The Care Quality Commission (CQC), has rated The Gables in Southampton, Hampshire, inadequate and placed the service in special measures to protect people following an inspection in November.
The Gables, run by Sonrisa Care Limited, is a care home for older people and those living with dementia. At the time of the inspection 21 people were using the service.
The inspection was prompted in part by an incident following which a person using the service died. The incident is subject to further investigation by CQC as to whether any regulatory action should be taken. As a result, this inspection did not examine the circumstances around the incident. However, the information shared with CQC about the incident indicated potential concerns about the management of risk of falls and health deterioration, and this inspection examined those risks.
Following this inspection, the service’s overall rating dropped from good to inadequate. The ratings for safe and well-led also dropped from good to inadequate. The rating for effective has fallen from good to requires improvement. This inspection did not look at how caring and responsive the service was.
CQC has served four warning notices to the provider to protect people and ensure they receive safe care and treatment, ensure the service gains consent to care, improve safeguarding, and are managing the service well.
The home has now been placed in special measures, meaning it must make rapid and widespread improvements, and will be kept under close review by CQC to make sure people are safe during this time. They will also be re-inspected in due course, to check on the progress of those improvements.
Roger James, CQC deputy director of operations for the south, said:
“When we inspected The Gables, we were concerned to find the quality of care at the home had deteriorated since our last inspection which placed people at risk of harm. Leaders need to introduce effective systems and processes to ensure incidents are investigated and actions are taken to protect people from harm.
“We didn’t see evidence that they were always monitoring and learning from incidents to protect people from mistakes being repeated in future. In one example, there had been an error with a high-risk medicine, and in another someone was hurt after a fall which nobody had seen. We didn't see evidence that incidents like these were looked at to see how they could be prevented from happening again in the future. Staff also hadn’t always followed safeguarding procedures and reported appropriate incidents to the local authority.
“People weren’t always being supported in the least restrictive ways possible and assessments of people’s mental capacity weren’t always completed. Where people were being restricted for safety, such as with bed rails or a wheelchair lap belt, we didn’t see evidence that consent had been sought or any assessments had been made. This infringes on people’s human rights.
“Inspectors heard positive feedback from people living at the home and their relatives, but staff had a lack of guidance and training to support people effectively. For example, staff had not been trained to support people living at the home who needed support with catheter care and preventing pressure sores. Staff also lacked instructions to safely give medicines that some people needed.
“We’ll continue to monitor the home closely to ensure improvements are made and won’t hesitate to take further action if we’re not assured people are receiving safe and dignified care.”
Inspectors also found:
- Care plans weren’t always updated or with enough detail to guide staff on people’s individual risks. Details about people’s individual needs weren’t always available in an emergency either, putting people at further risk of harm
- Medicines weren’t always managed safely. Records weren’t always updated with the time doses were given and staff didn’t always have instructions on how to safely give them to people, including pain relief and sedatives
- Although the home was found to be mostly clean in communal areas, infection risks weren’t always controlled, and the environment wasn’t always safe. Inspectors found one radiator hadn’t been covered and a sharp metal pipe was exposed in areas where people walked independently
- The decoration and design of the home didn’t enable people with dementia to move around easily which meant people weren’t always able to locate their bedroom or the bathroom
- Visitors weren’t asked to sign in when they arrived, which meant in an emergency the home couldn’t identify who was in the building.
However:
- People were supported with a good choice of food and dietary needs were catered for
- Leaders recognised improvements needed to be made and had started to make some improvements during the inspection.
The report will be published on CQC’s website in the next few days.