Archived: Cavendish House

Updated 29 July 2016

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.

This was the first inspection of this service since Cumbria County Council re registered in October 2015. Prior to this the registered provider was registered as Cumbria Care which is part of the County Council. The last inspection of the service was in September 2015 when we rated the service as Good. Cavendish House is situated within walking distance of the town. The service provides six places for people living with a learning or physical disability. Two of these places are used for emergency admissions. The accommodation is in single rooms.

An adult social care inspector conducted an unannounced inspection on Saturday 19 March 2016. A number of breaches and concerns were found at the inspection and a follow up visit with another adult social care inspector was carried out on 23 March 2016. On 4 and 13 April 2016 the lead inspector visited the service again because of our concerns about the safety and well-being of individuals in the service.

Prior to our visits the service had completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We planned the inspection using this information. Before our inspection we reviewed the information we held about the service. We contacted the local authority, social workers and healthcare professionals who came into contact with the home to get their views.

At our inspection we spoke with relatives who were in the home and looked at the questionnaires from relatives about their family members respite stay. We observed the care and support staff provided to people in the communal areas of the home and during the lunch time meals. There were up to five people staying across the four days we visited and we spoke with them and observed how settled they were in the house. We read eight care files: two of the long stay people and six files of people who came for respite care on a regular basis.

We spoke with four care staff and three seniors, the day to day manager, the registered manger and the operations manager for the service. We read the personnel files and development files for six members of the staff team.

We looked at records that related to how the home was being managed. This included quality monitoring records and records related to maintenance and fire and food safety.

Updated 29 July 2016

We carried out an unannounced comprehensive inspection of Cavendish House on 19 & 23 March and 4 & 13 April 2016 at which multiple of breaches of legal requirements were found. The Care Quality Commission found evidence that people were being exposed to harm or the serious risk of harm.

Cavendish House is a service provided by Cumbria County Council. The service provides short-term respite accommodation for up to six people who have a learning disability and/or a physical disability. Two places available were for emergency admissions. The house is situated near the centre of Workington in a residential area. Accommodation is in single rooms.

The home had a registered manager who had applied to remove her registration but was continuing to be registered for other services for Cumbria County Council. 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 and associated Regulations about how the service is run.

Staff had been trained in the protection of vulnerable adults but were not always identifying and reporting potential abuse appropriately. Some people were not being protected from potential or actual abuse and improper treatment.

This was a breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Risk assessments relating to the health, safety and welfare of people had not always been completed and did not include plans for managing and mitigating risk.

This was a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The premises were not secure and not suitable for providing short stay and emergency placements. The building and equipment were not being routinely cleaned or maintained to a good level. There were problems with infection control.

This was in breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The deployment of staff and staffing levels at the service did not ensure that people’s needs could be met. People were spending long periods of time with little or no staff interaction. Staff had received training relevant to their roles. However, we found that staff were not always putting this training into practice. Staff supervisions and team meetings were mostly up to date. However, the nominated ‘manager’ had not received supervision for several months. The registered manager who was legally responsible for the service did not supervise staff and was not based in the home.

This was a breach of Regulation 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Cumbria County Council had suitable recruitment and disciplinary procedures in place.

Medicines were managed appropriately.

Communication in the service was inconsistent between staff and between shift changes. Staff were not always up to date with the support people needed.

We had evidence of unlawful practices under the Mental Capacity Act 2005 in terms of a failure to obtain lawful consent.

This was a breach of Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Care staff prepared suitable meals and snacks for people but nutritional planning was not always in place. This was a breach of Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The environment, both inside and out, needed to be developed and refurbished. There were no plans to upgrade the building available during the inspection.

This was a breach of Regulation 15 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 as the registered provider had not ensured that the premises was fit for purpose and took into account national best practice.

We saw caring and positive interactions from staff who helped people to maintain their privacy and dignity. Staff had an understanding of the needs of people in the service but were not always guided to help people to maintain or improve their independent living skills. We made a recommendation about developing independence and promoting well-being.

Assessment and care planning did not identify all the health and social care needs of people. Care plans were not updated and reviewed after significant or serious events or when needs changed.

This was a breach of Regulation 9 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Activities and entertainments were not been developed to meet people's needs. We saw that people were isolated in the service, particularly in the evenings and at weekends.

This was a breach Regulation 10 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The service had a registered manager who did not line manage staff and had no control over resources. The service had not had consistent leadership for some time.

The provider had failed to notify the Care Quality Commission of safeguarding matters and other matters of concern. This was a breach of Regulation 18 of the (Registration) Regulations 2009 by Cumbria County Council or the Registered Manager. This was a breach of the provider's condition of registration and this matter is being dealt with outside of the inspection process.

Cumbria County Council’s quality assurance system had failed to identify all of the problematic issues in the home. Some problems had been identified but no action taken. There was a failure of governance and oversight by the provider, Cumbria County Council.

This was a breach Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We served a notice of decision to prevent admission to this service. The Provider complied with this condition and the home now has no one in residence.

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.