We carried out a responsive focused inspection at Southminster Residential home on the 4 September 2017 as a result of safeguarding concerns received by the Commission that peoples medications were not being managed safely.We reviewed the outcome from this inspection and due to concerns found we expanded this inspection across all the key areas. We have not reviewed all the key lines of enquiry but we will be returning to the service within three months of this reports publication and provide a comprehensive overview of each key question at this time.
The home had previously been inspected in July 2016 following Inadequate and Requires Improvement’s ratings in 2015. At this time the service had been found to have made improvements achieving an overall rating of Good, with Requires Improvement in the safe domain.
Southminster residential home can provide accommodation for to up to 40 older people who may or may not be living with dementia. At the time of inspection 33 people were living at the service.
The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’.
Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.
The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.
If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.
For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.
A long standing registered manager was in place at the home. 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.
Medicines were not managed safely and when errors had occurred they had not investigated these transparently. In most cases they had not identified errors or discrepancies through the services own quality assurance audits.
When lessons from errors had been identified, the service did not ensure that these actions were implemented in a timely way to mitigate future risk of the error reoccurring.
Entries in people’s daily records by care workers demonstrated that they did not have the skills or knowledge to support people safely. Discussions we had with the provider and registered manager also reflected their inability to manage complex risks appropriately with a person centred approach.
Language used to describe people presenting with behaviours that challenged was disrespectful and uncaring.
People who had complex mental and physical health care needs did not have care plans that reflected how these needs impacted on their daily life. They did not provide staff with sufficient information to care for people responsively.
We found concerns about how the provider was ensuring that they were open and transparent about mistakes made in line with their legal obligations of duty of candour. Investigations into incidents did not result in lessons learnt and improving the service.
Audits in place to monitor the quality of the service did not identify what the service needs were who was responsible and when actions would be reviewed.
We found multiple breaches in the Health and Social care Act. You can see what action we told the provider to take at the back of the full version of the report.
We were so concerned about our findings that we had a meeting with the provider and the local authority to discuss the shortfalls. The provider has responded to the urgent action we asked them to take and provided us with a clear action plan with timescales to improve the service. Will monitor these improvements and inspect again within the next three months.