Archived: Capesthorne House

Updated 9 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 checked 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 responsive inspection was prompted by information of concern we received from the safeguarding authority. This information and subsequent incidents is subject to a criminal investigation and as a result this inspection did not examine the circumstances of the specific incidents. However, the information shared with CQC indicated potential concerns about the management of risk to people’s health, safety and wellbeing. The Commission is aware the police were informed and were called to the location to support staff to manage incidents. The Commission have not received all statutory notifications regarding all activities which are reportable at the home including police statutory notifications. This is also subject to a criminal enquiry.

This unannounced urgent responsive inspection took place on 14 June 2018. A full comprehensive inspection was then undertaken on 15 and 18 June 2018 and 9 July 2018.

The inspection team consisted of one adult social care inspector and an expert by experience who visited the home on 14 June 2018 and one adult social care inspector who returned to inspect on 15, 18 June 2018 and 9 July 2018. A member of the Warrington safeguarding team accompanied us on 9 July 2018 in view of a serious incident on 6 July 2018.

An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert by experience expertise was in services for people with autism.

We reviewed all information we held about the home including the CQC intelligence report which indicated there were a higher than average number of accidents and incidents leading to hospital admission/attendance. This indicator of unusually high rates of emergency hospital admissions for this group of conditions may indicate poor risk management systems or prevention of injury programmes at the home and in some cases, could even indicate instances of abuse. Our intelligence report also confirmed there was a higher than average turnover of staff at this location.

The methods used to gather our evidence, included talking with people using the service and their family members, interviewing staff, pathway tracking {a review of all records}, observation, and review of records. We reviewed four people’s support plans/positive behaviour support plans and risk screen assessment documents. We pathway tracked two people living at the home and reviewed the electronic medication administration record on an IPAD. We spoke with three people who lived at the home, three relatives over the telephone and 12 staff including the registered manager, projects manager and operations manager. We also requested a telephone call with the senior managers to escalate our concerns and spoke with the managing director and nominated individual for the home on 18 June 2018. We spoke with commissioners of the service and local authority staff including people’s social workers.

Updated 9 August 2018

This inspection took place on 14, 15, 18 June 2018 and 9 July 2018 in response to concerns received from members of the public, safeguarding authority and commissioners of the service. The service was last inspected on 18 October 2017 and was rated good.

Capesthorne House is an eight bedded 'care home'. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The home is set back off a road in the centre of the local community within proximity to local shops and primary school.

The care service has been developed and designed in line with the values that underpin the Registering the Right Support and other best practice guidance. These values include choice, promotion of independence and inclusion. People with learning disabilities and autism using the service can live as ordinary a life as any citizen.

The provider applied to the Commission to deregister the home in view of the risks we identified during this inspection. At this inspection we found an extreme level of risk impacting on the people living at the home with a likelihood of the risks continuing at that level due to the provider not mitigating risks effectively enough during this inspection. This meant there was a serious level of risk to a person’s life, health or well-being. The Commission are considering undertaking a criminal investigation into the serious incidents which had occurred. You can see what action we told the provider to take at the back of the full version of the report.

This location requires a registered manager to be in post. A registered manager was in post at the time of our inspection. 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.

On this inspection we found there were safeguarding procedures in place but they had not always been followed appropriately. Safeguarding concerns had not been reported to the appropriate authorities.

We found risks to people and others had not been managed effectively. There was an override button above five doors which were in reach of people. This meant that people with a deprivation of liberty safeguard authorisation in place to keep them safe from leaving the premises were put at risk of accessing the community unsupervised, when it was unsafe for them to do so. The provider had known about this but had not acted quickly to mitigate the risk. After we raised our concerns with the provider, they acted by installing a new more secure key system.

Staff told us about the different types of abuse and they understood how to report a safeguarding concern. However, not all safeguarding concerns which had occurred since the last inspection had been reported to the relevant safeguarding authority.

There was a system in place of recording incidents and accidents however, we found multiple incident forms which had not been analysed. We undertook a random check and found not all incidents had been recorded onto the provider’s electronic system. This meant not all incidents were being reported appropriately or analysed for trends or themes. The provider was not aware of all serious incidents which had occurred in the home.

People who were living at Capesthorne House had a support plan and risk assessment screen in place. We found they were either not detailed enough or had not been reviewed every time an incident had occurred. For example, a detailed specific risk assessment had not been devised for one person who self-harmed.

The design of the home and the environment were not suitable for people with highly complex behaviours which were challenging. The garden fence was adjacent to a busy road and residential housing. People’s privacy and dignity was not being upheld as onlookers were able to observe people in distress.

The system in place of ensuring all building maintenance repairs were undertaken was not robust enough. There were several repairs which had not being completed in a timely manner. This meant the environment was unkempt and did not uphold people’s dignity.

We checked the electronic systems of administering and storing prescribed medications at the location. We found some anomalies where the stock control numbers of prescribed medicines did not correspond with the number of prescribed medicines recorded as administered. This was due to errors where staff had not signed for a prescribed medicine when it was administered.

The staffing levels were not always meeting the needs of the people at the home. This was due to the number of serious incidents which staff were required to respond to. The provider had not ensured everyone living at the home had their one to one or two to one support at all times in accordance with their care plan.

We have made a recommendation about staff recruitment. The provider's recruitment systems included a disclosure barring service check. The risk assessment for a previous conviction was not robust.

Staff we spoke with told us about people’s care needs. They understood people’s individual behaviours but reported they did not always feel safe when dealing with people’s behaviours. We found entries in the records of staff being injured during an incident where a person living at the home went into crisis.

People who lived at Capesthorne House had a deprivation of liberty safeguard authorisation in place for care and treatment. We had concerns people’s choices were not always being adhered to.

Staff did not always provide people with person centred care. They were aware of people’s likes and dislikes. People were supported to go out into their community.

Whilst we observed staff during the inspection treating people with respect and dignity we found examples whereby this was not always consistent.

The governance arrangements of the home were not robust enough. The senior managers had not ensured there was enough oversight of the home to check on the quality and safety of the service. The registered manager was suspended from duties during our inspection pending an investigation.

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.