Archived: Cowlersley Court Care Home

Updated 22 February 2017

We undertook an unannounced inspection of Cowlersley Court Care Home on 4 and 5 February 2016. This inspection was done to check that improvements to meet legal requirements planned by the provider after our 14, 15 and 19 October 2015 inspection had been made. The team inspected the service against two of the five questions we ask about services, is the service safe, and is the service well-led. This is because the service was not meeting some legal requirements.

The inspection took place on 4 and 5 February 2016 and was unannounced. The inspection was focussed and looked at the safe and well-led key questions.

The inspection was carried out by an adult social care inspector on both days and a specialist advisor who had extensive knowledge of the safe handling of medicines on day one. Prior to our inspection we had received information of significant concern from the local authority safeguarding team. This was in relation to safeguarding matters which we had not been notified of and related to the safe care and treatment of people who used the service. The service was last inspected during October 2015, and was found to be inadequate in all of the five key questions at that time. There were multiple breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We spoke to other agencies who worked with the service to gather further information; these included the district nursing service and the local authority contracting team.

During our inspection we looked at the care records of six service users, the medication administration records for all the people who used the service, weight records, bathing records, complaints file, incident and accident files, medicine competency checks, staff rotas and safeguarding records for the service since our last inspection.

We spoke with six of the people living at the service, three of care staff, a senior care workers and the area manager.

Updated 22 February 2017

We carried out an unannounced comprehensive inspection of this service on 14, 15 and 19 October 2015. Breaches of legal requirements were found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to the breaches of, Regulation 9 person centred care, Regulation 10 dignity and respect, Regulation 11 Need for consent, Regulation 12 Safe care and treatment, Regulation 13 Safeguarding people from abuse and improper treatment, Regulation 17 Good Governance, Regulation 18 staffing, this was in relation to there not being enough staff to meet people's needs, and staff not being adequately trained and skilled to carry out their duties.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Cowlersley Court Care Home on our website at www.cqc.org.uk.

The service is required to have a registered manager; there was no registered manager at the time of our initial inspection or at this inspection. There was a manager who was responsible for the day to day running of the service. 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.

We found that safeguarding incidents had not been recognised or reported to the Care Quality Commission, although some of the concerns had been recognised by other health professionals who had visited the service.

The registered provider had done some work on the risk assessments which needed to be in place to reduce identified risks. These were in some cases not adequate and in other cases not completed.

Accidents and incidents were not being recorded adequately and in cases where these were referred to in daily care records no accident or incident forms were available, although the area manager told us they had been completed.

There were not enough staff on duty to meet people's needs. This was due to the people who used the service being spread out over the home which is large, which meant there were long periods where there were no staff in some areas.

We looked at the processes in place for the administration of medicines. We found that there had been some changes made, however these were not sufficient to ensure that people were receiving their medicines as prescribed.

The home was not always kept clean. We saw several examples of poor cleanliness which would contribute to the risk of any infections within the home spreading.

There was little evidence of leadership in the home. The manager was on leave at the time of our inspection, however there was no manager covering for their absence. The area manager attended the service during our inspection but spent most of their time in the office which is away from the main areas of the home.

Staff told us that the manager asked them 'how they could support them' and 'did not tell staff what needed to be done'.

The registered provider was not meeting the requirements of their registration with the Care Quality Commission as they were not notifying CQC of events which they had a duty to do.

There was some evidence of oversight from the wider management team as there had been a visit made by the area manager to the service in January 2016 and we saw that there had been a report completed of this visit. However the action plan for the identified areas of concern was not completed and we saw no evidence that this information had been used to improve the service.

The records in the service were not of good quality and were not accessible. Records of accidents and incidents were not in the file marked as being for their storage and could not be located during the inspection or supplied afterwards. Daily records were loose in the medicines room and there was a care plan which was not in the file of the person it related to and was found to be loose in the medicines room.

You can see what action we told the provider to take at the back of the full version of the report.