments are accurate and person centred and does also not give any evidence that “the service is not responsive” and we therefore request that this comment be removed.
Again, we do not believe the inspector has sought advice from a clinical nurse when judging these assessments and has therefore made factually inaccurate statements due to a lack of understanding of our assessment process, the particular tools we use and how they are acted upon.
Due to all of the points mentioned above we find all these comments to be either factually inaccurate or irrelevant with regards to the “responsiveness” of our service, and in fact many of the comments serve to illustrate just how “responsive” we are when it comes to the assessments and care planning within our home.
The inspector states:
Staff did not have access to the care plans. All information was verbally given to staff.
He also states:
All the staff we spoke with said they did not access the Care Sys. The care plans were not printed out. This meant the care staff were not able to read people’s care plans or risk assessments. All care staff said they were told any information they needed by the clinical lead nurse. This meant they had to ask the clinical lead nurse for any details they could not remember as they were unable to refer to the care plans or risk assessments themselves. They also had to remember all the care details for each person.
Being able to refer to these plans is especially important for new staff or agency staff who did not regularly work at the home. We spoke with the registered manager who said the Care Sys was for the nurses to use and did not recognise that the care staff would benefit from being able to access the care plan information. They told us the verbal information provided by the clinical lead nurse and other nurses was sufficient.
We believe that the “staff” to which the inspector was referring were the care assistants, as quite clearly the registered nurses had complete access to the care sys system as this is one of the most important parts of their ability to plan, implement and delegate quality care within our home.
At the time of inspection there was a file with printed care plans available in the clinic room for care staff to access, although we accept that many of staff were unaware that these were available. The reason they were unaware is that we expect and require that all of our permanent care staff are fully familiar with each individual residents’ particular non nursing care needs.
If any of our permanent staff had to seek out and reference a written file in order to tell you what a resident needed in terms of their day to day requirements, we would not consider our service as “effective” and it is for this reason that many staff members were unaware of the printed care plans in the clinic room.
The inspector is clearly suggesting that our staff do not have the ability or the intelligence to remember important facts about our residents care even though in many cases they spend more time with these residents than with any other people in their lives.
The inspector provides no evidence that our care staff could not “remember”, and it is clearly much more efficient for a care staff member to ask a nurse than to go and pull out a file and start reading and searching for information. We fail to see how a nurse telling a member of staff something constitutes a “not responsive service” as we cannot find a logical reason why a care assistant would not ask as nurse if unsure about something. That is exactly what our nurses are there to provide and we would find it strange for a care assistant to ignore this advice and information and then go off and sit and read in order to learn. Our 30 years’ experience have taught us how to eliminate this kind of inefficient and unnecessary bureaucracy, and we favour common sense and efficient practices in our nursing home over inefficient bureaucratic ones.
We see no evidence as to why a written document is more “effective” for care assistants than clear verbal communication in a home that has a qualified registered general nurse present 24 hours a day to support the care staff and provide regular robust handovers and information daily to assist care staff in their role. It is clear that the information that would be passed over within this verbal communication would be accurate as it is clearly written and documented within care sys and is based on or clinical nurses qualified judgement from the identified care needs.
We did not notice the inspector asking any of our care staff what a particular residents’ needs were, that they would be responsible for, and therefore we question his ability to know if our care staff were “effective” in understanding each resident’s needs.
Our daily robust handover always informs staff of any significant changes to anyone’s needs and we expect and require our care staff to remember this information as we know they always do. This was clearly evidenced by the inspector in the below statement
We observed a morning handover meeting between the night shift and the incoming day shift. The handover was used to inform staff of people’s wellbeing and any changes that had been noted. Staff told us if they had been off work for a period, for example annual leave, they would ask for an extended handover from the clinical lead nurse or senior care worker so they were aware of any changes in people’s needs whilst they had been off.
We must bear in mind that our permanent staff members spend more time with our residents than often with their own family and friends and we expect them to know what our residents need by memory in the same way as they remember family and friends. Our clinical lead nurse, manager and long standing senior carers monitor and supervise this level of knowledge on a daily basis. This is what we call a “common sense” approach to care and because of the many positive comments (evidenced by the inspector in this report) from family members over the years, we find this system to work very well and promote excellent communication and relationships between staff. For any staff who have been away the inspector has evidenced that extended handovers are always given to keep staff up to date.
With regards to agency staff not having the knowledge or information, they are not left unattended and are always shadowed by one of our competent and knowledgeable staff members who can explain and inform them whilst on the job. We feel that this is a much more effective and efficient method than agency staff having to sit in a clinic room for hours reading through individuals care plans. This would clearly mean less interaction with the actual residents they are trying to care for. We would request that evidence by presented of how this system in not “effective” rather than placing a comment that staff relied on verbal information in the “inadequate” section of an inspection report. In all forms of learning and knowledge, verbal communication is quite simply one of the best ways for people to absorb information and we would question why anyone would think that this method would make our service “ineffective”?
Care sys is designed for qualified clinical professionals to use as a way of care planning, recording, delegating and administering care and is quite simply a state of the art and highly thorough system for doing this. Care assistants are quite simply unqualified for this purpose and we leave this task up to highly qualified and well trained nurses who are the correct and relevant persons to use such a system in a home that provides and specialises in nursing care. The fact that we use a system like this is direct evidence that we are an “effective” service and yet no positive comments were made by the inspector with regard to this.
I believe that the inspector may be forgetting that we are a nursing home and that virtually all of our residents require nursing care. It would be incompetent to allow care assistants to plan and use care sys with regards to our residents nursing care needs and if this is an area they are interested in pursuing then we would recommend that they seek employment in a residential home or undertake studies to become a registered general nurse.
We find no evidence that the above practices equate to an “unresponsive service” and therefore request that the statement be removed as it is either factually inaccurate, irrelevant to the question of whether “the service responsive?”, or simply incorrect.
The inspector states:
We saw the nurses and clinical lead nurse wrote the daily notes for each person on the Care Sys. They also reviewed people’s care plans and risk management plans monthly. However, we saw that not all areas of the Care Sys were kept up to date. For example, the record of professional visitors was not regularly completed. Lap tops and system not working We saw details of a GP visit recorded in the daily logs for one person and not in the professional visitors’ record. This meant it was difficult to track any ongoing professional visits without going through all the daily notes.
Whilst we accept that there were a number of missing entries to the visitors’ log within care sys, we do not see this as having any bearing on the “responsiveness” of the nursing home. These were missing due to some system downtime and were not re-entered as they are not a requirement of any regulation, and re-entering these in the system would not make our service any more “responsive”. It would only serve to make an inspector’s life easier, as if anyone was truly interested in the records of care for a particular resident then they would surely read the full care needs and daily records for this purpose, both of which most certainly contain all the records of visiting professionals with detailed information regarding why they were visiting and how that visit related to a resident’s care.
Whilst we accept that it may have been more difficult for the inspector to track GP’s visits, we are unaware of a situation relating to the administration of an individual’s care that would require this record to ensure that it was “responsive”. No evidence has been presented to show why this missing record (which is clearly not missing from our full records) makes us “unresponsive” and we therefore find this comment to be irrelevant to the question of whether “the service responsive?”
The inspector states:
Relatives were not formally involved in agreeing and reviewing care plans.
He then states:
People and relatives we spoke with told us they had not formally been involved in completing or regularly reviewing the assessments and care plans. One relative said they had given a lot of information to the service when their loved one had moved to the home, however they had not seen any care plans subsequently written. The registered manager said relatives could ask to see the care plans if they wanted to do so; however, the relatives we spoke with were not aware of this.
This is factually inaccurate as at the time of the inspection there was a file in the clinic room containing signed declarations from all family members and residents stating:
“I am aware that I have that I have the right to access all information stored in my care plan. I understand that if I wish to access this I only need to ask a member of staff. I am also aware that other authorised agencies may need to see my care plan.”
It is clear from this that they had forgotten being formally involved in this process as their own signatures would show otherwise. We also question the ability of a family member to “complete” a care plan for their relative as they are neither qualified nor experienced to do so. Whilst it is true that we make seek information from them verbally regarding their relative to aid in our planning, it is clear that the reason they had not seen any care plans subsequently written is because they have shown no interest or have made no request to do so.
Our initial efforts in trying to get families more involved met with little success and so the signed declaration is evidence that they are welcome and have the right to be involved. Our real experience has shown us that everyone we have asked to be involved in their care plan is not willing or interested in doing so and we fully understand their position.
They pay Flixton Manor for our professional experience, qualifications and ability to do this well and we fully understand why they would not want to be involved in the planning of their relatives care in the same way as we do not wish to be involved in the planning of a flight when we go on holiday. We trust the captain to get us there safely and in paying for the flight we expect a fully skilled and experienced captain will know all the plans and procedures to implement this safely. We find that family members feel exactly the same way about the care that their relatives receive at Flixton Manor and we are proud and happy to provide them with this care using all of our training, experience and expertise to ensure a quality service is provided.
The inspector states that:
We found the incomplete and contradictory assessments, lack of access to the care plans for care staff, incomplete recording and the lack of involvement of people or their relatives in the care plans to be a breach of Regulation 9 (1) with reference to 9 (3) a, b, c and d of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We refer to Regulation 9(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
9 Person-centred care (1) The care and treatment of service users must– (a) be appropriate, (b) meet their needs, and (c) reflect their preferences.
Due to all of the above points we can see no breach in this regulation and require that this be removed from the inspection report accordingly.
We refer to Regulation 9 (3) a, b, c and d of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
9 (3) Without limiting paragraph (1), the things which a registered person must do to comply with that paragraph include– (a) carrying out, collaboratively with the relevant person, an assessment of the needs and preferences for care and treatment of the service user; (b) designing care or treatment with a view to achieving service users’ preferences and ensuring their needs are met; (c) enabling and supporting relevant persons to understand the care or treatment choices available to the service user and to discuss, with a competent health care professional or other competent person, the balance of risks and benefits involved in any particular course of treatment;
We most certainly seek out the opinions of our residents for all their preferences and no evidence has been presented that would prove otherwise. Due to all of the above points made, we find no evidence to support that there is a breach in regulation and request that this also be removed.
The inspector states:
Few activities were arranged for people who used the service. They were seen to be asleep and withdrawn.
We feel that this is also factually inaccurate as at the time of inspection the following activities were in place.
Matt and Ange – these are a lovely couple who put their hearts and souls into delivering a wide variety of live music to our residents. They are booked to come in to the home twice a month.
David Bramwell – David is an entertaining one-man band who our residents particularly enjoy. He plays a range of different instruments including the accordion, flute and guitar and performs some classic old songs from the 50’s and 60’s which all our residents recognise and enjoy. He visits the home once a month.
Music for Health – Helen Brunton provides an interactive music session with our residents where instruments are provided to the residents and they are encouraged to join along with the music. This is stimulating for our residents and they really enjoy these sessions. This is arranged once per month.
Barry Dixon – Barry is a professional masseur who offers a hand, shoulders, neck and foot and massages to all of our residents which is enjoyed by all and he is booked to come to the home once a month.
At the time of the inspection we were short staffed and so whilst the staff on that day may have been more task orientated due to shadowing agency staff, we do not see this as a general reflection of the activities that were arranged on a regular basis as we usually provide general games and entertainment when we are fully staffed with our permanent staff.
The above entertainments arranged can be evidenced by invoices upon request. We therefore do not see this as evidence that our service is “unresponsive” and request that this comment be removed from the report.
We find the following comment regarding residents seen to be withdrawn placed in the “inadequate” section of the report as wholly unacceptable and demining to our residents and our home in general. To call an elderly resident with multiple medical conditions in the former years of their life “withdrawn” is quite frankly offensive and without a thorough understanding of that resident’s medical condition, age, history and personality we would question how anyone can honesty state that this is “inadequate”. Many of our residents remain in this condition during all of our entertainments, activities and attempted conversations and we do not think that this is an appropriate, relevant or educated observation of our residents. It certainly offers no constructive criticism of our service and we request that it be removed from the report.
Further to this, the comment relating to residents being asleep is also offensive in being placed in an “inadequate” section of an inspection report. We find no issue with any of residents wishing to have a little nap after a long and well lived life and we question why this is “inadequate” and why this would make our service “not responsive” These last two comments show a complete lack of understanding of our residents and no evidence has been sought by the inspector to find out the likes and dislikes of the particular residents who were asleep. To make a sweeping observation about many of them in the “inadequate” section of the report is inappropriate and should be removed.
The inspector states:
People and relatives said they were confident to raise any issues they had with staff or the registered manager. However, complaints made through a case conference had not been responded to.
The first part here serves to illustrate and evidence exactly why our service is “effective” and we are again confused as to why it is placed in the “inadequate” section of our report. The complaint in question was dealt with by the Trafford safe guarding team but believe it was initially made to the CQC and whilst we did not agree with all the opinions that were stated in this meeting and felt the minutes did not accurately reflect everything that was said, we were told by Helen Bottomly (the senior practitioner) that the safe guarding team considered the case completed by themselves and any outstanding matters that were raised to be a matter between the family and the home and that the family should put their complaints directly to the home in writing. This can be confirmed by contacting the safe guarding team and asking them, as in the 6 months following the meeting, and indeed to date, no request for any further response has been made to Flixton Manor. In the meeting the owner said he would be happy to respond to any of the concerns raised once they were received in writing as many of the extra questions or concerns during the meeting were raised verbally and we are unwilling to rely on the accuracy of the minutes taken in the meeting as they were not an accurate reflection of everything that was said. Furthermore, as no complaint was ever received by Flixton Manor regarding this, we would not even know who we were responding to. We must add that any verbal or written complaints made to our home directly have always been responded to pursuant to our complaints policy. We would also question that if the safeguarding team or the CQC considered the complaints that were made to be serious with evidence to justify them, then surely an immediate inspection would have been carried out promptly to safe guard the other residents who live at Flixton Manor. This complaint or request for a response was never made or followed up by either the CQC or safe guarding in almost 6 months after the case conference was concluded, and even during our most recent inspection the inspector made no request for us to respond to the CQC or the family. As stated previously Flixton Manor welcomes constructive criticism and the ability to improve its service in a common sense manner and have already taken our own action with regards to our internal procedures based on the complaint. However, we have to date received nothing in writing from the family and are therefore not in a position to respond to anyone in relation to apparent allegations which have yet to be set out and communicated to us. This is clearly a matter for the CQC or safeguarding to respond to and deal with as the complaint was made to them and not ourselves. If the safe guarding team or the CQC considered that there was strong evidence to substantiate these complaints, then we question their responsiveness, effectiveness and ability to regulate and safeguard the vulnerable adults within our nursing home. In excess of 6 months is hardly an “adequate” timeframe for them to deal with a complaint that was made to them regarding our home. The issues that were made in the complaint could have been much better dealt with if made directly to the home and we welcome a visit from the family anytime to come in and discuss their concerns or alternatively, place them in writing where we can respond in a constructive and accurate manner. We therefore do not see this as a relevant comment with regards to the “effectiveness” of our service but rather a question on the “effectiveness” of the CQC who the complaint was made to and request that this be removed from the report. Due to the factual inaccuracies and irrelevant statements with regards to “is the service effective?” We require that this outcome be changed to a “good” or an “outstanding” due to the amount of positive points in the inspectors’ findings and the lack of negative points which have been addressed and corrected in this response. We most certainly do not accept an “inadequate” outcome due to all of our reasons above.
Is the service well-led? The service was not well-led.
We find this statement to be factually inaccurate for the reasons stated below
The inspector states:
Although some auditing systems were in place they were not robust enough to identify the issues seen during the inspection.
The issues referred to have clearly been addressed and corrected in depth throughout this entire response and we therefore do not see any reason why this would mean that our service is not “well-led?”
We refer to the inspectors’ findings in this area which we find totally inconstant with a service that is not well-led.
The inspector states:
The service had a registered manager in post as required by their registration with the Care Quality Commission (CQC). The registered manager was due to retire shortly after our inspection. A senior carer with many years of experience at the home had been appointed as the new manager. They were in the process of applying to be registered with the CQC.
The “many years of experience” (which actually equate to over 20) mentioned above would serve as some evidence that the home is “well-led”
The registered manager at the time of the inspection had been with our home for more than 20 years and was highly respected in the community and had a consistent track record of providing quality and a great report and reputation with outside agencies and visiting professionals. We do not accept that this lady “led” the home poorly and no evidence has been provided to substantiate this.
The senior care mentioned above has also been with our home for more than 20 years and also has a proven track record of providing caring and dedicated services to our residents throughout that period. In the short time as acting manager, she has already shown herself to be providing a “well-led” service and no evidence has been provided to show otherwise. She is an extremely caring woman who has had her heart invested with our home and residents and the owners have full faith in her that she will lead our care team wonderfully.
The inspector states:
All the people and staff said the registered manager and senior staff were approachable and supportive. The clinical lead nurse was visible within the home throughout our inspection. All the staff we spoke with were positive about working at Flixton Manor. One staff member we spoke with had joined the staff team after working at the home as an agency worker.
The above findings by the inspector during the time of the inspection are clearly further evidence of a “well-led” home and we are quite baffled how a poorly led home could have everyone spoken to making such positive comments.
The inspector stated:
The registered manager showed us how the Care Sys computer system prompted them to undertake various audits of the service such as bed rails, mattresses, incidents, medicines and care plans. We saw any actions required following the audits were noted.
Again, this statement and finding by the inspector would further serve to evidence a “well-led” home.
The inspector states:
However the audits had not identified the shortfalls found during our inspection, especially with regard to staff recruitment and the duplication and quality of assessments and care plans. The registered manager did not think the care staff needed to be able to access and view the care plans and risk management plans, relying on all the required information to be communicated verbally. They also told us families are asked for information about their relatives as part of the assessment when they move to the home, but the care plans were for the nurses’ use and so the families were not involved in writing or agreeing them. There was a lack of staff supervisions, the service was task orientated in nature and the there was a lack of stimulation for the people who used the service.
All the points within this statement have been thoroughly addressed and corrected though our previous comments in this response and so do not bear relevance to the service being “well-led”.
The shortfalls in the auditing systems, staff not being able to view the care plans and the lack of involvement of relatives in writing and reviewing care plans was a breach of Regulation
17(1) with reference to 2a, b and e of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We refer to the 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
17 Good governance (1) Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part.
We have clearly evidenced any systems that were in question and explained how they are operated to ensure good governance and so due to all the previous points within this response that address this, we do not find any evidence to indicate a breach of this regulation and therefore request that this be removed.
We refer to the 172a, b and e of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
(2) Without limiting paragraph (1), such systems or processes must enable the registered person, in particular, to– (a) assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services); (b) assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity; (e) seek and act on feedback from relevant persons and other persons on the services provided in the carrying on of the regulated activity, for the purposes of continually evaluating and improving such services;
We have clearly covered all points with regards to point 2a in our response to “is the service safe?” and with regards to the quality of the experience of the service users receiving that service, the inspectors’ own findings have noted multiple positive comments regarding those services quoted numerous times throughout this response, and in actual fact the inspector’s comments go against virtually every comment that he himself evidenced by people who actually used the service.
We have clearly addressed point 2b in the sections “is the service responsive?” and “is the service safe?” and find no evidence that we are in breach of this regulation.
With regards to point 2e, we always welcome feedback from anyone entering our home and the following findings stated b inspector clearly show this.
We saw a relatives’ survey had been issued in January 2016, with five surveys being returned. These were positive.
People and relatives said they were confident to raise any issues they had with staff or the registered manager.
The above statement from the inspectors’ own findings clearly evidences that we are not in breach of this regulation and that we are in fact a “well-led” service. We therefore request due to the above information, that this and all other breaches relating to 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 be removed from this report.
The inspector stated:
The Care Quality Commission had not been notified of incidents and deaths as required.
He also stated in his findings:
Services providing regulated activities have a statutory duty to report certain incidents and accidents to the Care Quality Commission (CQC). Before the inspection we found CQC had not received any notifications from the service since July 2014. The registered manager told us they had tried to notify CQC of the deaths of people who used the service, however the emails they had sent to CQC had been returned as undeliverable. When we looked into this we found the registered manager had mistyped the email address for CQC. This meant the registered manager had not carefully looked in to why the emails had been undeliverable in order to resolve the issue. We were shown a file of completed notification forms that they had tried to send to CQC. This contained some, but not all, notifications concerning people who had passed away. There were no forms for any other notifiable events.
Whilst we accept that this was an error on behalf of the home, notifications of deaths are always sent to all other relevant organisations including the PCT and the council so clearly the home was not trying to hide anything here and was a simple clerical error that has now been very swiftly and easily rectified and full records of these notifications during this period can still easily be evidenced and obtained from the PCT and the council if needed. We would add that if the CQC had not received these notifications in over 2 years, one would have expected some level of enquiry from a regulatory body such as themselves during this period in order to investigate this, but Flixton Manor had not received any contact from the CQC regarding this, nor has it received and inspection in over 2 years.
The question about whether the home is “well-led” would seem to relate to the staff and the service, “the service” being the service we provide to our residents. As we have already solved this error and we do not see how this clerical error has resulted in any lowering in the standards of the service we provide to our residents, we therefore find it irrelevant to the question of “is the service well-led?”
The inspector stated in his findings:
Staff said the registered manager was approachable and they enjoyed working at the home.
Again, we are puzzled as to why this statement would appear in the “inadequate” section of the report and this finding by the inspector further supports that fact that the service is “well-led”
Due to all of the above points we see no evidence to support the statement “the service was not well-led” and have referenced multiple findings made by the inspector that indicate that the service was in fact, very “well-led”. We therefore request that this be removed from the inspection report and replaced with “the service was well-led”. We would also request that due to the above points the outcome is changed from “inadequate” to “good” or “outstanding” due to the numerous comments and findings from the inspector that clearly support this conclusion.
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I refer the provider to CQC’s provider guidance for details of Key Lines of Enquiry within each domain.
I am pleased the dementia training has been booked and look forward to talking with staff at my next inspection about how they have been able to use the information they have learnt from the course to effect positive outcomes for the people living with dementia at Flixton Manor.
Supervisions give staff time to discuss their work and provide two way feedback. A record of the meeting can be used to agree any actions or goals agreed. There are many ways that this can be achieved. The new manager had acknowledged that more formal supervisions were needed as she had started to complete some with staff. I am pleased you have started a programme of supervisions and look forward to seeing the evidence at my next inspection.
I am pleased that you have plans for a new bathing facility and look forward to seeing this at my next inspection.
I agree the shower room is a good facility; however it was the only accessible bathing facility available within the home.
The inspection highlighted that there were not enough accessible facilities for the number of people living at Flixton Manor. Facilities do not have to be en-suite to meet the regulations.
People and relatives told us that they had to wait a long time to be able to access the toilet due to there only being one accessible toilet plus the shower room on the ground floor where most people were during the day. One person said they had waited for two hours on one occasion. We saw staff after lunch support one person after another to use the bathroom. This meant people had to wait their turn to use the toilet.
It was the number of accessible facilities available that is the issue. I note the toilet facility in place is of high quality.
I look forward to seeing the new facilities at my next inspection.
I look forward to seeing the new pictures to assist people to orientate themselves within the home at my next inspection.
Please refer to the CQC provider guidance. Domains are rated for the key lines of enquiry within each domain. There may be areas of good practice within a domain that is rated requires improvement overall.
See comments above ref rating of domains.
I look forward to seeing these actions in practice at my next inspection.
The report states what we saw during our inspection. We saw some staff did not interact with people and this was not challenged and staff advised of what the home expects.
Whilst I can sympathise with the delays in obtaining DBS certificates for staff I am unable to comment further.
The senior care worker stated they were in the process of recruiting new staff and was aiming to increase the staffing levels. They also stated they wished to have a staff member in place to organise activities for the home. I am encouraged these are now taking place and look forward to meeting the new staff and at my next inspection.
Please see previous comments ref the CQC provider guidance and the ratings system used for each domain.
Thank you for your comprehensive response.
Following a review of your comments here we have responded to each of your points individually. This report remains factually accurate and our judgement is reflected in the outcome of this domain.
It is noted that you have contacted Care Sys to look at the assessment system. However we saw the unfinished assessments all had different sections completed, therefore all needed to be looked at to see all the information required. GG had two Care Sys assessments saved on the same day in August 2016 with different sections completed in each. IL had five Care Sys assessments all created on the same day in February 2015. This shows the issue is not a recent or one off issue
For example Person GG had three assessments for pressure sores, each of these conflicted as they had a different outcome (Pressure Ulcer risk assessment – low risk, Braden risk assessment – high risk and Waterlow assessment – very high risk). All these risk assessments are designed to assess a person’s risk of developing pressure area sores. It is therefore not possible to know whether the risk for GG developing pressure sores is low, high or very high.
See comments above.
See comments above. The number of assessments in use and the sometimes different outcomes of each can be confusing as to what the actual need is.
I refer to the Alzheimer’s society website which states ‘The Mini Mental State Examination (MMSE) is the most commonly used test for complaints of problems with memory or other mental abilities. It can be used by clinicians to help diagnose dementia and to help assess its progression and severity. It consists of a series of questions and tests, each of which scores points if answered correctly. The MMSE tests a number of different mental abilities, including a person’s memory, attention and language. The test include writing a sentence, remembering objects, following instructions and copying a shape.’ The MMSE tool for ME had the box ticked for ‘what is your name’. No other boxes were ticked nor was there any indication the full assessment tool had been used. The conclusion was ‘sometimes confused – support memory, decision making and choices.’ The conclusion drawn would not apply if the only question ME had been able to respond to was remembering their name. The MMSE for IL was exactly the same. The same box ticked and the same conclusion stated.
We saw in one risk assessment for ME she was referred to as ‘Beatrice’. This had been copied from another person’s assessment and the name had not been changed.
I have changed the report to make it clear that it is the care staff members I am referring to.
We spoke with the registered manager and senior carer at the inspection about care staff members having access to care plans and they did not inform us of the existence of printed care plans. None of the care staff members we spoke with were aware of the existence of the printed care plans held in the office.
I am not suggesting this at all. Staff members take time to get to know the needs of people who move to the service. Having care plans available to read and then refer to enables them to support people appropriately with their needs during this period. This is equally true for new staff who have to get to know the needs of all the people living at the home when they start working at the home.
Care plans are working documents and should be available for all staff to refer to, read and contribute to (via the nurses if this is the system used at the home.)
The inspector and expert by experience spoke with eight care staff during the inspection.
The report does not state that agency staff should spend hours reading care plans – care plans should be available for staff to refer to. The report states ‘Being able to refer to these plans is especially important for new staff or agency staff who did not regularly work at the home.’
I agree verbal communication is very important for informing staff of any changes in people’s health and well-being. This is stated in the inspection report.
The report does not state that care staff should complete the assessments on the Care Sys computer system. The report states care staff should have access to the information in people’s care plans. There are different ways of achieving this – for example through direct access to the computer system or through paper copies being available. The Care Sys had many features, however not all were used; for example a one page profile document, the recoding of professionals visits. See previous comments about the ease of use of the information held in the assessments.
Having information about professional visits eg GP easily accessible enables staff to view the frequency of visits and have a short record of the details of the reason for the visit and the outcome. This is important where people require ongoing medical support for the same or a re-occurring issue or for when a follow up appointment is required, for example chiropody. This is because different staff may be on duty at each visit. From the care records I viewed on the Care Sys computer system I saw: IL last GP visit noted 30/10/15, psychiatrist visit 14/5/16. DS last entry April 16 for chiropodist. JM last entry 13/4/16 for a GP visit. SG last GP entry 10/11/15. BE last entries for GP visits 23/8/16 and 1/9/16. This shows the system had not been used to record professional’s visits for a period of time for some people. However for BE it had been updated when the GP had visited.
Report changed to: People and relatives we spoke with told us they had not formally been involved in completing or regularly reviewing the assessments and care plans. One relative said they had given a lot of information to the service when their loved one had moved to the home, however they had not seen any care plans subsequently written. The registered manager said relatives could ask to see the care plans if they wanted to do so. Relatives had signed a form stating they could ask to access their loved ones care plans if they wished to do so. However, the relatives we spoke with seemed to be unaware of this.
Good practice guidelines would be to go through the completed care plan with people (where possible) and their relatives to ensure the information is accurate and gain their consent for the proposed care and support to be offered. This should be regularly reviewed with people (where possible) and their relatives to check it continues to reflect the care and support provided and they are in agreement with the care plans in place.
The evidence seen of multiple assessments, care staff not having access to the information in people’s care plans, relatives not being regularly involved in agreeing the care plans is a breach of Regulation 9 of the Health and Social Care Act 2008.
The report states that there was music entertainment twice a month and a masseur also visited monthly. We were not told of the other two music visits. Report changed from: ‘We saw the home organised for an external entertainer to visit the home twice a month, which we were told by relatives was enjoyed by the people who used the service. A masseur visited monthly and a hairdresser every week.’ To: ‘We saw the home organised for an external entertainers to visit the home four times a month, which we were told by relatives was enjoyed by the people who used the service. A masseur visited monthly and a hairdresser every week.
However this means that there was on average one session of entertainment per week and the monthly masseur visit.
Relatives and people we spoke with said there were no other activities arranged by the home, including when no agency staff were on duty. The remainder of the paragraph in the report remains accurate.
Please see previous comments ref the CQC provider guidance and the ratings system used for each domain. On both days of our inspection there was a lack of interaction with people. As stated in the report the TV was on low volume in both lounge areas all day.
Please see previous comments ref the CQC provider guidance and the ratings system used for each domain. I contacted the lead social worker for the safeguarding investigation before and after the inspection. As written in the inspection report the case conference minutes clearly show that the provider said on three occasions they would respond to the issues raised by the family. One of the recommendations from the case conference was that it was ‘stated during the meeting that [provider] would arrange for the family to receive answers to their complaints.’ This was the view of the lead social worker I spoke with. To date the provider has not arranged for the family to receive answers to their complaints. Minutes from case conferences are sent out in draft to allow any of the participants to query and challenge their accuracy before the final version is published. The notes above are taken from the agreed final minutes of the case conference and so must be taken as a true record of the meeting.
The issue identified during the inspection was the lack of response to the safeguarding case conference recommendation and was not a comment on the content of the safeguarding investigation that had been carried out and partially substantiated.
I discussed the safeguarding case conference with the provider and registered manager during the inspection and stated to both a response was expected from the case conference minutes.
The provider said that they would respond to the issues raised by the family during the safeguarding case conference.
The safeguarding investigation and case conference was the response to the concerns raised to CQC by the family. The result of this process was that the provider would respond to the issues raised by the family.
Thank you for your comprehensive response.
Following a review of your comments here we have responded to each of your points individually and a number of changes have been made. This does not, however, change the outcome of this domain.
See comments made above. The breaches of regulations identified during the inspection mean the inadequate rating for the responsive domain is proportionate.
See previous comments above to points raised by the provider. The points raised have not changed the breaches identified during the inspection and therefore this statement in the report is still valid.
The overall rating for the well-led domain is dependent on the findings for all the Key Lines of Enquiry (KLOE’s) with in CQC’s methodology. I refer the provider to the provider guidance on the CQC website for more details.
The overall rating for the well-led domain is dependent on the findings for all the Key Lines of Enquiry (KLOE’s) with in CQC’s methodology. I refer the provider to the provider guidance on the CQC website for more details.
The overall rating for the well-led domain is dependent on the findings for all the Key Lines of Enquiry (KLOE’s) with in CQC’s methodology. I refer the provider to the provider guidance on the CQC website for more details.
See previous comments above to points raised by the provider. The points raised have not changed the breaches identified during the inspection and therefore this statement in the report is still valid and factually accurate.
The overall rating for the well-led domain is dependent on the findings for all the Key Lines of Enquiry (KLOE’s) with in CQC’s methodology. I refer the provider to the provider guidance on the CQC website for more details.
See previous comments above to points raised by the provider. The points raised have not changed the breaches identified during the inspection and therefore this statement in the report is still valid.
The overall rating for the each domain is dependent on the findings for all the Key Lines of Enquiry (KLOE’s) for each domain, found with in CQC’s methodology. I refer the provider to the provider guidance on the CQC website for more details.
See previous comments above to the points raised by the provider. The points raised have not changed the breaches identified during the inspection and the breach of Regulation 17 is still valid.
This was a clerical error as the CQC email address was incorrect. This continued for two years. However when the delivery failed messages were received when trying to send notifications to CQC checks were not made to ensure the email address was the correct one and that this was remedied.
I am pleased to note this has been rectified – I gave the correct email address to the registered manager during the inspection.
The overall rating for the well-led domain is dependent on the findings for all the Key Lines of Enquiry (KLOE’s) with in CQC’s methodology. I refer the provider to the provider guidance on the CQC website for more details. See previous comments.
Thank you for your comprehensive response.
Following a review of your comments here we have responded to each of your points individually. This report remains factually accurate and our judgement is reflected in the outcome of this domain.
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Please describe (and provide copies of) any additional evidence which you consider should be taken into account in the report. Evidence must relate to the position on the day of inspection. | CQC decision
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CQC response
If you agree to make amendments you must confirm any impact on breaches or the rating. If you choose not to make any amendments you must provide reasons. |
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Finally, we will address the below alleged breach in regulation that we believe to be false and unsubstantiated and should be removed from the inspection report. All other alleged breaches that we believe are false and should be removed have been evidenced and referenced earlier on in this response and should be acted upon accordingly.
Regulation 10 HSCA RA Regulations 2014 Dignity and respect.
This meant people sat for long periods with no interaction with staff and people were not always engaged or re-assured when support was provided. This was a breach of Regulation 10
We quote the regulation10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
10 Dignity and respect (1) Service users must be treated with dignity and respect.
This half completed statement does not evidence anything to indicate that residents have not been treated with dignity and respect and we find this conclusion to be completely subjective based on the fact that some people had to wait to be toileted.
People have to wait in many services in life and we see no connection between waiting for the toilet for a period of time as being undignified and disrespectful. Furthermore, the term “long” is subjective and unless the inspector has timed this and can provide evidence to this as being inappropriately long, it cannot be used as evidence to support a breach of regulation.
It is also an assumption that the particular resident in question felt disrespected and undignified as the inspector has not sought evidence from that particular resident as to whether they knew why they were waiting and whether due to previous assurances in that situation, they already felt reassured because of the respect and dignity that they are always treated with by our staff.
As stated previously in our response there will always be a certain period of waiting time for the toilet and this is something that all residents, and family members understand. We have never received one single complaint in the history of our home regarding this as all residents and family members are fully aware of the service levels we provide within our home. We therefore find that the inspector has produced no evidence to prove that this regulation was in breach and find that this alleged breach is based on superficial and subjective observations without speaking to or seeking the opinions of the residents in question. We therefore request that this breach be removed from our inspection report as a “factual inaccuracy” with no evidence to support it.
Due to everything that we have pointed out as not relevant or factually incorrect within this report we see no reason for our nursing home to be placed under “special measures” and find the consistency, accuracy and evidence in this report to be flawed in virtually every area with regards to this outcome. In the 30 years that our nursing home has run we have never been placed under “special measures” and feel that the quality of our care is better now than it ever has been in the past. There is numerous statement’s from staff, residents, family members and outside professionals to support this within this inspection reports own findings and many of the findings contradict the outcomes suggested in the report especially when considered against the corrections in relevance and factual inaccuracies outlined in this response.
It is very sad and disappointing that this inspection and report was conducted in this way as Flixton Manor does not seek out adversarial relationships with any outside agency, professional or governing body and simply look to take on board helpful and intelligent criticism and improve the standards of care with in our home with the ultimate view of improving our residents’ quality of life.
We aim to have a constructive and co-operative relationship with the CQC as after all we are both seeking the same outcomes which is to provide the best quality care to the residents within our home. We do not find this report to be consistent with an organisation that is seeking these goals as under the section “Action we have told the provider to take”, there is not one single action listed but rather a list of “alleged” breaches in regulations with no advice or recommendations has to how to remedy these “alleged” breaches.
This is clearly not the actions of a caring and helpful organisation looking to help improve the lives of vulnerable residents but an unsupportive and false statement that offers no constructive criticism. It is clear from this report that we find all alleged breaches apart from regulation 16 which has already been corrected, to be false and unsubstantiated. A report like this has real consequences to our good reputation and for the moral of our staff and unless this report is amended accordingly, we have been placed in a position where we have no alternative but to seek legal action against the CQC for publishing a factually inaccurate report that is not a genuine and fair reflection of the care in our nursing home. These false breaches in regulations are evidenced very clearly in the CQC’s own findings from the inspection and so create a conflicting, confusing and contradictory report that is inconsistent with itself and previous inspections carried out within our nursing home.
We hope that we can work together to correct and amend this report accordingly as we genuinely wish to have a good relationship with the CQC and welcome their inspections as constructive ways for us to improve our service.
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The report clearly states that there was little interaction with people when staff were providing support and also when staff were walking through the lounge areas as well as people having to wait to access the toilet. This is evidenced from the inspector and Expert by Experience observations and talking with people and their relatives. This is a breach of Regulation 10.
See previous comments to the FAC made by the provider. The ratings have not changed due to the comments; therefore the home is rated overall as inadequate. Please see the CQC provider guidance for more information about special measures.
I received an email from the registered manager following the inspection saying how constructive the inspection had been and welcomed the feedback I gave on the second day of the inspection.
Please see CQC provider guidance which can be accessed through our website. CQC is not prescriptive in how providers meet the regulations as different services and homes support people with different needs, have different procedures and paperwork. Discussions took place with the registered manager, clinical lead nurse and senior carer throughout the inspection. Additionally you may find it useful to access external agency websites such as Care Improvement Works which has been developed by Skills For Care and SCIE.
See previous comments, the breaches identified in the original report have not been changed by the comments contained within this factual accuracy report. |
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CQC use only
| Responses prepared by (name) | Mick Gorton |
| Role | Inspection |
| Date | 31/10/16 |
| Responses reviewed by (name) | Michelle Henshall |
| Role | Inspection Manager |
| Date | 09 Sept 2016 |
We wee unsatisfied with this response and so then requested a review of the rating
Kind regards
Rashad Al-Safar
Flixton Manor – Company Director
We now request a review of the CQC’s rating within our inspection report as we believe the methodology that the inspector has used is flawed and thus the findings are incorrect also. We refer to the ambition stated within the CQC’s provider handbook which states “Our ambition is to encourage services to improve so that they can be rated as good or outstanding “ We have not found any evidence to show encouragement from the inspector or the CQC to achieve the good or outstanding ratings mentioned as contrary to the numerous comments made by residents and relatives evidencing good or outstanding care, not one single action or recommendation has been suggested within the entire inspection report. The section which states “actions we have told the provider to take” does not have one single word of encouragement, recommendations or actions suggested but rather asks us what actions we will take to breaches we believe to be incorrect. We would ask how this process and methodology aims to encourage our service to improve and meet the clearly stated ambition of the CQC? Further to this, we have provided a 60 page response using the factual inaccuracy form through the CQC’s website. This response clearly outlines why we believe the inspector has not followed a correct methodology in our ratings but the inspector has failed to provide evidence as to how the correct methodology used has resulted in certain breaches (mentioned below) and has failed to provide evidence to support the conclusions referencing the exact wording within the Health and Social Care We now request a review of the CQC’s rating within our inspection report as we believe the methodology that the inspector has used is flawed and thus the findings are incorrect also. We refer to the ambition stated within the CQC’s provider handbook which states “Our ambition is to encourage services to improve so that they can be rated as good or outstanding “ We have not found any evidence to show encouragement from the inspector or the CQC to achieve the good or outstanding ratings mentioned as contrary to the numerous comments made by residents and relatives evidencing good or outstanding care, not one single action or recommendation has been suggested within the entire inspection report. The section which states “actions we have told the provider to take” does not have one single word of encouragement, recommendations or actions suggested but rather asks us what actions we will take to breaches we believe to be incorrect. We would ask how this process and methodology aims to encourage our service to improve and meet the clearly stated ambition of the CQC? Further to this, we have provided a 60 page response using the factual inaccuracy form through the CQC’s website. This response clearly outlines why we believe the inspector has not followed a correct methodology in our ratings but the inspector has failed to provide evidence as to how the correct methodology used has resulted in certain breaches (mentioned below) and has failed to provide evidence to support the conclusions referencing the exact wording within the Health and Social Care Act 2008 that he believes to be in breach. We believe that the following breaches have not been arrived at using the correct methodology and that biased opinions based on a complaint from a family have influenced the ratings of our report. We have never been formally asked by the CQC to respond and have not received this complaint in writing. Regulation 9 HSCA RA Regulations 2014 Person centred Care, Regulation 10 HSCA RA Regulations 2014 Dignity and respect, Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed, Regulation 18 HSCA RA Regulations 2014 Staffing. We also believe contradictory ratings have been reached using their methodology as we fail to see how breaches in the law (The Health and Social Care Act 2008) in the above areas could only result in “requires improvement” We also fail to see a that a fair process of review regarding the rating has been offered by the CQC as no independent party has been involved before publishing the report following our 60 page response and 500 words is hardly an adequate amount to provide full details of what we wish to be reviewed now. On studying the provider handbook, we now request the CQC provide evidence to show how it has followed every part of its methodology and how that methodology has resulted in the breaches of regulations and how these breaches have resulted in the ratings stated in our published report.ct 2008 that he believes to be in breach. We believe that the following breaches have not been arrived at using the correct methodology and that biased opinions based on a complaint from a family have influenced the ratings of our report. We have never been formally asked by the CQC to respond and have not received this complaint in writing. Regulation 9 HSCA RA Regulations 2014 Person centred Care, Regulation 10 HSCA RA Regulations 2014 Dignity and respect, Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed, Regulation 18 HSCA RA Regulations 2014 Staffing. We also believe contradictory ratings have been reached using their methodology as we fail to see how breaches in the law (The Health and Social Care Act 2008) in the above areas could only result in “requires improvement” We also fail to see a that a fair process of review regarding the rating has been offered by the CQC as no independent party has been involved before publishing the report following our 60 page response and 500 words is hardly an adequate amount to provide full details of what we wish to be reviewed now. On studying the provider handbook, we now request the CQC provide evidence to show how it has followed every part of its methodology and how that methodology has resulted in the breaches of regulations and how these breaches have resulted in the ratings stated in our published report.
We then received 2 warning notices to which we responded to as follows
CQC Representations Citygate Gallowgate Newcastle upon Tyne NE1
4PA
For the attention of the Company Secretary or clerk Flixton House Limited
Telephone: 03000 616161 Fax: 03000 616171
2-8 Delamere Road Urmston Manchester Greater Manchester M41 5QL
01 December 2016
The Care Quality Commission The Health and Social Care Act 2008
WARNING NOTICE: PROVIDER: Flixton House Limited
REGISTERED MANAGER: Susan Gerrard Porter
REGULATED ACTIVITIES: Accommodation for persons who require
nursing or personal care Treatment of disease, disorder or injury
Our Reference: ENF1-3068540054 Account number: 1-127659242
Dear Company Secretary or clerk,
This notice is served under Section 29 of the Health and Social Care Act
2008.
This warning notice relates to your registration to carry on the above
regulated activities at or from the following location(s):
Flixton Manor 2-8 Delamere Road, Urmston, Manchester, Greater
Manchester, M41 5QL
We are notifying you that you are failing to comply with the relevant
requirements of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014.
You are failing to comply with Regulation 17, (1) (2)(a)(b)(e), Good
governance, of The Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014.
Why you are failing to comply with this regulation:
We are notifying you that you are failing to comply with the relevant
requirements of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
You are failing to comply with Regulation 17 (1) with reference to 2
(a)(b)(e) which states:
1. Systems or processes must be established and operated effectively to
ensure compliance with the requirements in this Part.
2. Without limiting paragraph (1), such systems or processes must enable
the registered person, in particular, to – (a) Assess, monitor and improve
the quality and safety of the services provided in the carrying on of the
regulated activity (including the quality of the experience of service users
in receiving those services); (b) Assess, monitor and mitigate the risks
relating to the health, safety and welfare of service users and others who
may be at risk which arise from the carrying on of the regulated activity.
(e) Seek and act on feedback from relevant persons and other persons on
the services provided in the carrying on of the regulated activity, for the
purpose of continually evaluating and improving such services;
Why you are failing to comply with this regulation:
1. An unannounced inspection of Flixton Manor, 2-8 Delamere Road,
Urmston, M41 5QL (the service) was undertaken by the Care Quality
Commission (‘CQC’ or ‘the Commission’) as part of a compliance review
on 6 and 7 September 2016. On the first day the inspection was carried
out by Mick Gorton (inspector) and Graham Brushett (Expert of
Experience). The second day the inspection was carried out by Mick
Gorton (inspector).
2. As part of this inspection Mick Gorton looked at the systems in place to
monitor the quality of the service provided.
3. Mick Gorton viewed the assessments of needs for seven people (GG,
IL, ME, DS, BE, JM and SG) on the Care Sys computer system. There were
multiple assessments for each person. For example person IL had 23
assessments. Six of these were the same assessment (the Care Sys
Assessment). None of these had been fully completed and each version
had a different section completed. Person GG had three assessments for
pressure sores, each of these conflicted as they had a different outcome
(Pressure Ulcer risk assessment – low risk, Braden risk assessment – high
risk and Waterlow assessment – very high risk) . As registered provider
you are failing to ensure that the risk to people’s health and safety are
assessed and that people’s needs are clearly identified so that they
receive the correct treatment and support.
RESPONSE:
The above point has no bearing on Regulation 17(1)(2)(a),(b) and (e) as,
whilst incomplete draft assessments were seen at the time of the
inspection, completed assessments for all residents were readily available
and identifiable. It required only a simple search to find the relevant
completed assessments.
It was admittedly a minor clerical error on our part that we retained draft
assessments, but we reject that retaining drafts of assessments is,
specifically, bad practice, and it at least illustrates that we endeavour to
hold complete files for residents – even including draft documents.
No evidence has been provided to even suggest that the draft
assessments had any bearing on the final care requirements or the
procedures implemented and care provided. There were quite clearly
processes in place to assess, monitor and improve the quality and safety
of the services provided in the carrying on of the regulated activity and no
evidence has been presented to suggest otherwise.
With regards to the pressure ulcer risk assessments, and once again, the
inspector has failed to provide any evidence that our care has been
implemented incorrectly and we are wholly confident that in all cases,
appropriate care was administered. If any breach of Regulation 17 is to be
alleged, then clear evidence as to how a resident’s care was affected must
be provided.
Assessment forms are tools to help nurses make clinical judgements about
a resident’s care, and if there is any suggestion that our nurses have
implemented any part of anyone’s care incorrectly, inappropriately or
inadequately, then we reasonably expect and demand that relevant and
appropriate evidence to substantiate such claims be provided – or
otherwise require you to formally retract such allegations.
All care needs and reviews at the time of the inspection were complete
and accurate, and these care needs are exactly what we rely on when
implementing care within the home. Whatever information is generated
by assessment forms, it still requires the judgement of a clinical nurse to
create the care needs, and assess and mitigate risks.
Conspicuously, no evidence has been provided to suggest otherwise.
We often find completely incorrect assessments from hospitals and
outside agencies have been provided to us upon admitting residents and
in practical terms it clearly takes time to accurately monitor and assess a
resident’s care. Assessments are not solely relied upon to implement care.
We rely on our nurses’ clinical judgements, which are stated in the actual
care needs, and these are always being reviewed and adapted in full
compliance with Regulation 17.
In order for our home to be properly inspected and judged, we submit
that inspectors should not rely solely on written assessments to judge our
performance with reference to Regulation 17 (or indeed any of the
applicable Regulations). Rather, and notwithstanding that they are not
appropriately qualified nurses, which puts them at something of a
disadvantage, the inspectors should be assessing residents and the care
they receive. How otherwise would they actually know whether the care in
our home was being implemented correctly – regardless of what an
assessment states?
This level of inspection and evidence could practically and accurately be
carried out only by (at the very least) a qualified nurse who had sufficient
time to spend with a particular resident in order to make their own
assessments and clinical judgments of the care that that resident required.
Once they had come to a conclusion they could then cross-reference their
findings with our own care needs and daily records to see that we clearly
do have the ability to:
(a) Assess, monitor and improve the quality and safety of the
services provided in the carrying on of the regulated activity
(including the quality of the experience of service users in receiving
those services);
(b) Assess, monitor and mitigate the risks relating to the health,
safety and welfare of service users and others who may be at risk
which arise from the carrying on of the regulated activity; and
(e) Seek and act on feedback from relevant persons and other
persons on the services provided in the carrying on of the regulated
activity, for the purpose of continually evaluating and improving
such services.
For this reason we see no evidence that we have breached Regulation 17
(1) with reference to 2 (a)(b)(e), and therefore request that you provide
relevant and appropriate evidence to substantiate the same.
4. Care plans and risk management plans are stored only on the Care Sys
on the computer. Care staff are not given access to this system which
means that they do not have access to the care plans and risk
management plans as well as other associated documentation relating to
the care and treatment of people using the service. We were told that FM
(the clinical lead nurse) provided information about people’s needs, care
plans and risk management plans to staff. However this means that staff
are reliant on verbal information passed to them only when they are on
duty and their recollection of the information over time. We observed a
daily handover took place, led by the clinical lead nurse or nurse on duty
to inform staff of any changes in people’s needs and wellbeing. As
registered provider you are failing to enable staff to have access to
people’s care plans and risk assessments to ensure they have the correct
information available when supporting people.
RESPONSE:
If the inspector is to use this as evidence of a breach of Regulation 17
then he must provide evidence as to where our current system of full
supervision of new staff members with knowledgeable staff and robust
handover sessions from our trained, competent, knowledgeable nurses
has failed to:
(a) Assess, monitor and improve the quality and safety of the
services provided in the carrying on of the regulated activity
(including the quality of the experience of service users in receiving
those services);
(b) Assess, monitor and mitigate the risks relating to the health,
safety and welfare of service users and others who may be at risk
which arise from the carrying on of the regulated activity; and
(e) Seek and act on feedback from relevant persons and other
persons on the services provided in the carrying on of the regulated
activity, for the purpose of continually evaluating and improving
such services.
All staff were fully aware of the current needs and risks of all the residents
within the home at the time of the inspection and Regulation 17 does not
dictate or prescribe which system should be used in order to ensure that
this is done correctly, effectively and efficiently.
The inspector has stated that
“We observed a daily handover took place, led by the clinical lead
nurse or nurse on duty to inform staff of any changes in people’s
needs and wellbeing”,
which clearly evidences that a system of informing care staff about, and
enabling them to have access to, people’s care plans and risks is
implemented and operational.
If the inspector felt that our current system was not compliant with
Regulation 17 at the time of his inspection, then he must provide
evidence as to where and how our current system is in breach of this
Regulation. Again, however, he has conspicuously failed to do so.
If care staff were to have access to the written care plans and risk
assessments they could just as easily ask one of our clinical nurses, who do
have access and are fully knowledgeable as to each resident’s specific
care needs. This is precisely the system we operate to administer effective
and efficient care and ensure compliance with every part of Regulation 17.
At the time of the inspection, written care plans were available in the
clinic room but care staff would not ordinarily be aware of them and they
are rarely if ever used due to the fact that we already have efficient,
effective and highly reliable methods of verbal communication – as indeed
is cited by the inspector in the report.
There is nothing stated within Regulation 17 to indicate that our non-
nursing staff require access to written records in order for us to have and
operate an effective system that complies with the Regulations.
Accordingly, we again see no basis for the allegation that we are in breach
of Regulation 17.
5. People who used the service and their families were not asked to be
involved in formulating, agreeing and reviewing of their care plans.
Families were asked for any relevant information during the initial
assessment process when their relative came to live at the service;
however they did not see, participate in or agree the care plans
subsequently written. Care plans were seen by the service as being for the
nurses’ use only. As registered provider you are failing to involve the
person using the service and their relatives in the development and review
of their care plans.
RESPONSE:
As stated in our previous factual accuracy response form – to which we
have to date received only a wholly inadequate response – at the time of
the inspection a file was located in the clinic room signed by all family
members stating that they were aware of, and had access to, the relevant
care plans whenever they wished, and that they were available on request
at any time.
This is clear evidence that directly disproves the inspector’s assertion that
we are failing to involve the person using the service and their relatives in
the development and review of their care plans.
Multiple comments within the report confirm that residents and their
families could approach staff and management at all times and would
therefore have no difficulty being involved in the planning and
implementation of the care, should they wish.
Our experience is that the vast majority of family members are extremely
happy with the care plans and the care provided. This is evidenced by a
vast array of letters and cards that we keep on file in our office. This is
something the inspector failed to ask for or review.
During the inspection the inspector has evidenced in his own findings
that:
“We saw a relative’s survey had been issued in January 2016, with
five surveys being returned. These were positive”
“People and relatives said they were confident to raise any issues
they had with staff or the registered manager”
This is clear evidence that we seek and act on feedback from relevant
persons and other persons on the services provided in the carrying on of
the regulated activity, for the purpose of continually evaluating and
improving such services.
Furthermore, we carry out regular reviews of care plans with family
members and social workers which, again, is clear evidence that we seek –
and act on – many methods of feedback.
Even though, as stated above, we have regular family reviews and
relatives are fully aware that they have access to care plans, we must
emphasise that direct involvement in the creation and review of care plans
is not a requirement or condition of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 and we therefore see no basis to
support the allegation that we have breached Regulation 17.
6. Mick Gorton viewed five staff personnel files (CA, DS, LM, LD and MM).
In each case there were incomplete employment histories as the
application form asked for the employment dates that covered the most
recent employer and one other employer only. Gaps in people’s
employment record were not explored. Additionally the Flixton Manor
policy states that ‘references will be obtained’. The registered manager
said this meant two references would be obtained. DS and MM files
contained no references and CA, LM and LD files contained one reference
only. At least two references should be obtained, one of which should be
from the current or most recent employer. As registered provider you are
failing to carry out proper checks to ensure the staff employed are
suitable to work with vulnerable people.
RESPONSE:
Notwithstanding that this point has been addressed in detail within our
factual accuracy response form, we are – in any event – unsure as to why it
has been placed here with reference, again, to Regulation 17.
Flixton Manor obtains DBS and POVA checks and ensures that all staff are
fully supervised and not left unattended during their induction period
when commencing their employment with us. This gives us ample time to
assess a staff member’s character.
Again, however, we do not find this to be relevant to the question of
compliance (or otherwise) with Regulation 17, as this has no bearing on
our assessment and monitoring of health and safety risks.
We therefore do not feel the need to comment on this any further, and
would refer you to our factual accuracy response form (in respect of which
we continue to await your satisfactory response). We can see no breach
here and would ask that you explain how these allegations are relevant to
Regulation 17.
7. Mick Gorton completed a tour of the building. There was a trip hazard
on the first floor corridor where the two buildings had been knocked
together in the form of a steep slope in the corridor floor. A sign to warn
people of this had been placed on the wall; however there were no risk
assessments in place and there were no plans in place to reduce this risk.
The majority of people who live at Flixton Manor are not independently
mobile. However the steep slope posed a risk to staff and visitors to
Flixton Manor. As registered provider you are failing to mitigate risks of
people potentially tripping as a result of the slope in the corridor.
RESPONSE:
This is a contradictory statement as the inspector states that there were
no plans in place to reduce the risk and that no risk assessment had been
recorded in writing but notes that a warning sign (namely “A sign to warn
people of this”) had been placed on the wall notifying residents and staff
of the hazard.
We question the criticism that there was no written risk assessment as it is
clear that such a risk assessment had taken place given the existence of
the prominent warning sign. The signed warning of the risk is clear
evidence that some form of assessment has taken place: we saw a risk,
assessed it (noting that the route is used only by staff, all of whom are
aware of the sloping floor), and concluded that a sign was necessary and
was duly placed visibly on the wall.
We cannot see the justification in the Inspector making this complaint.
This is a sloping floor which is clearly warned by signage.
We would respectfully request that the CQC – as per its stated intention in
the CQC provider handbook, namely “to encourage services to improve
so that they can be rated as good or outstanding” – at least provide us
with its suggestion(s) as to how this area can be improved to good or
outstanding?
We also seek further clarification as to how this specific issue means that
we are in breach of Regulation 17, namely in that we have failed to
“Assess, monitor and mitigate the risks relating to the health, safety
and welfare of service users and others who may be at risk which
arise from the carrying on of the regulated activity.”
We would also add that we have not had a single accident – or even
incident – in the 10 years plus that this slope has existed.
Signs are a very practical, logical and visible way of helping to reduce such
risks and make premises fit for purpose. Given that signage was in place
here, and in the absence of any incidents whatsoever, or issues of any kind
arising in relation to the sloping floor, we fail to see the basis upon which
any logical conclusion can be drawn that this small slope constitutes a
breach of Regulation 17(1)(2)(a), (b) and (e).
8. Mick Gorton saw there was one shower available for people to use. The
shower room on the basement level was not accessible as it was used as a
store room. The bathroom on the first floor was in need of refurbishment
and was not used. This also meant there were no facilities available for
people to have a bath. There was an additional accessible toilet on the
ground floor, which the majority of people used during the day as they
were sat in the lounge area of the home. Some rooms had en-suite toilet
facilities. These were not accessible for people who required mobility aids
and staff support as they were too small. They therefore were not used.
This meant people had to wait to be able to use the toilet during the day.
As registered provider you are failing to ensure enough facilities are
available for the people using the service to use without having to wait.
RESPONSE:
This statement is a duplication of another set of random statements made
in relation to our apparent breach (which for the avoidance of doubt is
denied) of Regulation 15(1) of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 to which we have responded to
thoroughly in our response to the warning notice that was issued towards
that alleged regulatory breach.
We see no breach here whatsoever and, further, fail to see the relevance
of this statement to Regulation 17(1)(2)(a), (b) and (e). Indeed we are
mystified as to why this claim would be repeated here.
There is a bathroom with a fully-functioning and fully-operational bath on
the ground floor of the building, and the Inspector’s statement that there
were no facilities for residents to have a bath is incorrect. With respect, he
has failed to look or even bother to establish the facts here.
We would add that in our 30 years’ experience of looking after elderly
residents, baths are not the most efficient, hygienic or practical way in
which to ensure residents’ cleanliness. This is why we have installed a
beautiful and extremely accessible shower room on the ground floor
which has a power-assisted shower located centrally in a large, well
decorated and specially designed room. The room has soft mood lighting
for an enhanced experience for our residents – a fact that was entirely
overlooked and omitted from our inspection report, despite the fact that
this facility has received a extremely positive feedback from numerous
family members and visitors to our home.
We would also add that there is a shower room on the 1st floor of our
home but we choose not to use it due to the advanced and improved
showering facilities on the ground floor.
The inspector is suggesting that one showering facility is not enough for
the 33 residents within the home but – notwithstanding that the inspector
is, in any event, incorrect – he has failed to provide any evidence to
support this assertion.
All residents are provided with bed-baths every morning and are provided
with showers at least once a week, or otherwise as and when required. At
the time of the inspection all the residents in our home were immobile
and required the assistance of 2 care assistants for showering. It takes
staff approximately 30 minutes to shower each resident, with – as we say –
all residents receiving on average, one shower per week: in the
circumstances, 1 extremely well-equipped shower room is – in our view
and experience – more than sufficient to accommodate 33 residents?
Due to time constraints and the need to ensure the close care and
supervision of all our 30-plus residents, it would not be possible to give
showers daily and, indeed, we do not hold ourselves out as a home that
can or does provide such a service.
It is clear that we have considered the issue of bathing/showering, and the
facilities for and timing of the same, and have implemented an
appropriate schedule and timetable accordingly: our approach is a
practical response to the time available and care required, and has
nothing to do with the actual number of available bathing or showering
facilities within the home.
We would also emphasise that our home is equipped with a fully working
lift and a stair lift, and therefore question the relevance of the location of
the facilities to the issue of whether the home has sufficient, and available,
bathing facilities.
We would ask that the inspector provide an explanation – and supporting
evidence – to justify his conclusion that there are insufficient showering or
bathing facilities for the number of residents within our nursing home?
Accordingly we reject the assertion that we are in breach of Regulation 17
with regards to our bathing and showering facilities, and put the inspector
to proof of his claims.
Further, we require clarification as to why you consider this issue even to
constitute any sort of risk whatsoever to the residents, and why this
apparently relates to all, or even any, of the Regulations or, for the
avoidance of doubt, that we have failed to:
“Assess, monitor and mitigate the risks relating to the health, safety
and welfare of service users and others who may be at risk which
arise from the carrying on of the regulated activity.”
9. Mick Gorton were told care worker supervisions were not held. The
senior care worker said they were starting to undertake annual appraisals
with care workers. Nursing staff had received supervision in March 2016,
but had none since. Staff had not received training in dementia
awareness. The majority of the people living at Flixton Manor were living
with dementia. The service supports people who live with dementia. As
registered provider you are failing to ensure staff have all the support,
training and supervision relevant to their role and is necessary to enable
them to carry out the duties they are employed to do to undertake their
role.
RESPONSE:
This is incorrect. The inspector was told that “formal supervisions” were
not held. We reject the assertion that supervisions were not held: we have
found informal supervisions to be far more beneficial to staff morale,
communication, and general team building within our organisation.
I would add that our clinical lead nurse was also a mental health nurse and
has invaluable experience when dealing with many mental health issues.
The support, training and supervision relevant to a staff-member’s roles,
and which are necessary to enable them to carry out the duties and
obligations for which they are employed, has no relevance to Regulation
17 (1)(2)(a), (b) and (e). Indeed, this point has already been responded to,
in detail, in our factual accuracy response form to which, as we have said,
we received a wholly inadequate response.
We again see no breach here and therefore respectfully request that you
clarify how – if at all – this point is relevant to Regulation 17, which does
not relate to staff supervisions, appraisals or training, but relates – instead
– relates to health and safety, feedback and evaluating and improving our
services.
10. We found some audits were in place, for example medicines, care
plans and incidents. However, these had not identified the shortfalls the
Commission had identified during the inspection, for example with regard
to staff recruitment and the duplication and quality of assessments and
care plans. We found that when using our decision tree these had a
medium impact on people using the service.
RESPONSE:
We have already addressed in detail, and proven to the contrary, each of
these apparent and alleged shortfalls in procedure. As stated numerous
times in all of the responses we have provided to date, we are dedicated
to improving our services – and constantly strive to do so. However, all of
the points raised and allegations by the inspector at best fall under the
category of “good practice”.
Whilst we are always actually striving for best practice, we reject that we
have breached or are in breach of any parts of the Regulations, and we
feel that the CQC has far exceeded both its remit and its interpretation of
the legislation.
We also find the report to be variously inconsistent, contradictory and
incorrect. We would question whether these are the actions of an
organisation whose stated ambition is to encourage services to improve
so that they can be rated as good or outstanding.
During the course of the inspection, and also within the report, there is
not even a single recommendation, suggestion or piece of advice
provided that would evidence the CQC’s clearly-stated intention.
You are required to become compliant with Regulation 17 of the Health
and Social Care Act 2008 (Regulated Activities) Regulations 2014 above
by 31 January 2017.
Please note: If you fail to achieve compliance with the relevant
requirement within the given timescale, we may take further action.
You are required to become compliant with Regulation 17, section (1)
(2)(a)(b)(e), of the Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014 above by 31 January 2017.
Please note: If you fail to achieve compliance with the relevant
requirement within the given timescale, we may take further action.
We will notify the public that you have been served with this warning
notice by including a reference to it in the inspection report. We may also
publish a summary more widely, but will not do so if there is a good
reason not to.
If you think that the notice has been wrongly served on you, you may
make representations to us. This could be because you think the notice
contains an error, is based on facts you consider to be inaccurate, that it
should not have been served, or is an unreasonable response to the
situation it describes. You may also make representations if you consider
that for these or any other reason, the notice should not be more widely
published.
RESPONSE:
In light of our comprehensive, robust and thorough responses, above, not
to mention our 60-page factual accuracy response form (to which we have
yet to receive an adequate response) and due to the review request that
we have now submitted (that, again, has yet to merit your response), we
believe that this notice is unjust, unfair, unreasonable and unlawful.
We also note that this alleged breach of Regulation 17 has not been
mentioned within the currently published inspection report, and we are
therefore confused and extremely concerned as to why this apparent
breach in regulation has been raised now, at this stage, when it was not
raised in the report.
As stated in our original email when providing our factual accuracy
response, we are taking legal advice and will be taking legal action
against the CQC for the damages incurred due to the publishing of the
latest inspection report. Should this notice be published, then we reserve
the right to further action as appropriate.
The CQC have provided no evidence to substantiate these alleged
breaches, and in the event that the review does not end in a satisfactory
outcome for us then we must emphasise our intention to take whatever
further action is required. Please note that such action may include an
application for judicial review together with any further action necessary
to protect our home, our business and our reputation (built over 3
decades in this specific area) from what is a clear injustice.
Finally, we request that this and our other responses be published
alongside this notice and on the CQC website without delay.
The Act and its associated regulations are available on the Commission’s
website: http://www.cqc.org.uk
Any representations should be made to us in writing within 10 working
days of the date this notice was served on you. To do this, please
complete the form on our website at:
www.cqc.org.uk/warningnoticerepresentations and email it to:
HSCA_Representations@cqc.org.uk
If you are unable to send us your representations by email, please send
them in writing to the address below. Please make it clear that you are
making representations and make sure that you include the reference
number ENF1-3068540054.
If you have any questions about this notice, you can contact our National
Customer Service Centre using the details below:
Telephone: 03000 616161
Email: HSCA_Representations@cqc.org.uk
Write to: CQC Representations Citygate Gallowgate Newcastle upon
Tyne NE1 4PA
If you do get in touch, please make sure you quote our reference number
(ENF1- 3068540054) as it may cause delay if you are not
CQC Representations Citygate Gallowgate Newcastle upon Tyne NE1
4PA
For the attention of the Company Secretary or clerk Flixton House Limited
Telephone: 03000 616161 Fax: 03000 616171
2-8 Delamere Road Urmston Manchester Greater Manchester M41 5QL
01 December 2016
The Care Quality Commission The Health and Social Care Act 2008
WARNING NOTICE: PROVIDER: Flixton House Limited
REGISTERED MANAGER: Susan Gerrard Porter
REGULATED ACTIVITIES: Accommodation for persons who require
nursing or personal care Treatment of disease, disorder or injury
Our Reference: ENF1-3067534971 Account number: 1-127659242
Dear Company Secretary or clerk,
This notice is served under Section 29 of the Health and Social Care Act
2008.
This warning notice relates to your registration to carry on the above
regulated activities at or from the following location(s):
Flixton Manor 2-8 Delamere Road, Urmston, Manchester, Greater
Manchester, M41 5QL
We are notifying you that you are failing to comply with the relevant
requirements of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014.
You are failing to comply with Regulation 15, (1)(e), Premises and
equipment, of The Health and Social Care Act 2008 (Regulated Activities)
Regulations 2014.
Why you are failing to comply with this regulation:
We are notifying you that you are failing to comply with the relevant
requirements of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
You are failing to comply with Regulation 15 (1) (c) which states:
1. All premises and equipment used by the service provider must be –
1(c) Suitable for the purpose for which they are being used.
Why you are failing to comply with this regulation:
1. An unannounced inspection of Flixton Manor, 2-8 Delamere Road,
Urmston, M41 5QL (the service) was undertaken by the Care Quality
Commission (‘CQC’ or The Commission) as part of a compliance review on
6 and 7 September 2016. On the first day the inspection was carried out
by Mick Gorton (inspector) and Graham Brushett (Expert by Experience).
The second day the inspection was carried out by Mick Gorton (inspector).
2. As part of this inspection Mick Gorton completed a tour of the building.
There was a trip hazard on the first floor corridor where the two buildings
had been knocked together in the form of a steep slope in the corridor
floor. A sign to warn people of this had been placed on the wall; however
a risk assessment had not been written and there were no plans in place
to reduce this risk. The majority of people who live at Flixton Manor are
not independently mobile. However the steep slope posed a risk to staff
and visitors to Flixton Manor. As registered provider you are failing to do
all that is practicably possible to mitigate risks of people potentially
tripping as a result of the slope in the corridor.
RESPONSE:
This is a contradictory statement as the inspector states that there were
no plans in place to reduce the risk and that no risk assessment had been
recorded in writing but notes that a warning sign (namely “A sign to warn
people of this”) had been placed on the wall notifying residents and staff
of the hazard.
We question the criticism that there was no written risk assessment as it is
clear that such a risk assessment had taken place given the existence of
the prominent warning sign. The signed warning of the risk is clear
evidence that some form of assessment has taken place: we saw a risk,
assessed it (noting that the route is used only by staff, all of whom are
aware of the sloping floor), and concluded that a sign was necessary and
was duly placed visibly on the wall.
We cannot see the justification in the Inspector making this complaint.
This is a sloping floor which is clearly warned by signage.
We would respectfully request that the CQC – as per its stated intention in
the CQC provider handbook, namely “to encourage services to improve
so that they can be rated as good or outstanding” – at least provide us
with its suggestion(s) as to how this area can be improved to good or
outstanding?
We also seek further clarification as to how this specific issue makes our
premises “unsuitable for the purposes for which it is being used”, given
that all buildings will have areas that could be deemed a potential hazard
including (but not limited to) staircases, doors, mobility ramps, steps, plug
sockets, walls and so forth.
We would also add that we have not had a single accident – or even
incident – in the 10 years plus that this slope has existed.
Signs are a very practical, logical and visible way of helping to reduce such
risks and make premises fit for purpose. Given that signage was in place
here, and in the absence of any incidents whatsoever, or issues of any kind
arising in relation to the sloping floor, we fail to see the basis upon which
any logical conclusion can be drawn that this small slope constitutes a
breach of Regulation 15(1)(c) of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014 on the basis that the premises and
equipment therein are apparently not “suitable for the purpose for which
they are being used”.
3. At the time of our inspection there were 33 people living at the service.
The home had bedrooms on three levels, including the basement. Mick
Gorton saw there was only one accessible shower available on the ground
floor for all people living at the service to use. Whilst there were other
facilities within the property, the shower room on the basement level was
not accessible as it was used as a store room. The bathroom on the first
floor was old and in need of refurbishment and was not used. This also
meant there were no facilities available for people to have a bath. As
registered provider you are failing to ensure enough bathing facilities
were available.
RESPONSE:
There is a bathroom with a fully-functioning and fully-operational bath on
the ground floor of the building, and the Inspector’s statement that there
were no facilities for Residents to have a bath is incorrect. With respect,
he has failed to look or even bother to establish the facts here.
We would add that in our 30 years’ experience of looking after elderly
residents, baths are not the most efficient, hygienic or practical way in
which to ensure residents’ cleanliness. This is why we have installed a
beautiful and extremely accessible shower room on the ground floor
which has a power-assisted shower located centrally in a large, well
decorated and specially designed room. The room has soft mood lighting
for an enhanced experience for our residents – a fact that was entirely
overlooked and omitted from our inspection report, despite the fact that
this facility has received a extremely positive feedback from numerous
family members and visitors to our home.
We would also add that there is a shower room on the 1st floor of our
home but we choose not to use it due to the advanced and improved
showering facilities on the ground floor.
The inspector is suggesting that one showering facility is not enough for
the 33 residents within the home but – notwithstanding that the inspector
is, in any event, incorrect – he has failed to provide any evidence to
support this assertion.
All residents are provided with bed-baths every morning and are provided
with showers at least once a week, or otherwise as and when required. At
the time of the inspection all the residents in our home were immobile
and required the assistance of 2 care assistants for showering. It takes
staff approximately 30 minutes to shower each resident, with – as we say –
all residents receiving on average, one shower per week: in the
circumstances, 1 extremely well-equipped shower room is – in our view
and experience – more than sufficient to accommodate 33 residents?
Due to time constraints and the need to ensure the close care and
supervision of all our 30-plus residents, it would not be possible to give
showers daily and, indeed, we do not hold ourselves out as a home that
can or does provide such a service.
It is clear that we have considered the issue of bathing/showering, and the
facilities for and timing of the same, and have implemented an
appropriate schedule and timetable accordingly: our approach is a
practical response to the time available and care required, and has
nothing to do with the actual number of available bathing or showering
facilities within the home.
We would also emphasise that our home is equipped with a fully working
lift and a stair lift, and therefore question the relevance of the location of
the facilities to the issue of whether the home has sufficient, and available,
bathing facilities.
We would ask that the inspector provide an explanation – and supporting
evidence – to justify his conclusion that there are insufficient showering or
bathing facilities for the number of residents within our nursing home?
Again, we find no reasonable basis for your conclusion that we are in
breach of Regulation 15(1)(c) of the Health and Social Care Act 2008
(Regulated Activities) Regulations 2014, in that our bathing and showering
facilities are apparently not “suitable for the purpose for which they are
being used”.
4. There was also only one additional accessible toilet on the ground floor
which the majority of people used during the day as they were sat in the
lounge area of the home. Some rooms had en-suite toilet facilities. These
were not accessible for people who required mobility aids and staff
support as they were too small. They therefore were not used. This meant
people had to wait to be able to use the toilet during the day. As
registered provider you are failing to ensure enough facilities are available
for the people using the service to use without having to wait.
RESPONSE:
The inspector’s comments are wholly confusing here as he states that the
majority of residents were seated in the lounges of the home, before
going on to assert that the size of the en suite toilets is (apparently) the
reason why people had to wait to be toileted during the day.
With respect, this statement makes no sense at all. If residents are seated
in the lounges, then how would the en suite toilets have any bearing on
residents’ toileting waiting times whilst in the lounge during the day?
Furthermore, any residents that stay in their rooms would be bed bound
and therefore physically unable to be taken to the toilet in any event.
The inspector has provided no explanation for his assertion that there is a
correlation between the available toileting facilities and people apparently
having to wait to use the toilet. Indeed he has failed to provide any
evidence that people did in fact have to wait to use the toilet – for any
length of time whatsoever.
As per the inspection report he has used statements from residents to
evidence this apparent waiting but has not clarified or sought further
evidence as to the mental capacity of the residents he has questioned.
On many occasions residents will state they have been waiting for the
toilet for hours when they have just been taken minutes before.
Our nursing home has set toileting times, which is commonplace in any
nursing home. During this time toileting will be prioritised to residents
who are more in need but this is clearly a staff management and time
issue: it has nothing whatsoever to do with the number of facilities
available.
The inspector’s entire statement in this respect is confusing. Immobile
residents will always have to wait for the toilet as they physically cannot
go to the toilet by themselves or unaided. Even when they request to go
to the toilet during non-toileting times, they must wait to be lifted or
hoisted, wait to be wheeled to the toilet, wait for the door to be opened,
wait to be lifted onto the toilet and so on.
The inspector’s comments are either irrelevant, unclear, contradictory or
incorrect, and additionally he fails even to offer any constructive criticism
or advice. They are therefore contrary to the CQC’s primary objective (as
stated in the first line of its provider handbook) to “encourage services to
improve so that they can be rated as good or outstanding”.
Furthermore, and also of concern to us, is the fact that the inspector has
failed even to mention that our toileting facilities are state-of-the-art, with
completely self-cleaning mechanisms that are fast, efficient, comfortable,
hygienic, and we use no abrasive papers so as to ensure that our residents
are clean and are toileted in a beautiful and safe environment with
bespoke custom cabinetry, modern elegant tiles and soft ambient mood
lighting.
Due to the lack of any relevant or robust evidence with regards to
evidence that our apparent lack of toileting facilities led to people having
to wait for the toilet we cannot accept the finding that we are in breach of
Regulation 15(1)(c) of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 (namely that our home and its facilities are
not “suitable for the purpose of which they are being used”.
You are required to have suitable plans in place to become compliant with
Regulation 15 of the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014 above by 16 January 2017.
Please note: If you fail to achieve compliance with the relevant
requirement within the given timescale, we may take further action.
You are required to become compliant with Regulation 15, section (1)(e),
of the Health and Social Care Act 2008 (Regulated Activities) Regulations
2014 above by 16 January 2017.
Please note: If you fail to achieve compliance with the relevant
requirement within the given timescale, we may take further action.
We will notify the public that you have been served with this warning
notice by including a reference to it in the inspection report. We may also
publish a summary more widely, but will not do so if there is a good
reason not to.
If you think that the notice has been wrongly served on you, you may
make representations to us. This could be because you think the notice
contains an error, is based on facts you consider to be inaccurate, that it
should not have been served, or is an unreasonable response to the
situation it describes. You may also make representations if you consider
that for these or any other reason, the notice should not be more widely
published.
RESPONSE:
Given our robust and thorough responses, above, and of course our
earlier 60-page factual accuracy response form – to which we are still
awaiting your substantive response – and in light of the review request
that we have submitted – and to which we also await your response – we
believe that this notice is unfair, unreasonable and unjust, and has been
incorrectly and indeed unlawfully served – given that it relies on
regulations which have not in fact been breached – other than in the
inspector’s misguided and ill-informed opinion.
We also note that this apparent breach of Regulation 15(1)(c) of the
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
has not been mentioned within the currently published inspection report,
and we fail to see therefore how and why this apparent alleged breach
has been raised now – other than in response to our repeated questioning
of and challenge to the inspector’s findings since we first received his
report.
It appears now that the original allegations have been dropped without
explanation and entirely new allegations made against us, in relation to
issues which we not raised by the inspector previously.
As stated in our earlier email (attaching our factual accuracy response) we
will be taking legal action against the CQC for the damage incurred due
to the publishing of the inspection report and for any damage suffered by
the CQC’s ongoing actions.
The CQC have provided no evidence to substantiate these alleged
breaches, and in the event that the review does not end in a satisfactory
outcome for us then we must emphasise our intention to take whatever
further action is required. Please note that such action may include an
application for judicial review together with any further action necessary
to protect our home, our business and our reputation (built over 3
decades in this specific area) from what is a clear injustice.
Finally, we request that this and our other responses be published
alongside this notice and on the CQC website without delay.
The Act and its associated regulations are available on the Commission’s
website: http://www.cqc.org.uk
Any representations should be made to us in writing within 10 working
days of the date this notice was served on you. To do this, please
complete the form on our website at:
www.cqc.org.uk/warningnoticerepresentations and email it to:
HSCA_Representations@cqc.org.uk
If you are unable to send us your representations by email, please send
them in writing to the address below. Please make it clear that you are
making representations and make sure that you include the reference
number ENF1-3067534971.
If you have any questions about this notice, you can contact our National
Customer Service Centre using the details below:
Telephone: 03000 616161
Email: HSCA_Representations@cqc.org.uk
Write to: CQC Representations Citygate Gallowgate Newcastle upon
Tyne NE1 4PA
If you do get in touch, please make sure you quote our reference number
(ENF1-3067534971) as it may cause delay if you are not able to give it to
us.
Michelle Henshall Inspection Manager
Following this we received the 2 below responses which we believed to be wholly inadequate
For the attention of the
Company Secretary or clerk
Flixton House Limited
2-8 Delamere Road
Urmston
Manchester
Greater Manchester
M41 5QL
30 December 2016
Care Quality Commission
Health and Social Care Act 2008
Representations against a Warning Notice
Registered provider: Flixton House Limited
Regulated Activities: Accommodation for persons who require nursing or personal care, Treatment of disease, disorder or injury.
Our reference: ENF1-3067534971
Account number: 1-127659242
Dear Company Secretary or clerk
I am writing about the representations that we received on 13 December 2016 in respect of the above regulated activity, at the following location:
Flixton Manor
2-8 Delamere Road, Urmston, Manchester, Greater Manchester, M41 5QL
After careful consideration, it has been decided not to uphold your representations. I have reviewed the inspection report and the warning notice dated 01 December 2016, Flixton manor inspection report and your factual accuracy response.
The information you have provided in your representations does not materially alter the findings of the inspection carried out on 06 and 07 September 2016. The inspection found that there was non-compliance with Regulation 15, (1)(e), Premises and equipment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
I will respond to each of your points individually:
Points one and two:
The information that you have provided does not challenge the evidence found in either of these points. There was no written risk assessment in relation to the hazard.
Point three:
The information that you have provided does not challenge the evidence found in this point. There were insufficient bathing and toilet facilities for service users to use.
Point four:
The information that you have provided does not challenge the evidence found in this point. There were insufficient toilet facilities for service users to use.
You also stated that the breach of Regulation 15 was not contained in the inspection report. Please refer to pages 11 and 14 of the inspection report and you will see that the breaches are clearly shown.
As advised within the warning notice we will publish a summary of this warning notice. However, please be assured that this does not mean publication of the warning notice letter in full.
In addition, we will only publish the fact that we have taken enforcement action against you on our website. Once you have achieved compliance then this ‘enforcement banner’ will be removed.
If you have any questions about this letter, you can contact our National Customer Service Centre using the details below:
Telephone: 03000 616161
Email: Enquiries@cqc.org.uk
Write to: Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
If you do get in touch, please make sure you quote our reference number ENF1-3067534971 as it may cause delay if you are not able to give it to us.
Yours sincerely
Catherine Challinor
Inspection manager
For the attention of the
Company Secretary or clerk
Flixton House Limited
2-8 Delamere Road
Urmston
Manchester
Greater Manchester
M41 5QL
30 December 2016
Care Quality Commission
Health and Social Care Act 2008
Representations against a Warning Notice
Registered provider: Flixton House Limited
Regulated Activities: Accommodation for persons who require nursing or personal care, Treatment of disease, disorder or injury.
Our reference: ENF1-3068540054
Account number: 1-127659242
Dear Company Secretary or clerk
I am writing about the representations that we received on 13 December 2016 in respect of the above regulated activity, at the following location:
Flixton Manor
2-8 Delamere Road, Urmston, Manchester, Greater Manchester, M41 5QL
After careful consideration, it has been decided not to uphold your representations. I have reviewed the inspection report and the warning notice dated 01 December 2016, Flixton manor inspection report and your factual accuracy response.
The information you have provided in your representations does not materially alter the findings of the inspection carried out on 06 and 07 September 2016. The inspection found that there was non-compliance with Regulation 17, (1) (2)(a)(b)(e), Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
I will respond to each of your points individually:
Points one and two and three:
The information that you have provided does not challenge the evidence found in any of these points. There were conflicting and incomplete assessments present in the care files looked at and no systems in place to recognise this.
Point four:
The information that you have provided does not challenge the evidence found in this point. The care staff did not have access to the care files.
Point five:
The information that you have provided does not challenge the evidence found in this point. The relatives spoken with at the inspection were not aware that they could access care plans and the registered manager confirmed that the plans were for the use of the nurses and so relatives were not involved in developing the care
plans or reviewing them.
Point six:
The information that you have provided does not challenge the evidence found in this point. As a registered provider you had not carried out the sufficient checks to ensure that staff were employed safely.
Point seven:
The information that you have provided does not challenge the evidence found in this point. There was no written risk assessment in relation to the risk.
Point eight:
The information that you have provided does not challenge the evidence found in this point. There were insufficient bathing and toilet facilities for service users to use.
Point nine:
The information that you have provided does not challenge the evidence found in this point. Formal supervision sessions were not held with staff and staff were not trained in dementia awareness.
Point ten:
The information that you have provided does not challenge the evidence found in this point. The audits had not identified the concerns found.
You also stated that the breach of Regulation 17 was not contained in the inspection report. Please refer to page 20 of the inspection report and you will see that the breach is clearly shown.
As advised within the warning notice we will publish a summary of this warning notice. However, please be assured that this does not mean publication of the warning notice letter in full.
In addition, we will only publish the fact that we have taken enforcement action against you on our website. Once you have achieved compliance then this ‘enforcement banner’ will be removed.
If you have any questions about this letter, you can contact our National Customer Service Centre using the details below:
Telephone: 03000 616161
Email: Enquiries@cqc.org.uk
Write to: Care Quality Commission
Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA
If you do get in touch, please make sure you quote our reference number ENF1-3068540054 as it may cause delay if you are not able to give it to us.
Yours sincerely
Catherine Challinor
Inspection manager
———————————————————————————————————————————————————————–
We then repsonseded with the following
———————————————————————————————————————————————————————–
Fao: Ms Catherine Challinor
10th Floor, 3 Hardman Street Inspection Manager
Spinningfields
Care Quality Commission Citygate Gallowgate
Manchester M3 3HF T: 0161 932 1739 F: 0161 850 1020
Newcastle Upon Tyne NE1 4PA
hiltonlaw.co.uk
By post & email: enquiries@cqc.org.uk
10 March 2017
Our ref: MJH.FLI01.04 Your ref:
Dear Madam
Our client: Flixton House Limited t/a Flixton Manor Nursing Home (“the Home”) Your reference: ENF1-3067534971 Account number: 1-127659242 Inspection ID: INS2-2445278139
We are instructed by our client regarding the inspection at the Home on 6 and 7 September 2016, the subsequent inspection report dated 15 November 2016 (“the Report”) and our client’s various substantive responses and submissions regarding both the draft inspection report and the Report itself.
We also refer to your letter dated 30 December 2016 in response to our client’s representations dated 13 December 2016 (“the Response”). This letter seeks further information and clarification on the content of your letter of 13 December which is, unfortunately, wholly unacceptable and hardly constitutes a reply to the numerous issues and matters detailed by our client in the Response.
We also note the contents of the letter from Vincent Ricot (Assistant Rating review Officer) dated 19 January 2017, in which our client’s complaint regarding the inspection and the Report were dismissed outright by Mr Ricot, on behalf of the CQC. Mr Ricot states that:
“In summary I am assured the full quality assurance process for this inspection and the reporting was followed, due consideration given to the relative weighting of the evidence collected and the aggregation principles correctly followed. As such there are no applicable grounds for challenge and therefore your request for a review of the ratings for Flixton Manor Nursing Home will not proceed to consideration by an Independent Reviewer. The published ratings will remain the same. ”
For the avoidance of doubt, Mr Ricot’s conclusions are unacceptable and we do not agree that the inspection was correctly carried out or that the basis upon which the Report’s findings are based are fair, reasonable or correct. (Indeed, the fact that no previous inspection has identified any of the issues detailed in the Report (for example,
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
the toilet and bathing facilities, the sloping floor, access to care records, the care records themselves), suggest that – for the Report to be correct – all previous inspections over the previous 12 years were flawed and the findings incorrect. Surely this cannot be correct).
We have now reviewed this matter in some detail on our client’s behalf, including your previous documents and notices, and our client’s detailed responses thereto.
We have to say that we are extremely concerned by your comments and at the content of your correspondence dated 30 December 2016. Whilst we note that, technically, you have noted our client’s detailed submissions in the Response to the Report, nevertheless, it is clear that the explanation provided by you and the level of detail (or rather the lack of detail) provided by you are at best problematic, and at worst fail to justify the findings of the Report, and your upholding the same, and fail to address any of our client’s numerous concerns at its treatment by the CQC in relation to the inspection at the Home on 6 and 7 September 2016, and the subsequent and resulting Report.
As an initial observation, you have failed to cite or cross-refer any actual wording from either the Response, the Report or the Health and Social Care Act 2008 (“the Act”), as a result of which your conclusions have no context. You simply and continually state that:
“The information that you have provided does not challenge the evidence found in this point”,
but provide no reference as to which piece of evidence, information or legislation you are referring.
We now seek and indeed require clarification and your detailed explanation as to the alleged breaches in the Act as none have been provided within any of your responses to date. We are concerned primarily (and at this stage) with your explanation of the specific breaches you have referenced in your [warning notice], as – before deciding on a future course of action – we wish to be clear about the precise statutory and legislative provisions upon which you are relying to prove your conclusion(s) that there has been an alleged breach (or rather, alleged multiple breaches) of the Act.
Therefore, please now explain clearly how the Inspector’s apparent findings in the Report and the points you have made subsequently (in defence of that Report) constitute a breach of the relevant Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the Regulations”), as alleged. We would also ask that you reference the actual wording from the Act and explain what information and evidence you rely upon, and how that evidence is relevant and applicable to the Act.
We must emphasise that simply repeating that –
“The information that you have provided does not challenge the evidence”
is not a sufficient or satisfactory explanation and offers no indication as to the exact breach being alleged under the relevant Regulation.
All of our client’s responses to date have sought clarification as to why the standing and reputation of the Home has been jeopardised by the CQC affecting its ability to attract
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
and admit new residents, recruit staff, and run its business effectively. If it is required to publicly display its apparent “inadequate” status as a care provider for residents, prospective residents and visitors to see, not to mention the fact that it is now displayed on your website, it is only fair and reasonable that you (i) refer specifically to the wording of the Act upon which you seek to rely, (ii) detail the evidence on which you rely to support the allegations made in the Report, and (iii) explain the basis upon which you have reached your conclusions and upheld the findings of the Report (which is, in our view, wholly flawed).
Without this information, our client cannot understand or accept the basis upon which it has been placed under “special measures” and, as matter stand, determine whether this decision has been just and equitable or unfair and unreasonable.
We respond to your comments as follows:
- “Points one and two”:
You state that:
“The information that you have provided does not challenge the evidence found in either of these points. There was no written risk assessment in relation to the hazard.”
Please provide the wording within Regulation 15 of the Act that relates to “written risk assessments” or risk assessments of any kind. Please also provide evidence as to why clearly marked warning signs do not constitute evidence of our client taking reasonable steps to mitigate any risk, and explain how this constitutes a breach of the Act. 2. “Point three”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. There were insufficient bathing and toilet facilities for service users to use.”
Please provide the wording within Regulation 15 of the Act that relates to bathing and toilet facilities, and also cross-reference with the evidence upon which you are apparently relying to justify a finding that the bathing and toilet facilities were insufficient, and explain how this constitutes a breach of the Act.
- “Point four”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. There were insufficient toilet facilities for service users to use.”
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
Please provide the wording within Regulation 15 of the Act that relates to toilet facilities, and also cross-reference with the evidence upon which you are apparently relying to justify a finding that the toilet facilities were insufficient, and explain how this constitutes a breach of the Act.
- Additional point:
You state that:
“You also stated that the breach of Regulation 15 was not contained in the inspection report. Please refer to page 20 of the inspection report and you will see that the breach is clearly shown.”
Whilst we note that this apparent breach has been mentioned, on page 20 of the Report, we should emphasise that it was not included within the list of “Actions we have told the provider to take”. Why then is our client now being required to take action now, when there was no such requirement stipulated in the Report? If these apparent breaches were strong enough to warrant and justify a warning notice, then why were they not highlighted at the time and in the Report as such?
We now refer to pages 11 and 14 of the Report:
“We found the trip hazard of the uneven floor and the rumpled carpets to be a breach of Regulation 15(1)e of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014”, and
“We found the lack of bathing facilities and the environment not helping to promote the well-being of people living with dementia to be a breach of Regulation 15 (1)c of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
We note that your warning notice dated 1 December 2016 citing the alleged breach of Regulation 15 fails to refer to the “rumpled carpets” within the hallway: Please confirm whether you now no longer consider this to be a breach of Regulation 15 – as stated within the Report.
In fact, not one of the apparent breaches set out in the “Actions we have told the provider to take” section has been considered as meriting a warning and, if these breaches were true and were used to justify your conclusion that the Home provides inadequate care, then why was no warning notice issued regarding those breaches?
We note that you sent our client a report of actions form on on 16 November 2016 which our client duly completed and submitted. We note that the breach of Regulation 17 was not included within this form and require your explanation as to why – if these issues warranted a warning notice – was our client not required to inform you of its actions regarding Regulation 17.
We submit that this clearly evidences significant inconsistencies within your process. You have simply changed your case when challenged by our client. We
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
further note that, to date, our client has not been asked to identify and detail actions it is taking with regards to the apparent breaches of Regulation 17. Please therefore confirm whether you are concerned to know what actions our client is taking – and if not, why not. This is without prejudice to our client’s contention that our client is compliant with Regulation 17, as indeed it believes it has always been.
Please note that our client requires your substantive response to the matters detailed in this letter, and currently reserves its rights regarding both the Report and the manner in which our client’s various responses to the Report have been handled by you. Our client feels that it has been treated extremely unfairly and prejudicially by the CQC, and that its business has been harmed without any genuine reason or justification.
We would emphasise that this is the first occasion our client has received such a report in the 30-plus years in which it has operated the Home. No previous inspection has identified any breaches, or considered the care provision to be in any way unsatisfactory or unacceptable. And, with specific reference to the Act, there has been no inspection carried out by you – or on your behalf – and no report produced, since 2008 (when the Act was introduced), which raises any of the concerns or identifies any of the issues which have been the subject of the Report’s negative findings, and your subsequent assertions and conclusions to support that Report.
Furthermore, if the findings of the Report are correct (which, of course, our client disputes) then it begs the question as to why no previous inspection has identified these issues and concerns.
Thus, if the findings in the Report are correct, as you have sought to assert, then a number – if not all – of the previous inspections, carried out by your inspectors, were defective, flawed and incorrect.
We are extremely concerned that, notwithstanding the detailed submissions lodged with you by our client, which have taken our client a significant amount of time and resource to prepare, not to mention the costs it is incurring in relation to this matter, you have been content simply to dismiss our client and the numerous statements it has made with regard to the flawed Report and the manner in which you have sought to defend and justify the contents thereof. You have sought to justify and substantiate the production of a patently flawed Report, with no regard to the damage caused to our client’s reputation, and indeed the financial damage suffered by the Home, and no regard to the fact that our client has spent more than 30 years building and developing that reputation and the goodwill enjoyed by the Home in and around the Flixton area.
Your Response to our client’s Submissions, and Mr Ricot’s conclusions in his letter dated 19 January 2017, are simply not acceptable, and fail to set out any substantive grounds to justify the Report’s conclusions. The Report refers to and relies upon legislation in support of findings against our client, when in fact (and indeed in law) there is no actual connection or link between the findings of the Inspector and the substance of the legislation referred to and apparently relied upon by both the Inspector and by you.
We trust that the contents of this letter are clear, but please contact Mark Hilton should you wish to discuss this matter further.
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
We look forward to hearing from you substantively and would ask that you respond to us by 4.00pm on 22 March 2017.
Yours faithfully,
Hilton Law
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
Fao: Ms Catherine Challinor
10th Floor, 3 Hardman Street Inspection Manager
Spinningfields
Care Quality Commission Citygate Gallowgate
Manchester M3 3HF T: 0161 932 1739 F: 0161 850 1020
Newcastle Upon Tyne NE1 4PA
hiltonlaw.co.uk
By post & email: enquiries@cqc.org.uk
10 March 2017
Our ref: MJH.FLI01.04 Your ref:
Dear Madam
Our client: Flixton House Limited t/a Flixton Manor Nursing Home (“the Home”) Your reference: ENF1-3068540054 Account number: 1-127659242 Inspection ID: INS2-2445278139
We are instructed by our client regarding the inspection at the Home on 6 and 7 September 2016, the subsequent inspection report dated 15 November 2016 (“the Report”) and our client’s various substantive responses and submissions regarding both the draft inspection report and the Report itself.
We also refer to your letter dated 30 December 2016 in response to our client’s representations dated 13 December 2016 (“the Response”). This letter seeks further information and clarification on the content of your letter of 13 December which is, unfortunately, wholly unacceptable and hardly constitutes a reply to the numerous issues and matters detailed by our client in the Response.
We also note the contents of the letter from Vincent Ricot (Assistant Rating review Officer) dated 19 January 2017, in which our client’s complaint regarding the inspection and the Report were dismissed outright by Mr Ricot, on behalf of the CQC. Mr Ricot states that:
“In summary I am assured the full quality assurance process for this inspection and the reporting was followed, due consideration given to the relative weighting of the evidence collected and the aggregation principles correctly followed. As such there are no applicable grounds for challenge and therefore your request for a review of the ratings for Flixton Manor Nursing Home will not proceed to consideration by an Independent Reviewer. The published ratings will remain the same. ”
For the avoidance of doubt, Mr Ricot’s conclusions are unacceptable and we do not agree that the inspection was correctly carried out or that the basis upon which the Report’s findings are based are fair, reasonable or correct. (Indeed, the fact that no previous inspection has identified any of the issues detailed in the Report (for example,
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
the toilet and bathing facilities, the sloping floor, access to care records, the care records themselves), suggest that – for the Report to be correct – all previous inspections over the previous 12 years were flawed and the findings incorrect. Surely this cannot be correct).
We have now reviewed this matter in some detail on our client’s behalf, including your previous documents and notices, and our client’s detailed responses thereto.
We have to say that we are extremely concerned by your comments and at the content of your correspondence dated 30 December 2016. Whilst we note that, technically, you have noted our client’s detailed submissions in the Response to the Report, nevertheless, it is clear that the explanation provided by you and the level of detail (or rather the lack of detail) provided by you are at best problematic, and at worst fail to justify the findings of the Report, and your upholding the same, and fail to address any of our client’s numerous concerns at its treatment by the CQC in relation to the inspection at the Home on 6 and 7 September 2016, and the subsequent and resulting Report.
As an initial observation, you have failed to cite or cross-refer any actual wording from either the Response, the Report or the Health and Social Care Act 2008 (“the Act”), as a result of which your conclusions have no context. You simply and continually state that:
“The information that you have provided does not challenge the evidence found in this point”,
but provide no reference as to which piece of evidence, information or legislation you are referring.
We now seek and indeed require clarification and your detailed explanation as to the alleged breaches in the Act as none have been provided within any of your responses to date. We are concerned primarily (and at this stage) with your explanation of the specific breaches you have referenced in your [warning notice], as – before deciding on a future course of action – we wish to be clear about the precise statutory and legislative provisions upon which you are relying to prove your conclusion(s) that there has been an alleged breach (or rather, alleged multiple breaches) of the Act.
Therefore, please now explain clearly how the Inspector’s apparent findings in the Report and the points you have made subsequently (in defence of that Report) constitute a breach of the relevant Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the Regulations”), as alleged. We would also ask that you reference the actual wording from the Act and explain what information and evidence you rely upon, and how that evidence is relevant and applicable to the Act.
We must emphasise that simply repeating that –
“The information that you have provided does not challenge the evidence”
is not a sufficient or satisfactory explanation and offers no indication as to the exact breach being alleged under the relevant Regulation.
All of our client’s responses to date have sought clarification as to why the standing and reputation of the Home has been jeopardised by the CQC affecting its ability to attract
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
and admit new residents, recruit staff, and run its business effectively. If it is required to publicly display its apparent “inadequate” status as a care provider for residents, prospective residents and visitors to see, not to mention the fact that it is now displayed on your website, it is only fair and reasonable that you (i) refer specifically to the wording of the Act upon which you seek to rely, (ii) detail the evidence on which you rely to support the allegations made in the Report, and (iii) explain the basis upon which you have reached your conclusions and upheld the findings of the Report (which is, in our view, wholly flawed).
Without this information, our client cannot understand or accept the basis upon which it has been placed under “special measures” and, as matter stand, determine whether this decision has been just and equitable or unfair and unreasonable.
We respond to your comments as follows:
- “Points one and two and three”:
You state that:
“The information that you have provided does not challenge the evidence found in any of these points. There were conflicting and incomplete assessments present in the care files looked at and no systems in place to recognise this.”
Please provide the wording within Regulation 17 of the Act that relates to “assessments”, and explain how this constitutes a breach of the Act.
- “Point four”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. The care staff did not have access to the care files.”
Please provide the wording within Regulation 17 of the Act that relates to non- nursing care staff requiring access to the care files, and explain how this constitutes a breach of the Act.
- “Point five”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. The relatives spoken with at the inspection were not aware that they could access care plans and the registered manager confirmed that the plans were for the use of the nurses and so relatives were not involved in developing the care plans or reviewing them.”
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
Please provide the wording within Regulation 17 of the Act that relates to relatives requiring access to the care files, and explain how this constitutes a breach of the Act.
- “Point six”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. As a registered provider you had not carried out the sufficient checks to ensure that staff were employed safely.”
Please provide the wording within Regulation 17 of the Act that relates to POVA checks and DBS checks being insufficient, and that it is mandatory that references and employment histories are required in all cases so as to ensure that safe staff are employed, and explain how this constitutes a breach of the Act.
- “Point seven”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. There was no written risk assessment in relation to the risk.”
Please provide the wording within Regulation 17 of the Act that relates to “written” risk assessments or risk assessments of any kind. Please also provide evidence as to why clearly marked warning signs do not constitute evidence of our client taking reasonable steps to mitigate any risk, and explain how this constitutes a breach of the Act.
- “Point eight”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. There were insufficient bathing and toilet facilities for service users to use.”
Please provide the wording within Regulation 17 of the Act that relates to bathing and toilet facilities, and also cross-reference with the evidence upon which you are apparently relying to justify a finding that the bathing and toilet facilities were insufficient, and explain how this constitutes a breach of the Act.
- “Point nine”:
You state that:
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
“The information that you have provided does not challenge the evidence found in this point. Formal supervision sessions were not held with staff and staff were not trained in dementia awareness.”
Please provide the wording within Regulation 17 of the Act that relates to supervisions or that states that such supervisions must be formal and recorded, and explain how this constitutes a breach of the Act.
- “Point ten”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. The audits had not identified the concerns found”
Please provide the wording within Regulation 17 of the Act that relates to auditing. If you are unable to explain how, and/or give clear evidence to justify the finding that breaches have arisen, then this point cannot hold any relevance or indeed be justified. Please also explain how this constitutes a breach of the Act.
- Additional point:
“You also stated that the breach of Regulation 17 was not contained in the inspection report. Please refer to page 20 of the inspection report and you will see that the breach is clearly shown.”
Whilst we note that this apparent breach has been mentioned, on page 20 of the Report,, we should emphasise that it was not included within the list of “Actions we have told the provider to take”. Why then is our client now being required to take action now, when there was no such requirement stipulated in the Report? If these apparent breaches were strong enough to warrant and justify a warning notice, then why were they not highlighted at the time and in the Report as such? There appears to be little if any consistency here, and you appear to be moving the goalposts – reacting to our client’s various submissions and revising your position after the event in order to justify your findings and actions.
Furthermore, and in any event, we now refer to page 20 of the Report:
“The shortfalls in the auditing systems, staff not being able to view the care plans and the lack of involvement of relatives in writing and reviewing care plans was a breach of Regulation 17(1) with reference to 2a, b and e of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
We note that only 2 points are mentioned here as constituting a breach of Regulation 17, namely those relating to “auditing” and “lack of involvement in care plans”. None of the other points mentioned in the Warning Notice were stated in relation to any alleged breach of this Regulation and were only brought up after our client had challenged the factual accuracy of the Report. You then sought to introduce an entirely new set of apparent breaches to this Regulation.
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
In fact, not one of the apparent breaches set out in the “Actions we have told the provider to take” section has been considered as meriting a warning and, if these breaches were true and were used to justify your conclusion that the Home provides inadequate care, then why was no warning notice issued regarding those breaches?
We note that you sent our client a report of actions form on on 16 November 2016 which our client duly completed and submitted. We note that the breach of Regulation 17 was not included within this form and require your explanation as to why – if these issues warranted a warning notice – was our client not required to inform you of its actions regarding Regulation 17.
We submit that this clearly evidences significant inconsistencies within your process. You have simply changed your case when challenged by our client. We further note that, to date, our client has not been asked to identify and detail actions it is taking with regards to the apparent breaches of Regulation 17. Please therefore confirm whether you are concerned to know what actions our client is taking – and if not, why not. This is without prejudice to our client’s contention that our client is compliant with Regulation 17, as indeed it believes it has always been.
Please note that our client requires your substantive response to the matters detailed in this letter, and currently reserves its rights regarding both the Report and the manner in which our client’s various responses to the Report have been handled by you. Our client feels that it has been treated extremely unfairly and prejudicially by the CQC, and that its business has been harmed without any genuine reason or justification.
We would emphasise that this is the first occasion our client has received such a report in the 30-plus years in which it has operated the Home. No previous inspection has identified any breaches, or considered the care provision to be in any way unsatisfactory or unacceptable. And, with specific reference to the Act, there has been no inspection carried out by you – or on your behalf – and no report produced, since 2008 (when the Act was introduced), which raises any of the concerns or identifies any of the issues which have been the subject of the Report’s negative findings, and your subsequent assertions and conclusions to support that Report.
Furthermore, if the findings of the Report are correct (which, of course, our client disputes) then it begs the question as to why no previous inspection has identified these issues and concerns.
Thus, if the findings in the Report are correct, as you have sought to assert, then a number – if not all – of the previous inspections, carried out by your inspectors, were defective, flawed and incorrect.
We are extremely concerned that, notwithstanding the detailed submissions lodged with you by our client, which have taken our client a significant amount of time and resource to prepare, not to mention the costs it is incurring in relation to this matter, you have been content simply to dismiss our client and the numerous statements it has made with regard to the flawed Report and the manner in which you have sought to defend and justify the contents thereof. You have sought to justify and substantiate the production of
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
a patently flawed Report, with no regard to the damage caused to our client’s reputation, and indeed the financial damage suffered by the Home, and no regard to the fact that our client has spent more than 30 years building and developing that reputation and the goodwill enjoyed by the Home in and around the Flixton area.
Your Response to our client’s Submissions, and Mr Ricot’s conclusions in his letter dated 19 January 2017, are simply not acceptable, and fail to set out any substantive grounds to justify the Report’s conclusions. The Report refers to and relies upon legislation in support of findings against our client, when in fact (and indeed in law) there is no actual connection or link between the findings of the Inspector and the substance of the legislation referred to and apparently relied upon by both the Inspector and by you.
We trust that the contents of this letter are clear, but please contact Mark Hilton should you wish to discuss this matter further.
We look forward to hearing from you substantively and would ask that you respond to us by 4.00pm on 22 March 2017.
Yours faithfully,
Hilton Law
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
We then received the following
Fao: Ms Catherine Challinor
10th Floor, 3 Hardman Street Inspection Manager
Spinningfields
Care Quality Commission Citygate Gallowgate
Manchester M3 3HF T: 0161 932 1739 F: 0161 850 1020
Newcastle Upon Tyne NE1 4PA
hiltonlaw.co.uk
By post & email: enquiries@cqc.org.uk
10 March 2017
Our ref: MJH.FLI01.04 Your ref:
Dear Madam
Our client: Flixton House Limited t/a Flixton Manor Nursing Home (“the Home”) Your reference: ENF1-3068540054 Account number: 1-127659242 Inspection ID: INS2-2445278139
We are instructed by our client regarding the inspection at the Home on 6 and 7 September 2016, the subsequent inspection report dated 15 November 2016 (“the Report”) and our client’s various substantive responses and submissions regarding both the draft inspection report and the Report itself.
We also refer to your letter dated 30 December 2016 in response to our client’s representations dated 13 December 2016 (“the Response”). This letter seeks further information and clarification on the content of your letter of 13 December which is, unfortunately, wholly unacceptable and hardly constitutes a reply to the numerous issues and matters detailed by our client in the Response.
We also note the contents of the letter from Vincent Ricot (Assistant Rating review Officer) dated 19 January 2017, in which our client’s complaint regarding the inspection and the Report were dismissed outright by Mr Ricot, on behalf of the CQC. Mr Ricot states that:
“In summary I am assured the full quality assurance process for this inspection and the reporting was followed, due consideration given to the relative weighting of the evidence collected and the aggregation principles correctly followed. As such there are no applicable grounds for challenge and therefore your request for a review of the ratings for Flixton Manor Nursing Home will not proceed to consideration by an Independent Reviewer. The published ratings will remain the same. ”
For the avoidance of doubt, Mr Ricot’s conclusions are unacceptable and we do not agree that the inspection was correctly carried out or that the basis upon which the Report’s findings are based are fair, reasonable or correct. (Indeed, the fact that no previous inspection has identified any of the issues detailed in the Report (for example,
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
the toilet and bathing facilities, the sloping floor, access to care records, the care records themselves), suggest that – for the Report to be correct – all previous inspections over the previous 12 years were flawed and the findings incorrect. Surely this cannot be correct).
We have now reviewed this matter in some detail on our client’s behalf, including your previous documents and notices, and our client’s detailed responses thereto.
We have to say that we are extremely concerned by your comments and at the content of your correspondence dated 30 December 2016. Whilst we note that, technically, you have noted our client’s detailed submissions in the Response to the Report, nevertheless, it is clear that the explanation provided by you and the level of detail (or rather the lack of detail) provided by you are at best problematic, and at worst fail to justify the findings of the Report, and your upholding the same, and fail to address any of our client’s numerous concerns at its treatment by the CQC in relation to the inspection at the Home on 6 and 7 September 2016, and the subsequent and resulting Report.
As an initial observation, you have failed to cite or cross-refer any actual wording from either the Response, the Report or the Health and Social Care Act 2008 (“the Act”), as a result of which your conclusions have no context. You simply and continually state that:
“The information that you have provided does not challenge the evidence found in this point”,
but provide no reference as to which piece of evidence, information or legislation you are referring.
We now seek and indeed require clarification and your detailed explanation as to the alleged breaches in the Act as none have been provided within any of your responses to date. We are concerned primarily (and at this stage) with your explanation of the specific breaches you have referenced in your [warning notice], as – before deciding on a future course of action – we wish to be clear about the precise statutory and legislative provisions upon which you are relying to prove your conclusion(s) that there has been an alleged breach (or rather, alleged multiple breaches) of the Act.
Therefore, please now explain clearly how the Inspector’s apparent findings in the Report and the points you have made subsequently (in defence of that Report) constitute a breach of the relevant Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (“the Regulations”), as alleged. We would also ask that you reference the actual wording from the Act and explain what information and evidence you rely upon, and how that evidence is relevant and applicable to the Act.
We must emphasise that simply repeating that –
“The information that you have provided does not challenge the evidence”
is not a sufficient or satisfactory explanation and offers no indication as to the exact breach being alleged under the relevant Regulation.
All of our client’s responses to date have sought clarification as to why the standing and reputation of the Home has been jeopardised by the CQC affecting its ability to attract
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
and admit new residents, recruit staff, and run its business effectively. If it is required to publicly display its apparent “inadequate” status as a care provider for residents, prospective residents and visitors to see, not to mention the fact that it is now displayed on your website, it is only fair and reasonable that you (i) refer specifically to the wording of the Act upon which you seek to rely, (ii) detail the evidence on which you rely to support the allegations made in the Report, and (iii) explain the basis upon which you have reached your conclusions and upheld the findings of the Report (which is, in our view, wholly flawed).
Without this information, our client cannot understand or accept the basis upon which it has been placed under “special measures” and, as matter stand, determine whether this decision has been just and equitable or unfair and unreasonable.
We respond to your comments as follows:
- “Points one and two and three”:
You state that:
“The information that you have provided does not challenge the evidence found in any of these points. There were conflicting and incomplete assessments present in the care files looked at and no systems in place to recognise this.”
Please provide the wording within Regulation 17 of the Act that relates to “assessments”, and explain how this constitutes a breach of the Act.
- “Point four”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. The care staff did not have access to the care files.”
Please provide the wording within Regulation 17 of the Act that relates to non- nursing care staff requiring access to the care files, and explain how this constitutes a breach of the Act.
- “Point five”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. The relatives spoken with at the inspection were not aware that they could access care plans and the registered manager confirmed that the plans were for the use of the nurses and so relatives were not involved in developing the care plans or reviewing them.”
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
Please provide the wording within Regulation 17 of the Act that relates to relatives requiring access to the care files, and explain how this constitutes a breach of the Act.
- “Point six”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. As a registered provider you had not carried out the sufficient checks to ensure that staff were employed safely.”
Please provide the wording within Regulation 17 of the Act that relates to POVA checks and DBS checks being insufficient, and that it is mandatory that references and employment histories are required in all cases so as to ensure that safe staff are employed, and explain how this constitutes a breach of the Act.
- “Point seven”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. There was no written risk assessment in relation to the risk.”
Please provide the wording within Regulation 17 of the Act that relates to “written” risk assessments or risk assessments of any kind. Please also provide evidence as to why clearly marked warning signs do not constitute evidence of our client taking reasonable steps to mitigate any risk, and explain how this constitutes a breach of the Act.
- “Point eight”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. There were insufficient bathing and toilet facilities for service users to use.”
Please provide the wording within Regulation 17 of the Act that relates to bathing and toilet facilities, and also cross-reference with the evidence upon which you are apparently relying to justify a finding that the bathing and toilet facilities were insufficient, and explain how this constitutes a breach of the Act.
- “Point nine”:
You state that:
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
“The information that you have provided does not challenge the evidence found in this point. Formal supervision sessions were not held with staff and staff were not trained in dementia awareness.”
Please provide the wording within Regulation 17 of the Act that relates to supervisions or that states that such supervisions must be formal and recorded, and explain how this constitutes a breach of the Act.
- “Point ten”:
You state that:
“The information that you have provided does not challenge the evidence found in this point. The audits had not identified the concerns found”
Please provide the wording within Regulation 17 of the Act that relates to auditing. If you are unable to explain how, and/or give clear evidence to justify the finding that breaches have arisen, then this point cannot hold any relevance or indeed be justified. Please also explain how this constitutes a breach of the Act.
- Additional point:
“You also stated that the breach of Regulation 17 was not contained in the inspection report. Please refer to page 20 of the inspection report and you will see that the breach is clearly shown.”
Whilst we note that this apparent breach has been mentioned, on page 20 of the Report,, we should emphasise that it was not included within the list of “Actions we have told the provider to take”. Why then is our client now being required to take action now, when there was no such requirement stipulated in the Report? If these apparent breaches were strong enough to warrant and justify a warning notice, then why were they not highlighted at the time and in the Report as such? There appears to be little if any consistency here, and you appear to be moving the goalposts – reacting to our client’s various submissions and revising your position after the event in order to justify your findings and actions.
Furthermore, and in any event, we now refer to page 20 of the Report:
“The shortfalls in the auditing systems, staff not being able to view the care plans and the lack of involvement of relatives in writing and reviewing care plans was a breach of Regulation 17(1) with reference to 2a, b and e of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.”
We note that only 2 points are mentioned here as constituting a breach of Regulation 17, namely those relating to “auditing” and “lack of involvement in care plans”. None of the other points mentioned in the Warning Notice were stated in relation to any alleged breach of this Regulation and were only brought up after our client had challenged the factual accuracy of the Report. You then sought to introduce an entirely new set of apparent breaches to this Regulation.
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
In fact, not one of the apparent breaches set out in the “Actions we have told the provider to take” section has been considered as meriting a warning and, if these breaches were true and were used to justify your conclusion that the Home provides inadequate care, then why was no warning notice issued regarding those breaches?
We note that you sent our client a report of actions form on on 16 November 2016 which our client duly completed and submitted. We note that the breach of Regulation 17 was not included within this form and require your explanation as to why – if these issues warranted a warning notice – was our client not required to inform you of its actions regarding Regulation 17.
We submit that this clearly evidences significant inconsistencies within your process. You have simply changed your case when challenged by our client. We further note that, to date, our client has not been asked to identify and detail actions it is taking with regards to the apparent breaches of Regulation 17. Please therefore confirm whether you are concerned to know what actions our client is taking – and if not, why not. This is without prejudice to our client’s contention that our client is compliant with Regulation 17, as indeed it believes it has always been.
Please note that our client requires your substantive response to the matters detailed in this letter, and currently reserves its rights regarding both the Report and the manner in which our client’s various responses to the Report have been handled by you. Our client feels that it has been treated extremely unfairly and prejudicially by the CQC, and that its business has been harmed without any genuine reason or justification.
We would emphasise that this is the first occasion our client has received such a report in the 30-plus years in which it has operated the Home. No previous inspection has identified any breaches, or considered the care provision to be in any way unsatisfactory or unacceptable. And, with specific reference to the Act, there has been no inspection carried out by you – or on your behalf – and no report produced, since 2008 (when the Act was introduced), which raises any of the concerns or identifies any of the issues which have been the subject of the Report’s negative findings, and your subsequent assertions and conclusions to support that Report.
Furthermore, if the findings of the Report are correct (which, of course, our client disputes) then it begs the question as to why no previous inspection has identified these issues and concerns.
Thus, if the findings in the Report are correct, as you have sought to assert, then a number – if not all – of the previous inspections, carried out by your inspectors, were defective, flawed and incorrect.
We are extremely concerned that, notwithstanding the detailed submissions lodged with you by our client, which have taken our client a significant amount of time and resource to prepare, not to mention the costs it is incurring in relation to this matter, you have been content simply to dismiss our client and the numerous statements it has made with regard to the flawed Report and the manner in which you have sought to defend and justify the contents thereof. You have sought to justify and substantiate the production of
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
a patently flawed Report, with no regard to the damage caused to our client’s reputation, and indeed the financial damage suffered by the Home, and no regard to the fact that our client has spent more than 30 years building and developing that reputation and the goodwill enjoyed by the Home in and around the Flixton area.
Your Response to our client’s Submissions, and Mr Ricot’s conclusions in his letter dated 19 January 2017, are simply not acceptable, and fail to set out any substantive grounds to justify the Report’s conclusions. The Report refers to and relies upon legislation in support of findings against our client, when in fact (and indeed in law) there is no actual connection or link between the findings of the Inspector and the substance of the legislation referred to and apparently relied upon by both the Inspector and by you.
We trust that the contents of this letter are clear, but please contact Mark Hilton should you wish to discuss this matter further.
We look forward to hearing from you substantively and would ask that you respond to us by 4.00pm on 22 March 2017.
Yours faithfully,
Hilton Law
Partners: M J Hilton, N A Scott This firm is authorised and regulated by the Solicitors Regulation Authority (564235)
We then received the following
CareOuality Commission
Hilton LaW 10 Floor, 3 Hardman Street Spinningfields
Manchester
M33HF
Your account number: 1-127659242
YOUr reference: ENF1-306854.0054 Inspection ID: INS2-2445278139
22 March 2017
Location name: Flixton Manor LOCation ID: 1-303.667371
Dear Sir/Madam,
Thank you for your letter dated 10 March 2017.
The Care Quality Commission (CQC) methodology and process for all inspections is
Care Quality Commission Citygate
Gallowgate Newcastle upon Tyne NE14PA
Telephone: 03000 616161 Fax: 03000 616171
www.cqc.org.uk
available on our website at http://www.cdc.org.uk/content/how-we-inspect-andregulate-guide-providers and Can be Summarised as followS.
o Following an inspection a draft report is written. Where required a meeting is held with inspection managers and legal advice is obtained to decide what, if any, enforcement action is to be taken in response to the identified breaches
in regulations.
O A draft inspection report is sent to the provider. This report identifies where we
have judged, against the Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014, that regulations have not been met. For identified breaches of the regulations which where we consider people using the service
are not at immediate risk of harm, Requirement Notices are included in the
draft report.
O At the same time the draft report is sent, the provider also receives a Factual
Accuracy Comment form (FAC). This provides the service an opportunity to tell us of any factual inaccuracies within the report before the report is made public.
o Where we have decided to take enforcement action, for example warning
notices, these are sent separately and are subject to representations from the provider. This information is not published within our reports until after this procedure has been completed.
O Factual Accuracy Comments received from the provider are considered by CQC and a response given to the provider prior to the final report being published. Factual Accuracy Comments were considered and responded to in the COC letter dated 14 November 2016.
o Warning Notices were sent to the provider and the provider was given the
opportunity to make representations to these Notices.
o Each Warning Notice refers to the breach of one regulation. The regulation is
quoted at the beginning of the Warning Notice. Evidence as to how the regulation was breached is provided with in the Notice.
O Guidance for providers to meet the regulations and the regulation in full can be
found On Our Website at http://www.cdc.org.uk/content/regulations-serviceproviderS-and-managerS.
o Any representations submitted with regard to the Warning Notices are
considered by an Inspection Manager who was unconnected with the inspection report and FAC process.
O Representations were received and COC responded on the 30 December
2016.
o Ratings reviews can be requested and involve checking whether or not CQC
followed its published methodology (the guidance in the provider handbook and appendices) in making judgements and awarding the rating(s). This review is completed independently from the inspection team. Please note that a rating review does not involve a reconsideration of the evidence and ratings awarded, unless it is found that the process has not been followed. The provider requested a ratings review. The ratings review team found that the inspection team had followed the Commissions published methodology. The response can be referred to in the letter dated 19 January 2017.
A thorough response has been provided by the CQC at each step in the above process. If the provider remains dissatisfied please refer to the Commissions complaints procedure. This can be accessed via:
Email: enouiriesOCGC.org.uk
Te: O30OO 616161
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