The inspection was carried out on 24 and 25 August 2015 by two inspectors, a specialist clinical adviser and an expert by experience. It was an unannounced inspection. The service provides personal, nursing care and accommodation for a maximum of 22 people.
The staff provided nursing and personal care for people with enduring mental health conditions, some of whom had a history of substance or alcohol misuse and a forensic background. Some people also had complex physical health conditions and behaviours which may challenge. Many people stayed at the service on a long term basis and may previously have experienced homelessness. The provider told us they aimed to support people to move to more independent services if their health needs allowed this, to enable them to live without full time support and nursing care.
There was an acting manager in post who was acting up from a previous deputy manager role. The previous registered manager had recently resigned from their role. The service was in the process of recruiting a new full time manager who was due to take up the post, dependent on satisfactory recruitment checks. At the time of our inspection there was no registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.
Staff had attended training in how to protect people from abuse and harm. However staff were not confident in describing how they would recognise potential signs of abuse and what processes they needed to follow to keep people safe. They said they would benefit from additional training in this area.
Staff did not have the necessary training to meet the individual needs of people at the service. One to one supervision sessions for staff were carried out, however staff had not received spot checks to observe their care practice, to support them to increase their performance and competence. Annual appraisals had not taken place, however they were scheduled to take place in 2015.
Staff were not able to describe the basic principles of the Mental Capacity Act (2005) (MCA) to ensure they supported people legally in line with their consent. Staff said they needed training to better understand the requirements of this legislation. The provider had scheduled staff training in MCA and DoLS on the 15 September 2015.
There was insufficient staff to meet people’s needs. There was not enough management hours allocated to support the effective operational running of the service. Whilst the provider had measures in place to recruit a new manager, deputy manager and additional nursing staff, this staffing arrangement was not in place at the time of our inspection.
A lack of adequate training in safeguarding adults; a lack of adequate training and staff support to meet people’s individual needs and a lack of sufficient staffing levels to meet people’s needs are breaches of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The provider had an improvement plan for the decoration and maintenance of the premises, however repairs we identified were not recorded on this plan. The acting manager said that it was difficult to change anything in the home as people often resisted change due to their health conditions. However, this should not prevent action being taken to make sure people remained safe.
Failure to ensure the environment is properly maintained to keep people safe is a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The provider did not have a system for monitoring the cleanliness or maintaining effective infection control standards at the home. Where people had blood borne viruses or infectious diseases, there was no protocols in place to reduce the risk of infection to them and others. The provider had not adequately assessed infection control risks including those that are health care associated.
Peoples care plans were not consistently reviewed to reflect any changes in their care and treatment needs. Where the responsibility for people’s care and treatment was shared with other people to include health care professionals, reviews of care had not always taken place with their involvement, in a timely and formalised way. Care reviews did not take into account preventative measures to ensure the health, safety and welfare of people.
The failure to provide safe care and treatment; to protect people from harm by ensuring the premises are safe; to assess the risks of infections, protect people from these risks and provide a clean and hygienic environment which is properly maintained are breaches of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
People’s individual risk assessments included measures to reduce identified risks and guidance for staff to follow to make sure people were protected from harm. Although risk assessments were in place they were not always up-to-date. People could not be assured that risks would be managed appropriately due to a lack updated records.
Audits were completed, however they did not adequately identify how the service could improve. The provider had not always identified all shortfalls or acted on the results of audits to make necessary changes to improve the quality of the service and care for people.
The service sought people’s feedback, comments and suggestions. However, the provider had not explored accessible means of obtaining people’s feedback. The provider had not analysed the results of any feedback given by people and acted upon this to improve the service.
Accidents and incidents were recorded, however they had not been monitored or analysed to identify how the risks of re-occurrence could be reduced to keep people safe.
Failure to adequately assess, monitor and improve the quality of the service, to include people’s views of the service, and the failure to ensure risk assessments records are up-to-date are breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Staff did not know each person well or understand how to meet their support needs. Each person’s needs and personal preferences had been assessed before they moved into the service, however, staff did not always have accurate knowledge to provide person centred, consistent care.
People’s care plans did not take into account or monitor progress with people’s longer term goals and objectives. Where people had expressed a preference to move on from the service, this had not been assessed to support those people to work towards meeting their goals where possible.
There were insufficient activities for people to engage in at the service. The acting manager and activities co-ordinator tried to involve people in the planning of activities. They said that it was difficult to engage people in activities. Some people were able to go out independently.
Failure to provide person centred care and treatment to meet people’s needs, to include activities and failure to provide care or treatment designed with a view to achieving people’s preferences are breaches of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
The provider had not notified the Care Quality Commission of all significant events that affected people or the service. We brought this to the attention of the provider and they implemented training sessions for the acting manager to update their knowledge in this area. It was too soon to evidence whether there was an improvement in this area.
Failure to notify CQC of significant events at the service is a breach of Regulation 18 of The Care Quality Commission (Registration) Regulations 2009.
Most staff treated people with kindness and respect. However, we observed one incident where a staff member spoke with someone in a way which was not compassionate or caring and did not promote their dignity. The acting manager was concerned to hear about this and said they would act swiftly to address this. Not everyone was satisfied about how their care and treatment was delivered.
We have made a recommendation about training for staff in providing care and support to people with dignity and compassion.
Information about how to access advocacy services was not provided in a clear and accessible way to all people. There was no information on activities available to people. Menus and satisfaction surveys were provided for people in a suitable format.
We have made a recommendation that the provider explores different ways of giving people information about services available to them in accessible formats and supports people to access these services.
Information leaflets were available to inform people about the complaints procedure. However these were not always provided in an accessible format. People were not always aware of how to make a complaint. No complaint had been received in the last 12 months before this inspection.
We have made a recommendation about giving people information about how to make a complaint in accessible formats and supporting people to make a complaint when required.
Not everyone had their cultural and spiritual needs met.
We have made a recommendation that the provider reviews and supports people to meet their diverse care, cultural and spiritual needs.
There were safe recruitment procedures in place which included the checking of references.
Accidents and incidents were recorded and although there was no system to analyse these to look for patterns or trends individually, control measures were put in place to reduce risks to people. All fire protection equipment was serviced and maintained.
Medicines were stored, administered, recorded and disposed of safely and correctly. Staff were trained in the safe administration of medicines and kept relevant records that were accurate.
The Care Quality Commission (CQC) is required by law to monitor the operation of Deprivation of Liberty Safeguards (DoLS) which applies to care homes. Where people required a DoLS the acting manager had completed DoLS applications appropriately. They understood when an application should be made and how to submit one.
The service provided meals that were in sufficient quantity, well balanced and met people’s needs and choices. Staff knew about and provided for people’s dietary preferences and restrictions.
The overall rating for this provider is ‘Inadequate’. This means that it has been placed into ‘Special Measures’ by CQC. The purpose of special measures is to:
Ensure that providers found to be providing inadequate care significantly improve.
Provide a framework within which we use our enforcement powers in response to inadequate care and work with, or signpost to, other organisations in the system to ensure improvements are made.
Services placed in special measures will be inspected again within six months. The service will be kept under review and if needed could be escalated to urgent enforcement action.