Archived: Bellevue Healthcare Limited

Updated 30 June 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. Four adult social care inspectors completed the inspection on 5 September 2016 and three adult social care inspectors visited on 16 September 2016.

Before the inspection we reviewed all of the information we held about the service, such as notifications we had received from the service and also information received from the local authority who commissioned the service. Notifications are changes, events or incidents that the provider is legally obliged to send us within the required timescale. We reviewed feedback from the local authority commissioning team for the service, from the serious concerns protocol forum (which we have regularly attended) and from the CCG.

At the time of inspection there were 52 people using the service who were supported by 97 staff.

During the inspection we spoke with four people who used the service, one relative and a district nurse. We also spoke with the registered provider, manager, clinical leader, five nurses, 12 care staff and the cook.

We spent time with people in the communal areas and observed how staff interacted and supported people. We looked at nine care records, medicine administration records, weight monitoring records and pressure care records. We also reviewed staff rotas, staff recruitment records, safeguarding records and quality assurance records.

We looked around the service and went into some people's bedrooms and bathrooms (with their permission) and spent time in communal areas.

Updated 30 June 2017

We inspected Bellevue Healthcare Limited on 5 and 16 September 2016. This was an unannounced inspection which meant staff and registered provider on each occasion did not know we would be visiting.

At the last comprehensive inspection completed on 21 March, 5 and 18 April 2016 we judged the home to be rated as inadequate and found multiple breaches of our regulations. The service had been placed into serious concerns protocol with the local authority in March 2016 and at the time of this inspection that remained the case. The service was entered into this protocol because of an increased number of safeguarding alerts made by external health professionals. The professionals involved in the serious concerns protocol had significant concerns about the registered provider’s ability to provide safe care and support to people. An embargo was put in place which meant that nobody new could move into the service.

We carried out a further inspection on 12 May 2016 because of growing concerns about people’s safety. We found that although the risks had not increased they still remained around ensuring people received safe care and treatment. People were not placed at any greater risks from staff failing to administer medication in line with their prescriptions and were receiving adequate food and fluid. However, when people lost weight, we found staff were still failing to ensure referrals to dieticians were consistently made.

This latest inspection was completed because concerns were still being identified and we wanted to make sure people were safe living at the service. We also wanted to make sure the registered provider was taking action to address the concerns which we had identified during the last two inspections completed in April 2016 and May 2016.

Bellevue Healthcare Limited is registered to provide care and support to 102 people. At the time of our inspection there were 52 people using the service and 97 staff employed. There were three units at the service which provided care and support to people living with a dementia, people who required nursing care and young adults living with a physical disability.

Bellevue Healthcare Limited was registered with the Commission in 2001. A registered manager was in place until 2014 when the registered manager retired. There had been three managers since then however none applied to become registered manager. A new manager is now in post and they have started the process to become registered manager. 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.

Not having a registered manager is a breach of the registered provider’s conditions of registration. Following the inspection completed in April 2016 we issued a fixed penalty notice for this matter and the registered provider paid the £4000 fine in order to deal with this breach.

We also made the registered provider aware that they were failing to notify us of incidents and deaths, which is a breach of the Care Quality Commission (Registration) regulations 2009. We are currently dealing with this matter outside of the inspection process.

On 5 September 2016 we identified that four people were grossly underweight and all had Body Mass Indicators (BMI) of below 18. This shows that people are at risk of being malnourished and developing a compromised immune function; respiratory disease; digestive diseases; cancer and osteoporosis. One person had a BMI of 12, which placed them at very high risk of developing life threatening health conditions. Despite referring people to dieticians in July 2016 the staff had not recognised that people continued to lose weight and that their BMI were extremely low so had not got back in touch with the dieticians.

Where safeguarding alerts established that malnutrition or dehydration had occurred, there was no evidence to show that the service had taken action to reduce the risk of the incidents re-occurring. Also when people’s nutritional supplements had not been received in a timely fashion the staff had not contacted the GP or dietician to request they were delivered. This had led to people not receiving the required supplements for over a month. In the interim these people continued to lose weight.

Food and fluid balance charts had not always been completed. Records showed that people consumed less fluid than were specified in their care plans. There was no evidence to suggest that people were offered snacks outside of meal times or that people at increased risk of malnutrition were offered nutritional supplements.

We found that staff were not identifying the development of pressure ulcers clearly. This meant care plans had not been produced to detail how these were being treated or the action they needed to take if the pressure ulcer changed or became infected. Staff had not been accurately identifying and recording when people had pressure ulcers. Referrals had not been carried out in a timely manner.

Following our visit on the 5 September 2016 we wrote to the registered provider to make them aware of our serious concerns about people’s welfare and asked them to take immediate action to ensure people’s health was not compromised.

On 16 September we visited to check that the action the registered provider had said would be taken had occurred. We found that they had compiled a list of people’s current weight and people who had wounds. They had contacted GPs and dieticians for all people who were found to have compromised weights and with wounds. Also they had ensured the cook was aware of people who were losing weight or had a low weight so the cook could provide these people fortified food. Additional supplies of fortified foods were provided throughout the day and the registered provider checked that people were eating. Although improved the records still did not fully evidence the actions staff were taking when providing care and treatment for people.

We also found that one of the registered provider’s directors, who is a retired GP and without a license to practice had been completing and signing ‘Do not attempt cardio-pulmonary resuscitation (DNACPR), as senior consultant. This is a breach of the Medical Act 1983. We found that some people’s DNACPR certificate stated ‘general frailty’ rather than a specific clinical condition, which does not following General Medical Council (GMC) code of practice.

We judged this to be a major risk and in line with our enforcement policy are taking action to deal with this issue, which we will report on once completed.

The registered provider visited the service each day and we observed them carrying out checks of the service, however they had not recorded any of their visits as part of quality assurance processes. This meant we could not see what checks were being carried out.

The service had started to introduce a small number of audits. However there were gaps within these. Where actions for improvement had been identified, no action plan had been produced and there was no evidence of any action taken following the audit.

The service had started to make safeguarding alerts, however these were limited to incidents between people using the service. Safeguarding alerts for people at risk of malnutrition, dehydration and pressure sores had not been made. However, safeguarding alerts regarding these incidents had been made by visiting health and social care professionals. Since 27 July 2016 a total of five safeguarding alerts had been up-held for abuse including ones for neglect because malnourishment and dehydration had occurred.

We found that risk assessments were not always in place for people who needed them. These included people at risk of falls, and those using calls bells and lap belts. Some risk assessments were not person-centred and did not always contain accurate information.

Core care plans had been introduced at the service. This meant people had care plans in place even when no care needs had been identified. We found care plans were generic rather than person-centred and did not accurately reflect people’s actual care needs and the risks in place.

There were gaps in recruitment records which meant that it was unclear about how the registered provider decided applicants were suitable to be employed. A recruitment exercise was taking place during our inspection. Two candidates were offered positions as carer on the day and were asked to start one week later. We were concerned about this because we could not been sure if two checked references and a Disclosure and Barring Services check for each person could be obtained within this time frame.

Care records contained conflicting information about people’s capacity. In some care records, there was evidence to suggest people had capacity and similarly did not have capacity. Where people lacked capacity there was no evidence of any ‘best interest’ decisions making.

Care plans had not been signed by the people they related to. This meant we did not know if people had been involved in their care plans or if they had agreed to them. Care plans were also required to be signed by people who lacked capacity. There was no evidence in the care records where people lacked capacity to show whether their relative had Lasting Power of Attorney for care and welfare, yet they were being asked to agree to and sign to care plans.

We found that restrictive practices in place without evidence of best interest decision making. For example, we found some people were in bed with minimal clothes on, such as an incontinence pad and protective pants . In one care plan this was recorded as the person’s choice but when we visited this person we found they could not communicate.

The service had started to make im