Saltshouse Haven Residential and Nursing Home, in Hull, East Yorkshire, has been rated Inadequate and placed into special measures following inspections in August and September this year.
Saltshouse Haven is registered to provide care for 150 people, some of whom may have nursing needs or who may be living with dementia. The service is divided into five separate lodges, Sutton (closed at present), Coniston for people with nursing care needs, and Bilton, Preston and Meaux for people with residential care needs. Each lodge has a unit manager.
This service had a full comprehensive inspection in September 2015 and was rated as Inadequate and placed into special measures, which meant CQC followed up with another inspection within six months. At that follow up inspection in February 2016, we found significant improvements and the service was removed from special measures and re-rated as Requires Improvement. As is standard, inspectors wanted to make sure the improvements were sustained and planned to return and inspect the service again within 12 months.
Due to concerns raised by health professionals about the nursing care provided at the Coniston Lodge unit, CQC inspected this part of Saltshouse Haven on 11 and 26 August this year. As a result of findings, inspectors took urgent action and worked with Hull City Council and Hull clinical commissioning group to find alternative placements for the residents in this unit. Due to the level of concerns that we found on this unit, the registered provider agreed to a voluntary suspension on further admissions to any of the units at Saltshouse Haven Residential and Nursing Home and prompted us to inspect rest of the provider on the 8-9 September.
Debbie Westhead, Deputy Chief Inspector of Adult Social Care in the North, said:
“Our focused inspection at the Coniston Lodge unit raised wider concerns for us about the care being provided at Saltshouse Haven Residential and Nursing Home as a whole. The provider was of the same opinion and agreed to voluntarily suspend admissions to all of their units.
“We found that inadequate staffing levels had negatively impacted the level of care people were receiving at Coniston Lodge specifically. It was unacceptable that people had sustained injuries due to a number of poor moving and handling incidents. It was also very concerning that we had to prompt staff to take action regarding one person’s health needs.
“Some people had not received their medicines as prescribed due to stock control issues and errors in administration. We also saw an improper use of physical intervention for one person. This simply isn’t good enough.
“Although there were better levels of care provided on the residential care units, there were still things that needed to improve across the board. There were shortfalls in how the service was managed overall, and how care staff were supported to carry out their roles such as training and supervision.”
In relation to Coniston Lodge CQC findings included the following:
- There was a lack of robust risk management, staff had not always following guidance from health professionals and there was the use of improper physical interventions for one person.
- Inspectors found general concerns in documentation such as care planning and recording, advice from health professionals not transferred to care plans, risk assessments identified issues but lacked some control measures and care plans were not always updated following incidents. There was a lack of follow-through in recording of some issues so it was difficult to see if the care had been provided and the issue addressed.
- There were gaps in some people's monitoring charts and wound care records, and re-dressing times were not always followed.
- There were concerns with the management of infection prevention and control as some areas and equipment required cleaning.
- We found specific staff lacked understanding about the Mental Capacity Act 2005, Deprivation of Liberty Safeguards, obtaining consent and carrying out care and support in people's best interests. Documentation that showed best interest decision-making had not been completed appropriately
Findings for the service as a whole included the following:
- Improvement was required regarding a more customer focus approach and accuracy of the complaint letters sent out to people who had raised concerns.
- There was insufficient induction, supervision and support to staff in lower management positions. There were shortfalls in how the service was managed overall and how care staff were overseen and supported when carrying out their roles. Some care staff had received formal supervision but others had not received any for some months. Staff had received a range of training but we were concerned some areas had not been fully understood.
- We found audits had taken place regarding Saltshouse Haven as a whole, which highlighted specific issues, but there lacked analysis to ensure lessons were learned and incidents did not reoccur.
Any regulatory decision that CQC takes is open to challenge by a registered person through a variety of internal and external appeal processes.
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For further information, please contact Kerri James, CQC Regional Engagement Communications Officer by email kerri.james@cqc.org.uk or by phone on 07464 92 9966.
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