This inspection took place on 24, 25 and 26 July 2016. The visits on 24 and 25 July were unannounced and we told the provider we would return on 26 July to complete the inspection.
We inspected the service on 21 July 2015 and found breaches of regulations covering safeguarding people using the service, recruitment procedures, staff training, the management of complaints, safe care and treatment and failure to notify the Care Quality Commission of significant events affecting people using the service. We placed the service in special measures and took enforcement action. This included issuing four Warning Notices and imposing a condition on the provider’s registration on 01 September 2016 that prevented them from admitting new people to the service without the written agreement of CQC. The provider sent us representations against the imposed condition but we did not uphold these and confirmed the condition on their registration on 16 June 2016.
We also carried out a further inspection on 12, 13, 17 and 18 January 2016 to monitor the provider’s progress in meeting the requirements we made following the July 2015 inspection. At this inspection we found medicines were not being managed safely, people were not always receiving their medicines as prescribed, staff had completed some training but there was no evidence the provider had checked staff understood the training they completed and applied it to their daily work, the provider did not have systems to support staff through the use of supervision or appraisals and the provider did not operate effective systems for planning the care and support people received.
As the provider had not demonstrated improvements and the service was still rated as Inadequate, it remained in special measures. We also took enforcement action and issued a Notice of Proposal to cancel the provider’s registration. The provider sent us representations against our proposal to cancel their registration and we have carried out this inspection to continue monitoring the provider’s progress in addressing the issues we have identified at previous inspections.
At this inspection we found the provider had improved the management of people’s medicines and had started to meet the requirements of the Deprivation of Liberty Safeguards (DoLS). However, concerns remained about standards of care planning, risk management, staff recruitment and training and some care practices.
Threen House is a registered care home for older people who require nursing or personal care, some of whom are living with the experience of dementia. The service can accommodate up to 26 older people, in single or shared rooms. Following the inspection in January 2016 we placed a condition on the provider’s registration that prevented them from admitting new people to the service without our written agreement. When we inspected, 15 people were living in the service.
The service did not have a registered manager. A registered manager is a person who has registered with the Care Quality Commission (CQC) to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The previous registered manager resigned from her post in May 2016. The provider appointed a new manager who applied to register with CQC on 8th June 2016. However, the manager resigned shortly before this inspection.
We found six breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. All six breaches were repeated breaches of those we found at our inspection in January 2016. The provider did not mitigate risks to people using the service, staff did not move or transfer people safely, staff recruitment checks were incomplete, the provider did not assess the competence of staff to carry out their work, staff did not have access to supervision or appraisals of their work, staff did not always obtain people’s consent to the care they received, the provider did not arrange appropriate activities for people and did not monitor quality in the service and make improvements.
The overall rating for this service is ‘Inadequate’ and therefore the service remains in special measures. We do this when services have been rated as ‘Inadequate’ in any key question once they have been placed in special measures.
People using the service were not always safe as the provider did not produce risk management plans to mitigate risks to people using the service and staff did not have guidance on how to manage risks to people.
People may have been at risk of unsafe care as the provider did not always carry out pre-employment checks before staff started to work in the service.
People were at risk because staff did not follow manual handling assessments or guidance and people were not always transferred safely, for example from an armchair to a wheelchair.
We could not be sure people were supported by staff that had the correct skills as the provider did not follow systems to assess their understanding of the training they completed or their competence. Also, staff did not always have access to supervision and appraisal of their performance.
People told us they enjoyed meal times and the food provided in the service. However, the observations we carried out at lunchtime showed some people did not have a positive experience and there was little interaction with staff. Throughout the inspection we saw little interaction between staff and people using the service, although people told us staff were caring. Staff told us they did not have enough time to spend with people as they had to carry out household tasks.
Most of the care we saw was focussed on meeting people’s personal care needs in a regimented, rather than a person-centred way. For example, people’s care records showed they were supported to use the toilet every three hours, rather than when they felt they needed to.
The manager had made some improvements to care planning but this needed to be completed for each person using the service. Care records focussed on people’s health and personal care needs and there was limited information about their social care.
There was a lack of meaningful activities for people using the service. Following our last inspection, the provider told us they would appoint a part-time activities co-ordinator but this had not happened. We saw little evidence of meaningful activities during the inspection and people were left for extended periods of time with no interaction or activity.
People using the service told us they had no complaints. Staff told us they would raise any concerns with the provider and they felt he would listen and respond.
The provider is registered with the Care Quality Commission (CQC) as an individual and does not require a registered manager. The provider held the Registered Manager’s Award but had always appointed a registered manager to manage the service. The last registered manager left the service in May 2016. The provider appointed another manager in May 2016 but they left in July 2016, shortly before this inspection. The provider appointed a new manager in August 2016 and told us they would apply for registration with the CQC.
The provider was unable to evidence that they had carried out audits of quality in the service or had taken action to address issues they identified.
The provider had made changes to the service’s medicines management procedures since the last inspection and people now received the medicines they needed safely.
The provider assessed and recorded people’s health care needs and people using the service had access to the healthcare services they needed, including the GP, dentist, optician, hospital and clinics.
The provider had completed some health and safety audits and they were able to show us reports that analysed responses to questionnaires sent to people using the service, their relatives and professionals involved in their care.
Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.