Archived: The Augustinian Nursing Sisters Ince Blundell Hall

Updated 17 May 2022

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.

As part of this inspection we looked at the infection control and prevention measures in place. This was conducted so we can understand the preparedness of the service in preventing or managing an infection outbreak, and to identify good practice we can share with other services.

Inspection team

On day one and three the inspection was carried out by two inspectors. On the second day it was carried out by one inspector.

Service and service type

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

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means that they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was not a registered manager in post.

Notice of inspection

This inspection was unannounced.

What we did before inspection

We reviewed information we had received about the service since the last inspection. We sought feedback from the local authority and professionals who work with the service. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We used all this information to plan our inspection.

During the inspection

We spoke with three people who use the service and one relative about their experience of the care provided. We spoke with nine members of staff including the provider, senior care workers and care workers.

We reviewed a range of records. This included seven people’s care records, and multiple medication records. We looked at five staff files in relation to recruitment and staff supervision. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We continued to seek clarification from the provider to validate evidence found.

We made a referral to the local fire service to raise concerns with fire safety at the home. We also referred concerns to the local safeguarding team.

Updated 17 May 2022

About the service

The Augustinian Nursing Sisters Ince Blundell Hall is a residential care home providing personal care to 8 people aged 65 and over at the time of the inspection, including people living with dementia. The service can support up to 22 people. The service is a domestic style property and accommodation is over three floors.

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

Risks to people were not always appropriately assessed or managed. Care plans did not contain enough information to support people safely. Plans were not updated when people’s needs changed which put them at risk of not receiving appropriate care that kept them safe from harm.

There were no systems in place to effectively and consistently analyse incidents to ensure learning could be implemented at the earliest opportunity to prevent reoccurrence.

People were at risk of being supported by staff that had not been recruited safely. There were enough staff to meet people's basic needs. However, there were ineffective systems to determine staffing levels and not all staff had completed training necessary for their role.

There was a lack of leadership, oversight and governance in the home. There had been a high turnover of managers at the service. There was no current manger in place. A senior member of staff had assumed some management responsibilities, but this was not clearly defined. There was confusion amongst all staff about roles and responsibilities.

People were not always supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

There were some concerns with fire doors and fire safety. Some fire doors did not close fully or had smoke seals missing. Fire evacuation drills had not taken place regularly and not all staff were aware of the fire evacuation procedure. A fire evacuation plan was in place but was not effective. The local fire service had recommended the evacuation plan was changed but this was not completed. We raised concerns with the local fire service and the provider responded immediately to address these.

Safeguarding procedures were in place and appropriate, but the safeguarding policy was out of date. Staff knew how to recognise, and report concerns of a safeguarding nature, however they had not all been trained in safeguarding. We made a recommendation about the providers safeguarding procedures.

Medicines were safely managed. However, not all staff had appropriate competency checks in place to ensure their practice remained safe. This was addressed during the inspection.

People were at risk of not having their nutritional needs met. Records showed that when people required their food and fluid intake to be monitored, this was not always recorded effectively. Care records did not always accurately reflect people’s nutritional needs and staff did not always know what people’s nutritional needs were.

People were supported by staff who were kind and caring in their interactions. A relative told us staff were “too caring” and sometimes did too much for people restricting their independence. One person told us, although staff were kind and caring, they were sometimes demeaning in the way they spoke to people.

People were supported at the end of their lives in a respectful and dignified way.

People were supported with their religious needs and to maintain social contact with loved ones.

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

Rating at last inspection

The last rating for this service was good (published 28th January 2020).

Why we inspected

The inspection was prompted in part due to concerns received about standards of care, staffing and records. A decision was made for us to inspect and examine those risks under the key questions of safe and well-led.

We inspected and found there were further concerns, so we widened the scope of the inspection to become a comprehensive inspection which looked at all five key questions.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

You can see what action we have asked the provider to take at the end of this full report.

The registered provider has been responsive to concerns noted during the inspection and has started to take action to make improvements and promote safety within the home.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for The Augustinian Nursing Sisters Ince Blundell Hall on our website at www.cqc.org.uk.

Enforcement and Recommendations

We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to the assessment, management and mitigation of risk, recruitment processes, compliance with Mental Capacity Act 2005 and governance and oversight of the service.

We have made a recommendation about the providers safeguarding procedures and policy.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress with improvements and the closure of the service. We will return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The overall rating for this service is ‘Inadequate’ and the service is therefore 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.