Archived: Glen Heathers

Updated 30 August 2018

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 18 and 19 June 2018 and was unannounced.

The inspection team consisted of one adult social care inspector, a specialist nurse advisor and an expert by experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. They had personal experience of caring for older people with dementia who used regulated services.

Before the inspection we reviewed the information we held about the service including notifications the provider had made to us. This helped to inform what areas we would focus on as part of our inspection. We also reviewed the previous inspection report and the provider information return (PIR); this is a form that asks the provider to give us some key information about the service, what the service does well and improvements they planned to make. This had been completed just after our last inspection. Before the inspection we sought feedback from a member of social care staff at the local authority.

During the inspection we spoke to 12 people and 10 relatives. We spoke to 14 staff, including registered nurses, care staff, kitchen staff, activity staff, maintenance staff, the clinical lead and a senior manager. In addition, we also spoke to the registered manager. Due to the nature of people’s illnesses we were not always able to communicate with them so we spent time observing the interactions between people and staff, in public areas of the home, to help us understand people’s experiences.

We looked at the care records for 18 people who used the service and the personnel files for five staff members. We also looked at a range of records relating to how the service was managed. These included training records, complaints, quality assurance systems and policies and procedures.

Updated 30 August 2018

The inspection took place on 18 and 19 June 2018 and was unannounced.

Since our last inspection a new manager had become registered with CQC. 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.

Glen Heathers has a history of breaching legal requirements. Following an inspection in March 2015 multiple breaches of regulations were identified and CQC took appropriate enforcement action and placed the service in special measures for having an overall Inadequate rating. Some improvements were seen during a focused inspection in June 2015 and further improvements were found at the comprehensive inspection in November 2015 when the service was rated overall Requires Improvement and came out of special measures. However, they remained in breach of Regulation 17, Good governance. During the next comprehensive inspection in November 2016, we identified multiple breaches of the regulations related to providing safe care and treatment, safeguarding, staffing, person centred care and good governance systems. The overall rating following the November 2016 inspection decreased to Inadequate and the service was placed into special measures again. At our last inspection in May 2017 we found improvements had been made again and only one breach of regulation was found, relating to the governance of the service. The overall rating was Requires Improvement, however the key question of well led remained Inadequate and as such the service remained in special measures. CQC took enforcement action and imposed a condition on the registered provider. This condition meant the registered provider was required to undertake certain audits and to provide CQC with monthly reports about these audits.

At this inspection we found that the improvements previously made had not been sustained and we identified multiple concerns about the safety of people who lived in the service.

We found that people were at times placed at risk of harm because appropriate assessments of risk had not been carried out; staff knowledge of some risks and the management of these was not sufficient to ensure they could provide safe care; people were placed at risk because the checking of equipment used to prevent injuries was not accurate; where factors for people indicated concerns to their health, they had not been followed up and appropriate checks were not always undertaken following unwitnessed falls.

Where people had been losing weight, appropriate action had not been taken to ensure they were receiving the nutritional support they needed.

In addition, people were placed at risk because good infection control and maintenance measures were not in place. Several items of equipment were worn or ripped meaning they could not be sufficiently cleaned. There was a lack of schedules in place to ensure cleaning of some equipment. Some areas of the home smelt strongly of urine and we could not be confident that when housekeeping staff had signed to confirm they had cleaned an area, that this had been done.

Following the inspection, we asked for an action plan to address the immediate concerns we had for people’s safety. We also referred our concerns to the local authority.

Staffing levels were sufficient to meet the personal care needs of people but they did not support staff to provide any social or emotional engagement and support. Care planning was not always personalised and was not fully responsive to people’s changing needs. End of life care planning was in place for some people but needed further development.

People did not always receive effective care and support because staff had not received some training to help them meet people’s needs. Where training was provided in a specific areas staff competency had not been assessed to ensure they understood the area of need. People and their relatives provided positive feedback about staff. However, our observations showed that not all staff provided support in a respectful and dignified way.

There was a process in place to deal with any complaints or concerns if they were raised. However, when feedback via alternative formats such as surveys suggested concerns these were not investigated and acted upon. This meant we could not be confident the systems in place to seek feedback and address concerns were used effectively to ensure a safe and quality service was provided and drive improvements.

Despite knowing that there had been a problem with care plans and risk assessments, there had been a failure on the provider’s behalf to follow this up in the home and ensure people’s safety and a quality service was provided. The senior management team, provider and registered manager did not have an effective system to ensure they had good oversight of the safety and quality of the service.

Medicines were managed safely. Staff felt supported and were receiving supervisions to support them in their roles.

Prior to people moving into the home, assessments were undertaken to ensure the home and staff could meet the person’s needs. Staff were aware of the need to treat people as individuals and ensure care reflected their individual needs. Where applicable mental capacity assessments had been undertaken and we consistently saw and were told people’s permission was sought before staff provided care.

Some efforts had been made to adapt the environment to meet people’s needs but more work could be done to develop this further.

People were protected against abuse because staff had received training and understood their responsibility to safeguard people. Concerns were reported and investigated. The provider’s recruitment process included appropriate checks to ensure staff suitability to work in the home.

Communication with the kitchen staff needed to improve. The registered manager had defined staff roles and was open to suggestions and feedback. Staff felt supported by the registered manager and able to raise concerns at any time. They were confident these would be addressed. People and their relatives were confident to raise concerns if they needed to and spoke positively about the registered managers approach.

The overall rating for this service is ‘Inadequate’ and the service remains 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.”

We found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. CQC are considering what regulatory action to take in response to the serious concerns found during the inspection. Full information about CQC’s regulatory response is added to reports after any representations and appeals have been concluded.