Archived: Temple Court Care Home

Updated 25 June 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. This inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Act, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

Inspection team:

The inspection team consisted of one inspector, an assistant inspector and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. In this instance their main area of expertise was as a family carer of people using regulated services.

Service and service type:

Temple Court Care Home is a care home. People in care homes receive accommodation and personal care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

The manager had been in post since January 2019 and was awaiting registration with the Care Quality Commission. The registered manager and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection:

The first day of our inspection was unannounced, the second and third days of inspection were announced.

Inspection site visit activity started on 01 May 2019 and ended on 03 May 2019.

What we did:

We reviewed information we had received about the service. This included details about incidents the provider must notify us about, such as abuse; and we sought feedback from the local authority, clinical commissioning group (CCG) and other professionals who work with the service. We used this information to plan our inspection.

We used information the provider sent us in the Provider Information Return (PIR). This is information we require providers to send us at least once annually to give some key information about the service, what the service does well and improvements they plan to make. The provider completed and returned the PIR in March 2018 and we considered this when we made judgements in this report.

During this inspection we spoke with six people who used the service and eight relatives. As part of this inspection, we spent time with people who used the service and used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people that could not talk with us.

We spoke with 13 members of staff including the manager, clinical lead, nurse, chef, catering assistant, activities co-ordinator, administrator, team leaders, housekeeping, maintenance and care staff.

We reviewed 24 care records including three people's complete care records, individual risk assessments, personal emergency evacuation plans (PEEP’s) and medicines records.

We reviewed four recruitment files, and other documents relating to the management of the service such as policies, audits, meeting minutes, medicines administration records, notifications we received from the service, audits, records of accidents, incidents and complaints.

We requested and received policies relating to the running of the service, training records and maintenance logs following our inspection.

Updated 25 June 2019

About the service: Temple Court Care Home, is a care home that is registered to provide personal and nursing care to 54 older people including people with a physical disability and people living with dementia. At the time of our inspection 24 people were living at the home.

People's experience of using this service:

Quality assurance systems and processes were not effective. They had not identified that risk assessments and care plans had not been completed; non-compliance with health and safety guidance in relation to bedrails; incorrect and missing personal emergency evacuation plans (PEEPS); inconsistencies in the completion of Mental Capacity Act (MCA) documentation; inconsistent recording of people’s fluid intake in care records and an inaccurate record of staff training.

Risk assessments did not always accurately reflect people’s needs. Risks to people becoming trapped in gaps between bed rails, bed frames and their mattresses had not been identified or reduced.

The manager was not aware of all incidents and accidents that had occurred which meant they were unable to ensure appropriate action had been taken to safeguard people.

Documentation for use by the emergency services to identify people’s needs and their whereabouts to support a safe evacuation were inaccurate putting people at risk of an unsafe evacuation.

Confidential information was not always securely stored.

Activities were available for people to access, these were being developed and needed embedding into practice.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People were able to personalise their rooms to their choosing. We have made a recommendation about personalising bedroom doors, so people are able to easily locate their rooms.

People were supported by staff that had been safely recruited. Staff knew how to report safeguarding concerns and had a good knowledge of infection control procedures. We observed the environment to be clean with a pleasant odour.

People were supported to access healthcare appointments and were referred to healthcare professionals as needed.

People received their medicines at the time they needed it, Medicines were safely stored.

People were supported by kind and caring staff, that knew them well and enjoyed their jobs.

Rating at last inspection:

This is the first comprehensive inspection of this location.

Why we inspected:

This was a planned inspection.

Enforcement:

At this inspection we found the service to be in breach of Regulation 12 Safe Care and Treatment, and Regulation 17 Good Governance of the Health and Social Care Act 2008 (Regulated Activity) Regulations 2014.

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

Follow up:

We will continue to monitor intelligence we receive about the service until we return to visit as per our re-inspection programme. Should further concerns arise we may inspect sooner.

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