Background to this inspection
Updated
24 February 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 registered 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.
We visited the service unannounced on 6, 13 and 26 September 2017. The inspection team consisted of one adult social care inspector on the first day and two adult social care inspectors on the second and third days.
Before the inspection, we received concerns regarding the provision of care at the service. We therefore decided to bring forward our inspection. We reviewed information provided by the Local Authority and Safeguarding teams. We also reviewed other information we held about the service including notifications of incidents that the registered provider sent us since the last inspection, including complaints and safeguarding information.
We spoke with six people who lived at the service and three of their family members. We also spoke with six members of staff and the registered manager and registered provider. We looked at the care records relating to five people living at the service, which included, care plans, daily records and medication administration records. We observed interaction between people who lived at the service and staff.
Updated
24 February 2018
This inspection took place on the 6, 13 and 26 September 2017. All our visits to the service were unannounced. The inspection was prompted in part by notification of an incident following which a person using the service sustained a serious injury. Information shared with CQC about the incident indicated potential concerns about the management of risk of falls from moving and handling equipment. This inspection examined those risks.
The Old Hall residential service is registered to provide accommodation and personal care for up to 16 older people. At the time of our inspection there were 11 people living at the service.
The service had a registered manager in post. 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.
At the last comprehensive inspection on 24 and 25 January 2017 we found a continued breach of regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the registered provider's quality assurance systems were not effective. We asked the registered provider to take action to make improvements in this area.
After the inspection, the registered provider wrote to us to say what they would do to meet legal requirements in relation to the breach identified. They informed us they would meet all the relevant legal requirements by 31 May 2017. This inspection found a continued breach of Regulation 17 and in addition a breach of Regulations 10, 12 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The CQC are now considering the appropriate regulatory response to the concerns we found. We will publish the actions we have taken at a later date.
Staff had been employed following appropriate recruitment checks that ensured they were suitable to work in health and social care. Since our last visit the needs of people living at the service had significantly changed. However, staffing levels in place at the service were not sufficient to protect people from the risk of harm. When we arrived at the service there were only two staff on duty. People were left unsupervised and with no access to staff for periods of up to 40 minutes. Inspectors were required to intervene with one person to prevent them from the risk of falling. The registered manager confirmed that the staffing levels were too low. We asked the registered provider to take immediate action to address safe staffing levels during our visit.
Quality assurance systems in place were not effective, they failed to identify areas of concern we highlighted during our inspection. Where action plans had been put in place to address the improvements needed, we found no evidence that these had been completed by the registered manager or registered provider. There was a lack of management oversight to ensure that robust checks were carried out as required across the different areas of the service. Records were not properly maintained to make sure they were accurate and fully complete. Care plans did not always contain accurate information regarding people’s care needs and failed to clearly record the care people had received.
Accidents and incidents were recorded by staff, however there was a lack of evidence within audits to demonstrate that a robust analysis of falls, patterns or trends were identified. There were no recorded actions completed for people who had experienced multiple falls to state what had done to prevent and minimise the risk of further harm/occurrences.
People were not always protected from the risk of malnutrition and dehydration. There was a lack of action taken when it was identified that one person had lost a significant amount of weight over a short period of time. Weight monitoring charts showed that they had lost 4.7kg between June and August 2017. There was no evidence that the person was referred onto a dietician for their input. Supplementary charts required to monitor food and fluid intake could not be found by the registered manager. Care records relating to the monitoring of peoples skin integrity were not always kept up to date.
People told us and we observed that they received their medication at their preferred times. However, we found that the management of medicines was not always safe. Medication stock checks were not always accurately recorded on people’s medication administration records (MARs). This meant that the registered person would not be able to clearly identify from the stock levels if people had received their medicines as prescribed. The registered manager confirmed that she was responsible for the management and recording of stock received and leaving the service. Care plans for PRN (as required) medication were not always in place for staff guidance. Appropriate guidance from relevant health professionals had not always been sought where changes to medication had been required. We asked the registered manager to take immediate action to address these concerns.
Risks to people’s health and safety were not always safely managed. Where people had required the use of equipment to assist with moving and handling, the registered manager had not sought advice or guidance from relevant professionals. Where people had been assessed as requiring the use of assistive technology to minimise any risk of harm, we found that the relevant equipment was not always working or in place. Care plans contained out of date information relating to the current care needs and risks to people’s health and safety.
Staff received supervision and attended team meetings as required. However, the registered provider training matrix identified that training in relation to moving and handling was not up to date for all staff working at the service. In addition training in areas such as safeguarding adults from abuse and the Mental Capacity Act 2005 required updating. The registered manager confirmed that as of now only staff that had up to date moving and handling training would carry out this practice at the service. We asked them to take action to ensure staff were provided with relevant training.
People’s privacy was not ensured as records were not held securely at the service. People’s rights to choice, privacy and dignity were not always respected.
The registered provider had not displayed their ratings from the previous inspection.
People were supported throughout our visits to make a number of choices regarding how they received their care. Staff understood the importance of seeking consent from people and we observed this on most occasions where support was offered. Care plans contained decision specific capacity assessments and where required, best interest meetings had been held. However the review dates for these assessments set by the registered manager had not been met. Family members confirmed that were appropriate they had been consulted on any decision making regarding their relatives care.
People knew how and who to raise any complaint to. People were complimentary about the service and the support they received from staff. Staff were described as “Kind”, “Caring” and "Patient.” Family members described the service as “Warm”, “Welcoming” and “Homely".
The CQC were notified as required about incidents and events which had occurred at the service.
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 registered provider’s registration of the service, will be inspected again within six months.
The expectation is that registered 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 registered 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 registered provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.