The Care Quality Commission (CQC) has rated Ascot House care home in Nottingham inadequate and placed it in special measures to protect people, following an inspection in May.
This unannounced inspection was prompted, in part, due to concerns received about poor care and environmental issues at the service.
The care home supports people with mental health and/or substance misuse issues. It can provide accommodation and personal care for up to 20 people. At the time of the inspection there were 19 people using the service.
As well as the overall rating dropping from requires improvement to inadequate following this inspection, safe and well-led have also declined from requires improvement to inadequate. Caring and responsive were not inspected on this occasion, therefore remain rated as good. Effective was also not inspected and remains rated as requires improvement.
CQC has taken urgent enforcement action to prevent the service from admitting anyone until they have addressed the safety concerns. It will be kept under close review by CQC to check sufficient improvements have been made to ensure people are safe.
Greg Rielly, CQC deputy director of operations in the midlands, said:
“When we inspected Ascot House, we found lessons hadn’t been learned since our last inspection and the quality and safety of the service had deteriorated even more. Our experience tells us that when a service isn’t well-led, it’s less likely they’re able to meet people’s needs in the other areas we inspect, which is what we found here.
“The provider failed to implement effective systems across many areas of the service which had been identified at our previous inspection. We found there had been little to no improvement with regards to environmental safety, staff training, staff supervision and poor risk assessments.
“We also found people were at high risk of being burnt by hot water in the showers because staff weren’t checking if the temperature was safe for people to use. When the inspector tested the temperatures, they were all above the recommended guidance, with one measuring at 55 degrees celsius which could cause serious injury as it should be below 43 degrees celsius.
“Inspectors also found the environment wasn’t suitable to support people with mobility needs. There were exposed ledges and steps around the property that put people at risk of falls. We saw one person was at high risk of falls when using an unsuitable ramp. We raised our concerns with the management team at the time, but when we returned six days later, no action had been taken and the person still remained at risk of falling when using this ramp.
“Following our inspection, we reported our findings to the provider, so they know the areas where we expect to see rapid improvement. If sufficient progress has not been made, we will not hesitate to take further action to ensure people’s safety and well-being.”
Inspectors found:
- Staff did not have the training, competency, or supervision to carry out their roles safely
- There was poor record keeping
- The environment was unclean and not safe
- Medicines were not given hygienically or safely
- Lessons were not learnt when things went wrong
- Health professionals visited the service; however, their recommendations were not always clearly followed
- The governance of the service did not ensure that high quality care was provided
- Reviews and audits were not effective at identifying and driving improvements
- Staff were not always safely recruited.
However:
- There were enough staff to support people safely
- Staff knew how to report concerns of abuse.