Archived: Eagle Nursing Home

Updated 31 August 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check 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.

This comprehensive inspection took place on 20 and 23 April 2018 and was unannounced. The inspection team consisted of one inspector, an assistant inspector and an expert by experience. An Expert by experience is a person who has personal experience of using or caring for someone who uses this type of care service. On 05 June 2018 we received information of concern from the local authority. In response to this information we conducted additional inspection visits to the service on 06 and 07 June 2018. On these dates the inspection team was made up of two inspectors. We have gathered the findings from our visits in April 2018 and June 2018 to inform this report.

We used information the provider sent us in the Provider Information Return. This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. We took this into account when we inspected the service and made judgements in this report.

Before the inspection we reviewed any information we held about the service. We reviewed safeguarding alerts and notifications that had been sent to us. A notification is information about important events which the provider is required to send us by law.

During our inspection in we spoke with the registered manager, the area operations manager, the provider, the clinical lead, one registered nurse four members of care staff, two agency care staff, the cook, two housekeepers, the activity coordinator and five people who lived at the service and two visiting relatives. We also observed staff interacting with people in communal areas, providing care and support.

We looked at a range of records related to the running of and the quality of the service. These included four staff recruitment and induction files, staff training information and arrangements for managing complaints. We looked at the quality assurance audits that the registered manager and the provider completed. We also looked at care plans for ten people and medicine administration records for 23 people. Following our initial inspection in April 2018 the registered manager provided us with information that was not made available to us during our inspection. When we returned in June 2018, we found it difficult to access some of the documents we requested.

Updated 31 August 2018

We undertook a comprehensive inspection on 20 and 23 April 2018. The inspection was unannounced. On 05 June 2018 we received information of concern from the local authority. In response to these concerns we undertook additional inspection visits to the service on 06 and 07 June 2018.

Eagle Nursing Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The service is registered to provide accommodation for up to 29 older people or people living with a dementia type illness or mental health problems. On day one of our inspection there were 23 people living in the service.

There was a registered manager in post at the time of our inspection. 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 the legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Since our inspection the registered manager left the service.

We last inspected the service in January 2017. The service was rated requires improvement.

On this inspection we found five breaches of the regulations. This was because the registered provider failed to ensure that there were systems and processes in place to assess, monitor and improve the quality and safety of the service to keep people safe.

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, 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.

There was not always enough staff on duty with the right skill mix to keep people safe and respond to their care needs in a timely manner. People were at risk of harm from poor infection control practices, environmental issues and poor management of risk factors. Medicines management was not always practiced safely.

The provider followed national guidelines to lawfully deprive a person of their liberty. Care staff often worked on their own initiative without supervision and visible leadership. People were not always provided with their choice of food or with a balanced and nutritious diet.

People and their relatives were not involved in planning their care. Care was not person centred, but was task orientated. Staff had little insight into the needs of people with cognitive problems and poor spatial awareness. There was a high staff turnover and people did not always know the staff looking after them. Staff treated people with dignity.

People did not always receive personalised care that was responsive to their needs. Staff did not acknowledge their likes and dislikes. People lacked social and emotional stimulation. Individual faith beliefs were acknowledged. People received compassionate care at the end of their life.

There was a lack visible leadership and effective role models to support inexperienced staff. The provider did not have a clear vision or philosophy to promote a positive culture. The providers approach to quality assurance and clinical governance processes were inconsistent and ineffective and did not lead to improvements in the care people received. The provider did not carry out the correct safety checks when recruiting staff.