Background to this inspection
Updated
25 August 2017
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.
The inspection took place on the 6 and 7 July 2017 and was unannounced. The inspection team was made up of three inspectors, a pharmacist and a professional advisor. The professional advisor was a nurse with a background in the care of older people.
Before the inspection we used information we already held about the service including recent notifications which are important events services are required to tell us about. We looked at outcomes from safeguarding investigations, meetings with social services and feedback from other health care professionals.
As part of this inspection we carried out observations on the care provided. As a number of people who lived in the service were living with dementia we used the Short Observational Framework for inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us.
We looked at records in relation to people’s needs, the management of the service, maintenance, the recruitment, and training of the staff. We spoke with thirteen people, four relatives, eight care staff, five ancillary staff and the manager. We interviewed three visiting health professionals and viewed ten care plans. We looked at eleven peoples medicines and carried out a medication audit.
Updated
25 August 2017
The inspection took place on the 6 and 7 July 2017 and was unannounced. The previous inspection had been undertaken on 8 February 2017 to follow up concerns found at the inspection in September 2016. The inspection in February 2017 found that there had been some improvements and the overall rating of the service changed from inadequate to requires improvement. At our inspection in July 2017 we found that the improvements made had not been sustained.
The provider continued not to provide a manager registered with the Care Quality Commission (CQC). The home had a manager who had been in day to day charge of the service for a significant period of time but they were not yet registered with the CQC. At the last inspection in February 2017 and at this inspection they told us their application was being processed. However we found no record of this being submitted. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
The premises were not well maintained and there were insufficient controls in place to mitigate risks. For example we found windows without restrictors and the risks regarding legionella were not being managed in a way that protected people. Individual risks to people had been identified but the management plan was not always followed by the staff supporting people. For example we identified issues with the use of moving and handling equipment, catheter care and the management of wounds.
Medicines were not managed safely and we did not have confidence in the auditing process as it had failed to identify some of the issues that we found such as people being given the incorrect amount of medication. We found that the stock did not tally with the records and creams and lotions were not being administered as prescribed.
There were systems in place to calculate the numbers of staff needed to meet people’s needs but we found that the service was dependent on agency staff and staff were not always deployed effectively which meant that people did not receive care when they needed it. The service was in the process of recruiting new staff but the issues that we identified at the last inspection about the robustness of the process had not been addressed.
Staff received training but we were not assured about its effectiveness as staff knowledge in areas such as infection control and dementia did not reflect best practice. There was a system of induction for newly appointed staff but we found that new staff were working without sufficient guidance. Checks were not undertaken on staff competency and understanding of what they had learnt.
Some training had been provided on the Mental Capacity Act 2005 and consent. However staff responsibilities were not well understood and the best interest decisions were not accessible or clearly documented within people’s care plans.
Mealtimes were not well organised and people needed more support with eating and drinking.
People’s nutritional needs were assessed and where there were concerns referrals had been made to dieticians. However, the advice given was not always followed and greater monitoring and oversight of people’s intake was needed.
Staff were well meaning and had good relationships with those they supported. However interactions were largely based around the completion of a task and staff did not always promote people’s privacy and dignity. We were not assured that people always received care that took account of their wishes and what was important to them.
Care plans did not provide sufficient guidance to staff on people’s needs. We identified gaps in how people’s needs were monitored and had concerns that information was not always handed over which meant that issues were not addressed promptly. Documentation was not completed contemporaneously and as a result not always accurate.
Activities were provided to promote peoples wellbeing. There was a policy in place which set out how complaints should be managed however none were recorded as received which was contrary to what people told us. The policy was out of date and we could not see that complaints were used to drive improvement.
This service was operating well below the numbers of people for which it is registered. The local authority has been supporting the service to improve over a long period of time. They had placed a consultant within the service to support the improvements, the provider had continued to employ the consultant for a short period but had not continued with this support. It was a concern that the service has failed to sustain some of the improvements implemented with the support of the consultant.
Staff and people spoke positively about the manager and told us that they were assessable and helpful. There were some audits in place but they were not effective as they had not identified the shortfalls that we found. Overall we concluded that there was a lack of management oversight.
During this inspection we identified a number of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of this report.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, they will be inspected again within six months.
The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.
For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.