The Care Quality Commission
  • Care Home
  • Care home

Archived: Admiral Court Care Home

Overall: Inadequate read more about inspection ratings

Cleveland Road, Hartlepool, Cleveland, TS24 0SY (01429) 866893

Provided and run by:
Four Winds Care Limited

All Inspections

15 April and 6 May 2015

During an inspection looking at part of the service

We inspected Admiral Court Care Home on 15 April and 6 May 2015. This was an unannounced inspection which meant that staff and provider did not know that we would be visiting.We visited in order to check the actions the provider had taken to safeguard people who lived at the home.

We had inspected Admiral Court Care Home in December 2014 and issued formal warnings in respect to the provider failing to meet the following regulations:

• Regulation 13: Management of medicines, as staff were failing to ensure people were protected against the risks associated with the unsafe use and management of medicines.

• Regulation 15: Safety and suitability of premises, as the service was failing to ensure people at its property were protected against the risks associated with unsafe or unsuitable premises.

• Regulation 22: Staffing, as the service was failing to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed at the home.On 3, 4, 8 and 15 March 2015 we inspected Admiral Court care home to determine what improvements had been made. We found the home had made no improvements and were breaching all 16 of the regulations in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

These were all of the regulations from 9 to 26. Also there were failures to meet the requirements of regulations 11, 12 and 18 of the Care Quality Commission (Registration) Regulation 2009. The care was so poor that we judged the home as failing to meet every aspect of the CQC assessment framework and rated it as inadequate.

We had serious concerns about the service provided at the home and took urgent action to prevent any admissions to the home. This led to a condition being imposed on the provider’s registration to that effect.Admiral Court Care Home is a large purpose built home registered to provide nursing care. The home has the capacity to take up to 50 residents.

Admiral Court Care Home is registered to care for older people, people living with mental health disorder and/or dementia as well as people with sensory impairments. On 6 May 2015 there were 23 residents living there, 12 upstairs and 11 downstairs.

Since the last inspection the registered manager who had been in place since 1 December 2014 has resigned and no registered manager is 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. A manager from one of the provider’s other services was working at the home.

We were told by placing authorities that in general families remained content for their relatives to remain at the home.

At this inspection we saw that where relatives had raised concerns with the standard of care the manager acknowledged the legitimacy of these concerns and gave assurances that action was being taken to make improvements. They also outlined to families that this may take some time to achieve. Relatives that we spoke with felt the staff were more caring and the manager was actively trying to make improvements.

We found that little had changed. Although some minor improvements were noted we found that the provider continued to breach all 16 of the regulations relating to care in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These were all of the regulations 9 to 26. Also there were failures to meet the requirements of regulations 11, 12 and 18 of the Care Quality Commission (Registration) Regulation 2009. Despite us making the provider aware of these failings following the last inspection and the need to make notifications these breaches of the Care Quality Commission (Registration) Regulation 2009 continued.

We also found that the provider failed to recognise when they needed to make safeguarding referrals. We found that the manager did not follow the provider’s disciplinary procedures so failed to take action in line with the home’s policy and dismiss staff when they were found to be asleep on duty. We also noted the manager had not received a copy of the new certificate from the provider and was unaware that we had imposed a condition to prevent admissions to the home.

Alongside these breaches we found although some of the staff tried to provide good care the provider had not supported staff and ensured they understood the need to provide basic care such as drinks and food when people asked for this or appeared thirsty.

We found that care and treatment was not planned and delivered in a way that was intended to ensure people’s safety and welfare. Although some action had been taken to write new care plans these remained inadequate to meet people’s nursing needs.

Staff continued to remain unaware of the current people’s conditions, needs and their risk profiles and were not able to demonstrate how they meet people’s needs. Care staff told us they did not know why people were at the home and felt it was not appropriate for them to look at the care records. Therefore they could not outline how to support people, particularly those with mental health needs.

We found that the provider had a disregard for people’s humanity and the Human Rights Act 1998, particularly Article 5, the right to liberty, and Article 14 prohibition of discrimination. We found that staff failed to adhere to the five principles of the Mental Capacity Act 2005 and were imposing restrictions upon people although staff had not assured themselves that people did lack capacity to make decisions. We found that people were unlawfully detained at the home.

We saw that the provider did not have adequate systems in place to protect service users from abuse caused by acts of omission and neglect.

We saw that staff continued to fail to ensure people who remained in bed had access to ample fluids and saw that some people’s water was not provided fresh each day. We started the inspection at 5.30am and saw that one person had a half full beaker of blackcurrant juice dated 4 May 2015. The person told us that staff had kindly given them a drink of that juice and throughout the day we saw this was not refilled but the level of fluid gradually reduced. People were not protected from the risks of inadequate nutrition and dehydration.

We found that staff were still not taking action to minimise presenting risks associated with immobility, choking and poor nutrition/hydration. Staff failed to ensure service users received appropriate medical care for wound care, deterioration in health conditions and the monitoring of potential adverse effects of their medication.

We found that people were still not protected against the risks associated with medicines because the provider had not ensured appropriate arrangements were in place to manage medicines.

Staff did not ensure suitable arrangements were in place to protect service users against the inappropriate use of physical intervention.

We found that where people had requested to challenge the decision to subject them to a deprivation of liberty authorisation staff took no action to ensure they were supported to contact the Court of Protection and appeal this decision. Staff also took no action to ensure people had advocates where needed or when people told them they wanted to move from the home that their social worker was contacted so their care could be reviewed and a move facilitated.

The home is not registered to accept people with a physical disability or learning disabilities. Although since the last inspection some of the people with physical disabilities had moved elsewhere people who required adapted wheelchairs remained at the home, as did people with learning disabilities.

There was a walk-in shower room on the first floor which was large enough for people with mobility needs. The passenger lift is too small to accommodate the adapted wheelchairs people used, which meant they could not use this facility. Since the last inspection a shower table had been provided to one ground floor bathroom but the two people with significant physical disabilities were still to be assessed to see if they would be able to use this facility. This meant that these people had still not been able to have a bath or shower.

None of the shared toilets were designed for people with physical disabilities and did not have any equipment, such as grab rails, to support people with reduced mobility.

Staff failed to protect people from avoidable harm and despite us highlighting on 3, 4, 8 and 15 March 2015 the risks associated with completing the refurbishment work whilst people lived in the area they took no action to reduce this risk until a person was injured at the end of March 2015.

We found that the provider had continued to take no action to address the unsatisfactory elements identified on the electrical installation condition report issued in November 2014. We were provided with two new fire installation certificates but the forms indicated that these were completed by electricians registered with the regulating bodies for electrical contractors. The certificates were for the work completed during the refurbishment and not a full review of the safety of the overall wiring. We noted on one of the certificates one of the faults identified as low risk was identified by a competent electrician as dangerous and requiring urgent action.

We found some works had been completed to address matters raised in the Regulatory Reform (Fire Safety) Order 2005 issued 8 January 2015 and the recommendations from 23 February 2015 Hartlepool Borough Council fire risk assessment. However, night staff still could not tell us how many people were living in the home or locate the Personal Emergency Evacuation Plans. The newly appointed night nurse was not clear about the fire procedures although they assured us they had received a thorough induction.

We found that since the last inspection the provider had ensured the passenger lift complied with Lifting Operations and Lifting Equipment Regulations 1998 (LOLER). One of the baths had not been serviced at the required interval in January 2015 and had not been decommissioned. The manager stated this was because it required a new battery to be fitted. There was no signage to instruct staff not to attempt to use this equipment. We highlighted this to the manager and they put a sign in place.

We found that the provider continued to fail to have adequate systems in place to assess and monitor the quality of the service that was being provided. They had not taken action to ensure they were assured that the building was safe and that satisfactory checks of the building were in place. The manager had put new templates in place for some aspects of the service but these were either not completed or inadequately completed. The provider continued to fail to meet the needs of the people who used the service.

We found that the provider did not operate effective recruitment procedures. Although evidence was now available to show checks had been completed, when Disclosure and Barring Service clearance (DBS) or references highlighted previous convictions or that people had been dismissed from other services the provider did not undertake further checks; take action to risk assess the impact this might have; or reduce the risk. Since the last inspection staff had been appointed although these concerns were evident and following the provider obtaining DBS for the other staff no action had been taken to reduce any associated risks when convictions were highlighted.

There were not sufficient numbers of suitably qualified, skilled and experienced staff employed to provide the care that people required. Staff had not received appropriate professional development and had not been suitably trained. No competency checks had been completed for the nurses and the manager told us this was not necessary because they were nurses so accountable for their own practice. This is untrue as the provider is accountable for ensuring all of the staff working in their services are competent to deliver the care being provided.

We found that the agency nurses who worked at the home were still not provided with suitable or detailed information about the people’s conditions, primary needs and current nursing needs. We also found that people were not protected against the risks of unsafe or inappropriate care because the care records were not accurate.

We found that the ambient temperatures within the home remained in excess of 25°c and the provider continued to take no action to resolve this or ensure it did not adversely impact the that adequate cleaning and infection control prevention were maintained.

We found there were multiple of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Following the last inspection we issued a notice of decision which imposed a condition that prevents the provider admitting people to Admiral Court Care Home.

 

3, 4, 8 and 15 March 2015

During a routine inspection

We inspected Admiral Court Care Home on 3, 4, 8 and 15 March 2015. This was an unannounced inspection which meant that staff and provider did not know that we would be visiting. We visited in order to check the actions the provider had taken to improve the home.

We had inspected Admiral Court Care Home in December 2014 and issued a formal warning telling the provider that by 23 February 2015 they must improve the following areas.

  • Regulation 13: Management of medicines, as staff were failing to ensure people were protected against the risks associated with the unsafe use and management of medicines.
  • Regulation 15: Safety and suitability of premises, as the service was failing to ensure people at its property were protected against the risks associated with unsafe or unsuitable premises.

And by 9 March 2015 they must improve in the following area.

  • Regulation 22: Management of medicines, as the service was failing to ensure that, at all times, there are sufficient numbers of suitably qualified, skilled and experienced persons employed at the home.

Admiral Court Care home is a large purpose built home registered to provide nursing care. The home has the capacity to take up to 50 residents. Admiral Court is registered to care for older people, people living with mental health disorder and/or dementia as well as people with sensory impairments. At the time of the inspection there were 32 residents living at the home, 16 upstairs and 16 downstairs.

A registered manager had been in place since 1 December 2014, which was the date the home opened under the management of Four Winds Care Limited. 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 this inspection we found that there were breaches of all 16 of the regulations relating to care in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These were all of the regulations 9 to 26. Also there were failures to meet the requirements of regulations 11,12 and 18 of the Care Quality Commission (Registration) Regulation 2009. We had serious concerns about the service provided at the home and found that staff failed to meet the needs of the existing 32 people who resided at the home.

We found that the provider had commenced major refurbishment work on the top floor but had taken no action to reduce the impact this had upon people who resided on that floor. They had not moved people to a safer environment whilst the work was completed or put measures in place to ensure people were not living in the area whilst the building work was underway.

We found that the provider had taken no action to address the unsatisfactory elements identified as C2 (Potentially dangerous – Urgent remedial action required) on the electrical installation condition report issued in November 2014. They had failed to address matters raised in the Regulatory Reform (Fire Safety) Order 2005 issued 8 January 2015 or the recommendation made in the Hartlepool Borough Council fire risk assessment dated 23 February 2015.

We found that the provider had not ensured that checks were undertaken to ensure the passenger lift complied with Lifting Operations and Lifting Equipment Regulations 1998 (LOLER). Staff and service users continued to use this lift even though they could not be assured that it was safe.

We found that staff had admitted people who because of the design of the home needs could not be met. For instance the home is not registered to accept people with a physical disability but the provider had admitted people with physical disabilities who required adapted wheelchairs into the home and onto the first floor. These are larger than regular wheelchairs. The passenger lift at the home was too small to accommodate these wheelchairs yet we found that people with adapted wheelchairs lived upstairs and the only way up or down from this floor for them was to be carried by staff, which is an unsafe practice. We found that these people had not been able to leave the top floor since admission some months earlier.

We found that the provider had not ensured staff completed fire training and that Personal Emergency Evacuation Plans were in place for all the people residing at the home. Staff initially could not explain how they would safely evacuate people from the home. On 5 March 2015 we asked that the matter was addressed immediately.

We found that the provider did not have adequate systems in place to assess and monitor the quality of the service that was being provided. They had not taken action to ensure they were assured that the building was safe and that satisfactory checks of the building were in place.

We found that care and treatment was not planned and delivered in a way that was intended to ensure people’s safety and welfare. Staff had not taken action to ensure people were re-assessed when the facilities in the building were unsuitable for their needs. Staff were unaware of the current people’s conditions, needs and their risk profiles and were not able to demonstrate how they meet the needs of the existing people at the home.

We found that staff were not taking action to minimise presenting risks associated with immobility, choking and poor nutrition/hydration. Staff failed to ensure service users received appropriate medical care for wound care; deterioration in health conditions and the monitoring of potential adverse effects of their medication.

We found that staff had failed to follow the directions of medical professionals and ensure service users were seen by out-patient consultants or that these appointments were made. Staff had not taken action to ensure service users were in receipt of suitable mobility equipment and seating so therefore able to get out of bed.

We found that the provider did not operate effective recruitment procedures and evidence was not available to show that people had the appropriate qualifications, skills and experience for the role. There were not sufficient numbers of suitably qualified, skilled and experienced people employed to provide the care that people required. Staff had not received appropriate professional development and had not been suitably trained.

We found that people were not protected against the risks associated with medicines because the provider had not ensured appropriate arrangements were in place to manage medicines. Neither were people protected from the risks of inadequate nutrition and dehydration.

We saw that the provider did not have adequate systems in place to protect service users from abuse caused by acts of omission and neglect. Staff did not ensure suitable arrangements were in place to protect service users against the inappropriate use of physical intervention.

Where people did not have the capacity to consent the provider had not ensured that staff acted in accordance with legal requirements.

We found that agency nurses who worked at the home were not provided with suitable or detailed information about the people’s conditions, primary needs and current nursing needs. We also found that people were not protected against the risks of unsafe or inappropriate care because the care records were not accurate.

We found that the ambient temperatures within the home were in excess of 25°c and the provider had taken no action to ensure this did not adversely impact the wellbeing of the people who used the home. There were no effective systems in place to ensure that adequate cleaning and infection control prevention were maintained.

We found there were multiple of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We have judged these findings to have a major impact. This is being followed up and we will report on our action when it is complete. You can see a summary of the actions we have asked the provider to take, which you can see at the back of the full version of this report.

17/12/2014 and 19/12/2014

During a routine inspection

The inspection took place over two days. The first visit was on the 17 December 2014 and was unannounced which meant the provider and staff did not know we were coming. Another visit was made on 19 December 2014.

As this home was registered with a new provider on the 1 December 2014 this was classed as their first inspection. The inspection was carried out because concerns were raised with CQC by several members of the public, and was a response to those concerns. As the service had only been registered for 17 days at the time of our inspection we have not been able to rate the service, instead have focused on the areas for improvement.

Admiral Court Care home is a care home over two floors. The home has the capacity to take up to 50 residents. At the time of the inspection there were 37 residents living there, 17 upstairs and 20 downstairs.

There was a registered manager in place at the time of the inspection. 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.

We were responding to concerns raised with us by members of the public and we concentrated on looking at those issues. Those issues related to the premises, staffing levels and how medicines was administrated. We spent time looking at all areas of the home but have not reported on this as at this time are focusing on the areas that require immediate improvement.

We found that staffing levels were not sufficient to ensure people received care in a safe way. The registered manager told us, they were struggling to get sufficient suitably qualified and prepared staff to meet people’s health needs. At times qualified nursing levels were low, with the registered manager having to cover many shifts.

We were unable to examine what training people had received as the previous owner’s records were not available and the home did not have a system in place to show what training people had received. We discussed this with the registered manager, and the area manager who recognised this shortfall and were in the process of ensuring that it was put right.

When we arrived on the first day there were no policies or procedures available, to guide staff. By the second day there were policies and procedures in place relating to medicines, fire safety and recruitment and selection but these were not yet available to the staff team.

Staff understood the Mental Capacity Act 2005 for people who lacked capacity to make a decision and Deprivation of Liberty Safeguards to make sure they were not restricted unnecessarily. Relatives confirmed they had been involved in the agreements about keeping people safe and that people were able to take “reasonable risks” with support so they had as independent a lifestyle as possible.

We examined the care records for seven people who lived there and noted that these had not been updated for many months. There had been no updating since the new providers took over.

We did see some people needed special support with their diets due to a variety of factors such as being unable to feed themselves or needing help and support during their meals to ensure they ate their food. We saw those people who needed help with feeding receiving appropriate support.

However in at least one case we saw that a person (although we saw they were supported appropriately) were considered at risk because they had difficulty swallowing had no assessment of the potential risks and no written guidance for the staff as to how they should be supported.

In another case where a person could forget to eat we saw very little support to ensure that they continued to eat their meal and little evidence of any effective monitoring of this. In that case the records showed that they had eaten a full meal where we observed they had only eaten one mouthful before the meal was removed.

We examined all of the records relating to medicines. We saw there were records missing and noted that some people received their medicines late which due to the type of medicines could lead a person to suffer from unnecessary pain. We noted one person had no form of communication so could not have articulated if they were in pain or not.

There were other concerns regarding medicines in relation to how well the storage was organised and how peoples changes in medicines was recorded.

We examined the premises. It was clear that the home was in a poor state of up keep prior to being taken over. The new provider had made some changes particularly with regard to the bedrooms upstairs. We saw that the “middle” branch corridor upstairs was closed off and undergoing major transformation. However the current conditions where people were living upstairs were poor.

The lounge and dining areas had been re decorated but the corridors, toilets and bathrooms were in a very poor state. There was heavily embedded dirt in most of the flooring.

One bathroom was locked off as unusable; one bathroom had a patch of bare wood under the toilet which would be difficult to clean properly. This area of bare wood where a new toilet had been fitted also had a three by two inch hole at the back of the toilet underneath the waste pipe. This meant proper cleaning could not be achieved and it held the potential to harbour bacteria and become foul smelling should “any accidents” occur. We noted similar concerns with other bathrooms.

You can see what action we told the provider to take at the back of the full version of the report.