We inspected the service on 3 April 2018. The inspection was unannounced. Chestnut Lodge Care Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. The Care Quality Commission regulates both the premises and the care provided, and both were looked at during this inspection. Chestnut Lodge Care Home is registered to provide accommodation and personal care for 60 older people and people who live with dementia. There were 41 people living in the service at the time of our inspection visit.
The service was run by a company who was the registered provider. There was a 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. In this report when we speak about both the company and the registered manager we refer to them as being, ‘the registered persons’.
At the last comprehensive inspection on 14 December 2015 the overall rating of the service was, ‘Good’. However, after this we received concerning information that people were not always receiving safe care and treatment. We completed a focused inspection on 21 June 2017 to check that people were being kept safe. We found there were two breaches of regulations. This was because suitable arrangements had not been made to ensure that people consistently received safe care and treatment. Also, the registered persons had not suitably assessed, monitored and improved the quality and safety of the service given the shortfalls that had occurred in the provision of safe care and treatment.
We told the registered persons to take action to make improvements to address each of our concerns. However, the registered persons failed to submit written information to us saying what action they intended to take to enable the breaches of regulations to be met.
At the present inspection we found that sufficient steps had not been taken to address either of these breaches. This was because there were serious shortfalls in the arrangements used to provide people with safe care and treatment that had significantly increased the risk of people experiencing harm. There were also serious shortfalls in the systems and processes used by the registered persons to assess, monitor and improve the quality and safety of the service. This had resulted in the persistence of a large number of problems in the running of the service that had reduced people's ability to receive the high quality care to which they were entitled. In addition, the registered manager did not appreciate the seriousness of the concerns we had identified and there was no realistic prospect of them quickly being put right.
There were five additional breaches of the regulations. Robust recruitment checks had not been completed to ensure that that only people of good character were employed to work in the service. The accommodation was not designed, adapted and decorated to meet people’s needs and expectations. Care staff had not received all of the training and guidance they needed in order to know how to care for people in the right way. People had not always had their dignity respected and suitable provision had not been made to ensure that people always received person-centred care.
As a result of these breaches of regulations 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 registered persons’ registration of the service, will be inspected again within six months. The expectation is that registered persons 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 registered persons 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. When 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 registered persons from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.
We also found that there were other shortfalls in the service. Sufficient care staff had not always been deployed. We have made a recommendation about the deployment of care staff. Suitable provision had not been made to ensure that people consistently received care in line with national guidelines. This included supporting people who lived with dementia if they became distressed. We have made a recommendation about ensuring that care staff have the knowledge and skills to provide enriched care for people who live with dementia. Complaints and concerns had not consistently been managed in the right way to reassure people that issues would be addressed. We have made a recommendation about the systems and processes used to respond to complaints and concerns. In addition, care staff had not identified as a cause for concern the numerous examples of poor practice we identified. This lack of insight had contributed to people not always receiving the safe and person-centred care to which they were entitled.
Our other findings were as follows: Medicines were managed safely and people were safeguarded from situations in which they may experience direct abuse. There were suitable arrangements to obtain consent so that people only received lawful care. People receive coordinated care when they moved between different services and they had been helped to obtain any healthcare they needed.
People had been supported to make decisions about their care as far as possible. This included them having access to lay advocates if necessary. Confidential written information was managed in the right way.
Arrangements had been made to promote equality and diversity. This included promoting the citizenship rights of people if they chose gay, lesbian, transgender and bisexual life-course identities. Provision had been made to support people at the end of their life to have a comfortable, dignified and pain-free death.
Care staff had been helped to understand their responsibilities to develop good team work. The registered persons were actively working in partnership with other agencies to support the development of joined-up care. The quality ratings we gave the service at our last inspection had been displayed and the registered persons had told us about significant incidents that had occurred in the service.
At this inspection seven breaches, including two continued breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were identified. Full information about CQC’s regulatory response to the breaches of regulations relating to the breaches will be added to our report after any representations and appeals have been concluded.