Archived: Chasewood

Updated 4 September 2019

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.

The inspection was prompted in part because we had concerns about the provider’s governance systems and leadership at their other home when we inspected it in April 2018. We were also aware that the local authority had imposed a placement stop at both services, due to their concerns about how both homes were managed.

The inspection visit was undertaken by two inspectors on 29 May 2018 and was unannounced. One inspector returned unannounced on 18 June 2018, to check the provider had taken the actions they said they would take, to minimise risks related to the premises. We reviewed the information we held about the service. We looked at information received from relatives, the local authority commissioners and the statutory notifications the registered manager had sent us. A statutory notification is information about important events, which the provider is required to send to us by law. Commissioners are people who work to find appropriate care and support services, which are paid for by the local authority. We did not ask the provider to send us a provider information return, because the inspection was undertaken in response to information we already knew from other agencies and our knowledge of the provider’s other service.

We spoke with two people and a relative about what it was like to live at the home. We spoke with the deputy manager, three care staff and the provider about what it was like to work at the home.

Most of the people who lived at the home were not able to tell us in detail, about how they were cared for and supported because of their complex needs. However, we used the short observational framework tool (SOFI) to help us assess whether people’s needs were appropriately met and to identify if people experienced good standards of care. SOFI is a specific way of observing care to help us understand the experiences of people who could not talk with us

We reviewed three people’s care plans and daily records, the medicines administration records for two people and other aspects of medicines management to see how care and support were planned and delivered. We checked whether staff were trained to deliver care and support appropriate to each person’s needs. We reviewed elements of the provider’s quality monitoring system to see what actions were taken and planned to improve the quality of the service.

Updated 4 September 2019

The inspection took place on 29 May and 18 June 2018 and was unannounced. We made a second visit on 18 June 2018 to check that the provider had taken the actions they said they would take, to minimise risks related to the premises. At our previous inspection the service was rated Good overall but rated Requires Improvement in well-led. At this inspection, we found the provider had not made the required improvements in well-led, the safety and quality of the service had deteriorated and we found breaches of the Regulations. The rating has changed to Inadequate.

Chasewood 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 care home accommodates up to 26 people, who may live with dementia, in one adapted building.

There was not a registered manager in post. The registered manager had left the service in December 2016. 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 new manager had not registered with us and they left the service in May 2018.

We found systemic and widespread failings in the management, monitoring and oversight of the service, which meant people did not always receive safe care. There was not an effective system to identify and manage risks to people's safety through planning and delivering care or in how the premises were used. The provider's fire risk management arrangements did not include a register of everyone who lived at the home and their oversight of fire prevention and control measures was inadequate.

The provider had failed to take the actions they said they would take to minimise risks to people’s safety related to the premises. The provider had failed to identify new risks to people’s safety related to the premises and failed to respond to staff’s repeated requests for repair or replacement of the premises and equipment.

The provider’s systems and processes did not ensure people were protected from the risks associated with medicines management, infection prevention and control and food safety and here were not always enough staff on duty to support people safely.

The provider and staff did not understand the principles of the Mental Capacity Act 2005, and one person was unlawfully deprived of their liberty. People were not always supported to receive the healthcare support they needed to minimise risks to their health.

The provider’s oversight, monitoring and auditing of the service failed to identifying risks, trends or patterns that would have enabled to them make changes to the quality of the service. The provider did not challenge staff’s practice when they were less than caring or responsive to people’s health, social and emotional needs. The provider’s failure to ensure people were treated with respect and dignity, did not give the right leadership or support to enable staff to treat people as valued individuals. Care plans contained insufficient detail about people's personal histories and interests to support staff to deliver person centred care and staff did not deliver a person-centred service.

People had limited opportunities to engage in meaningful activities that they enjoyed. The provider did not operate an effective complaints handling system that would have enabled them to identify trends or areas of risk that they could have addressed to improve people's experience of the service.

People's care plans were not updated accurately when their needs changed, to give staff the guidance they needed to support people safely and minimise their personal risks. Other records related to people's care, support and treatment were incomplete or not up to date. There was not an effective or auditable system of sharing important information about people's needs, or any changes to their abilities and the support they needed.

People's and relatives' views of the service were not sought, heard or responded to. Staff experienced a lack of communication, inconsistent direction and guidance and were not supported to be instrumental in making the required improvements.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures. This is the second time the service has been in special measures since November 2015. 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.