Archived: St Andrews Court

Updated 25 August 2020

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, a pharmacy inspector and a specialist advisor. One inspector and a specialist advisor visited the service on 25 September 2019; two inspectors visited the service on 02 October 2019 and a pharmacy inspector visited the service on 03 October 2019. One inspector visited the service again on 16 October 2019.

Service and service type

St Andrews Court 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 nominated individual is responsible for supervising the management of the service on behalf of the provider. The nominated individual was also the registered provider and registered manager for this service. Registered persons are legally responsible for how the service is run and for the quality and safety of the care provided. We refer to the nominated individual and registered manager as the ‘registered provider’ or ‘provider’ within this report.

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 checked for any feedback available through Healthwatch. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We also used the information the provider sent us in the provider information return. This is information providers are required to send us with key information about their service, what they do well, and improvements they plan to make. This information helps support our inspections. We used all of this information to plan our inspection.

During the inspection

We spoke with six people who lived at the home and observed the care and support people received.

We spoke with the provider and nine staff members including four senior support workers, two support workers, the deputy manager who had re-joined the service on 16 October 2019, a domestic staff member and another support worker employed at another of the provider’s services who was present during our inspection.

We spoke with one visiting professional during our inspection visit and held discussions with local authorities and health professionals involved in people’s care throughout our inspection and enforcement processes. We reviewed a range of records. This included records related to each person living at the home and eight people’s medication records. We looked at five staff files in relation to recruitment. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

During and after our inspections, we continued to share information and the concerns we had identified with the local authorities and professionals involved in people’s care. We continued to seek updates and assurances from the provider and received some information such as a training matrix after the first day of our inspection.

Updated 25 August 2020

About the service

St Andrews Court is a care home which is registered to provide personal and nursing care for up to 12 people with mental health needs. St Andrews Court accommodates 12 people in one adapted building and there were 12 people being supported at the time of our inspection.

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

Numerous incidents including abuse and/or allegations of abuse were not adequately responded to and escalated to relevant partner agencies such as the local authority. This meant people were not protected from harm. People did not all feel safe. Incidents including where people and staff had come to harm, were not learned from and risks were not adequately managed. This was a breach of the regulations.

We identified a second breach of the regulations due to inadequate risk management and further significant shortfalls in the safety of the service. People’s risks and complex needs were not adequately assessed and known to all staff, and the premises presented hazards and further risks to people’s safety. Where people’s risks were known to staff, they were not consistently managed. Systems also failed to ensure safe medicines management at all times.

We identified a third breach of the regulations because there were not enough suitably skilled and qualified staff, including nurses, to safely meet all people’s needs. This meant clinical support, agreed with local authorities, could not always be provided to people. Recruitment checks had been carried out appropriately and the home was clean.

People’s needs were not adequately assessed or always known to staff. This meant people’s needs could not always be met. People gave mixed feedback about the support provided. Staff did not have adequate training and guidance for their roles.

Staff did not always take care to ensure people had enough to eat. People’s choking risks were not effectively managed which put people at risk of harm. People gave mixed feedback about the food; some people made and prepared their own meals.

People were not 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 systems in the service did not support good practice and we identified a fourth breach of the regulations, around consent.

The provider failed to ensure the service was adapted to meet all people’s needs. The service was decorated in a homely way. Staff helped people to access healthcare support.

We identified a fifth breach of the regulations because the provider failed to consistently support people’s autonomy, independence and involvement in the community. Institutional practices negatively impacted on people’s dignity, privacy and positive experiences. People were not all encouraged to have control and choice as far as possible.

People were not always well treated and supported, and people’s diverse needs were not always met. Staff often had a caring approach, but this was not consistent. People were not adequately supported to have their needs heard and met.

We identified a sixth breach of the regulations because people did not all receive personalised care and were not empowered to have choice and control over their care. People were not involved in care plan reviews, and the views people expressed were not always listened to. Care planning failed to ensure everyone had good access to activities and have their communication needs met. People did not show full confidence in the complaints process.

We identified a seventh breach due to the provider’s continued failure to notify CQC of specific events and incidents at the service as required by law.

We identified an eighth breach related to the provider’s poor governance systems which exposed people to ongoing risk of harm and poor care. Our inspection found widespread and significant shortfalls in the quality and safety of the service. Systems failed to ensure risks and incidents were appropriately responded to; that there were adequately skilled staff to safely meet people’s needs; that regulatory requirements were met and that there were continuous and sufficient improvements to the quality and safety of the service. The provider failed to understand the principles of good quality assurance and failed to act to address serious concerns highlighted through our urgent enforcement activity.

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 Requires Improvement (published September 2018).

At this inspection, enough improvement had not been made and the provider was still in breach of regulations for their continued failure to notify the Commission of specific incidents and events as required. This inspection found the provider was in breach of additional regulations.

Why we inspected

This was a planned inspection based on the previous rating.

Enforcement

At this inspection, we identified an additional seven breaches of the regulations. This was because the provider failed to provide safe care and treatment and to adequately protect people from abuse and improper treatment. The provider failed to ensure there were enough, sufficiently skilled staff and consent was appropriately sought for the care and treatment provided. The provider failed to ensure people were always treated with dignity and respect and that people always received person-centred care. The provider failed to establish and operate effective systems and processes to ensure compliance with the regulations and to assess, monitor and improve the quality and safety of the service.

After our inspection, we took urgent enforcement action to require the provider to immediately address significant concerns that placed people at immediate risk of harm. We informed relevant partner agencies of our serious concerns and carried out a further visit to check what action the provider had taken to ensure people’s safety. We found the provider had failed to take enough action to ensure people’s safety and we identified additional concerns that continued to place people at immediate risk of harm. We continued to liaise closely with the local authorities and other relevant partners. We also carried out responsive inspections of other services registered with the provider based on the concerns at this service. Due to the seriousness of our concerns we took further enforcement action to remove this location from the provider’s registration. The local authority sourced alternative homes for each person who previously lived at St Andrews Court and this service is no longer active.

Follow up

During and after our inspection processes, we requested information from the provider about what action they were taking to address our serious concerns. We also worked alongside the relevant local authorities in light of the immediate and urgent concerns we identified. We placed the provider into special measures and carried out urgent and non-urgent enforcement action in relation to this service. During our enforcement processes, we continued to monitor the service for any further concerning information to help inform our inspection activity. At the time of publishing this report, the service has been de-registered by CQC.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service was therefore placed into ‘special measures’. We have completed the process of preventing the provider from operating this service by varying the conditions of the provider’s registration.