Archived: Carden Bank Rest Home

Updated 20 August 2019

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Care Act 2014.

Inspection team

The inspection was carried out by two inspectors.

Service and service type

Carden Bank Rest 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.

There was not a registered manager at the service because this was not a condition on the provider's registration. The provider managed the service and they are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

The provider was not asked to complete a provider information return prior to this inspection as this was a responsive inspection. This is information we require providers to send us 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 the judgements in this report.

We used the information we held about the service to formulate our planning tool. This included notifications about events that had happened at the service, which the provider was required to send us by law. For example, safeguarding concerns, serious injuries and deaths that had occurred at the service. Before the inspection we contacted commissioners to gain their experience of working with the service.

During the inspection

We spoke with three people who used the service. We observed care and support in communal areas to assess how people were supported by staff. We spoke with three care staff, the acting manager and a consultant.

We viewed five people’s care records. We looked at how medicines were stored, administered and recorded for eight people. We also looked at documents that showed how the home was managed which included staff recruitment and records that showed how the service was monitored by the provider.

Updated 20 August 2019

About the service

Carden Bank Rest Home is a residential care home providing personal and nursing care to 13 people aged 65 and over at the time of the inspection. The service can support up to 14 people.

People’s experience of using this service and what we found

People were placed at risk of harm because the risks to their skin had not been mitigated. People continued to be placed at risk of harm as medicines were not administered as prescribed. People were not protected from abuse because safeguards in place were not followed. There were not enough staff available to mitigate people’s risks.

There was a lack of clear governance and leadership in the service. The provider did not have effective systems in place to monitor the service and mitigate risks to people. The provider did not have effective systems in place to learn when things went wrong. The provider had not consistently worked with professionals to make improvements to people’s care. This meant people had continued to receive poor care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was Inadequate (report published 12July 2019) and there were multiple breaches of regulation.

We took enforcement action after the last inspection and asked the provider to complete an action plan to show what they would do and by when to improve.

At this inspection improvements had not been made and the provider was still in breach of multiple regulations.

Why we inspected

We received concerns in relation to the management of people’s medicines, pressure care, staffing and the management of the service. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

The provider had not taken action to mitigate the risks to people. The overall rating for the service has remained as inadequate. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Carden Bank Rest Home on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to the safe care and treatment of people, safeguarding people from abuse, staffing levels and management at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

The overall rating for this service is ‘Inadequate’ and the service therefore remains in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe. And there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the 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.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk