Archived: Carrwood House

Updated 20 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 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 inspection took place over two days on 27 and 29 April 2016 and both days were unannounced.

On 27 April 2016, the inspection was carried out by two adult social care inspectors, an expert by experience and a specialist advisor. A specialist advisor is a professional with experience of working with people who use this type of care service. This specialist advisor was a qualified nurse. 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 29 April 2016 the inspection continued with the same two adult social care inspectors.

Prior to the inspection we reviewed the information we held about the service, which included correspondence we had received and any notifications submitted to us by the service. A notification should be sent to the Care Quality Commission every time a significant incident has taken place, for example where a person who uses the service experiences a serious injury. Before our inspection we contacted staff at Healthwatch and they had no concerns recorded. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We also contacted members of

Sheffield City Council Social Services and Sheffield Clinical Commissioning Group. They told us they were continuing to jointly monitor the service and trying to support the registered provider to improve as they had concerns regarding the level of risk to people living at Carrwood House.

During the inspection we spoke with six people who lived at the service. We met with the manager, the registered provider, the registered provider’s legal representative and an independent consultant the registered provider had recruited to assist with managing the service. We spoke with four members of staff. We spent time looking at written records, which included four complete care records, eight staff files and other records relating to the management of the service. We spent time observing the daily life in the service including the care and support being delivered by all staff. We checked the medication administration records for everyone living at Carrwood House.

Updated 20 June 2017

We carried out this inspection on 30 and 31 March 2017. The first day of our inspection was unannounced. This meant no-one at the service knew that we were planning to visit.

Carrwood House is registered to provide accommodation and personal care for up to 16 people with learning disabilities and mental health needs. The home is situated in the Grimesthorpe area of Sheffield and is close to local amenities. The home has a communal lounge and dining room, access to a garden and a small car park. There were eight people living at the service on the days of the inspection.

It is a condition of registration with the Care Quality Commission that there is a registered manager in place. 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. There had not been a registered manager at the service since 2011. We met with the manager during the first day of our inspection who told us they were in the process of applying for registration with the Care Quality Commission.

At the last inspection on 27 and 29 April 2016 the service was rated inadequate and placed in special measures. This inspection was undertaken to check the registered provider now met all of the legal requirements. At this inspection we found that there were not enough improvements to take the service out of special measures. The Care Quality Commission is now considering the appropriate regulatory response to resolve the problems we found.

Staff did not fully understand what it meant to protect people from abuse. There were no effective systems in place to monitor allegations of abuse and any action subsequently taken. This would have enabled to service to identify any trends and lessons learnt.

There were not enough staff to meet the needs of people living at Carrwood House, particularly at night when only one member of staff was employed.

We found there were not appropriate arrangements in place to manage medicines to ensure people were protected from the risks associated with medicines.

Safe staff recruitment procedures were adhered to.

People were offered a limited amount of options to meet their nutritional and hydration needs. Food and drink was not always stored correctly which meant it may not have been safe to consume. People told us they liked the food provided at Carrwood House.

Care records did not fully reflect whether a person had capacity to make decisions about their care and treatment. Staff did not fully understand the Mental Capacity Act and its implications on their practice.

Staff did not receive regular supervision, annual appraisals, or appropriate training to support them to carry out their jobs effectively.

There were few activities available to people living at Carrwood House. No activities were advertised to be taking place.

People’s care records contained gaps in information and were not regularly reviewed. This meant the information as how to best support people to meet their needs was incomplete and may have changed. There was no evidence that people’s views and aspirations were taken into account when care records were reviewed.

The views of people living at the service and their relatives were not regularly obtained, and were not recorded

There were no policies and procedures available to view. These should be available to people living at Carrwood House to give them information about the service. For staff they can provide good practice guidance and information about the service’s expectations of them.

We found the service did not have processes in place to enable them to respond to people and/or their relative’s concerns or complaints.

There was no evidence of regular quality audits being undertaken to ensure safe practice and identify any improvements required.

During this inspection we found the service was in breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Regulation 15, Premises and equipment, Regulation 18, Staffing; Regulation 9, Person-centred care; Regulation 11, Need for consent; Regulation 17, Good governance; Regulation 12, Safe care and treatment; Regulation 16, Receiving and acting on complaints; and Regulation 13, Safeguarding service users from abuse and improper treatment.

We found omissions in the reporting of incidents to CQC as required by regulations which was a breach of Regulation 15 and 18 of the Care Quality Commission (Registration) Regulations 2009 .

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.